Troubleshooting the Problem Patient Immucor User Group Meeting - PowerPoint PPT Presentation

Troubleshooting the Problem Patient Immucor User Group Meeting Livonia, Michigan May 5, 2015 Anne Rapundalo, MT(ASCP)BB, CLS(NCA) Section Leader, Transfusion Service St. Joseph Mercy Hospital Ann Arbor

Objectives • Describe the workflow used to resolve antibody problems • Use case studies to demonstrate the importance of: – Following the positive reactions – Getting a patient history – Using multiple methodologies to problem solve

Background St. Joseph Mercy Hospital Ann Arbor – 537 bed, Level 2 trauma center, teaching hospital – Sister facilities: Chelsea (113 beds), Livingston (136 beds), St. Mary’s in Livonia (304beds) and Brighton (emergency and cancer care) – Transfusion Service in Ann Arbor staffed by 13 dedicated FTEs – Transfusion Service Protocols for:  Massive Transfusion  Bleeding Obstetrical Patient (BOP)  Potential Emergent Reversal Care (PERC)  Group O policy  Irradiated products – Reference Lab for St. Joseph Mercy Chelsea and occasionally St. Joseph Mercy Livingston

Transfusion Service Automation • Ann Arbor: – 2006 Galileos – 2013 NEOs • Sister sites: 2014 Echo • Primary method for BT, ABSC and ABID at all sites • Secondary method is manual Ortho gel (except Livingston, using PeG)

Initial ABID Protocol Positive Capture ABSC 1) Previously identified allo-antibody within the last 12 months? 2) Do the current results match the previous screen results? • Yes? Has the reaction strength increased? – NO : “Anti - ___ was previously identified in the patient’s specimen. Current reaction strengths have not increased since previous testing and additional antibody identification studies were not performed.” – YES : Perform Capture panel(s) • No? Perform Capture Panel(s) All previous inconclusive, WAA and CAA require workup

Antibody Identification Capture Panel Negative Positive Flowchart Results? Antibody Identified? Perform No Yes gel screen Negative Positive and Inconclusive Antibody Report Antibody panel (further investigation Specificity needed) Repeat Capture Repeat Screen Positive Antibody Identified? Repeat Negative Yes No Inconclusive Antibody All clinically significant Report Antibody (Further investigation allo-abs ruled out Specificity needed)

If Capture and gel have not resolved the antibody problem? • Tube testing – LISS screen and panel – Saline screen and panel – DAT (tube) – Gamma Elu-Kit • SEM American Red Cross Reference Lab – Adsorptions – Rare antigen negative units

Crossmatch Policy at St. Joe’s Ann Arbor • Electronic – No clinically significant antibody – No history of a clinically significant antibody – Antibody screen is not interpreted as positive – Two blood type interpretations on file • Immediate Spin – First three rules for electronic crossmatch apply – Only one blood type interpretation on file • XMEXT/AHG – Previous or currently reacting clinically significant antibody – Antibody screen interpreted as positive

Compatibility Decisions • Clinically significant antibody present – Antigen negative, AHG compatible units • Clinically insignificant antibodies – AHG compatible units • Inconclusive, antibodies of indeterminate specificity, or WAA – Least incompatible units by AHG – Crossmatch method used determined by testing method used

Antibody Significance • Always clinically • Antibodies don’t significant: require antigen negative units if AHG – Rh compatible: – Kell – Le a* , Le b * – Duffy – M*N – Kidd – P1 – Ss – Xg a – Zg a , Lu b , Co b , Wr a , Go a – Sd a – WAA, CAA

Ruling Antibodies In and Out • Ruling Out (generalizations) • Ruling In – Two homozygous cells: E, – Three cells positive for the Jk a , Jk b antigen to the suspected antibody and negative for – One homozygous cell: C, c, any other antigen to which e, K, k, Kp b, Js b , Fy a , Fy b , S, the patient has the s, M. N, Lu b corresponding antibody – One positive cell: D, C w , V, Kp a , Js a , Le a , Le b , P1, Lu a , Xg a

Case #1: Don’t dismiss weak reactions, get the whole picture • 51 year old female, B Neg, NPR • 2 days post-op, 2 units of prbc ordered Rpt D C c E e K Fya Fyb Jka N1 N2 I + + 0 0 + + + 0 + 0 0 II + 0 + + 0 0 + + + ? 0 Should we ignore that “?” reaction?

Run a Ready-ID panel D C c E e K Jka Jkb Fya NEO 1 + + 0 + + 0 + + 0 3 2 + + 0 0 + 0 + + 0 0 3 + 0 + + 0 0 0 + + 0 4 + 0 + 0 + + + + 0 0 5 0 + + 0 + 0 + + + 0 6 0 0 + + + + + + + 0 7 0 0 + 0 + 0 0 + 0 0 8 0 0 + 0 + + + 0 0 0 9 0 0 + 0 + 0 + 0 + 0 10 0 0 + 0 + 0 + 0 0 0 11 0 0 + 0 + 0 + 0 0 0 12 0 0 + 0 + 0 + + + 0 13 0 0 + 0 + 0 + 0 + 0 14 + + 0 0 + + + + + 0

Let’s get some more information • Call and talk with the patient’s nurse: – Has the patient been transfused or hospitalized anywhere else (particularly in the last 3 months)? – Has the patient ever been pregnant? • Yes, she was at UM about two months ago and has two children • Call UM: identified – D, -C, and – E • Meanwhile, we are still testing, using another method

