Transcript PowerPoint
Unit 8 Pretransfusion Testing
Part 1
Terry Kotrla, MS, MT(ASCP)BB
Introduction
Purpose to select for each recipient blood components which
when transfused will survive and not cause destruction of
recipients rbcs.
Must prevent transfusion of incompatible donor cells which
may cause HTR.
US federal government regulates by giving authority to CLIA
to oversee testing:
ABO/D
Antibody detection
Antibody identification
Compatibility testing
Pretransfusion Testing Requirements
Positive identification of recipient and recipient’s sample.
Review of transfusion records for previous results.
Tests on donor blood.
ABO/D recipient
Antibody detection using serum or plasma
Select ABO/D appropriate components
Test serum/plasma with donor RBCs, i.e., crossmatch
Labeling.
Pretransfusion Testing
Transfusion usually safe and beneficial.
Donor or recipient RBCs may undergo accelerated
destruction.
Most HEMOLYTIC transfusion reactions caused by errors in
patient or sample identity.
Antibody may be below level of detectability.
Even when all done correctly cannot guarantee survival of
transfused RBCs.
Pretransfusion Testing
If performed PROPERLY testing WILL:
Ensure patient receives correct components.
Verify in most cases components are ABO compatible.
Detect most clinically significant unexpected antibodies.
Modern Blood Banking Practices
Many changes over last 20 years.
In 1980’s time for eliminating unnecessary tests.
Ongoing reevaluation led to streamlining procedures for cost
effectiveness AND patient safety.
Intelligent approach, requires rigid adherence to guidelines
and standards.
Changes based on:
Patient safety
Elimination of unwanted reactions
Increase speed of testing procedures performed.
Transfusion Request Form
Can be oral, electronic or written and must include
information sufficient to positively ID patient.
Two identifiers required:
Patient full name
Unique ID number
Other identifier
DOB
Driver’s license number
Photographic ID
Blood is a drug and requires physician prescription.
Transfusion Request Form
Additional helpful information
Sex
Age
Diagnosis
Transfusion and pregnancy history
Special needs: CMV negative, irradiated, etc.
Reject requisition if
Information is incomplete or lacking.
Inaccurate
Illegible
Specimen Requirements
Testing performed only as good as sample submitted.
Properly collected sample from CORRECT patient is
CRITICAL to safe blood transfusion.
Patient must be identified with TWO identifiers, best to
allow properly trained individuals to collect.
Labeling
Minimum patient full name
Patient unique ID number.
Date and time, although some institutions require date only.
Phlebotomist identification
Specimen Requirements
Patient does not have armband physically attached.
DO NOT DRAW
Have qualified healthcare provider band patient.
Emergency protocol must be followed in STAT situations
Emergency room patient identity unknown use temporary
ID.
Preadmission testing must stress to patient importance of
returning with ID band or will start over.
Sample must be labeled in physical presence of patient.
Specimen Requirements
Commercial armbands may be
utilized in addition to institution
armbands.
Top right: Typenex
Bottom right: Bio-logics.
Specimen Requirements
Sample
Draw into stoppered tube
May use serum or EDTA plasma
Can draw from IV line as long as proper protocol followed
Hemolyzed samples should not b used
Samples cannot exceed 3 days if transfused or pregnant last 3
months.
Collection day is day 1, can be used until 11:59pm on day 3.
Sample must represent current immunological status.
No pregnancy or transfusion last 3 months the institution will
set requirement for use.
Specimen Requirements
Infants less than 4 months old.
No unexpected antibodies detected and infants receive no
components containing clinically significant antibodies no
additional testing required during neonatal period.
After initial ABO/D type determined this test can be omitted
during neonatal period as long as infant receives ABO specific
or group O cells with compatible D type.
Specimen Requirements
Sample must be verified by qualified laboratory personnel.
Any doubt as to identity of patient or labeling of sample new
sample must be obtained.
UNACCEPTABLE and EXTREMELY RISKY to correct
incorrectly labeled sample.
Each lab will have policies for accepting mislabeled samples.
Must be able to defend in court reason.
If sample can easily be recollected there should be zero
tolerance.
Study found mislabeled samples 40 times more likely to have
blood grouping discrepancy.
