TRANSFUSION SURPRISES...THE ONES YOU NEVER EXPECT

Allan Dubon, MLS

This is a presentation about transfusion medicine. It is not, in the end, a presentation about antibody identification.

It is about what laboratory professionals do when a result, a history, a patient, a process, a clinical situation, or a body of evidence does not fit the expected answer.

MONDAY

A routine diabetes appointment. A physician who needed a hemoglobin and hematocrit, and asked whether the annual laboratory work had been done yet. It had not, so she ordered the broader panel.

A few hours later she called with bad news. The expectation was an A1C. What she said instead was: your white count is 58,000.

MINE.

“That one almost got away.”

Consistent with B lymphoblastic leukemia/lymphoma

The dangerous cases are not always the ones where nobody knows the answer. Sometimes they are the ones where we think we know enough.

— Michelle Dubon

When something doesn't fit,

go back to the last thing you KNOW is correct.

The phrase belongs to my wife, Michelle Dubon. She used it while I was going through college, and she meant something simple: trust what you have learned, and don't overthink yourself out of the answer you already know is right.

Blood banking gave it a second meaning. When something in an investigation stops making sense, do not force the evidence to fit the conclusion. Stop. Go back to the last thing you know is correct. Then work forward again.

RhD ALLOIMMUNIZATION

Historical risk compared with appropriate RhIG prophylaxis.

These are not exam questions. They are exercises in knowing when an investigation is complete.

Screen positive. Autocontrol negative.

Reactivity tracks with E.

WOULD YOU STOP HERE?

PREMATURE CLOSURE

The cognitive error here is premature closure: the investigation ends at the first interpretation that explains the reactions, rather than at the point where clinically significant alternatives have been appropriately addressed.

Stronger reactions with homozygous antigen expression.

Weak or nonreactive heterozygous cells.

WHAT DO YOU NOTICE?

GO WITH WHAT YOU KNOW.

“Sometimes the most important result in today's workup was performed four years ago.”

THE HISTORY ALMOST GOT AWAY.

Historical clinically significant antibodies remain important even when current serologic reactivity has weakened or disappeared.

WHAT DO YOU WANT NEXT?

WARM AUTOANTIBODY? ARE WE DONE?

IS THAT ACTUALLY WHAT WE'RE LOOKING FOR?

Current transfusion-medicine guidance discourages searching among serologically incompatible units for the one with the weakest reaction simply in order to label it “least incompatible.”

“The way I learned to say this isn't necessarily the way we should say it today.”

WHAT AM I MISSING?

GO WITH WHAT YOU KNOW.

MASSIVE TRANSFUSION PROTOCOL ACTIVATED

Level I trauma · Active hemorrhage · No completed type and screen · Reliable history unavailable

B. Initiate the facility’s emergency-release/MTP process while compatibility testing continues concurrently.

NOT THE ABSENCE OF ONE.

SPEED DOESN'T REPLACE PROCESS.

GOOD PROCESS CREATES SAFE SPEED.

THEY WERE LOOKING AT A DYING HUMAN BEING.

I WAS LOOKING AT IDENTITY, COMPATIBILITY, TESTING, AND AVAILABLE PRODUCTS.

THE SAFEST ANSWER REQUIRED BOTH OF US.

Once an unlabeled specimen leaves the patient's side, the laboratory cannot scientifically reconstruct patient identity from the blood inside it.

THE RESULT CAN BE PERFECTLY ACCURATE

AND STILL BELONG TO THE WRONG PATIENT.

At my former facility, a dedicated blood-bank identification band was part of the transfusion identification process.

IDENTITY ISN'T ADMINISTRATIVE.

IT IS PART OF COMPATIBILITY.

BOTH SIDES NEED A DIFFERENT QUESTION.

WHAT CAN SAFELY HAPPEN RIGHT NOW?

What still needs to happen next?

NONE OF THESE ARE ANTIBODIES.

ALL OF THEM CAN HURT A PATIENT.

WLBT / Gray Media / WXIX · August 6, 2026

WLBT / GRAY MEDIA / WXIX · AUGUST 6, 2026

WHAT’S WRONG WITH THIS STORY?

WE DO NOT HAVE ENOUGH INFORMATION.

O-negative tells us: ABO group O · RhD-negative

It does NOT tell us the donor unit’s K antigen status.