Using Ortho gel: screen and panel D C c E e K Jka Jkb Fya gel I + + 0 0 + + + 0 + 3 II + 0 + + 0 0 + + 0 2 1 + + 0 0 + 0 + 0 + 3 2 + 0 0 0 + + + + + 3 3 + 0 + + 0 0 + 0 0 2 4 + + + 0 + 0 + + 0 1 5 0 0 + 0 + 0 + + + 0 6 0 0 + + + 0 0 + + 0 7 0 0 + 0 + + 0 + 0 0 8 0 0 + 0 + 0 + + 0 0 9 0 0 + 0 + 0 + 0 + 0 10 0 0 + 0 + 0 + 0 + 0 11 + + 0 0 + 0 0 + 0 3 PtCo 0

Resolution • Remainder of exclusion cells done using gel • Pt control and DAT negative • Honor the antibodies identified at another institution • Give Rh- C- E- units that are AHG compat in gel

Case #2: Every method has its drawbacks or “ No one method is capable of detecting all antibodies.” • Pt at Chelsea 70 year old male, A Pos • Last ABSC 5 years ago= Neg, • no history of txn D C c E e K Fya Jka Jkb Echo I + + 0 0 + 0 + 0 + 1 II + 0 + E 0 0 0 + 0 2 III 0 0 + 0 + + + + 0 2 D C c E e K Fya Jka Jkb NEO I + + 0 0 + 0 0 0 + 1 II + 0 + + 0 + + + 0 2

Run a Ready-ID panel on NEO- well that didn’t help much D C c E e K Jka Jkb Fya NEO 1 + + 0 + + 0 0 + + ? 2 + + 0 0 + 0 0 + + 2 3 + 0 + + 0 + + 0 2 4 + 0 + 0 + 0 + + 0 1 5 0 0 + 0 + 0 + 0 + 2 6 0 0 + + + 0 + 0 + 2 7 0 0 + 0 + 0 0 + 0 2 8 0 0 + 0 + + 0 + 0 2 9 0 0 + 0 + 0 + + + 1 10 0 0 + 0 + + 0 + + 2 11 0 0 + 0 + 0 + 0 0 2 12 0 0 + 0 + 0 + 0 0 1 13 0 0 + 0 + 0 + 0 0 2 14 + 0 0 0 + + + 0 0 2

Let’s try another method - Ortho gel D C c E e K Jka Jkb Fya gel I + + 0 0 + + + 0 + 2 II + 0 + + 0 0 + + 0 1 1 + + 0 0 + 0 + 0 + 2 2 + 0 0 0 + + + + + 2 3 + 0 + + 0 0 + 0 0 1 4 + + + 0 + 0 + + 0 2 5 0 0 + 0 + 0 + + + 2 6 0 0 + + + 0 0 + + 1 7 0 0 + 0 + + 0 + 0 2 8 0 0 + 0 + 0 + + 0 2 9 0 0 + 0 + 0 + 0 + 1 10 0 0 + 0 + 0 + 0 + 2 11 + + 0 0 + 0 0 + 0 2 PtCo 0

Lots of positive reactions, but that patient control is negative • Run patient with LISS D C c E e K Fya Jka Jkb LISS I + + 0 0 + + + + 0 0 II + 0 + + 0 0 0 + + 0 • Resolution: Do additional testing in LISS to exclude all allo-abs, AHG xm in LISS • Report with a chartable comment “The patient’s specimen contains an antibody of indeterminate specificity. The clinical significance of this antibody is not certain.”

Case #3: Remember that negative reaction on the screen • 50 year old female, in ER with 6.0 hgb • Requesting 2 units of prbc D C c E e Fya Fyb Jka Jkb NEO I + + 0 0 + + + + 0 4 II + 0 + + 0 + 0 + + 0

Run Ready-ID panel: again not looking really helpful D C c E e K Jka Jkb Fya NEO 1 + + 0 + + 0 0 + + 4 2 + + 0 0 + 0 + + 0 4 3 + 0 + + 0 + + + 0 4 4 + 0 + 0 + 0 + 0 0 4 5 0 0 + 0 + 0 0 + 0 2 6 0 0 + + + 0 0 + + 4 7 0 0 + 0 + 0 + 0 0 4 8 0 0 + 0 + + + + 0 3 9 0 0 + 0 + 0 + 0 + 4 10 0 0 + 0 + 0 + + 0 4 11 0 0 + 0 + + 0 + + 4 12 0 0 + 0 + 0 + + + 4 13 0 0 + 0 + 0 0 + 0 3 14 + + 0 0 + + + + + 4

Run a second panel: D-Pos (Extend II) D C c E e K Jka Jkb Fya NEO 1 + + 0 0 + 0 + 0 + 4 2 + + 0 0 + + + + + 4 3 + + 0 0 + 0 0 + 0 4 4 + + 0 0 + + + + 0 4 5 + + 0 0 + 0 + 0 + 4 6 + + 0 0 + 0 0 + 0 4 7 + + 0 + + 0 0 + + 4 8 + + + + 0 0 0 + 0 0 9 + 0 + + 0 0 0 + + 0 10 + 0 + + 0 + + 0 + 4 11 + 0 + + 0 0 + 0 + 0 12 + 0 + + 0 0 + + 0 0 13 + 0 + + 0 0 0 + + 0 14 + + + + 0 + + + + 4