Chapter 8: Compatibility Testing

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Chapter 8 Compatibility Testing
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• Compatibility Testing
• A.K.A. crossmatch
• Defined as all the steps necessary in I.D. and
  testing of or for potential transfusion in an
  attempt to provide blood product that survives in
  vivo and provides a therapeutic effect.
• Includes
• Recipient Identification
• Sample collection and handling
• Pretransfusion test

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• Steps involved
• Accurate patient identification
• Proper collection and handling
• Review of Patient history
• ABO/Rh donor unit
• ABO/Rh and Antibody screen of recipient.
• X-match of recipient and donor unit
• If identified clinically significant antibody,
  screen unit for antigen for transfusion.

4

• Two types of crossmatches
• Major Patients serum crossed with donor RBC.
• Minor Patients RBC crossed with donor serum.
• Major is the one we perform in transfusion
  medicine.
• Incompatible crossmatch indicated by hemolysis or
  agglutination at any phase of testing.

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• Transfuse blood product RBC vs. whole blood.
• Historical Overview
• 1st venous transfusion- William Harvey
  1628-result in patient death due to the lack of
  understanding of the ABO compatibility.
• 1920 and 30s discussion of performing major and
  minor X-match.
• AABB deemed the minor x-match unnessary-1976.
• Wiener suggested tube method over slide- 1940,
  along with the discovery of Rh factor and the
  need for 37ºC, enhancement media and AHG during
  x-match testing.
• 1980 movement toward the abbreviated or IS
  crossmatch.
• 1990 computer and advanced technology (gel and
  microplate)

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• Purpose of X-match
• Prevent transfusion reaction.
• Maximize in vivo survival of blood product.
• Check records and previous testing.
• Check recipient history or development of
  antibodies.
• Design to detect and eliminate donor units that
  are unlikely to survive once transfused.
• Increase blood volume- 1 unit of RBC increase
  Hemoglobin 1g/dl and Hematocrit 3.

7

• Limitations Compatibility in vitro
• does not guarantee a successful transfusion.
• does not guarantee a optimal survival of blood
  product.
• Delayed reactions may occur.
• Reaction may be febrile to severe.

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• Recipient Blood sample
• Properly labeled accuracy is essential
• Specimen (serum or plasma)
• Samples
• Must be collected within 3 days of transfusion
  (limitation previous transfusion, multiple
  transfusions or pregnancy).
• Sample must not contain any hemolysis.

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• AABB standards (minimum labeling requirements)
• Positively I.D patient.
• Patient states name.
• Tubes labeled at the patient side
• Name as it printed on the request, armband and
  label, unique I.D. , date and time of
  collection, phlebotomist initials.
• Information must match.

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• AABB requires comparison of test results if
  patient has past demographics.
• Repeat Testing
• Confirm ABO/Rh of all donor units and recipient.
• Any discrepancy with the label and test results,
  the donor unit is rejected.

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• Standards and Regulations
• AABB and FDA are the 2 principle organizations
  that apply standard to blood baking and
  transfusion medicine.
• AABB require that all crossmatch procedures
• always be performed using the recipient serum and
  donor cells from a segment attached to the
  original unit.
• Technique used to demonstrate ABO/Rh
  incompatibility and clinically significant
  antibodies.

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• Crossmatch procedure
• 3 phases that may be utilized.
• Immediate Spin (not useful in detecting all your
  antibodies, only utilized in emergency
  situations)
• Anti-human globulin ( used in most facilities
  today)
• Electronic (computer matches up data)
• Most facilities use AHG in combination with
  electronic information.

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• Tagging, Inspecting and Issuing the blood
• Once compatibility establish we have to tag or
  reserve the unit for the recipient.
• Tag
• Clearly state name and I.D.
• Name of the product
• Donor
• Expiration date
• Interpretation of the crossmatch.
• Box 8-3, 8-4

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• Reissuing unit of unused blood products
• Only if temperature is monitored (1-10ºC)
• Unit not entered or compromised
• Returned within 30 minutes of original issue
  time.
• Very important to follow protocol of facility and
  the AABB standards for blood product usage.

