Mayhem – Get More Information Call the floor/or computer search of patient record Pregnancy Hx? 4 children Transfusion Hx? Never Other Hospitals? None Current Diagnosis Mitral Valve Relapse Recent Drug History Vitamins, Lipitor, Aspirin 11/30/2018

Mayhem– Crossmatch for Compatibility Take Group A units and XM by IS and AHG Advantage: Find units for procedure scheduled If units are incompatible, then the incompatible crossmatch may aid in the antibody definition/characteristics Disadvantage: No clear answer to reactivity detected in the panel testing One may not find compatible units, and this may have wasted tech time 11/30/2018

Mayhem– Crossmatch for Compatibility Example DIN IS Echo Interpretation Unit 1 Compatible Unit 2 1+ Incompatible Unit 3 Unit 4 Unit 5 Unit 6 11/30/2018

Mayhem – XM and Call Unidentified Calling an antibody unidentified Advantage All common alloantibodies are excluded on non-reactive cells The AHG-crossmatch may be used as an indicator of transfusion safety Disadvantage That unidentified will stay in the patient’s record going forward Always receive AHG crossmatch Delay in provision of blood 11/30/2018

Capture-R® Ready-ID ® Extend I (D-Positive Panel) *= 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 + 1+ 2 3 4 5 6 7 8 9 10 11 12 13 14 w Pos Cntrl 4+ Neg Cntrl Run Another Echo Panel 11/30/2018

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 2+ 6 7 8 9 10 11 12 13 14 Pos Cntrl 4+ Neg Cntrl Re-evaluate the first panel after the second panel – Is pattern there? 11/30/2018

Mayhem – Panoscreen® *= presumptive   Rh Kell Duffy Kidd Lewis P MNS Lu Xg Cell D C c E e f* V Cw K k Kpa Kpb Jsa Jsb Fya Fyb Jka Jkb Lea Leb P1 M N S s Lua Lub Xga IS LISS 1 + W 2 3 DAT is negative Anti-M pattern suggested in the Echo panels verified in tube method 11/30/2018

Mayhem – Take Away Points With weak reactions with Solid Phase or Manual Testing Rule out, but look for a pattern Testing options The history indicated that this would be a naturally occurring antibody since the patient had no history of transfusion Crossmatching and interpretations when all common alloantibodies Advantages Disadvantages 11/30/2018

Mayhem – Take Away Points (cont.) Trust your process Look to rule out the presence of clinically significant alloantibodies (per Standards) Use the clues in the pattern of positives History Naturally occurring since no transfusion XM results IgM and IgG detected Dosage Antibody demonstrates variability Circle back to the initial ABS and panels to verify that the specificity is verified. 11/30/2018

One Night in the Blood Bank…… Sad But True Trilogy 11/30/2018

Trilogy On Monday night in the Fall (after football game, of course), a sample arrive at the Blood Bank on a 40-year-old male CBC Chemistries WBC 16 x 103/uL Billi 2.0 RBC 2.8 x 106/uL Creat. 3.0 Plt 110 x103/uL K+ 5.0 Hgb 6 g/dL Cl 105 Hct 18% Na 145 Gluc 100 LDH 200 BUN 30 11/30/2018

Trilogy Patient history Many years of a Kidney disorder Anemia secondary to kidney disorder Last transfusion was two weeks earlier History of A Positive and ABS Negative. -A -B -D A1 Cell B Cell Interpretation 4+ A, D Positive Screen Cell Results Interpretation I 4+ Positive II 11/30/2018

Trilogy – Next Steps Direct Antiglobulin Test (DAT) DAT and eluate Yes, since the patient was transfused two weeks prior this will investigate the potential immune response to transfusion DAT and eluate Yes, DAT is helpful but only test the eluate if the DAT is positive DAT and antibody panel Yes, DAT will investigate the IgG coating the cells and antibody panel will investigate the antibody detected DAT, antibody panel and autocontrol Yes, best answer Investigate reaction on cells (DAT and autocontrol) and serum with panel testing. 11/30/2018

Trilogy – DAT Testing DAT Testing IgG DAT Anti-Complement (Anti-C3b,d) DAT Interpretation IgG coating the cells but not complement Mixed-field indicates patient and transfused donor cells present consistent with transfusion reaction IgG DAT DAT Control IgG DAT Interp. Anti-C3b,d Anti-C3bd Control C3b,d DAT Interp. Patient 2+mf Positive Negative 11/30/2018

Trilogy – Eluate Testing Rh Kell Duffy Kidd MNS P Lewis Cell D C c E e f V Cw K k Fya Fyb Jka Jkb M N S s P1 Lea Leb AHG 1 + 2 3 3+ 4 5 6 7 8 9 10 Last Wash Pooled Cell 11/30/2018

Trilogy – Panel and Autocontrol Rh Kell Duffy Kidd MNS P Lewis Cell D C c E e f V Cw K k Fya Fyb Jka Jkb M N S s P1 Lea Leb AHG 1 + 2 3 1+ 4 5 2+ 6 7 8 9 10 Autocontrol 2+ mf 11/30/2018

Trilogy – Panel and Autocontrol Rh Kell Duffy Kidd MNS P Lewis Cell D C c E e f V Cw K k Fya Fyb Jka Jkb M N S s P1 Lea Leb AHG 1 + 2 3 1+ 4 5 2+ 6 7 8 9 10 Autocontrol 2+ mf 11/30/2018

Trilogy – Selected Cells Rh Kell Duffy Kidd MNS P Lewis Cell D C c E e f V Cw K k Fya Fyb Jka Jkb M N S s P1 Lea Leb AHG 1 + 1+ 2 2+ 8 Antibodies are proven with 3+3 rule 3 E+Jk(b-) 3 E-Jk(b+) 3 E-Jk(b-) and all other allos are excluded with non-reactive cells Mixed-field in autocontrol and DAT correlate Consistent with transfusion reaction 11/30/2018

Trilogy – Provision of Blood ABO/Rh identical fully antigen matched ABO/Rh appropriate fully antigen matched The patient was transfused 2 weeks ago Cannot verify full phenotype without additional testing ABO/Rh identical E-Jk(b-) ABO/Rh appropriate E-Jk(b-) Both are acceptable, but ABO/Rh appropriate is the only requirement for provision of blood. E-Jk(b-) units are required. This patient should not be transfused The patient’s testing indicates that transfusion would be helpful. 11/30/2018

Trilogy – Screen for Units? Screen units for E antigen and then the E- units for Jk(b-) E - 71% 7 of 10 units Jk(b-) 26% 2 of 7 units Screen units for the Jkb antigen and then the Jk(b-) for E- Jk(b-) 26% 2 of 10 units E 71% <1 of 2 units Call the donor center for E-Jk(b-) units This is the most efficient .71 x .26 = 18.5% in population Suggest anything less than 25%-50% call and request matched units 11/30/2018

Trilogy – What happened? Summary Finalized as delayed transfusion reaction stimulated by the transfusion two weeks earlier Anti-E in eluate and serum Anti-Jkb in serum Proactive measures A full molecular genotype was completed Physician was made aware of potential delays in provision of blood for this patient due immune response 11/30/2018

Story Summary We have used stories and shared experiences to discuss problem solving for Blood Types Massive Blood Transfusions Problem solving instrument results Antibody Identification 11/30/2018

Story Summary 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 Blood Bank Stories of Glory 11/30/2018

Closing – Follow Up Questions? 11/30/2018