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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG.

| HSVF
Pretransfusion Testing
- A series of serologic and nonserologic protocols Clerical error
- Testing procedures w/ the ultimate objective of preventing an - Is the greatest threat to safe transfusion therapy
immune mediated hemolytic transfusion rxn - Most common cause of error is misidentification of the
recipient
TESTING STANDARDS - Examples include
Transfused RBCs o Misidentification of the recipient when the blood
- Should have an acceptable survival rate sample is drawn
- There shouldn’t be significant destruction of the recipient’s o Mix-up of samples during handling in the laboratory
own RBCs o Misidentification of the recipient when the
- TABLE 10–1 steps in pretransfusion testing and associated transfusion is given
AABB standards from the AABB’s Technical Manual, 16th
edition

Pretransfusion testing Must be established and utilized by all staff responsible for each aspect
- Cannot guarantee normal survival of transfused RBCs in the of transfusion therapy
recipient’s circulation - Exact procedures for proper identification of the recipient
- Recipient sample
Clinical Laboratory Improvement Amendments of 1988 (CLIA ‘88) - Donor unit
- Gives the US federal gov’t authority to regulate pretransfusion
testing To prevent collecting samples from wrong px
- Testing regulated via CLIA ‘88 includes - A facility-generated recipient ID wristband must always be
o ABO group compared w/ the blood requisition form (blood request form)
o Rh type
o Antibody detection and identification Blood request form must state
o Crossmatch testing - Recipient’s full name
- Unique hospital identification number
Identification, Collection, and Preparation of Samples
Used to further verify px identity but is not required on the form
- Age
Pretransfusion testing
- Date of birth
- Begins and ends w/ the proper identification and collection of
- Address
the px sample
- Sex
- Those responsible for identifying the px and collecting
- Name of requesting physician
recipient blood
o Must adhere to the strict standards set forth to
Printing must be legible, and indelible nameplate impressions or
ensure recipient safety and acceptable survival rates
computer printouts are preferable to handwritten forms.
Positive Recipient Identification
Discrepancies must be completely resolved before the sample is taken.
Major cause of transfusion-associated fatalities is
- Clerical error resulting in incorrect ABO groupings
- Transfusion of ABO incompatible blood

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
Nameplates on the wall or bed labels Transfusion services are using plasma today due to the ease of handling
- Never be used to verify identity, as the px specified may no - 10 mL of blood
longer occupy that bed o Sufficient for all testing procedures if there are no
known serologic problems
If the px does not have a wristband or if the px identity is unknown Tubes
- Some form of positive identification must be attached to the - Must be labeled before they leave the recipient’s bedside
px before collecting the samples - If imprinted labels are used, they must be compared w/ the
o Temporary tie tag recipient’s wristband and requisition form before the tubes
o Wristband are used
o Ankle band
 It should not be removed until proper Labels
identification has been attached to the px - Must be attached to the tubes at the bedside in a tamper-
and the person collecting the recipient proof manner that will make removal and reattachment
sample verifies identity impossible
- All writing must be legible and indelible, and each tube must
Some transfusion facilities be labeled with the px
- If the px does not have a wristband and is coherent, o Full name
o It is permissible to ask the px to state his or her full o Unique identification number
name and to spell it out o Date of sample collection
- If the date of birth or home address is printed on the - Phlebotomist must initial or sign the label and add additional
requisition form pertinent information as required by the facility’s SOP
o Px might be asked to state this information
To avoid contamination w/ materials that may cause confusing serologic
Occasional errors can result from two px w/ the same name being results
mistaken for each other - Blood samples should not be taken from intravenous (IV)
- Phlebotomist should never tubing lines
o Offer a name - Venous samples are to be drawn only from below the infusion
o Ask the px to confirm that it is correct site, not above it
- For example, if a px has an IV line in the antecubital area of the
Commercially manufactured identification systems using preprinted tags arm, any vein below the angle of the arm to the hand can be
and numbers (Figs. 10–1, 10–2, and 10–3) used
- Useful in verifying px and donors - If a sample must be taken from an IV line
- Emerging systems include o The line should be disconnected for 5 to 10 minutes
o Bar-code readers o The first 10 mL of blood drawn should be discarded,
o Radio frequency identification (RFID) and then the sample should be obtained
- Whatever procedure is adopted, it must be an integral part of
the blood bank’s standard operating procedure (SOP) manual, When a specimen is received in the laboratory
thus resulting in the requirement that all blood bank - Blood bank personnel must confirm that the information on
personnel demonstrate competency in the process the sample and requisition form agree
- All discrepancies must be resolved before the sample is
Collection of Patient Samples accepted
Collection of Patient Samples - If any doubt exists, a new sample must be drawn
- After positive identification has been made, blood samples - Receipt of an unlabeled specimen requires that a new sample
should be drawn, carefully using a technique that avoids be obtained
hemolyzing the sample
Recipient samples
In vitro hemolysis of recipient samples for pretransfusion testing - Should be tested as soon as possible after collection
- Cannot be used because it can mask hemolysis caused by
antigen–antibody complexes that activate complement to If using a serum sample, the recipient serum
completion - Should be separated from the RBCs as soon as possible after
the sample has clotted
Px experiencing in vivo hemolytic processes (such as hemolytic anemia)
- Hemolysis occurs in the px prior to collection and cannot be If testing cannot be performed immediately
avoided - Samples should be kept at 1°C to 6°C

