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ISBT Science Series - 2008 - Armstrong - Compatibility testing

The document discusses compatibility testing for blood transfusions, emphasizing the importance of correct patient identification and blood selection to prevent transfusion errors. It outlines the procedures for major and minor crossmatching, the use of electronic crossmatching, and the need for standard operating procedures to ensure accuracy and safety. Additionally, it highlights the potential risks associated with transfusion reactions and the importance of quality control in the process.

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ISBT Science Series - 2008 - Armstrong - Compatibility testing

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chomaw2007sitotaw

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ISBT Science Series (2008) 3, 197–215

© 2008 The Authors.

Compatibility testing
Blackwell Publishing Ltd

B. Armstrong, R. Wilkinson & E. Smart

– provision of blood in malaria areas

Introduction
– massive transfusion
Compatibility or pretransfusion testing involves the – changing donor blood type during one transfusion
crossmatching of selected donor blood of appropriate ABO episode
and RhD type for a patient requiring a blood transfusion. The • Alternatives to transfusion
donor blood selected is considered compatible if there is no – replacement fluids
observable reaction in the compatibility tests between the – red cell substitutes (oxygen therapeutics)
blood of the donor and the blood of the patient. The assumption – recombinants
can then be made that when transfused, the blood will survive – modified red cells
normally in the recipient. • Incompatibilities
The most important steps during the process are correct – dealing with incompatibilities efficiently and effectively
identification of the patient and selecting blood of the correct – antibodies to high incidence antigens
ABO group for the patient. Crossmatching is a relatively – cold agglutinins
simple process but if not carried out correctly, can lead to the – haemolytic anaemias
wrong blood being transfused into the patient, with possible • Patient records
disastrous consequences. When this happens it is usually the – repeat blood orders
result of patient misidentification and/or the switching of – transplantation leading to change in blood type
patient samples, either in the hospital or in the crossmatching – retention of specimens and transfused units
laboratory/blood bank. • Issue of blood
– starting the transfusion
• Transfusion reactions and haemovigilance
Learning objectives – transfusion reaction investigations
By the end of this section, the student should be able to • Quality control
describe compatibility testing, the selection of blood in – critical control points
various situations and the use of replacement fluids and red – reagent controls
cell substitutes, relating all aspects of crossmatching to – random quality control.
quality standards. The student should also be able to discuss
the importance of patient identification and records, and the
preliminary investigation of transfusion reactions.
Concepts of crossmatching
• Concepts of crossmatching The objective of crossmatching is to carry out the appropriate
• Patient and sample identification laboratory tests to provide evidence that blood selected for
– handling infectious specimens transfusion into a specific patient should survive normally
• Avoiding pitfalls that lead to crossmatching errors and benefit that patient.
• Approaches to compatibility testing
– requirements for good crossmatching technique
Major crossmatch
– crossmatching methodologies
– abridged crossmatching This involves testing the serum/plasma of the intended recipient
– electronic crossmatching with the red cells of each unit of blood selected for transfusion.
– type and screen The major crossmatch is of most value as it tests whether
• Selection of blood or not the red cells of the blood donation/s selected for
– standard and emergency situations crossmatching contain antigens against which the intended
– use of fresh blood recipient has antibodies. If the crossmatch is positive (signify-
– use of autologous blood ing a reaction between the donation red cells and recipient
– transfusion in chronic anaemia antibodies), then the donation is incompatible and would be
– blood for infants destroyed or have a reduced lifespan if transfused.

197
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198 Compatibility testing

