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

Capture Panel Results? Positive

Antibody Identified?

Negative

Perform gel screen and panel Positive Negative Repeat Capture Screen Repeat Negative All clinically significant allo-abs ruled out Antibody Identified? Inconclusive Antibody

(further investigation needed)

Report Antibody Specificity Report Antibody Specificity Repeat Positive Inconclusive Antibody (Further investigation needed)

Yes No No Yes

Antibody Identification Flowchart

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

significant:

– Rh – Kell – Duffy – Kidd – Ss – Zga, Lub, Cob, Wra, Goa

• Antibodies don’t

require antigen negative units if AHG compatible:

– Lea*, Leb* – M*N – P1 – Xga – Sda – WAA, CAA

Ruling Antibodies In and Out

• Ruling Out (generalizations)

– Two homozygous cells: E, Jka, Jkb – One homozygous cell: C, c, e, K, k, Kpb, Jsb, Fya, Fyb, S, s, M. N, Lub – One positive cell: D, Cw, V, Kpa, Jsa, Lea, Leb, P1, Lua, Xga

• Ruling In

– Three cells positive for the antigen to the suspected antibody and negative for any other antigen to which the patient has the corresponding antibody

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

Should we ignore that “?” reaction?

D C c E e K Fya Fyb Jka N1

Rpt

N2 I + + + + + + II + + + + + + ?

Run a Ready-ID panel

D C c E e K Jka Jkb Fya NEO 1 + + + + + + 3 2 + + + + + 3 + + + + + 4 + + + + + + 5 + + + + + + 6 + + + + + + + 7 + + + 8 + + + + 9 + + + + 10 + + + 11 + + + 12 + + + + + 13 + + + + 14 + + + + + + +

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 + + + + + + 3 II + + + + + 2 1 + + + + + 3 2 + + + + + + 3 3 + + + + 2 4 + + + + + + 1 5 + + + + + 6 + + + + + 7 + + + + 8 + + + + 9 + + + + 10 + + + + 11 + + + + 3 PtCo

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 + + + + + 1 II + + E + 2 III + + + + + 2 D C c E e K Fya Jka Jkb NEO I + + + + 1 II + + + + + + 2

D C c E e K Jka Jkb Fya NEO 1 + + + + + + ? 2 + + + + + 2 3 + + + + + 2 4 + + + + + 1 5 + + + + 2 6 + + + + + 2 7 + + + 2 8 + + + + 2 9 + + + + + 1 10 + + + + + 2 11 + + + 2 12 + + + 1 13 + + + 2 14 + + + + 2

Run a Ready-ID panel on NEO- well that didn’t help much

Let’s try another method- Ortho gel

D C c E e K Jka Jkb Fya gel I + + + + + + 2 II + + + + + 1 1 + + + + + 2 2 + + + + + + 2 3 + + + + 1 4 + + + + + + 2 5 + + + + + 2 6 + + + + + 1 7 + + + + 2 8 + + + + 2 9 + + + + 1 10 + + + + 2 11 + + + + 2 PtCo

Lots of positive reactions, but that patient control is negative

• Run patient with LISS
• 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.”

D C c E e K Fya Jka Jkb LISS I + + + + + + II + + + + +

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 + + + + + + 4 II + + + + + +

Run Ready-ID panel: again not looking really helpful

D C c E e K Jka Jkb Fya NEO 1 + + + + + + 4 2 + + + + + 4 3 + + + + + + 4 4 + + + + 4 5 + + + 2 6 + + + + + 4 7 + + + 4 8 + + + + + 3 9 + + + + 4 10 + + + + 4 11 + + + + + 4 12 + + + + + 4 13 + + + 3 14 + + + + + + + 4

Run a second panel: D-Pos (Extend II)

D C c E e K Jka Jkb Fya NEO 1 + + + + + 4 2 + + + + + + + 4 3 + + + + 4 4 + + + + + + 4 5 + + + + + 4 6 + + + + 4 7 + + + + + + 4 8 + + + + + 9 + + + + + 10 + + + + + + 4 11 + + + + + 12 + + + + + 13 + + + + + 14 + + + + + + + + 4

Resolution: Need to do a little more work….