Serum or plasma Recent pregnancy or transfusion


- Used for pretransfusion testing - Indicates an opportunity for a humoral immune response

Disadvantages to using plasma include Specimens used in pretransfusion testing


- Formation of small fibrin clots, which may be difficult to - Should ideally be collected during the critical phases of the
distinguish from true agglutination immune response
- Also, plasma anticoagulants may inactivate complement so o In an attempt to capture this important time for
that some antibodies may not be detected each px

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
o Serum obtained from samples fewer than 72 hours Commercially manufactured segment puncture devices
after collection must be used for antibody screening - Eliminate the need for scissors and lancets
and - Enabling the dispensing of the RBCs into a test tube in one
o Crossmatch testing motion
 If the px was pregnant - Segment
 Received RBC products by transfusion w/in o May be stored w/ the cut end down in a properly
the last 3 months labeled test tube
 If these histories are unknown o Covered or stoppered to minimize contamination
o Maintain RBC integrity
Px RBCs - Contents of the segment should not be emptied into a test
- Obtained from either tube for storage because of the increased risk of
o Clotted contamination
o Anticoagulated samples - It is important that engineering or work practice controls be
- Washed w/ physiological saline before use to remove plasma used to eliminate or minimize aerosol production when the
or serum, which may interfere w/ some testing procedures segment is cut or opened
- 2% to 5% saline suspension of RBCs is used for most serologic
testing procedures Refer to Chapter 25, “Transfusion Safety and Federal Regulatory
Requirements” for additional information on procedures.
Collection of Donor Samples
Collection of Donor Samples Both donor and recipient samples
- Samples for donor testing must be collected at the same time - Must be stored for a minimum of 7 days following transfusion
as the full donor unit - Samples should be
- Depending on the method used for testing, clotted or o Stoppered
anticoagulated pilot samples are obtained o Carefully labeled
o Refrigerated at 1°C to 6°C
Must be labeled w/ the same unique number before starting the - Should be adequate in vol so they can be reevaluated if the px
phlebotomy, and the numbers must be verified again immediately after experiences any adverse rxn to the transfusion
collection
- Donor information COMPATIBILITY TESTING PROTOCOLS
- Medical history card
- Pilot samples for processing Compatibility testing
- Collection bag - Refers to the serologic aspect of pretransfusion testing.
Donor unit identification number - Includes every serologic facet, beginning w/ donor blood and
- Used to identify all records of testing and eventual disposition ending w/ the recipient blood sample
of all component parts of the unit of blood.
Testing the Donor Sample
More detailed information on donor samples can be found in Chapter According to Code of Federal Regulations and the AABB Standards for
13, “Donor Screening and Component Preparation.” Blood Banks and Transfusion Services
- ABO grouping
RBCs for donor pretransfusion testing - Rh typing (including a test for weak D)
- Prepared from the segmented tubing through which the donor - Tests intended to prevent disease transmission
blood was collected o Must be performed on a sample of donor blood
o The tubing or segment is attached to the collection taken at the time of collection
bag AABB Standards
o Each segment is imprinted with the same number - Requires a screening test for unexpected antibodies to RBC
 These numbers are different from the antigens on samples from donors who have a history of
donor unit identification number transfusion or pregnancy
- Testing is performed by the facility collecting the donor unit,
Donor RBCs and results must be clearly indicated on all product labels
- Obtained from the segments in many ways that permit several appearing on the unit
procedures to be performed from the same segment - Requires that the transfusing facility confirm the ABO cell
grouping on all units and Rh typing on units labeled Rh-
One technique that works well for sampling negative
- Is using a lancet to make a tiny hole in the segment through - Repeat weak-D testing is not required.
which a single drop of blood can be expressed and then - Transfusing facility is not required to repeat any other testing
disposing the lancet in a biohazard sharps container procedure on donor blood
- The hole is essentially self-sealing, so the rest of the blood in - Sample used for this testing must be obtained from an
the segment remains uncontaminated attached segment on the donor unit
Another technique All testing must be performed
- Is to cut the RBC end of the segment tubing w/ scissors and - Using in-date licensed rgnts according to manufacturers’
use an applicator stick to remove cells or squeeze the tubing directions and
to express a drop - Protocol established in the facility’s written SOP

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
Testing the Patient Sample o DAT should be performed on the px RBCs to
Testing the Patient Sample determine whether uptake of autoantibodies or
- A record must be maintained of all results obtained in testing alloantibodies (if the recipient has been recently
px samples transfused) is responsible for the positive control
- Same unique identification number should be assigned each o If DAT is positive, accurate Rh typing can sometimes
time a px is admitted to a health-care facility for treatment be performed using
- The number used as a method for positive identification by  Saline-active or
comparing results of previous and current testing  Chemically modified Rh blood typing
- Before transfusion is initiated serum w/ an appropriate diluent or
o Any discrepancies between previous and current  8% albumin control
results must be resolved o If the Rh type of the recipient cannot be determined
- New sample should be collected from the px, if necessary, to and transfusion is essential
resolve the problem  Rh-negative blood should be given

Should be included in the record Monoclonal or monoclonal blend anti-D reagents


- ABO, Rh, and unexpected antibody screening test results - Are RT–reactive
- Notations concerning unusual serologic rxn - Don’t require the use of a control
- The identity of unexpected antibodies in the px serum
o Most important information. Test for weak D
o Sometimes unexpected antibody can drop below - Unnecessary when testing transfusion recipients
detectable levels in a px serum, and previous records - Individuals typing as Rh-negative in direct testing should
are the only source of information regarding its receive Rh-negative blood
presence, identity, and clinical significance - Those typing as Rh-positive in direct testing should receive Rh-
positive blood
ABO, Rh grouping, and antibody screening of the px serum - Female px whose RBCs type as weak D are considered
- Can be performed in advance or at the same time as the o Rh-positive
crossmatch. o May receive Rh-positive blood during transfusion