• Transfusion of blood into the wrong patient (bedside

Minor crossmatch
error).
This involves testing the red cells of the intended recipient with It is important that standard operating procedures (SOPs)
the plasma from each unit of blood selected for transfusion. are in place for all tasks related to compatibility testing,
The minor crossmatch is seldom performed unless including:
investigating an adverse reaction to the transfusion of whole • Patient identification
blood or plasma products, to determine whether donor • Specimen collection and labelling
plasma contained antibodies directed towards a red cell antigen • Registering the crossmatch in the laboratory
in the patient. Transfused plasma that is ABO incompatible • Selection and crossmatching of blood
and of low titre or free of haemolysins, is rapidly diluted in • Issue of compatible units
the circulation of the recipient, and may also be neutralized • Patient identification and administration of blood products.
by ABH substances present in a recipient’s tissues, so is All personnel authorized to carry out these tasks should be
unlikely to cause a serious reaction. In the case of a red cell trained and able to demonstrate competency. SOPs should
concentrate, very little plasma remains in the blood product stress the importance of checking and rechecking to ensure
that is supplied. that patient and unit misidentification does not occur.
Donor plasma may, however, cause reactions in the following
circumstances:
Handling infectious blood specimens
• Donor plasma with potent ABO antibodies may cause a
haemolytic reaction. For example, strong anti-A,B in • Every crossmatch specimen should be treated as
group O donor blood may haemolyse the red cells of a potentially infectious and appropriate care taken during
group A or B recipient. handling.
• Donor plasma containing HLA antibodies to recipient • With a clinical diagnosis of ‘haemorrhagic disease’ the
white cell antigens may cause transfusion related acute specimen is potentially hazardous and should not be
lung injury (TRALI). This adverse effect of transfusion is handled or even submitted to the blood bank. Specimens
discussed in Section 14: Benefits and risks of transfusion. from patients with haemorrhagic diseases such as Marburg
fever or Ebola fever carry a greater risk, as the viruses
responsible for these infections are very easily spread by
Electronic crossmatch
blood and other body fluids. Arrangements should be
In electronic crossmatching, a computer program is used to made by the medical officer of the transfusion service,
guide the process of checking the critical aspects of com- with the prescribing clinician, to use uncrossmatched
patibility testing, including patient identification, matching group O blood for such patients.
of blood groups of intended recipient with blood groups of
units selected for transfusion, as well as transfusion history.
Electronic crossmatching is discussed in more detail later in
Avoiding pitfalls that lead to crossmatching
this section.
errors
The identity of technologists responsible for crossmatching
tests in the laboratory should be documented for traceability.
Patient and sample identification The same applies to hospital personnel responsible for
The most common cause of error in crossmatching is misi- identification of the patient at the bedside. Both laboratory
dentification of the patient or the sample. This can happen and hospital personnel are responsible for their respective
either at the bedside or in the crossmatching laboratory. tasks that lead to the transfusion of blood to a patient.
Studies have shown that mistakes are more likely to occur
during emergency situations when personnel are working
In the hospital
under extra pressure and time constraints.
Reasons for patient/sample misidentification include the The first critical step is taking the specimen from the correct
following: patient, which is the responsibility of the clinician. The
• Specimen taken from the wrong patient (bedside error) following points are for the information of laboratory staff.
• Specimen labelled with incorrect patient information • The patient may be correctly identified by following the
(bedside error) steps provided.
• Wrong specimen used for crossmatching (laboratory – ask the patient to give his/her full name (as several
error) patients may have the same name).
• Wrong blood unit selected for labelling (laboratory error) – check the case sheet to ensure that the name docu-
• Incorrect unit of blood issued (laboratory error) mented is the same as the name provided by the patient.

© 2008 The Authors.

Journal compilation © 2008 Blackwell Publishing Ltd. ISBT Science Series (2008) 3, 197–215
17512824, 2008, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1751-2824.2008.00198.x by CochraneAustria, Wiley Online Library on [15/04/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Introduction to Blood Transfusion Technology 199

– check the patient’s wristband ID, if available, to con- • On acceptance, every crossmatch request should be
firm identity details. assigned a unique laboratory number to identify the
– complete the specimen tube label at the bedside at the sample and the respective documentation. This number
time the specimen is collected. should appear on the crossmatch specimen tube, the
– check that the name and all other details entered onto request form and in the crossmatch register.
the specimen tube label and the blood request form are • Patient details should be entered into a computer registra-
the same as those relating to the patient and his/her tion program or manual register for record and reference
case sheet. purposes. If a further request for blood is received at a
– check the social security/ID number/hospital number of later stage for that same patient, the record may then be
the patient. checked for blood type and any other information. Labo-
– take the sample into a correctly labelled test tube. ratory personnel should always note the clinical diagnosis
• A system should be in place to link the patient to the provided on the crossmatch request form on receipt, and
correct case sheet in the event of the patient being ascertain the blood products required, the time required
unconscious. and the reason for blood being required.
• There should be no interruptions when taking the specimen • The crossmatching process from the determination of the
from the patient, recording the details on the label and patient’s blood group, selection of appropriate blood
request form, and checking for errors or omissions. If units and setting up of the compatibility tests, should be
there is an interruption, the process of checking should be undertaken by the same technologist, handling only one
repeated. crossmatch request at a time.
• The specimen tube label should be firmly attached to the • The crossmatch specimen and request form should travel
tube containing the blood of the patient, and should not together through the process of compatibility testing.
become detached during handling. If the label is separated Every time the specimen is handled, the details on the
from the tube, then the blood in the tube cannot be label should be rechecked against the details on the form,
guaranteed as being that of the patient. to ascertain that they correspond.
• Ideally, the ABO group on the patient should be performed
twice, by two different technologists, and the results of
In the laboratory/blood bank
the second grouping compared with the first to check
The following points deal with the responsibilities of the that they are the same. If available, the ABO group should
compatibility testing personnel in the laboratory or blood then be compared with the patient’s ABO group on record.
bank. If any discrepancy is noted, the technologist in charge
• When several requests reach the laboratory at the same should immediately be informed and an investigation
time, they should be handled and registered separately, initiated to resolve the problem.
one at a time. Every detail on the specimen tube label and • The ABO group of each selected blood unit should be
request form should be checked to ascertain that they checked to ensure that it matches the group label assigned to
correspond exactly. Details should include the following: that unit and is compatible with the ABO group of the patient.
– last name (family name) • At the time of blood being issued for transfusion, all
– first name (calling name) details should be carefully checked between blood unit
– hospital and request form to confirm that they match and that the
– hospital number and/or social security/ID number correct blood is selected for issue, and is compatible.
– ward if applicable
– age or date of birth
When the blood has been issued
– date the specimen was taken
– signature of requesting clinician. Prior to the administration of the blood, the attending
• If the patient has received blood previously, laboratory clinician should check the identity of the patient and the blood
records should be consulted for documented blood type bag and correlate the following to confirm that they match:
and transfusion history. This information should be noted • Verbal verification of the patient’s name
for checking during crossmatching. • All the details on the blood unit label
• If the request form and specimen tube label do not corre- • Details on the wristband of the patient, if available
spond, or lack information, the crossmatch should not • Details on the patient’s case sheet.
be accepted. Action should immediately be taken to The identification of the patient is improved by using
resolve the problem. The requesting clinician should be bar-coded wristband identification. In some hospitals the
asked to submit a new sample and the original should be ABO blood group of the patient to be transfused is checked
discarded. by carrying out a rapid grouping test at the bedside.