• Can’t exclude everything in Capture, so do a

gel screen and exclusion cells

• Can’t exclude C
• Pt control (gel) and tube DAT are positive, so

can’t antigen type the patient

• Give C-e-K- units, compat by Capture

Case #4: Too Many Positives….

• 83 year old female in ER as PERC
• B Pos, NPR
• Never tx’d to her knowledge, three children

D C c E e Fya Fyb Jka Jkb NEO I + + + + + + 4 II + + + + + 2

Run the Ready-ID panel: lots of positives

D C c E e K Jka Jkb Fya NEO 1 + + + + + + 4 2 + + + + + 4 3 + + + + + + 4 4 + + + + 3 5 + + + 4 6 + + + + + 3 7 + + + 3 8 + + + + + 3 9 + + + + 4 10 + + + + 4 11 + + + + + 4 12 + + + + + 3 13 + + + + 3 14 + + + + + + + 4

Let’s see what we get in gel…

D C c E e K Jka Jkb Fya gel I + + + + + + 4 II + + + + + 1 1 + + + + + 4 2 + + + + + + 4 3 + + + + 1 4 + + + + + + 3 5 + + + + + 3 6 + + + + + 2 7 + + + + 2 8 + + + + 2 9 + + + + 2 10 + + + + 2 11 + + + + 4 PtCo 3

• Pt control is positive, start thinking about WAA
• Try LISS to see if can reduce any non-specific

reactivity and allow allo-ab reactivity to be seen

• Use Immucor Panoscreen cells with LISS

D C c E e K Fya Jka Jkb AHG LISS CC I + + + + + 3+ NT II + + + + + + 2+ PtCo 2+

D C c E e K Jka Jkb Fya AHG LISS CC 1 + + + + + 3+ NT 2 + + + + + 3+ NT 3 + + + + 2+ 4 + + + + + + 2+ 5 + + + + + + 3+ NT 6 + + + + + 2+ 7 + + + + + 2+ 8 + + + + 2+ 9 + + + + 2+ 10 + + + + 3+ NT

Run the Panocell -10 with LISS

• Additional exclusion cells run in LISS.
• DAT Negative (not WAA)
• AHG XM in LISS

Case #5: Capture- The New Ficin?

• 67 year old male in OR, no pre-operative type and

screen performed

• Seen 6 months previously and received 4 units of

blood at that time

• Surgeon wants 4 units of blood available as soon as

possible

• Capture antibody screen results:

D C C E e K Fya Jka Jkb NEO I + + + + + 3 II + + + + + + 2

We are very pressed for time so the Capture and gel work are started at the same time. The gel work finishes first….

D C c E e K Jka Jkb Fya gel I + + + + + + II + + + + + 1 + + + + + 2 + + + + + + 3 + + + + 4 + + + + + + 5 + + + + + 6 + + + + + 7 + + + + 8 + + + + 9 + + + + 10 + + + + 11 + + + + PtCo

The Ready-ID panel comes out next with very different results

D C c E e K Jka Jkb Fya NEO 1 + + + + + + 2 + + + + + 3 + + + + + 2 4 + + + + + 2 5 + + + + 3 6 + + + + + 4 7 + + + 8 + + + + 9 + + + + + 2 10 + + + + + 11 + + + 3 12 + + + 4 13 + + + 4 14 + + + + 4

Resolution and Caution

• Extend I (D-pos) NEO panel run and able to exclude all
• ther allo-antibodies
• Tube DAT negative, so the patient was able to be

antigen typed: Jka negative

• Four units of Jka neg blood were crossmatched using

Capture

• We have seen this pattern of reactivity with Kidd

antibodies (both Jka and Jkb) that react in Capture and are completely non-reactive in gel at least a dozen times since implementing solid-phase testing

Remarkable Medicine Remarkable Care