IMMUNOHEMATOLOGY (LECTURE)

COMPATIBILITY TESTING 2. Sample Identification and Collection

- Also called pretransfusion testing Sample Identification
- Purpose: To select blood components that will - The sample
not cause harm to the recipient and will have should also have
acceptable survival when transfused the full patient
- If properly performed, compatibility tests will name, hospital
confirm ABO compatibility between the number, and
component and the recipient and will detect the physician
most clinically significant unexpected - Date and time of
antibodies collection, phlebotomist’s initials
- Series of testing procedures and processes with - All of this should be on the request form and the
the ultimate objective of ensuring the best sample
possible results of blood transfusion. - Poor labeling leads to sample mix up or
- Steps in Compatibility Testing confusion
1. Positive patient identification - Labels must be the same in the information
2. Proper sample collection, labeling, and handling found in the request form
3. Review of recipient’s past blood bank records - Phlebotomist initials: if the patient received a
4. ABO and D typing, antibody screening, and
infectious disease testing on donor units
blood transfusion and suffers in HTR, and
5. ABO and D typing, antibody screening of the undergoes investigation, in every step we are
recipient; crossmatch of the recipient’s sample with responsible in every act
the donor units
6. If a recipient is determined to possess clinically
significant Ab, donor units are screened and found
negative for the corresponding antigen and Specimen Collection
crossmatched - Collected in tube with EDTA or no additives
7. Tagging, inspecting an issuing blood products o Pink Top: EDTA for RCS
8. Reidentification of the recipient before transfusion o Red Top: no additives for serum
9. Careful observation of the recipient’s vital signs
following transfusion and monitoring of post- - Minimum of 10mL of blood should be collected
transfusion Hct and Hgb levels for efficacy of from a patient subjected for compatibility testing
transfusion o 5mL for pink top and 5mL for red top
- These steps can be divided into 3 categories: - If the venipuncture causes hemolysis, the
o Pre-analytical procedures (steps 1-3) sample may be rejected because it is regarded as
o Serological testing or analytical false positive in blood bank
procedures (steps 4-6) o Note: must recollect specimen!
o Post-analytical procedures (steps 7-9) - True hemolysis in the patient is the result of
- Compatibility testing begins automatically when complement activation
we receive a transfusion request from the doctor - Samples are labeled at the bedside (pre-labeling
- It will end up with the successful transfusion of is not recommended)
the donor’s blood to the patient and carefully - A record of individuals who collect (or test) the
monitoring the patient’s vital signs for any signs specimens should be documented in order to
of possible transfusion reaction “backtrack” in case of an error specimen
- Goal in compatibility testing: no reaction collection
- Only the nurses and the doctors are authorized - If the sample is drawn from an IV line, the IV
persons to receive the crossmatched blood for infusion should be stopped 5-10 minutes prior to
transfusion blood drawing and the first 10 mL discarded
- Note: oftentimes, compatibility testing and o Select or search for a vein in other parts
crossmatching are interchanged. Remember of the body if ever that the site of
that crossmatching is only part of the venipuncture has IV infusion
- Testing should be performed on samples less
compatibility testing
than 72 hours or else complement dependent
antibodies may be missed (complement can
PRE-ANALYTICAL PHASES become unstable upon storage, resulting to false
1. Patient Identification negative result)
- Must confirm recipient’s ID from bracelet on the - The sample used for compatibility testing should
patient be kept for 7 days in the laboratory for
o Full patient name investigation purposes in cases of transfusion
o hospital number (unique number reaction
assigned to every patient)
o Name of physician 3. Getting the history
o Bar code in some hospitals - Look at recipient’s records for any prior
- Same when performing phlebotomy unexpected antibodies
o Let the patient state his or her full name - Previous transfusion reactions
- If the patient is unconscious, bedridden, and not - Getting the history can give us a clue in our
capable of speaking, ask the relative or the nurse procedure
- Do not depend on the patient’s label on the door
or on the wall
 IMMUNOHEMATOLOGY (LECTURE)

