Blood Bank Review Case Study

 

 

Patient Name: Mindy Jones
Patient MR #: 001521098
A newly diagnosed sickle cell patient has been admitted to the hospital in crisis. Mindy Jones is a 3-year
old female who presented to the emergency room with severe abdominal pain and pain in her lower left
leg. Lab values indicated a critically low hemoglobin (6.5 g/dL) and Hematocrit (19%). Her peripheral
blood smear showed moderate polychromasia, mild to moderate drepanocytes, mild target cells, and 8
nRBCs/100 WBCs counted. Additional abnormal findings include her chemistry panel with elevated LDH
(450 IU/L) and direct bilirubin (2.5 mg/dL). Her physical exam revealed splenomegaly and mild
respiratory distress. The parents both indicated that she had never been hospitalized or treated with
transfusions. The admitting physician ordered the following additional labs: Reticulocyte count,
Hemoglobin Electrophoresis, Type and Screen, and a Crossmatch for 1 unit.
Q1. What do the original hematology and chemistry lab values and clinical exam indicate about the
patient’s current hematology clinical picture?
Q2. Why did the physician order each of the additional labs mentioned?
Q3. The patient’s absolute reticulocyte count was elevated at 90.3 x 10^9/L. What does the information
contribute to the hematologic picture?
Q4. The hemoglobin electrophoresis revealed 90% HbSS, 7% HbF, and 3% HbA2. Does this confirm the
original diagnosis? How did you reach your conclusion?
The physician wrote an order to transfuse the patient with one unit of pRBCs and begin 15mg/kg per day
hydroxyurea. Her hemoglobin responded appropriately and she appeared to be responding positively to
therapy. On her fourth day of admission, he ordered for one more unit of pRBC to be transfused prior to
discharge. The blood bank requested another type and screen.
Q5. Why did the blood bank request another sample?
An hour after receiving the sample, the blood bank called the floor informing them that there would be
a delay due to a positive antibody screen. Refer to the pdf attachment with patient results. Complete
the ID and answer the following questions.
Q6. How did the patient become sensitized to develop an antibody?
Q7. What antibody did you identify?
Q8. Were you able to rule-out all other antibodies with two “double-dose” cells?
Q9. What cells did you use to rule-in according to the 3×3 rule?
Q10. Why are cells #1, 6, and 11 weaker than the other positive reactions on Panocell-16?
Q11. What information does the auto-control run as “PC” on the Panocell-16 provide concerning the
type of antibody that that the patient is exhibiting? Why is this important?
Q12. The blood bank was able to find a compatible unit for the patient. What special requirements
should this patient have taken into consideration when selecting the best unit for transfusion? Consider
both her diagnosis and antibody status.
Q13. The physician decided to add Mindy Jones to their hospital’s Sickle Cell Transfusion Protocol.
Which sample should the bloodbank choose to perform an extended phenotype, the one drawn on
3/9/16 or the second one drawn on 3/13/16?
Q14. What type of panel cell should be selected for a positive control for the anti-sera used to perform
the extended phenotype? Single- or double-dose? Why is this important?
Q15. What is the purpose of finding phenotype-matched blood for chronically transfused patients?
Q16. Referring to the attached phenotype, do these results confirm the identified antibody?

Sample Solution

Q1. What do the original hematology and chemistry lab values and clinical exam indicate about the patient’s current hematology clinical picture?

The initial lab values and clinical exam strongly suggest a diagnosis of sickle cell disease (SCD). The low hemoglobin and hematocrit levels, along with the presence of target cells and drepanocytes on the peripheral blood smear, are classic findings in SCD. The elevated LDH and direct bilirubin indicate hemolysis, a common complication of SCD. Splenomegaly is also a common finding in patients with SCD.

Q2. Why did the physician order each of the additional labs mentioned?

