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
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 Objectives
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 Flowchart Negative Capture Panel Results? Positive Negative Perform gel screen and panel Positive No Inconclusive Antibody (further investigation needed) Antibody Identified? Yes Report Antibody Specificity Repeat Capture Screen Repeat Positive Repeat Negative Yes Antibody Identified? No All clinically significant allo-abs ruled out Report Antibody Specificity Inconclusive Antibody (Further investigation 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 significant: Rh Kell Duffy Kidd Ss Zg a, Lu b, Co b, Wr a, Go a Antibodies don t require antigen negative units if AHG compatible: Le a*, Le b * M*N P1 Xg a Sd a WAA, CAA
Ruling Antibodies In and Out Ruling Out (generalizations) Two homozygous cells: E, Jk a, Jk b One homozygous cell: C, c, e, K, k, Kp b, Js b, Fy a, Fy b, S, s, M. N, Lu b One positive cell: D, C w, V, Kp a, Js a, Le a, Le b, P1, Lu a, Xg a 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 D C c E e K Fya Fyb Jka N1 Rpt 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
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 D C c E e Fya Fyb Jka Jkb NEO I + + 0 0 + + + + 0 4 II + 0 + + 0 + 0 0 + 2 Never tx d to her knowledge, three children
Run the Ready-ID panel: lots of positives 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 3 5 0 0 + 0 + 0 0 + 0 4 6 0 0 + + + 0 0 + + 3 7 0 0 + 0 + 0 + 0 0 3 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 + + + 3 13 0 0 + 0 + 0 0 + + 3 14 + + 0 0 + + + + + 4
Let s see what we get in gel D C c E e K Jka Jkb Fya gel I + + 0 0 + + + 0 + 4 II + 0 + + 0 0 + + 0 1 1 + + 0 0 + 0 + 0 + 4 2 + 0 0 0 + + + + + 4 3 + 0 + + 0 0 + 0 0 1 4 + + + 0 + 0 + + 0 3 5 0 0 + 0 + 0 + + + 3 6 0 0 + + + 0 0 + + 2 7 0 0 + 0 + + 0 + 0 2 8 0 0 + 0 + 0 + + 0 2 9 0 0 + 0 + 0 + 0 + 2 10 0 0 + 0 + 0 + 0 + 2 11 + + 0 0 + 0 0 + 0 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 + + 0 0 + + 0 + 0 3+ NT II + 0 + + 0 0 + + + 0 2+ PtCo 0 2+
Run the Panocell -10 with LISS D C c E e K Jka Jkb Fya AHG LISS 1 + + 0 0 + 0 0 + + 3+ NT 2 + + 0 0 + 0 0 + + 3+ NT 3 + 0 + + 0 0 + 0 0 0 2+ 4 + 0 + 0 + + + + 0 0 2+ 5 0 + + 0 + 0 + + + 3+ NT 6 0 0 + + + 0 + + 0 0 2+ 7 0 0 + 0 + + + + 0 0 2+ 8 0 0 + 0 + 0 + 0 + 0 2+ 9 0 0 + 0 + 0 + 0 + 0 2+ 10 0 + 0 0 + + 0 + 0 3+ NT Additional exclusion cells run in LISS. DAT Negative (not WAA) AHG XM in LISS CC
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 + + 0 0 + + 0 + 0 3 II + 0 + + 0 0 + + + 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 + + 0 0 + + + 0 + 0 II + 0 + + 0 0 + + 0 0 1 + + 0 0 + 0 + 0 + 0 2 + 0 0 0 + + + + + 0 3 + 0 + + 0 0 + 0 0 0 4 + + + 0 + 0 + + 0 0 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 0 PtCo 0
The Ready-ID panel comes out next with very different results D C c E e K Jka Jkb Fya NEO 1 + + 0 + + 0 0 + + 0 2 + + 0 0 + 0 0 + + 0 3 + 0 + + 0 0 + + 0 2 4 + 0 + 0 + 0 + + 0 2 5 0 0 + 0 + 0 + 0 + 3 6 0 0 + + + 0 + 0 + 4 7 0 0 + 0 + 0 0 + 0 0 8 0 0 + 0 + + 0 + 0 0 9 0 0 + 0 + 0 + + + 2 10 0 0 + 0 + + 0 + + 0 11 0 0 + 0 + 0 + 0 0 3 12 0 0 + 0 + 0 + 0 0 4 13 0 0 + 0 + 0 + 0 0 4 14 + 0 0 0 + + + 0 0 4
Resolution and Caution Extend I (D-pos) NEO panel run and able to exclude all other 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
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