SEROLOCIGAL OR ANALYTICAL PHASES o Invasive method because the patient is

exposed to radioactive material
4. ABO/Rh Typing
▪ Note: consent of the patient is
- ABO and Rh typing should be repeated important!
- In the ABO typing, the forward and reverse must
match
Two Categories or Classification:
- In the Rh typing, the control must be negative
➢ Computer/electronic Crossmatch
- Both of these will indicate what type of blood
➢ Serologic Crossmatch
should be given
o Abbreviated or Immediate Spin
Crossmatch / incomplete crossmatch:
5. Antibody screen and/or ID the only test performed is the immediate
- The antibody screen will detect the presence of spin phase
any unexpected antibodies in patient serum o Antiglobulin Crossmatch / Complete
- If antibodies are detected, identification should crossmatch: the test is done in three
be performed using panel cells (with an phases (IS, Thermo, and AHG phases)
autocontrol)
o IS Two types of crossmatches:
o 37° (LISS) ➢ Major: routinely performed in labs
o AHG o patient’s serum and donor’s red cell are
- If an antibody is present, units negative for the mixed (PSDR)
antigen must be given o to check if the patient’s serum has an
- The antibody screening should be performed for unexpected antibodies against donor’s
both the donor and the patient. red cells
- Then proceed to crossmatching. ➢ Minor: not required by AABB since 1976
o donor’s serum and patient’s red cells are
6. Crossmatching mixed (DSPR)
- Heart of compatibility testing o to check if the donor’s serum contains
- It is the final check for ABO compatibility antibodies against the patient’s red cells
between the patient and his donor
- Purpose: History
o Prevent transfusion reactions
o Increase in vivo survival of red cells
o Double checks for ABO errors
o Another method of detecting antibodies

Two methods to check for the survival of donor’s

red cell inside the patient’s body:
➢ Measurement of pre- and post-transfusion
hemoglobin and hematocrit
o Most commonly performed method Major vs Minor Crossmatch
o 1 unit FWB/PRBC = 3% increase in
hematocrit
▪ Example: 33% pre-transfusion
hematocrit should become at
least 36% after transfusing 1
unit FWB/PRBC
o 1 unit FWB/PRBC = 1 g/dL (gms%)
increase in hemoglobin on the average - Why is the minor crossmatch unnecessary?
▪ Example: 6 g/dL pre-transfusion o Donated units are tested for antibodies
hemoglobin should be at least 8 through antibody screening
g/dL after transfusing 2 unit o Most blood is transfused as packed cells,
FWB/PRBC having little antibodies
o Decreased or equal results indicates that - Minor crossmatch is performed if antibody
there is a hemolytic transfusion reaction screening is not routinely done
➢ Radiolabelled donor’s RBC o Trivia: minor crossmatch is still
o radioactive material (cobalt or performed in the Philippines since
technetium) is added to the donor’s red antibody screening is not yet done
cell before transfusion routinely by most blood banks.
o After blood transfusion, get blood from
the patient and measure radioactivity Crossmatches
▪ absence of radioactivity (not - The AABB and FDA develop the standards for
detected) indicates that the blood banking
donor’s RBC did not survive. - According to the AABB Standards: The
▪ presence of radioactivity crossmatch “shall use methods that
(detected) indicates that the demonstrate ABO incompatibility and clinically
donor’s RBC survived in vivo. significant antibodies to red cell antigens and
shall include an antiglobulin phase”
 IMMUNOHEMATOLOGY (LECTURE)

Incompatible Crossmatches
Antibody
Crossmatch Cause Resolution
screen
Antibody directed ID antibody,
Positive Negative against antigen on select antigen
screening cell negative blood
Antibody directed
against antigen on ID antibody,
donor cell which select antigen
Major Crossmatch Procedure may not be on negative blood
Negative Positive
screening cell OR OR perform
- Donor cells are taken from donor unit may DAT on donor
segments that are attached have IgG previously unit
to the unit itself attached
o Used in making RCS Antibodies directed
Antibody ID,
against both
- Segments are a sampling of Positive Positive select antigen
screening and
the blood and eliminate negative blood
donor cells
having to open the actual unit
- ABO/Rh typing is first performed Investigation of Incompatible Major Crossmatches
OBSERVATIONS POSSIBLE INTERPRETATIONS
o With anti-A, anti-B, anti-D
Crossmatch + ✓ Incorrect ABO Grouping of patient or
o With A1 cells and B cells Auto-control 0 donor
- Antibody Screen is performed next Antibody Screen 0 ✓ Patient’s serum may contain an ABO
o With screening cells antibody
- if antibodies are not detected: ✓ Alloantibody in patient’s serum reacting
with antigen’s RBC but not present in
o Only immediate spin (IS) is performed screening cells
using patient serum and donor blood Crossmatch + ✓ Donor unit may have a positive DAT
suspension Auto-control 0 ✓ Alloantibody in patient’s serum reacting
o This fulfills the AABB standard for ABO Antibody Screen + with antigens on donor’s cell and
incompatibility screening cell
Crossmatch + ✓ Both an autoantibody and alloantibody
o This is an incomplete crossmatch Auto-control + may be present in patient’s serum
o Can only be done only if the result in Antibody Screen + ✓ Abnormalities in patient’s serum owing
antibody screening is negative and if the to imbalance between Albumin and
patient has no history of pregnancy, Globulin
o Plasma expanders
blood transfusion, or organ
o Caprylate antibodies
transplantation in the past o Contaminants
- If antibodies are detected: Auto-control tube: Patient’s serum + patient’s red cells
o Antigen negative units found and
Causes of (+) Results in the Serologic Crossmatch
crossmatched
• Incorrect ABO grouping of the patient or donor
o All phases are tested: IS, 37°, AHG
o This is a complete crossmatch • An alloantibody in the patient’s serum reacting
with the corresponding antigen on donor’s RBCs
• An autoantibody in the patient’s serum reacting
with the corresponding antigen on donor’s RBCs
• Prior coating of the donor’s RBC with protein,
resulting in a positive antihuman globulin test
• Abnormalities in patient serum
• presence of dextran, high albumin:globulin ratio,
antibodies against caprylate
• Contaminants in the test system