Sample must be obtained from the px w/in 3 days of the scheduled Antibody Screening
transfusion Recipient’s serum or plasma
- If the px has had a transfusion - Must be tested for clinically significant unexpected antibodies
- Has been pregnant w/in the last 3 months
- If the history is unavailable or uncertain Antibody screening test
- To detect as many clinically significant unexpected antibodies
An accurate medical history, including the ff, may help to explain as possible
unusual results
- Information on medications “Clinically significant unexpected antibody”
- Recent blood transfusions - Refers to antibodies that are reactive at 37°C or in the
- Previous pregnancies antihuman globulin test
- Known to have caused a transfusion rxn or unacceptably short
I. ABO Grouping survival of transfused RBCs
ABO Grouping TABLE 10–2
- Most critical pretransfusion serologic test
- Can be performed on slides or in tubes Incidence of unexpected alloantibodies depends on the fact that
o Using solid-phase RBC adherence or - Antibody formation
o Column gel technology o Is the result of exposure to a foreign RBC antigen
- If ABO forward and reverse grouping results don’t agree, and the px ability to respond to that exposure
additional testing must be conducted to resolve the o Occurs by
discrepancy  allogeneic transfusion of RBCs
- If the px ABO group can’t be satisfactorily determined and  pregnancy
immediate transfusion is required, group O–packed RBCs  transplantation
should be used
The more frequently a px is exposed to foreign RBC antigens, the more
II. Rh Typing likely that px will produce unexpected alloantibodies
Rh Typing - This is evidenced by a study of multiply transfused sickle cell
- Performed using anti-D blood typing rgnts px in which 29% of pediatric and 47% of adult px developed
- Tube or slide tests should be performed according to the clinically significant alloantibodies
manufacturer’s directions for the rgnt,
o Include the use of a suitable diluent control Detection of unexpected antibodies
- When indicated, these controls must be run in parallel when - Is important for
Rh typing tests are performed on px samples to avoid o The selection of donor RBCs that will have the best
incorrectly designating Rh-negative px as Rh-positive survival rate in the px circulation
- If the diluent control is positive, the result of the Rh typing test o Reduce the risk of hemolytic transfusion rxn
is invalid

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
Antibody screening tests
- Should demonstrate the presence of all potentially clinically
significant alloantibodies in the recipient’s serum or plasma
- All antibodies encountered in the screening test must be
identified
o To determine potential clinical significance
o To decide whether there is need to select antigen-(-) Rh-negative blood
units for transfusion  can be given to Rh-positive patients
 near expiration
o unit should be given rather than wasted
Rh-positive blood
 should not be given to Rh-negative female patients of
childbearing age
Transfusion of Rh-negative male patients and female patients beyond
menopause with Rh-positive blood
 acceptable as long as no preformed anti-D is demonstrable in
their sera
80% of Rh-negative patients who receive 200 mL or more of Rhpositive
blood
 produces anti-D
 formation of anti-D: unlikely to be of great significance
o Ex: in an Rh-negative elderly surgical patient
o use of Rh-positive blood is judicious
o approval by or notification of the blood bank’s
medical director is necessary