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• Problem solving (Table 8-1)
• ABO errors
• Unexpected antibody
• Primary cause of incompatibility.
• Special topics
• Emergency Release situation
• O negative or AB plasma
• Need pretransfusion sample
• After issue of blood complete the crossmatch
  work-up.
• Box 8-5 Emergency release requirements

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• Massive transfusion
• Total volume exchange of blood through
  transfusion within 24 hours.
• Transfusion exceeds total blood volume (10-12
  units)
• New sample needed for further crossmatch
  procedures.
• For both emergency situations and massive
  transfusion want most compatible, least
  incompatible blood group. Prefer type specific,
  if not known or available at least Rh negative.
  (Type O )

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• Type and Screen protocols
• May be performed on patient undergoing non
  invasive procedures.
• If clinically significant antibody present must
  transfuse antigen negative product.
• Type and screen is on record so if problem
  occurs, we know the blood type of the patient and
  if there is an antibody present we should have it
  identified.

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• Crossmatch of Autologous Units involves same
  steps of a routine crossmatch with the exception
  of using the patients own donor unit instead of a
  unit from the general stock.
• Compatibility testing for infants
• Less than 4 months old- no antibody production,
  antibodies are from the maternal origin.

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• ABO/RH test- we omit serum test- no antibodies
• If we perform antibody screen- use maternal blood
  along with infant to verify presents of suspected
  antibody. If clinically significant antibody
  identified, must give antigen negative product.
• Pediatric units available commercially- very
  expensive.
• Split units for pediatric use.

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• Pre-transfusion on non-RBC products
• Other products include Frozen plasma, platelets
  concentrates, and cryoprecipitate. (contain
  little or no RBC)- dont usually require
  crossmatch procedure.
• Platelet pheresis and granulocyte concentrates
  may contain RBC- need crossmatched.

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Chapter 9 Donor selection and Phelbotomy
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• Donor screening- 3 Phases
• Registration
• Health History interview
• Physical exam
• Registration Documentation of individual on
  permanent records- retained indefinitely.
• Keep up eligibility status, past donations and
  donor history on database except for 1st time
  donor.
• Bullets on pg. 206

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• Pre-interview educational material
• Prior to any donation must give educational
  material which includes information on
• Risk of diseases transmission.
• Signs
• Symptoms
• High-risk behavior associated with HIV/AIDS

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• Health History
• Protects both the donor and recipient
• Determine donor suitable
• FDA and AABB set criteria for health
• 2 types of questions
• Questions to protect the donor
• Questions to protect the recipient.

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• Donor deferral involve questions regarding
  general health, previous surgeries, bleeding and
  pregnancy
• Temporary deferred
• 6 week deferral
• 12 month deferral
• Medical director deferral
• Permanent deferral
• Table 9-2, pg 216, box 9-1 and 9-2

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• Physical exam
• Donor should appear in general good health
• H/H requirements 12.5 g/dl and 38
• Determined by capillary tube or CuSO4
• Temperature 37.5 C or 99.5 F
• Blood pressure lt180/100
• Pulse 50-100
• Weight 110lb or 50kg- can donate up to 525ml

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• Confidential unit exclusion method that allows
  donor to exclude their unit from the general
  population in a confidential manner
• Bar code labels
• Informed consent- written consent from donor for
  procedure and use of blood products

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• Phlebotomy important Identification confirmed
  before venipuncture.
• Bag labeling Primary bag with satellite bags for
  separated products.
• Adverse reactions (table 9-4)
• Post donation care

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• Special Blood collection
• Autologous- used for planned surgeries, donor
  donates own blood for use. (advantages vs.
  disadvantages ,box 9-3)
• Special operative collection
• Preoperative
• Intraoperative Hemodilution
• Intraoperative
• Postoperative

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• Directed Donor
• Donor requirements and testing must be met as
  usual.
• Hemapharesis (Blood , to move)
• Whole blood is collected or removed from a donor,
  separated by mechanical device and the rest is
  returned to the donor.
• Leukapheresis
• Plateletpheresis
• Plasmapheresis

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• Therapeutic Phlebotomy
• Intentional removal of blood for therapeutic
  purpose, used to treat certain disease processes.

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Chapter 10 Donor Blood Testing
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• Infectious disease testing involves various
  method
• Indirect EIA
• Sandwich EIA
• Competitive EIA
• Utilize internal and external controls to verify
  reactivity or lack of.
• Need to know the test that are performed on donor
  units. (table 10-2)
• Western Blot test
• Look back method

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Chapter 11 Blood component Preparation
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• Donor blood collected as whole blood then
  separated out into different products.
• For optimal storage and patient needs
• FDA regulates all processes in collection,
  separation and distribution.
• Blood collection bag that consist of 2 systems.
• Open system
• Closed system

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• Collection process is determined by the product
  that is being collected for.
• Different anticoagulants that are used for
  different products.
• If less than 350ml collected in a unit, must
  reduce the anticoagulant.
• Anticoagulants used
• Dextrose
• Adenine
• Citrate
• Sodium biphosphate