POST-ANALYTICAL PHASE
- Involves labeling, inspecting, and issuing the
blood unit
- Labeling form includes patient’s full name, ID
- Crossmatches will: number, ABO/Rh of patient and unit, donor #,
o Verify donor cell ABO compatibility compatibility results, and tech ID
o Detect most antibodies against donor - Form is attached to the donor unit and only
cells released for the recipient
- Crossmatches will not: - The unit is visually inspected for abnormalities,
o Guarantee normal survival of RBCs such as bacterial contamination, clots, etc
o Prevent patient from developing an 7. Inspecting an Issuing Blood Product
antibody
Bacterial contamination
o Detect all antibodies
- This unit shows bacterial
▪ cannot detect antibodies to HLA,
contamination and should
platelets, WBC, etc.
not be given to the patient
▪ there may be transfusion
- The plasma in the segments
reaction that are due to these
is fine, but the plasma in the
incompatibilities
unit shows heavy hemolysis
o Prevent delayed transfusion reactions
from bacteria
o Detect ABO/Rh errors
 IMMUNOHEMATOLOGY (LECTURE)

Issuing blood - Crossmatching the segments from the released

- When it’s time to release a blood product to the unit should be tested
nurse or physician, a few “checks” must be done - In addition, the lab may crossmatch additional
o Requisition form units as a precaution if more blood is needed
o Comparing requisition form → “donor - If death should occur, testing should be
unit tag” → blood product label complete enough to show that the death was
o Name of persons issuing and picking up unrelated to an incompatibility
blood
o Date and time of release What can be given in an emergency?
o Expiration date ➢ Group O Rh-negative red cells or AB plasma
- Don’t forget to ask the doctor to sign the o Emergency release
releasing log book o Women below or of childbearing age
- What if the unit is unused? o Or if in doubt
o Blood can be returned if it is not needed ➢ Group O Rh-positive red cells
for transfusion o Used as a substitution (because Rh
o Unit closure has to remain unopened negative is rare)
o Storage temperature must have o Male or elderly females
remained in the required range (1° to - The risk of transfusing an incompatible blood to
10°C for RBCs) patient during emergency may be judged less
o If not at correct temperature, unit must than depriving the patient of oxygen that is
be returned within 30 minutes of issue delivered by RBCs

Infusion Device and Blood Warmer Suggested ABO Group Selection Order
➢ Infusion device will trap the microclots that are for Transfusion of RBCs
not palpable when we inspect the blood bag for Recipient
1st choice 2nd choice 3rd choice 4th choice
ABO Group
the presence of clot AB AB A B O
➢ Blood warmer will ensure that the blood will be A A O
warm to prevent hypothermia. B B O
o If blood warmer is not available, the O O
blood bag will be settled at room - ABO compatible should always be given first
temperature - Group O individuals are “universal donors”,
they can donate to any blood group because
they have no A or B antigens
- Group AB individuals are “universal recipients”,
they can receive blood from any group because
they do not have A or B antibodies