antibody screening test: unexpected antibody is found in the patient’s


serum
 donor units selected at random are crossmatched with the
patient’s serum
o include
 incubation at 37°C
Selection of Appropriate Donor Units  AHG test
ABO group–specific clinically significant antibody is identified
 first choice for transfusion  Serologically compatible units: phenotyped with commercial
 Blood and blood components of the patient’s own ABO and Rh antiserum
group o to verify that they are ag-negative for the
 If not available corresponding ab
o units selected must lack any antigen against which o Ex: recipient has anti-K1 antibody
the recipient has a clinically significant antibody  crossmatch-compatible donor RBC unit:
o completely acceptable to use : bld and bld tested with commercial anti-K1 antisera for
components that do not contain all of the antigens the presence of the K1 antigen
carried on the patient’s own RBCs
 Ex: group A– or B–packed RBCs no need to provide antigen-negative RBCs
 can be safely given to a group AB  for patients whose sera contain antibodies that are reactive
recipient only below 37°C
o because these antibodies are incapable of causing
recipient: must be given blood of a diff ABO group significant RBC destruction in vivo.
 packed RBCs: only given Potent exs of IgG, warm reactive abs in patients’ serum
 Whole blood: cannot be administered  can also be used to select suitable donor units
o bec incompatible, preformed ABO antibodies are o by direct crossmatch testing
present in the WB plasma Commercially prepared typing reagents
 Ex: group A whole blood cannot be  used to select blood for patients whose
transfused into a group AB recipient o serum contains weak examples of antibodies active at
 plasma of the group A WB has 37°C
anti-B abs present o antibodies react well only with panel cells carrying
Group O packed RBCs homozygous expression of the corresponding
 can be safely used for all patients antigens
 conservation of a limited supply of group O blood  used for patients whose serum no longer exhibits demonstrable
o should dictate its use for recipients of other ABO in vitro reactivity
types only in special circumstances o but that previously was known to contain clinically
ABO group–specific blood: not available or low supply significant IgG antibodies such as
 alternative blood groups are chosen  anti-Jka
 anti-K1
 anti-E
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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
Donor units
 should be selected so that the RBCs are of Serologic Crossmatch Tests
o appropriate age for the patient’s needs  consists of mixing the recipient’s serum with donor RBCs
o will not expire before use  Several procedures used
For efficient inventory management o Immediate spin
 units that will be transfused o antiglobulin crossmatch
o selected from units close to their expiration date  objective
Before compatibility testing o to select donor units that can provide maximal benefit to
 donor units should be examined visually for the patient
o unusual appearance  categorized by the test phase in which the procedure ends
o correct labeling
o hermetic seal integrity Immediate Spin Crossmatch
 Donor units showing the ff should be returned to collecting Immediate Spin Crossmatch
facility
 accomplished by mixing the recipient’s serum with donor RBCs and
o Abnormal color centrifuging immediately
o Turbidity o When
o Clots  no clinically significant unexpected antibodies
o incomplete or improper labeling info are detected
o leakage of any sort  no previous records of such antibodies
 serologic test to detect ABO incompatibility
Crossmatch Testing  Absence of hemolysis or agglutination
Crossmatch Testing o indicates ABO compatibility
 testing of the patient’s serum with the donor RBCs,
o including type-and-screen procedure
 antiglobulin phase  involves testing the patient’s blood sample for
 immediate spin phase o ABO
 to confirm ABO compatibility o Rh
terms: compatibility test and crossmatch o clinically significant unexpected antibodies
 sometimes used interchangeably  patient sample
 crossmatch o storage: blood bank refrigerator
o only one part of pretransfusion testing  for future crossmatch
o Table 10–1  application
o patients undergoing many elective procedures who
serologic crossmatch may need blood
 preceded antibody screening as part of pretransfusion abbreviated crossmatch
compatibility testing  type and screen + immediate spin crossmatch
 check unexpected alloantibodies  safe and effective method of pretransfusion testing
99% of clinically significant unexpected antibodies  99.9% effective in preventing occurrence of an incompatible
 detected by adequate ab screening procedures transfusion
 others abbreviate or even eliminate the serologic crossmatch Walker
2 main functions of serologic crossmatch test can be cited:  frequency with which an incompatible antiglobulin crossmatch
o final check of ABO compatibility bet donor and px follows a negative screen is very low
o detect the presence of an antibody in the patient’s serum o 0.06%
 that will react with ags on the donor RBCs
 that was not detected in antibody screening immediate spin
 bec the corresponding antigen was lacking  does not detect all ABO incompatibilities
from the screening cells  False reactions may be seen in the ff
o presence of other immediate spin-reactive antibodies
current AABB Standards  Ex: autoanti-I
 state that tests to detect ABO incompatibility are sufficient o patients with hyperimmune ABO antibodies
o if no clinically significant antibodies were detected in o when the procedure is not performed correctly
the antibody screening process  Ex: delay in centri or reading
o if no historical record exists of clinically significant o when rouleaux is observed
unexpected antibodies being detected o when infants’ specimens are tested
Elimination of advanced crossmatch testing  Adding EDTA to the test system
 for patients undergoing surgical procedures o eliminates some of the false-positive reactions
o in which blood is unlikely to be used o improving the sensitivity of IS
 implemented successfully in many facilities
 accomplished by using the “type and screen” Antiglobulin Crossmatch
o in conjunction with the maximum surgical blood Antiglobulin Crossmatch
order schedule (MSBOS) approach or the abbreviated  begins in the same manner as: IS crossmatch
crossmatch  continues to a 37°C incubation
 leads to the next generation of crossmatch decisions  finishes with an antiglobulin test
o computer crossmatch  enhancement media
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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
o applied to boost antigen-antibody reactions  Color Plate on red cell antigen-antibody reactions: front of the
o include: book
 albumin
 low ionic strength solution (LISS) Code of Federal Regulations
 polyethylene glycol  all results: recorded immediately in a permanent ledger by
 polybrene means of a logical system
 All work: signed or initialed by the technologist performing the
 antihuman globulin (AHG) reagent test
o containing
 anti-IgG Resolution of Incompatibilities in the Serologic Crossmatch
 anticomplement primary objective of the crossmatch test
o selected for the final phase of xmatch method  detect the presence of antibodies in the recipient’s serum
o used for greatest sensitivity o including: anti-A and anti-B
o monospecific anti-IgG AHG reagents  could destroy transfused RBCs
 used routinely by many laboratories positive result in the crossmatch test
 requires explanation
autocontrol  recipient: should not receive a transfusion until the cause of the
 consisting of the patient’s own cells and serum incompatibility has been determined
 may be tested in parallel with the crossmatch test  results of the autocontrol and antibody screening test: should
 current AABB Standards be reviewed to identify patterns that may help determine the
o no longer requires an autocontrol cause of the problem
 Perkins
o Calculated the predictive value of a positive Causes of Positive Results in the Serologic Crossmatch
autocontrol (3.6%) when the antibody screen was
positive result in the serologic crossmatch test may be caused by any of
negative
the following:
o decided to continue using the autocontrol in
pretransfusion testing
I. Incorrect ABO grouping of the patient or donor
ABO grouping
 should be immediately repeated
Interpretation of Results
o if strong incompatibility is observed in a reading taken
Tubes (gel cards, etc.) after immediate spin
 carefully labeled  should be used for retesting
o so contents can be identified at any stage of the o Samples that bear undisputable identity with the
procedure original patient sample
 centrifuged o donor bag
o supernatant: examined for hemolysis
 if present: positive result II. An alloantibody in the patient’s serum reacting with the
 Results corresponding antigen on donor RBCs
o read against a white or lighted background autocontrol tube
o magnifying mirror or hand lens  negative
 can be used to facilitate reading o unless the patient has been recently transfused with
 button of RBCs incompatible RBCs
o gently resuspended antibody screening test: positive
o ideal mtd of resuspension: “tilt and wiggle”  antibody identification panel studies
 initial tilt o allow identification of antibody specificity
o when clear supernatant sweeps over the button of o permits selection of units lacking the antigens for
RBCs compatibility testing
o indicates a positive or negative reaction
 positive agglutination reaction  RBCs of all donors tested
o jagged or firm button edge  incompatible with the patient’s serum
 negative reaction  antibody screening test: positive
o smooth swirling of free cells off the RBC button o suspect either
 antibody directed against an antigen
Violent or excessive shaking or tapping of the tubes of high incidence
 yield false-negative results  multiple antibodies in the patient’s
o bec weak reactions or fragile agglutinates serum
 may be shaken loose  unable to identify the specificity
 misread as negative  Consult a reference laboratory
Patient: has ABO-compatible siblings
button has been completely resuspended  siblings
 contents of the tube: interpreted o may lack the antigen(s) to which the patient has been
 positive results: graded according to a scale sensitized
 Results: examined microscopically for verification o may be excellent potential donors in an emergency