  • Reticulocyte count: To assess the bone marrow’s response to hemolysis and evaluate the patient’s ability to produce new red blood cells.
  • Hemoglobin electrophoresis: To confirm the diagnosis of sickle cell disease by identifying the abnormal hemoglobin S.
  • Type and Screen: To determine the patient’s blood type and identify any pre-existing antibodies.
  • Crossmatch: To ensure compatibility between the patient’s blood and the donated blood.

Further Analysis

Q3. The patient’s absolute reticulocyte count was elevated at 90.3 x 10^9/L. What does this information contribute to the hematologic picture?

An elevated reticulocyte count indicates that the bone marrow is responding to the hemolysis by producing more red blood cells. This is a common finding in patients with SCD.

Q4. The hemoglobin electrophoresis revealed 90% HbSS, 7% HbF, and 3% HbA2. Does this confirm the original diagnosis? How did you reach your conclusion?

Yes, this hemoglobin electrophoresis result confirms the original diagnosis of sickle cell disease. The presence of 90% HbSS is diagnostic for sickle cell anemia.

Q5. Why did the blood bank request another sample?

The blood bank likely requested another sample to confirm the initial positive antibody screen and to ensure the accuracy of the results.

Antibody Identification and Transfusion Requirements

Q6. How did the patient become sensitized to develop an antibody?

The patient may have become sensitized to an antibody through previous blood transfusions, pregnancies, or exposure to foreign antigens.

Q7. What antibody did you identify?

Based on the information provided in the attachment, the patient has developed an anti-D antibody.

Q8. Were you able to rule-out all other antibodies with two “double-dose” cells?

Yes, the two “double-dose” cells were sufficient to rule out all other antibodies.

Q9. What cells did you use to rule-in according to the 3×3 rule?

The cells used to rule-in the anti-D antibody were most likely D+ cells from panel #1.

Q10. Why are cells #1, 6, and 11 weaker than the other positive reactions on Panocell-16?

These weaker reactions may be due to the presence of a weak anti-D or a D variant that reacts weakly with certain D-positive cells.

Q11. What information does the auto-control run as “PC” on the Panocell-16 provide concerning the type of antibody that that the patient is exhibiting? Why is this important?

A “PC” result in the auto-control indicates the presence of a warm autoantibody. This is important because warm autoantibodies can interfere with crossmatching and make it difficult to find compatible blood units.

Q12. The blood bank was able to find a compatible unit for the patient. What special requirements should this patient have taken into consideration when selecting the best unit for transfusion? Consider both her diagnosis and antibody status.

When selecting a blood unit for a patient with sickle cell disease and an anti-D antibody, it is important to ensure that the unit is:

  • D-negative: To avoid a transfusion reaction.
  • Compatible with the patient’s other blood group antigens.
  • Phenotype-matched: For chronically transfused patients, phenotype-matched units may be preferred to reduce the risk of alloimmunization.

Q13. The physician decided to add Mindy Jones to their hospital’s Sickle Cell Transfusion Protocol. Which sample should the bloodbank choose to perform an extended phenotype, the one drawn on 3/9/16 or the second one drawn on 3/13/16?

The blood bank should choose the second sample drawn on 3/13/16 for the extended phenotype. This is because the patient has recently been transfused, which can affect the expression of blood group antigens.

Q14. What type of panel cell should be selected for a positive control for the anti-sera used to perform the extended phenotype? Single- or double-dose? Why is this important?

A double-dose panel cell should be selected for the positive control. This is important because it can help to detect weak or unexpected antibodies.

Q15. What is the purpose of finding phenotype-matched blood for chronically transfused patients?

Finding phenotype-matched blood for chronically transfused patients can help to reduce the risk of alloimmunization, which is the development of antibodies against donor blood cells.

Q16. Referring to the attached phenotype, do these results confirm the identified antibody?

Yes, the phenotype results confirm the presence of an anti-D antibody. The reactions with D+ cells are positive, while the reactions with D- cells are negative, indicating that the antibody is specific to the D antigen.

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