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• Preservatives added to increase shelf life
• Citrate Phosphate dextrose-CPD.
• Citrate phosphate-2 dextrose- CP2D
• Citrate phosphate dextrose adenine-1 CPDA-1
• CPD and CP2D storage 21 days _at_ 1-6C
• CPDA-1 storage 35 days _at_ 1-6C

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• Additives added to enhance survival and function
  of RBC.
• Additive solution AS-1, AS-3 and AS-5
• AS-1 and AS-5 contain mannitol, stabilizing
  agent.
• AS-3 citrate and phosphate added within 72
  hours- extends storage to 42 days.
• Rejuvenation solution- restores 2,3 DPG in RBC

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• Blood component Preparation
• Unit is centrifuged (time and speed is determined
  by product collected)
• Light spin vs. Heavy Spin
• Plasma- frozen for Fresh Frozen plasma (FFP),
  Stored within 8 hrs. and _at_ -18C for 1 year or _at_
  -65C for 7 yrs.

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• Whole Blood unmodified contains RBC, WBC,
  Platelets, Plasma and anticoagulant.
• Problem with volume, must be ABO identical, has
  limited use.
• Packed Red Blood Cells (PRBC)
• Replaced Whole blood
• Rich in HGB
• Used most often today to replace circulating RBC
  volume.
• 1 unit increase HGB 1g/dl and HCT 3 .

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• Leukocyte Reduced Red Blood Cells (LRBC).
• RBC washed or filtered to remove WBC.
• Filter 170 micron or Leuko-reducing filter
• Reduces the transfer of WBC along with CMV
  infection that may be present on the WBC.

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• Frozen RBC
• Freezing extends storage-10 years
• Use glycerol to protect the cells
• Not a common practice
• Deglycerolized RBC
• The removal of glycerol from frozen RBC
• Wash the unit with 12 , 1.6 and 0.9 saline.
• Unit becomes an Open system and must be
  transfused within 24 hours.

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• Washed RBC
• Process of washing the unit with normal saline
• Used on intrauterine or infant transfusions
• Prevents exposure
• Irradiated RBC
• Used to prevent GVHD
• Rid the unit of most on the HLA cells
• Expiration of unit is changed to 28 days on
  irradiated RBC.

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• Platelets
• Used for essential hemostasis
• Not utilized in disease effected platelets.
• Do not require cross-match, but should be type
  specific.
• Platelet concentrate
• Pooled platelets
• Platelet Pheresis

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• Fresh Frozen Plasma use
• Contains coagulation factors
• Indicated for
• Bleeding patients who required Factors II, V,
  VII, X, XI
• Patients on anticoagulants need surgery or are
  bleeding.
• Treat TTP or HUS
• Bleeding related to liver disease
• Deficiency of a Factor
• DIC

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• Thawing FFP
• Performed in water bath _at_ 37C for 30-45 minutes
  in protective wrap.
• Store _at_ 1-6C and transfuse within 24 hrs.
• Cross match not necessary
• Solvent detergent treated plasma

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• Cryoprecipitate Antihemophilic Factor
• Product of FFP
• Contains most of the Coag Factors needed by
  hemophiliac patients.
• VWF, Fibrinogen, Factor VIII, Fibronectin
• CRYO is used primarily as supplement for patients
  def. in Factor VIII and Fibrinogen
• Pooled Cryoprecipitant

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• Granulocytic Pheresis
• Collection of granulocytes
• Used to increase WBC neutrophils
• Crossmatch needed to prevent GVHD
• Labeling of all products use uniform guideline
  implemented by FDA. Any additional process to the
  unit must be identified. Storage is essential.
  Transport of products is checked and monitored.

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• Administration of Blood products
• Requirements for safe transfuse include
• Positive ID (Check s and name)
• Observe patient for 1st 15 minutes and every 30
  minutes thereafter.
• Use 0.9 saline with transfusion
• Use 170 filter and or Leukoreduce filter
• Time limit, infuse within 4 hrs, if gt 4 hrs split
  unit
• Documentation of every step.

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Chapter 14 Transfusion therapy
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• Goal is to supply
• transfusion support for patients with
  hematological problems.
• Blood for rapid blood loss
• DIC
• To treat acute blood loss
• Table 14-2
• Massive transfusion (10-12 unit given in 24
  hours)
• Complications (table 14-1)

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• Hemostatic Disorders
• Decrease or lack of coagulation
• Most common deficiency in Factor VIII and X
• Goal is to products to replace factors
• FFP and CRYO- Type specific is preferred

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• Cardiac surgery- certain precautions-bleeding
  tendency
• Neonatal and pediatric transfusion
• May have to split units
• HGB change
• Erythropoietin response
• Metabolic concerns
• Type and screen, if antibodies exist in baby or
  mother- give antigen negative units.
• CMV neg units

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• Organ Transplant
• Massive blood loss and/or hemostasis problems
• Graft survival is enhanced with HLA match
• ABO compatibility most important in liver, heat
  and kidney.
• Not as significant in Tissue, but suggested.