Specimen Requirements - Storage
Sample and sample from donor RBCs (if crossmatch) MUST
be stored at 1-6C for SEVEN days AFTER transfusion.
Donor RBCs may be actual segment used for testing.
Donor segment removed upon issuing unit may be saved.
Must have sample for repeat testing if patient has transfusion
reaction either immediate or delayed.
Storage capacity will many times determine amount of time
sample may be used.
Three day sample plus 7 days = 10 days
For non-pregnant/transfused for last 3 months may elect to use
for 14 days + 7 = 21 day storage
Previous Records
Compatibility testing MUST include checking previous records for
patient’s serological history.
If patient has history must compare current with previous testing.
If discrepancy present MUST resolve.
NOTE: Becoming standard practice to collect SECOND sample after
first for patients with no history.
Most significant information is history of clinically significant antibodies
Specificity compared to current antibodies detected.
Regardless of result, may be negative, antigen negative blood MUST be
provided.
Serological Testing – ABO Grouping
Test unknown RBCs with reagent anti-A and anti-B.
Testing unknown serum with reagent A1 and B cells
Discrepancies MUST be resolved prior to issuing blood.
In an emergency provide
Group O negative RBCs
AB plasma products
Serological Testing – D Typing
Test patient and donor RBCs with anti-D.
Tests with anti-D must be controlled to avoid incorrect interpretation.
If problem arises transfuse D negative blood.
Weak D unnecessary for recipients
Donors
No weak D test required at transfusion service.
D typing of D positive donors not required by transfusion service.
Weak D test must be performed by blood collection facility for donors.
If positive labeled “D positive”.
Antibody Detection Tests
Serum or plasma tested against single-donor suspension of
cells selected to carry blood group antigens necessary for
detection of most important CLINICALLY SIGNIFICANT
unexpected antibodies.
Unexpected antibodies are those OTHER than anti-A and –B
Clinically significant antibody is/has:
Caused hemolytic disease of the fetus and newborn.
Caused a hemolytic transfusion reaction
Caused unacceptable survival of transfused RBCs
Is reactive at 37C or AHG.
Antibody Detection Tests
IgG coated RBCs (check cells) MUST be used to detect false
negative antiglobulin tests due to inactivation of Coomb’s
serum.
Commercially available screen cells, 2-3 vials, Group O
Following antigens MUST be present: D, C, E, c, e, M, N, S, s,
P1, Lea, Leb, K, k, Fya, Fyb, Jka and Jkb.
No requirement for low incidence antigens (Lua, V or Cw)
No requirements for homozygous cells to be present.
May not be used beyond expiration, some antigens deteriorate.
Type and Screen
Safe alternative to full crossmatch.
Perform ABO, D and antibody screen.
When done correctly will detect 99.9% of unexpected
antibodies.
If antibody screen positive MUST identify antibody and
crossmatch antigen negative donors.
If antibody screen negative no crossmatch performed.
Extremely safe and effective.
Most frequently done for obstetrical and pre-operative
patients where risk of bleeding is minimal.
Type and Screen
If complications arise patient can receive ABO, D type
specific immediate-spin crossmatch compatible within 10
minutes.
Transfusion service must have adequate stock of blood.
Type and Screen - Limitations
CANNOT detect ALL antibodies
Antibody may be directed against low incident antigen absent
from screen cells.
Antibody may have fallen below level of detectability.
Antibody may be exhibiting “dosage” affect, react more
strongly with homozygous and weakly or negative with
heterozygous.
Type and Screen - Limitations
Dosage
RBC which is positive for Jka and Jkb is a heterozygous cell.
Half of the antigens on the RBC will be Jka positive and half will be Jkb
positive.
RBC which is positive for Jka and negative for Jkb is assumed to be
homozygous for Jka , 100% of the antigens will be Jka .
Example of patient with Jka showing dosage reaction at AHG:
Jka
Jkb
Patient 1
Patient 2
+
0
4+
1+
0
+
0
0
+
+
2+
0
References
AABB Technical Manual, 16th edition, 2008
CAP Today http://tinyurl.com/4cd4qgd
Basic & Applied Concepts in Immunohematology,
2nd edition, 2009
Ortho WIRE, http://www.ortho-wire.com