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
 antibody in the patient’s serum may be directed against an antigen  Strong rouleaux
of relatively low incidence that is present on that donor’s RBCs  may mimic true agglutination
 If  strongest after 37°C incubation
 antibody screening test: negative  do not persist through washing before
 only one donor unit: incompatible the AHG test

 antibody screening test: negative  presence of high-molecular-weight dextrans or other plasma


 patient’s serum may contain either expanders
 naturally occurring (e.g., anti-A1)  cause false-positive results in pretransfusion testing
 passively acquired ABO agglutinins  Bartholomew
 doubt that the use of dextran interferes with
Passive acquisition of anti-A, anti-B, or anti-A,B pretransfusion testing
 may occur  plasma expanders: interfere
o after transfusion of non-ABO-specific blood products  all tests: including the autocontrol
(e.g.,platelets)  affected equally
o after organ (e.g., liver) or bone marrow  Saline replacement
transplantation  useful to resolve the problem
 antibody against additives in the albumin reagents
helpful when investigating these cases  cause false-positive results: compatibility tests
 Checking the serum grouping result patient’s serum reacts against the albumin in testing rgts
o to confirm the presence of an unexpected reaction  rare
with A1 cells  occurs when patient has antibodies to the stabilizing
 checking the patient’s transfusion and transplant histories substances
o such as caprylate
III. An autoantibody in the patient’s serum reacting with the o added to the albumin reagents
corresponding antigen on donor RBCs o caprylate-free albumin solutions
autocontrol tube  should be used in testing
 positive
o antibody screening test
o tests of the patient’s serum with donor cells
Most autoantibodies
 have specificity for antigens of relatively high incidence
Panel adsorption and elution studies
 important to assess whether underlying alloantibodies are also
present
Techniques for management of patients with autoantibodies
 include: autoadsorption of the patient’s serum
o to remove autoantibody activity.
Compatibility testing
 could be performed using the autoabsorbed serum

IV. Prior coating of the donor RBCs with protein,


Resulting in positive AHG test
If one isolated positive
 result is obtained
 DAT: should be performed on the donor’s RBCs

Donor cells: positive DAT


 incompatible w/ all recipients tested in AHG phase
o bec the cells are already coated with immunoglobulin
or complement

V. Abnormalities in the patient’s serum


 Imbalance of the normal ratio of albumin and gamma globulin (A/G VI. Contaminants in the test system
ratio) produce false-positive compatibility test results
o Dirty glassware
 in diseases such as
o Bacterial contamination of samples
 multiple myeloma
o chemical or other contaminants in saline
 macroglobulinemia
o fibrin clots
 cause RBCs to stick together on their flat sides
 mic appearance: stacks of coins
 called rouleaux formation
 affect all tests: including autocontrol

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
Computer Crossmatch AABB Standards
Computer Crossmatch  specifies that the computer crossmatch can be used only for the
 reported by Judd purpose of detecting an ABO incompatibility between the
 electronic (computer) crossmatch donor unit and the recipient sample that was submitted for
 detection of ABO incompatibilities was as safe as the serologic pretransfusion testing
immediate spin test  Current testing for unexpected antibodies
 safer than the immediate spin o must be nonreactive
o bec of the integrity of the computer software to detect o must not be any history of such antibodies
ABO incompatibility between  at least two concordant patient ABO/Rh types
 sample submitted for pretransfusion testing o must be on file or the computer crossmatch is not
 donor unit permissible
 compares recent ABO serologic results and interpretations on file for
both the donor and the recipient being matched PRETRANSFUSION TESTING IN SPECIAL CIRCUMSTANCES
 determines compatibility based on this comparison
 Butch and colleagues Emergencies
o provide an excellent model of the computer crossmatch Blood component
SOP  needs sometimes exceed pre-transfusion testing requirements
 “Computer Crossmatch” (Electronic Based Testing for the recipient
Compatibility between the Donor’s Cell Type and the Recipient’s  may require transfusion of RBC components prior to
Serum or Plasma Type) Draft Guidance, CBER June 2007: also helpful completion of pre-transfusion testing
 Additional benefits include
o annual savings several approaches:
o reduced sample requirements  use an “emergency” pre-transfusion testing procedure
o reduced handling of biological materials o employs shortened incubation time
o elimination of false reactions assoc with the immediate  often w/ addition of LISS
spin crossmatch  to accelerate Ag-Ab reactions
 compilation of the College of American Pathologists’ interlaboratory
comparison program survey data  maintains regular procedures
o indicates: 2004, only 2.1% of labs participating in the CAP o should be used in all circumstances blood should be
survey use a computer crossmatch issued before completing standard pre-transfusion
testing procedure, if necessary
o They believe:
 there is greater danger in using unfamiliar
procedure under pressure than in releasing
blood w/o completed testing
ideal compromise
 to develop regular testing procedures
o that are most efficient so that can be used in
emergency & routine situations

