Blood antibodies

[turnupthevapor]

Did a cranial remodeling the other day on some poor guy that had a cranial decompression a few months earlier.

Sent a type and cross in holding and went off to the OR

.....After some hemmorage I wanted to transfuse, called the blood bank who stated the patient had some antibodies and they needed a new specimen and another hour.

what would you all do assuming you could not wait. I would suspect we should just give type specific and see how it goes? Watch the BP, urine, and temp. Any idea the risk involved here


thanks again
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[dfk]

O neg in a pinch.. go more than 2 units and you run the risk of transfusing pt's type-specific after that point. either way, O neg gives you what you need.

 

[9french]

Blood bank is telling you that the patient has antibodies against some of the minor antigens, i.e., he is alloimmunized. It is significantly more difficult to find a crossmatch in these patients. O neg is the wrong answer. He is likely to have antibodies against the minor antigens of O neg as well. If you were to transfuse him, he is significantly more likely than another patient to develop intravascular hemolysis.

If at all possible, do not transfuse him until you have a type and cross. Treat with crystalloids or colloids for volume expansion and 100% oxygen. Tolerate a low crit which you would otherwise transfuse for. Perhaps place a central line and monitor SVO2. Also at this point give steroids in case you have to transfuse.

If you get to a point where it is possible death versus transfusion, you have to do what you have to do. Speak with the director of the blood bank, not a tech, and explain what is happening. Get the closest blood you can get ahold of. Be prepared to deal with a likely transfusion reaction. Give steroids, H2, and H1 blockers; maintain excellent UOP with mannitol and lasix; also consider alkalinizing the urine. Get a hematology consult immediately post-op if signs of tx reaction develop.

Lastly, keep outstanding documentation as to why you absolutely had to give the blood you did.

 

[huktonfonix]

O neg in a pinch.. go more than 2 units and you run the risk of transfusing pt's type-specific after that point. either way, O neg gives you what you need.

Also, the 2 units theory also only applies to whole blood. Not so much to prbcs. However, in this particular patient see 9 french's post. Otherwise in your everyday patient who walks in the door, safety margins are 99.8, 99.95, 99.98 (i thnk, i would have to look up the last 2 to be sure) in regards to type, type and screen, type and cross.

 

[Jeff05]

giving o neg is the wrong answer. that refers to major ag/ab. the patient's problem is having minor ones.

 

[Noyac]

Blood bank is telling you that the patient has antibodies against some of the minor antigens, i.e., he is alloimmunized. It is significantly more difficult to find a crossmatch in these patients. O neg is the wrong answer. He is likely to have antibodies against the minor antigens of O neg as well. If you were to transfuse him, he is significantly more likely than another patient to develop intravascular hemolysis.

If at all possible, do not transfuse him until you have a type and cross. Treat with crystalloids or colloids for volume expansion and 100% oxygen. Tolerate a low crit which you would otherwise transfuse for. Perhaps place a central line and monitor SVO2. Also at this point give steroids in case you have to transfuse.

If you get to a point where it is possible death versus transfusion, you have to do what you have to do. Speak with the director of the blood bank, not a tech, and explain what is happening. Get the closest blood you can get ahold of. Be prepared to deal with a likely transfusion reaction. Give steroids, H2, and H1 blockers; maintain excellent UOP with mannitol and lasix; also consider alkalinizing the urine. Get a hematology consult immediately post-op if signs of tx reaction develop.

Lastly, keep outstanding documentation as to why you absolutely had to give the blood you did.

Very well said, 9'er.

As usual the wrong was posted b/4 you.

All I can add is what you touched on. Remember that you can always call the pathologist (probably what 9'er meant by lab director) and run through the scenario with him/her. And if the surgeons can stop for a little while to allow lab to catch up this may help.

 

[Planktonmd]

O neg in a pinch.. go more than 2 units and you run the risk of transfusing pt's type-specific after that point. either way, O neg gives you what you need.