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• Therapeutic Hemapharesis
• Removal of abnormal cells, plasma or plasma
  constituents for clinical benefits.
• Examples
• Multiple Myeloma
• Hyperleukosytosis
• Thrombocythemia
• TTP/HUS
• Sickle cell Disease

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• Oncology needs normally rely on transfusions for
  blood replacement as a result of the disease or
  treatment.
• Blood products used to replace or increase
• WBC
• RBC
• HGB
• HCT
• PLTS

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• Chronic Renal Failure
• Complication in hematological production and
  destruction.
• Require RBC support
• Disease alters RBC shape and prematurely removes
  good cells (dialysis)
• Need to replenish RBC volume

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• HUS/TTP disorder that damage the vessels
  endothelial which activates and consumes
  platelets and coagulation factor leading to
  production of thrombi that lodge in the kidneys.
• Treat with therapeutic apharesis.
• Can lead to multiple organ failure.
• Anemia's decrease HGB and HCT
• Treat with the transfusion of PRBC to increase
  HGB and HCT.

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• Chapter 12 Adverse Complications
• Any unfavorable response by patient to an infused
  product is a transfusion reaction.
• Hemolytic vs. Nonhemolytic
• Acute vs. Delayed
• Immune mediated vs. non-immune
• Infectious vs. noninfectious

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• Hemolytic Transfusion Reaction (HTR)
• Symptoms range from as mild as a fever to severe
  reaction death.
• Acute HTR
• Delayed HTR
• HTR caused by the Properties of Antibody (IgG or
  IgM). Complement, Bradykins, Kinins,
  norepinephrines released. Activation of
  coagulation, lead to renal failure.

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• Bacterial Contamination- cause serious to fatal
  complications. Investigation of reaction
  involves finding the source of bacteria.
• From donor?
• From Transfusion technique?

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• Circulatory overload cardiopulmonary system
  exceeds blood volume capacity.
• Clinical signs and symptoms
• Dyspnea
• Severe headache
• Peripheral edema
• CHF
• To prevent we transfuse PRBC instead of whole
  blood over a long period 4-6 hrs.

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• Hemosiderosis condition that results from
  accumulation of excess iron in macrophages in
  various tissues.
• Citrate toxicity Large volume of blood product
  transfused over short period of time.
• Post transfusion purpura occurs rarely, plts
  decease and bleeding occurs.

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• Evaluation of Transfusion Reaction
• Facilities have written procedures to follow
• All records are verified and checked
• Vital signs recorded (pretransfusion, during and
  post transfusion)
• Monitor patient 1st 15 minutes then every 30
  minutes thereafter.
• If transfusion reaction suspected- stop
  transfusion, notify Dr. and Blood bank, maintain
  all equipment, if Dr. thinks transfusion
  reaction, reaction must be worked-up.

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• Role of Clinical Laboratory
• Check for errors
• Visual check of unit and tubing
• Visual check of post transfusion sample,
• Check bilirubin, hgb, hct, haptoglobulin, urine.
• DAT performed
• Repeat ABO/Rh, Screen and Antibody ID on pre,
  post sample and unit.

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Chapter 13 Hemolytic Disease of the newborn
67

• Hemolytic Disease of the Newborn
• Caused by IgG antibodies cross placenta and
  attack the fetus.
• BB role to identify the problem and treat.
• Can be result of ABO or Rh incompatible mother
  and fetus.
• 3 factors that must be present for HDN to
  develop
• Mother must lack the antigen.
• Fetus must posses the antigen.
• Antigen must be well developed at birth.

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• Anti-D HDN is the most severe
• Need RHIG during or soon after 1st pregnancy.
• ABO HDN
• More common
• Less severe
• Infant has milder complications
• Important to perform prenatal testing.
• Postpartum testing Cord Blood to verify infants
  blood type- performed on all infants born to Rh
  neg mothers.

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• Suspect HDN
• ABO typing-only a forward grouping
• Rh test to verify Rh grouping
• DAT performed- rule out weak reactions.
• Treatment for HDN
• Uterotreatment- intraperitoneal transfusion.
• Exchange transfusion