protocol for handling emergencies


 must be decided in advance of situation & be familiar to all
staff in transfusion service

Adequate pre-transfusion samples


 should be collected before transfusion of any donor blood

If blood must be issued in emergency


 patient’s ABO & Rh group
o should be determined so that ABO group-specific
blood can be given
In extreme emergencies
 when there is no time to obtain & test pre-transfusion sample
o used: group O Rh-(-) packed RBC
 If Px is Rh-(-) & large amounts of blood are likely to be needed
o decision should be made rapidly
 whether inventory allows & the situation
demands transfusion of Rh-(-) blood
Conversion to Rh-(+)
 best made immediately if Px is man or woman beyond child-
bearing age (old)

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
Injections of RhIg Intrauterine Transfusions
 prevent formation of anti-D Blood for intrauterine transfusion
o sometimes appropriate after the crisis has been  must be compatible w/ maternal Ab capable of crossing
resolved placenta

conspicuous tie tag or label If ABO & Rh groups of fetus have been determined
 must be placed on each unit  group-specific blood
o indicates compatibility testing was not completed o could be given if no fetomaternal ABO or Rh
before release of unit incompatibility

 physician If ABO & Rh groups of fetus are not known


o must sign a waiver authorizing & accepting  group O Rh-(-) RBCs
responsibility for using blood products prior to o should be selected for intrauterine transfusion
completion of pre-transfusion testing o must lack any antigens against w/c mother’s serum
o according to: Code of Federal Regulations contains unexpected Ab
 (e.g., anti-K1, anti-Jka)
Subsequent pre-transfusion testing
 should be completed according to chosen protocol Crossmatch testing
any incompatible result  performed using mother’s serum sample
 should be reported immediately to:
o recipient’s physician Neonatal Transfusions
o BB medical director Blood for exchange or regular transfusion of neonate (<4 months)
 should be:
Transfusion of Non-Group-Specific Blood o compatible w/ any maternal Ab that have entered the
When donor units of ABO group other than recipient’s own type have infant’s circulation
been transfused o reactive at 37°C or AHG
 Example: giving group A recipient large volumes of group O Blood of infant’s ABO & Rh group
RBCs  can be used, as long as the ABO and Rh groups are not involved
 testing recipient’s serum in freshly drawn sample for presence in fetomaternal incompatibility
of unexpected anti-A or anti-B
o performed prior to giving any additional RBC initial pretransfusion specimen from infant
transfusions  typed for ABO and Rh groups
o only anti-A & anti-B reagents
When serum from freshly drawn sample is compatible w/ donor RBCs of  required for ABO grouping
recipient’s own ABO group,  omitting the testing of infant’s serum w/
 ABO group–specific blood may be given for transfusion reagent RBCs
Antibody detection testing
If the serologic crossmatch reveals incompatibility  performed using:
 additional transfusions should be of alternative blood group o maternal serum
 example: if group B patient has been given large number of o infant’s serum (e.g., cord serum)
units of group O packed RBC o eluate prepared from infant’s RBCs
 anti-B
o present in adequate amounts when cells selected for transfusion are not group O
 result in (+) reaction in immediate spin (IS)  infant’s serum or plasma
crossmatch o tested to demonstrate absence of anti-A & anti-B
 Group O units  using A1 cells
o should be used instead, for any additional  testing must include:
transfusions o AHG phase

Compatibility Testing for Transfusion of Plasma Products unnecessary to repeat these pretransfusion tests during any one
Compatibility testing procedures hospital admission
 not required for transfusion of plasma products  provided that infant received only ABO/Rh-compatible
 but, transfusion of large volumes of plasma & plasma products transfusions & no unexpected Ab in serum or plasma
o crossmatch test between donor plasma & patient  presence of clinically significant Ab
RBCs o including:
 may be performed  anti-A
 current Standards: does not  anti-B
require crossmatch test o indicates that cells lacking corresponding Ag
 primary purpose for testing o must be selected for transfusion until Ab is no longer
o to detect ABO incompatibility between donor & demonstrable in infant’s serum
patient
o immediate spin crossmatch: sufficient crossmatch
 does not have to be performed in these situations

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
For both intrauterine and infant (<4 months) transfusions Specimens With Prolonged Clotting Time
 blood Testing difficulties
o fresh as possible  observed in blood samples from patients who have prolonged
o no older than 7 days clotting times
o caused by coagulation abnormalities assoc. w/
disease or medications (such as heparin)
fibrin clot
 form spontaneously
o when partially clotted serum is added to saline-
suspended screening or donor RBCs
Complete coagulation of these samples
 often accelerated by adding thrombin