Wrong answer.

 

[Noyac]

Wrong answer.

I'm starting to see just how useful this nurse can be here. How about you?

If you SDN old timers remember back when I was a mod I argued that the nurses should be welcome here. I stated that it was only going to prove the difference in training and lack of knowledge on their part. We could use this site to show that they were a necessary addition to the anesthesia world but only under supervision, not as independent practitioners.

This guy proves my point every time he opens his mouth.

 

[aredoubleyou]

Also, the 2 units theory also only applies to whole blood. Not so much to prbcs.

Beat me to it.

Was I even born when whole blood was being routinely used for transfusion?

 

[aredoubleyou]

I'm starting to see just how useful this nurse can be here. How about you?

If you SDN old timers remember back when I was a mod I argued that the nurses should be welcome here. I stated that it was only going to prove the difference in training and lack of knowledge on their part. We could use this site to show that they were a necessary addition to the anesthesia world but only under supervision, not as independent practitioners.

This guy proves my point every time he opens his mouth.

Not trying to stir things up, but I am quite shocked, honestly. I think there were three recent threads that demonstrated this.

I think there is a big difference between the so called residency/ academia dogma based on theoretical concerns which likely lead to unnecessary tests/ delays/ cancelations/ monitors, etc... AND the lack or garbling up of knowledge that would result in morbidity, bad outcomes, etc if you for example poured o neg blood into this patient thinking that the problem is solved.

Seems like such a f'ing waste how many hours of studying and abuse endured learning medicine to be replaced or equated to those who have essentially went to an on the job technical school and can perform the basics but cant navigate the potholes.

 

[Noyac]

Seems like such a f'ing waste how many hours of studying and abuse endured learning medicine to be replaced or equated to those who have essentially went to an on the job technical school and can perform the basics but cant navigate the potholes.

If you are in this for yourself then the nurse route is the way to go.

If you are in it for the knowledge, the quality of care, the flexibility, and the badgering on SDN then the doctor route is better.

To me the money is the same if you practice long enough as a doc.

 

[dhb]

man how many smack down does one need

 

[lucy07]

Do most folks have a type and screen done before an elective C section? If it comes back with antibodies, do you hold up surgery while waiting for cross matched blood? As a recently graduated attending, I have come across this issue, and the OB's at my hospital have given me a hard time. They prefer to not have a type and screen done, and just use O neg if they get into bleeding. (Which of course they assure me never happens to them!)

 

[Planktonmd]

Do most folks have a type and screen done before an elective C section? If it comes back with antibodies, do you hold up surgery while waiting for cross matched blood? As a recently graduated attending, I have come across this issue, and the OB's at my hospital have given me a hard time. They prefer to not have a type and screen done, and just use O neg if they get into bleeding. (Which of course they assure me never happens to them!)

We don't do type and screen before elective c sections.

 

[jwk]

We don't do type and screen before elective c sections.

We do, but I often wonder why. It seems like a tremendous waste of resources and time. If I had to guess, we transfuse less than 1% of our C-Sections, and the ones that we do are almost always ones that we have concerns about ahead of time, particularly placenta accreta's of some variation or another, which are on the rise because of lots more repeat C-sections. Those get X-matched ahead of time for 4-6 units.

Leaving out the accreta's, I'll bet we don't transfuse 1 in 500.

 

[Gaseous Clay]

I am a Resident and every L&D patient gets a T&S. I've seen a few + Ab screens and we have held up C/S's because of this. The OB staff always go balistic about this. It's funny, one "Attending" went crazy even though she had a prior + Ab screen a few weeks prior in her clinic and did nothing about it. She claimed it was our fault, that we should have started to pre-op and notice this at 5:30 AM so she'd be ready to go for the 7:30 section.

I wonder if the PP answer is to forge ahead and the Academic/Boards answer is to wait for a crossmatch.