© 2008 The Authors.

• The crossmatch test tubes, into which the serum/plasma

Approaches to compatibility testing
of the patient is dispensed for testing, should be checked
Although the abridged crossmatch and the electronic cross- to ensure the presence of serum/plasma in each, before
match are becoming more frequently used in blood transfusion adding donor red cells.
services today, the traditional crossmatch between the serum/ • If test tube techniques are used: the serum/plasma of the
plasma of the patient and the red cells of the unit selected patient should be dispensed firstly into the crossmatch
for transfusion, is also commonly carried out. Some of the tubes and then immediately into the reverse ABO group-
different approaches to providing suitable blood for patients ing tubes. When reverse ABO grouping results correspond
are described. with forward grouping results, it indicates that the
patient’s serum/plasma was added to the tubes and was
therefore also added to the crossmatch tubes.
Requirements for good crossmatching technique
• If other techniques are used such as microcolumn tech-
Irrespective of the approach to compatibility testing, good niques the manufacturer’s instructions should be followed
clinical and laboratory practices should be followed to ensure for setting up and reading the crossmatch.
that errors are avoided or detected. This starts with taking the • Only one crossmatch should be handled at a time, and the
specimen from the patient. The attending clinician should crossmatch specimen should never be placed in the same
ensure that when collecting the specimen, it does not become testing rack or centrifuge, as another crossmatch specimen.
diluted or contaminated with intravenous fluid being This is to avoid using the wrong specimen for testing.
administered to the patient at that time. The specimen should
be taken into the correct tube, according to local requirements
Crossmatching methodologies
(dry tube or anticoagulated), be correctly labelled, and of
sufficient volume. It should reach the laboratory while still For ABO grouping during crossmatching, the use of anti-A,B
fresh, and show no sign of haemolysis. is optional. To determine the group of the patient, forward
The systems in place to avoid patient misidentification are grouping is carried out using anti-A and anti-B blood grouping
usually distinct and separate for hospital and laboratory reagents and reverse grouping is determined using group A
personnel. Therefore, good laboratory practice will not be able and B reagent red cells. To retest the ABO group of donations,
to prevent the consequences of patient misidentification at the anti-A and anti-B reagents are used.
bedside. Likewise, good bedside identification will not prevent Although the methods below apply to manual tube tests,
identification errors in the laboratory. One of the important the same principles apply to other methodologies such as
functions of a hospital transfusion committee is to address microcolumn/gel techniques (see Section 4: Principles of lab-
such issues. The role of the hospital transfusion committee is oratory techniques) and to the various automated techniques.
described in Section 14: Benefits and risks of transfusion. In the major crossmatch, both saline ‘immediate spin’
The following measures should be taken in the cross- and indirect antiglobulin test (IAT) methods are used for
matching laboratory, to ensure that recipients are transfused compatibility testing. The immediate or rapid spin result is
with blood of the correct group: designed to check that blood selected is ABO compatible
• If the specimen was taken into a dry tube, it should be and to show any incompatibility with an irregular IgM (or
properly clotted before use to avoid interference by fibrin saline-reacting IgG) antibody. The same crossmatch test may
in the tests. then be continued to the IAT phase, to detect any additional
• The information on the crossmatch specimen label and incompatibility with IgG antibodies.
request form should be compared to ensure that they are Blood that is urgently required may be released for trans-
the same. fusion if suitable at the immediate spin phase, provided that
• The ABO group on the patient should be performed twice the requesting clinician understands that there has been
and the RhD type determined and cross-checked. insufficient time to detect whether or not an IgG antibody is
• If the patient has received a blood transfusion previously present. If an IgG antibody is detected after blood has been
the ABO and RhD group of the current sample should be issued, the clinician should be requested to discontinue the
compared with the group on record. transfusion immediately. It is therefore important that when
• The ABO group of units selected should be repeated blood is issued on emergency, the crossmatch is continued to
(and RhD group confirmed for Rh-negative recipients), the IAT phase as soon as possible.
although this does not necessarily take place during the
crossmatch procedure. IAT and other test tube methods
• The ABO and RhD group of the units selected should be • IAT phase: is performed to detect IgG antibodies that may
compared with the group of the patient to confirm that cause transfusion reactions, and is used for the antibody
they are compatible. screening procedure using reagent screening cells and