Usually sufficient to induce clotting, either:


o 1 drop of thrombin (50 U/mL) to 1 mL of plasma
o amount of dry thrombin that will adhere to end of an applicator
stick

protamine sulfate
 small amount
 added to counteract the effects of heparin in samples of blood
collected from patients on heparin AC

Preoperative Autologous Blood


Autologous transfusion
 removal & storage of blood or components
o from donor, for donor’s possible use at later time
 usually during or after an elective surgical
Massive Transfusions procedure
When amount of WB or pRBC components infused w/in 24 hours  units
approaches or exceeds patient’s total blood volume o must be labeled “For autologous use only”
 compatibility testing procedure: shortened or eliminated at
discretion of transfusion service physician ABO & Rh groups of units
o following written policy guidelines  must be determined by facility collecting the blood

current technical manual not required when blood will be used w/in collecting facility:
 uses the ff guideline: o Tests for unexpected Ab
o Massive transfusion (MBT) o tests designed to prevent disease transmission
 arbitrarily defined either as:
 8-10 RBC units to adult patient in According to AABB Standards
<24 hours  required & must conform to protocols:
 acute admin. of 4-5 RBC units in o Pre-transfusion testing
1 hour o ID of recipient & blood sample
If patient is known to have clinically significant unexpected Ab  Optional:
 all infused units should be tested for & lack the corresponding o Tests for unexpected Ab in recipient’s serum or
Ag, if time permits plasma
Ab in patient’s serum o crossmatch test
 may not be demonstrable
o because of dilution w/ large volumes of plasma and
other fluids

rapid rise in Ab titer level & subsequent destruction of donor RBCs


 occur if Ag-(+) units are infused
transfusion service physician
 decide that it is better to give Ag-untested units than to hold up
transfusion by waiting for test results
o rationale : important to give patient a chance to
survive & then to treat the immune-mediated anemia
induced by massive transfusion of Ag-untested units

physician
 must always sign:
o waiver of testing
o release form for all untested units for transfusion

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF

LIMITATIONS OF COMPATIBILITY TESTING PROCEDURES Utilization of type & screen policy


In vivo compatibility  Another method to manage blood inventory levels efficiently
 determined using donor RBCs labeled w/: either & to reduce BB operating costs
o radioactive chromium (51Cr)
o radioactive technetium (99mTc) Type and screen method
 to measure likelihood of successful transfusion  Involves: testing recipient’s blood sample for:
 when standard in vitro testing procedures o ABO
are inconclusive o Rh
o unexpected Ab
Transfusion of in vitro incompatible unit need to be considered, if:  specimen
o If transfusion is needed to save patient’s life o refrigerated & kept available for immediate
o If all units are incompatible crossmatching if need arises
o If 51Cr studies indicate adequate survival of donor RBCs
If transfusion becomes necessary, may be performed:
This decision o IS
 should be made in consultation w/ BB medical director & o computer crossmatch
patient’s physician
 blood blood bank
o should be transfused slowly o must ensure that appropriate donor blood is available in case it
 patient is needed
o should be monitored carefully
type and screen policy
 does not apply to patients w/ existing clinically significant
BLOOD INVENTORY MANAGEMENT
unexpected alloantibodies
blood bankers o because donor blood:
 acutely aware of need to use blood efficiently  lacking corresponding Ag must be available
o due to limited blood supplies & ↑ demands for blood  should be fully crossmatched prior to
 pointed out that for many other surgical procedures, more units surgery or transfusion
were being ordered than were used
Technologists  applies to recipient who:
 observed that there have been many surgical procedures, for o not have any clinically significant unexpected
w/c blood was routinely ordered but rarely used, such as: alloantibodies present
o dilatation o any abnormal serologic results in the ABO or Rh
o curettage testing
o cholecystectomy
Maximum Surgical Blood Order Schedule (MSBOS) If blood is needed quickly
 developed to promote more efficient utilization of blood  the BB is then prepared to perform IS (or computer) crossmatch
 goal: o release blood of same ABO and Rh group as that of
o to establish realistic blood ordering levels for certain recipient before releasing unit to hospital floor
procedures  Once blood is issued
 Because variation exists in surgical requirements of institutions o 37°C incubation & AHG crossmatch
o standard blood orders should be:  both can be performed using same tube
employed for IS crossmatch
 based on transfusion pattern of each  if AHG crossmatch is the standard
institution protocol used by lab
 agreed upon by staff surgeons,
anesthesiologists, & BB medical director

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
If either 37°C incubation or AHG phase of testing is (+) o initials or signature of technologist performing the
 patient’s physician is notified immediately testing
 transfusion of unit of blood is stopped o signatures of persons who verify recipient’s identity
before transfusion & those (2) who start the
application of type and screen in combination w/ MSBOS transfusion
 greatly enhance the effectiveness of blood inventory
management program in health-care facility by: 1st copy of form
o minimizing crossmatch-to-transfusion ratio  placed on recipient’s chart after transfusion is completed
o reducing BB personnel workload 2nd copy of form
o using blood inventory efficiently  returned to BB , if desired, for filing
last copy of form
REIDENTIFICATION OF THE PATIENT BEFORE TRANSFUSION  might be printed on card stock & perforated
Reestablishing the intended recipient’s identity & selected donor o so that it can be easily removed & attached to the
product donor unit in lab
 final step in the transfusion process
patient’s nameplate impression rather than handwritten transcription
same careful approach used to properly identify patient before sample  most important feature of this system
collection  indicates all forms used to identify Px-donor combination
 must now be applied to verify that recipient is indeed the same
person who provided the initial blood sample for testing Most facilities now
 use computer-generated labels to attach to each form
must be verified as relating to same donor unit number:  Recognizing the complexity of process
o actual product o other useful systems
o accompanying record of testing  emerging e/o transfusion center & t/o
health care as a whole,
bedside check just prior to blood admin.  including for administering patient
 most critical step for preventing mistransfusion medications

