Blood Bank Case Studies/Stories: “One Night In the Blood Bank…..” Jayanna Slayten, MS, MT(ASCP)SBBcm IUH Blood Bank Supervisor and Adjunct Professor, University of Texas Medical Branch SBB Program 11/17/2018

The Story Starts at Home or Lab 11/17/2018

Objectives Identify Options for responses to case study scenarios presented Apply deduction an logic to resolve a case study from the Blood Bank Review and respond to the case study material for serologic trouble shooting and provision of blood 11/17/2018

Story of the Switch-a-roo One Night in the Blood Bank….. Story of the Switch-a-roo 11/17/2018

Switcharoo Friday night of a full moon at five minutes after midnight, a sample arrive at the Blood Bank on a 32-year-old female CBC BMP WBC 10 x 103/uL Normal Values RBC 2.3 x 106/uL Plt 110 x103/uL Hgb 8 g/dL Hct 24% 11/17/2018

Switcharoo T and S ordered History Check Echo Testing – Solid Phase Patient has a history of A, D Positive -A -B -D A1 Cell B Cell Interpretation 4+ A, D Negative Screen Cell Results Interpretation I Negative II 11/17/2018

Switcharoo - What do you think? Wrong Blood In Tube Yes, this is definitely a possibility! Analyzer is correct but the Blood Bank history is wrong If the patient’s history was manually entered or historically reported, then is possible. Analyzer is incorrect due to patient history not reported by the ER If the patient is transfused, per Echo package insert then it may not type the patient correct. Good possibility. Limitation of analyzer to detect a weak expression of the D antigen Per package insert, not all weak expressions of D can be detected by the analyzer. Good possibility….. 11/17/2018

Switcharoo – What happened? Wrong Blood In Tube Redrew the patient. Same results Analyzer is correct but the Blood Bank history is wrong The ABO/Rh entry was done 2 years early prior to a surgery. The testing was completed by manual method at that time. Analyzer is incorrect due to patient history not reported by the ER The patient was asked for transfusion history. She was not currently pregnant and has never been transfused. Limitation of analyzer to detect a weak expression of the D antigen The sample was tested by manual method. The patient was tested as A, D Negative by direct manual method 11/17/2018

Switcharoo – What happened? Report as No Type Determined. Indicate to give A Neg Good option Report as A D Positive because of history Computer would not allow this scenario Don’t report and complete weak D testing This is the best answer to investigate the discrepancy Report as A Neg and override previous A Positive result This is what happened A Neg was entered with an override and reported results did not change the historical ABO/Rh(it remained A Positive) 11/17/2018

Switcharoo – Additional Testing Weak D Testing Molecular Confirmation Testing was submitted to Molecular Lab Verified as Weak D Type 4.2 Antisera -D Rh Control Weak D Weak D Control Interpretation Series 4 Anti-D 1+ 0 Weak D Pos Series 5 Anti-D w 11/17/2018

Switcharoo Summary The patient as a Weak D 4.2 is considered D negative Candidate for Rh Immune Globulin Give D Negative RBCs Changed the patient to D Negative in computer with a history flag about the Weak D status 11/17/2018

Saga of the Massive Missus One Night in the Blood Bank….. Saga of the Massive Missus 11/17/2018

Massive Missus On a frosty, icy evening the day after the full moon, a 50 year-old female was in a multiple MVA Level 1 trauma was called and Blood Bank was notified of the patient’s status in route to the hospital In route, the name of the patient was provided with date of birth. The patient had no ABO/Rh or antibody screen history at the facility 11/17/2018

Massive Missus Current protocol for Massive Transfusion Protocol (MTP) was started (1:1 Ratio) 6 RBC Group O RBC If female patient is less than 51 years old, then give O Neg If female patient is more than 51 years old, then give O Pos 6 Group A Thawed Plasma 1 Platelet, give one every other “Dose” 11/17/2018

Massive Missus After the first dose of Rh negative RBC with Group A plasma is sent out, a sample is received in the blood bank for the type and screen. The patient types as A, D Negative Antibody Screen = Negative 11/17/2018

Massive Missus The tech decided Switched the patient to A Negative RBC Maintained Group A Plasma At the time of the third cooler of MTP Dose (6 RBC and 6 Plasmas) the volume of A and O Negative RBCs were getting less than 10 units on the shelf. Inventory A Neg 4 units O Neg 8 units 11/17/2018

Massive Missus – What happened? The tech switched from A Negative to A Positive RBCs and continued with A Positive Plasma The MTP continued for 6 doses, with the 7th dose returned as not used. Dose # RBC Plasma Platelet Pooled Cryoprrecipitate 1 6 Gp. O Neg 6 Gp. A Gp A 2 6 Gp. A Neg 3 Gp O 4 6 Gp. A Pos 5 6 Total 36 RBC 36 Plasma 3 Plt 2 Pooled Cryo 11/17/2018

Massive Missus When the MTP was stopped and the patient stabilized, the patient was switched back to A Neg RBCs After 3 days, a new sample was submitted and tested on Gel -A -B -D A1 Cell B Cell Interpretation 4+ 2+mf A, D Positive Screen Cell Results Interpretation I Negative II 11/17/2018

Massive Missus The mixed-field continued to be detected for the patient’s stay in the hospital Related to the massive transfusion Continued support with A Negative Learning Points after this case Decision point about what blood type to give was very stressful Adding a job aid to help tech’s make the decision more quickly and with confidence 11/17/2018

Tale of Analyzer Mayhem One Night in the Blood Bank…… Tale of Analyzer Mayhem 11/17/2018

Mayhem 65 year old female patient is scheduled for a cardiovascular procedure in two days, but has arrived this evening in the ED with chest pains. Physician has ordered T and S CBC and BMP The patient is being monitored 11/17/2018

Capture-R ® Ready-Screen ® *= presumptive Mayhem Capture-R ® Ready-Screen ® *= presumptive   Rh Kell Duffy Kidd Lewis P MNS Lu Xg Cell D C c E e f* V Cw K k Kpa Kpb J sa J sb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub Xga Echo 1 + 2 3 1+ Pos Cntrl 4+ Neg Cntrl 11/17/2018

Mayhem Capture-R® Ready-ID ® *= presumptive   Rh Kell Duffy Kidd Lewis P MNS Lu Xg Cell D C c E e f* V Cw K k Kpa Kpb J sa J sb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub Xga Echo 1 + 2 3 4 1+ 5 6 7 8 9 10 11 12 13 14 Pos Cntrl 4+ Neg Cntrl Case B 11/17/2018

Capture-R® Ready-ID ® *= presumptive Rh Kell Duffy Kidd Lewis P MNS Lu Xg Cell D C c E e f* V Cw K k Kpa Kpb J sa J sb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub Xga Echo 1 + 2 3 4 1+ 5 6 7 8 9 10 11 12 13 14 Pos Cntrl 4+ Neg Cntrl Case B 11/17/2018