MASSIVE TRANSFUSION
Infusion device blood warmer - Defined as a transfusion approaching or
exceeding the recipient’s own blood volume
8. Reidentification of the recipient before (about 5 liters or 10-12 units in an adult male)
transfusion within 24 hour period
- It is done to avoid and prevent misidentification - The original sample no longer represents the
incidents that can result in significant adverse patient’s condition
outcomes, such as transfusing incompatible - Complete crossmatch not necessary (if no
blood antibodies were detected originally)
- Give ABO identical units
o If antibodies were originally ID’s,
9. Careful observation of the recipient’s vital signs
continue to give antigen negative units
- The recipient’s vital signs are carefully observed
following transfusion and monitoring of post-
TYPE AND SCREEN
transfusion Hct and Hgb levels for efficacy of
transfusion - Used to conserve blood inventory
- Methods are performed to check for the survival - On average, a surgical procedure uses about 1
of donor’s red cell inside the patient’s body unit of RBCs, however, many times the units are
on “hold” in the lab and will not be needed
(reducing inventory)
- For this reason, only a type and screen are
EMERGENCY RELEASE performed and if any blood is needed, the
- In an emergency (ER or OR), there may not be sample can be retrieved for crossmatching (only
enough time to test the recipient’s sample the IS phase is required)
- In this case, blood is released only when signed - If antibodies are identified, then antigen
by the physician (O negative) negative blood is reserved or crossmatched
- The tag must indicate it is not crossmatched
- Segments should be retained for crossmatching NEONATAL TRANSFUSION
- Every detail is documented (names, dates, etc.) - A neonate who is <4 months old does not have
- Once the specimen is received, ABO/Rh typing antibodies
and antibody screening should be performed - ABO/Rh compatible blood is given
 IMMUNOHEMATOLOGY (LECTURE)

- However, if clinically significant antibodies are

detected, they are usually maternal, and antigen
negative units are given
- Either infant or maternal serum can be used for
the crossmatch
- Pedipacks are small aliquots of larger units and
prepared by the donor facility or hospital lab for
infant transfusion

AUTOLOGOUS CROSSMATCHING
- Autologous refers to a donation from the
recipient for later use
- Special procedures/protocols must be available
so that the autologous unit is found and
transfused to the recipient
- Pretransfusion testing procedures vary
- Safest among all types of donation
- Crossmatching is not required - June, 1938
- A hospital in Los Angeles, California, is equipped
OTHER COMPONENTS with a specially designed refrigerator which
- Other components to be given do not need to be serves as a “blood bank,” storing quantities of
crossmatched because they have been human blood for later use in cases requiring
thoroughly screened for antibodies blood transfusions.
- Examples of donor’s blood that contains <2mL of - The “blood bank” is expected to save more than
RBC that doesn’t need crossmatching $10,00 annually and eliminate delays in
o Frozen plasma operations.
o Platelet concentrate - The refrigerator is kept at a temperature of four
o Cryoprecipitate degrees above freezing; an alarm being
o Platelets pheresis automatically sounded when the temperature
o Granulocyte concentrates varies.
- Give ABO compatible units - The blood is kept on hand not longer than two
- Crossmatching is done to any blood components weeks, a fresh supply being secured at regular
containing >2mL RBCs intervals.
o Fresh whole blood (FWB)
o Packed RBC (PRBC) MAXIMUM SURGICAL BLOOD ORDER (MSBO)
- To minimize the wastage of blood, there is MSBO
COMPUTER OR ELECTRONIC CROSSMATCH in every hospital
- According to the AABB, the following must be - In MSBO, the number of donor units to be
fulfilled: crossmatched is pre-determined for a particular
o Critical elements of the information type of surgery.
system have been validated on-site. - Hypovolemia → Hypotension → Multiple Organ
o No clinically significant antibodies are Failure → death
detected in the current blood sample
and there is no record of clinically
significant antibodies in the past
- Two different medtechs should collect different
blood samples from the same patient
o Blood samples are also tested separately
o The patient's ABO group and Rh type has
been done twice and entered in the
computer
- The donor ABO/Rh have been confirmed and
entered in the computer. The donor unit
identification number, component name, and
ABO/Rh type must also be entered in the
computer
- The computer system will alert the technologist
to ABO & Rh discrepancies between information
on the donor label and results of donor
confirmatory testing
- The computer will be the one who will choose
the best donor for the patient based on their
compatibility in terms of their blood type and
antibody screening results
- ISBT nomenclature is used as the terminology
for encoding the results of the patients