Mistransfusion Machine-readable, bar-code patient–blood unit identification


 wrong blood is transfused to recipient  wristbands
 single most frequent error resulting in ABO-incompatible  ideally suited to bedside check requirements
transfusions  recently reported to significantly improve transfusion practice
 1 of leading causes of morbidity & death resulting from blood
transfusion radio frequency identification devices (RFID)
 being integrated
After pre-transfusion testing is completed  now used for identification purposes at every stage of
 2 records must be prepared pretransfusion testing
o statement of compatibility  consists of at least 2 parts:
 must be retained as part of patient’s o integrated circuit
permanent medical record if blood is  for storing, processing, & sending
transfused information
o label or tie tag  (i.e., patient number, ABO group, Rh type,
 must be attached to unit etc.)
 stating: o antenna or receiver
 intended recipient’s identity  to collect or transmit the information
 results of pre-transf. testing
 donor unit # information
 This identification  Whatever system is used, should be verified at least twice
 must remain on donor unit t/o before blood product is transfused
transfusion copy of original blood requisition form
 placed on the recipient’s chart after samples are collected
original blood transfusion request form  can be used as request for release of units from BB
 used conveniently to accomplish or both of above record- o allows another check of nameplate impressions on all
keeping requirements forms

Some facilities Before blood is taken from BB to the patient treatment area
 use multipart form ff records must be checked:
o to record history of pre-transfusion testing & o ABO and Rh results
transfusion of unit o clinically significant unexpected antibodies
 Useful information might include: o adverse reactions to transfusion
o initials or signature of phlebotomist taking the sample
o donor numbers person releasing & person accepting the units
o results of pretransfusion testing  should verify agreement between donor numbers & ABO and
Rh groups on compatibility form & on products themselves

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BB LEC | CHAPTER 10: Pretransfusion Testing VCMC | ChumG. | HSVF
 unit Nucleic acid amplification techniques
o should also be inspected visually for any abN’s in  based on PCR
appearance, indicating contamination  demonstrated application in blood typing & in screening blood
o If any abnormality is seen for hepatitis C
 Unit should not be issued unless specifically  goes beyond detecting antigenic determinants on RBC
authorized by medical director membrane
o Before transfusion is initiated  & goes directly into genetic foundation of those antigens
 reliable professional (preferably 2)
 must once again verify identity of Molecular testing
patient & donor products  currently 1 of hottest topics in pretransfusion testing

system of (+) patient ID by comparison of wristband ID & compatibility As a result of French requirement
forms  to perform final check of ABO compatibility of recipient & donor
 must be followed strictly  several methods are available, including:
 most critical check & yet the most fallible o card w/ 4 columns
o because the transfusion may take place in operating  containing reagent anti-A & anti-B
suite or ER where person responsible for ID may be  2 for recipient
involved w/ many other duties as well  2 for donor
o card w/ 6 wells
If unit is returned to BB for any reason w/in specified time for that lab, it  2 for recipient and donor samples,
should not be:  4 w/ dried anti-A and anti-B
o reissued if container closure was opened  for testing of recipient & donor
o if unit was allowed to warm >10°C or to cool <1°C
Preparing for clinical care in space
THE FUTURE OF PRETRANSFUSION TESTING  National Aeronautics and Space Administration (NASA)
Automation w/ pre-transfusion testing instruments scientists
 Such as: o can be performed under microgravity:
o continuous-flow  ABO
o batch analyzers  Coombs-sensitized standard blood
 has streamlined compatibility testing esp. in large blood centers grouping tests
o done using closed self-operating system
2 of most successful approaches, used: o automatically performed the tests & fixed the results
 microplates onto filter paper for analysis on Earth
o to perform either: o Agglutinates
 liquid agglutination tests  smaller than usual
 solid-phase RBC adherence tests  reaction endpoints: clear
 column agglutination technology o researchers
o whether using gel or glass beads in the column  noted that additional expt in space
o to capture agglutinates  needed to confirm and quantify their
o on the rise in hospital and transfusion services results
 these preliminary findings
These 2 methods  indicate yet another method for
 provide efficient and economic compatibility tests for performing compatibility testing
processing large numbers of donor specimens
automated flow cytometry system
gel test (column test)  currently being developed & investigated for pretransfusion
 sensitive for both: compatibility testing
o Ag testing & Ab detection & ID  comparing flow cytometry with:
o ABO & Rh typing o column agglutination
 Advantages: o standard tube testing for ABO, Rh typing
o standardizing pipetting of reagents and specimens o antibody detection
o reading of agglutination reactions  revealed a system equivalent for each methodology
o reviewing stable reaction endpoints up to 24 hours  comparable in many aspects, including:
o significantly reducing specimen volume o sensitivity
 Disadvantages: o accuracy
o longer turnaround time for ABO determinations o specimen turnaround time
o less sensitive detection of ABO Ab in patient serum
or plasma when compared w/ tube method

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