1. 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

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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. 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

23. Mayhem Capture-R® Ready-ID ® *= presumptiveRh
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

24. Capture-R® Ready-ID ® *= presumptiveRh
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