MAYBE SOMEBODY MEANT K-NEGATIVE.

MAYBE “UNSCREENED” MEANT ANTIGEN STATUS HAD NOT BEEN CONFIRMED.

MAYBE IT WAS EMERGENCY RELEASE.

MAYBE IS NOT DATA.

When a story does not make sense, do not repair the missing clinical story in your own head.

GO WITH WHAT YOU KNOW.

IS THE EVIDENCE?

HEMODYNAMICALLY STABLE ADULT

TRANSFUSE?

2023 AABB RBC GUIDELINE

For most hemodynamically stable hospitalized adults, the guideline recommends a restrictive transfusion strategy, considering RBC transfusion when hemoglobin is below 7 g/dL.

AT 8.4 g/dL:

THE GUIDELINE THRESHOLD ALONE WOULD NOT INDICATE RBC TRANSFUSION.

ACUTE MYOCARDIAL INFARCTION

NOW?

The number did not change. Only the clinical context changed.

2025 AABB AMI GUIDELINE

For hospitalized patients with acute myocardial infarction, the panel suggests a liberal RBC transfusion strategy when hemoglobin is below 10 g/dL.

Conditional recommendation · Low-certainty evidence

AT 8.4 g/dL:

THIS PATIENT FALLS WITHIN THE RANGE WHERE THE AMI GUIDELINE SUGGESTS A LIBERAL TRANSFUSION STRATEGY.

SAME HEMOGLOBIN.

DIFFERENT CLINICAL CONTEXT.

THE NUMBER DIDN'T CHANGE.

THE PATIENT DID.

THAT'S THE WRONG QUESTION.

FOR WHOM?

IN WHAT CLINICAL CONTEXT?

BASED ON WHAT EVIDENCE?

EVIDENCE DOESN’T INTERPRET ITSELF.

A RECOMMENDATION IS NOT JUST A NUMBER.

The 2023 recommendation was built for general hospitalized adults. The 2025 recommendation was built for patients with acute myocardial infarction — a different population, a different body of evidence, and a different certainty.

This is not a failure of science. It is part of responsible evidence evaluation.

THE CONTEXT GIVES IT MEANING.

GO WITH WHAT YOU KNOW.

Know the population.

Know the recommendation.

Know the certainty.

Know the patient in front of you.

Scientists distinguish observation from interpretation.

PLATELETS · SCHEDULED FOR LUMBAR PUNCTURE

TRANSFUSE?

2025 AABB / ICTMG GUIDELINE

Lumbar puncture

Strong recommendation

High/moderate-certainty evidence

AT 18,000 /µL:

YES — THE GUIDELINE RECOMMENDS PROPHYLACTIC PLATELET TRANSFUSION.

SAME PATIENT · SAME PROCEDURE

NOW?

SAME PATIENT · SAME PROCEDURE

THE GUIDELINE THRESHOLD ALONE WOULD NOT INDICATE PROPHYLACTIC TRANSFUSION.

BUT THAT IS NOT THE REAL LESSON.

THE REAL QUESTION IS NOT:

“WHAT IS THE PLATELET THRESHOLD?”

THAT'S THE WRONG QUESTION.

THRESHOLD FOR WHOM?

DOING WHAT?

AND WHY?

THE PATIENT PROVIDES THE CONTEXT.

GO WITH WHAT YOU KNOW.

Know the recommendation.

Know the procedure.

Know the patient.

Know what the evidence actually applies to.

DON'T LET THE FIRST ANSWER END THE INVESTIGATION.

DO I KNOW ENOUGH YET?

“I'd spent my career understanding transfusion as a laboratorian. Then I became the patient.”

THE NUMBER ISN'T THE PATIENT.

THE GUIDELINE ISN'T THE PATIENT.

They're tools we use to take care of one.

MONDAY

WHAT IF SHE HAD ONLY ORDERED THE H&H?

WHAT AM I MISSING?

— Michelle Dubon

When something doesn't fit,

go back to the last thing you KNOW is correct.

WHO NEVER GET SURPRISED.

THEY'RE THE PEOPLE WHO KNOW WHAT TO DO

WHEN THEY ARE.

A result that didn't fit.

A history that changed everything.

A process that failed.

A case you still remember.