© 2008 The Authors.

for the crossmatch using donor cells. The IAT is usually the crossmatching process is automated, anticoagulated
carried out in a low ionic strength medium, by adding a samples are required. If a specimen is anticoagulated with
low ionic strength additive reagent to the mixture of a substance that chelates calcium, such as EDTA, then
serum/plasma and cells at the time of setting up the test or complement-dependent antibodies may not be detected during
by suspending the donor cells in low ionic strength saline crossmatching or antibody screening.
(LISS). Using LISS, the incubation period is reduced to
between 10 and 30 minutes at +37°C ± 1°C, with a maxi-
Abridged crossmatching
mum of 2 hours. The advantages of using LISS are that
the sensitivity of the crossmatch is increased in addition ‘Abridged’ means shortened or abbreviated crossmatching. It
to the reduction in incubation time. has value in busy laboratories handling many specimens on a
• Polybrene: Positively charged polybrene (a polymer of daily basis, and applies to crossmatches without serological
hexadimethrine bromide) enhances the agglutination of complications. The objective is to provide suitable blood
sensitized cells by reducing their negative charge. Polybrene quicker, and more cost effectively, without compromising
is usually added to cells that have been incubated with patient safety.
serum/plasma in a low ionic strength, low pH medium. • ABO and RhD type is performed on patient’s sample and
• Polyethylene glycol (PEG): PEG is a water-soluble poly- blood units selected.
mer used as an additive to increase antibody uptake. PEG • An immediate spin test is performed, using serum/plasma
removes water molecules from around red cells, enhancing from the patient and cells from the blood units, to check
antibody uptake and reaction strength. for ABO compatibility.
• Proteolytic enzymes: historically, enzymes were also used • The IAT phase of the crossmatch using the donor cells is
to detect antibodies during crossmatching. Because of omitted.
their tendency to detect autoantibodies and other • The patient’s serum/plasma is tested against the reagent
antibodies that are not of clinical significance, their use in screening cells by the same IAT method as would have
compatibility testing has largely been discontinued. been used in the full crossmatch.
The abridged crossmatch is only suitable if no irregular
Anti-IgG versus broad spectrum AHG reagent antibodies have been detected in the patient’s serum/plasma.
The laboratory management team should decide whether or When the antibody screen tests are positive or the patient has
not to use anti-IgG AHG for compatibility testing or whether a history of irregular antibodies of clinical significance, then
the AHG reagent should be a blend of anti-IgG and anti-C3. compatibility testing using the donor cells by IAT must be
A blend will detect both IgG and complement-dependent performed.
antibodies. If PEG is used then anti-IgG AHG avoids numerous
false positives/cold/apparent non-specific antibodies.
Electronic crossmatching
Antibody screening The electronic or computer matching of blood has been
Testing the patient’s serum/plasma against known reagent introduced into busy crossmatching laboratories that have
screening red cells in addition to the donor cells is considered the appropriate infrastructure. The donor blood is matched
an integral part of the crossmatch procedure. The same IAT electronically with the patient; no serological crossmatch is
method as used in crossmatching the donor blood should be performed. The sample from the patient must be typed for
used for the antibody screening. ABO group and RhD and the serum/plasma must be tested for
• An appropriate set of group O reagent red cells is selected, the presence of IgG antibodies by screening by IAT. Provided
that together contain the common antigens within the that antibody screening tests carried out on the patient are
population, to enable the detection of antibodies of clinical negative, and no anomalous results are obtained in the
significance. It is preferable to use cells that are apparently grouping, and there is no history of irregular antibodies,
homozygous for Fya, Fyb, Jka, Jkb, S and s antigens as blood of the same ABO and Rh type can be selected and
some antibodies react better with homozygous cells. The issued using a validated computer program.
minimum to achieve this is probably a two-cell screen set. The following apply to the electronic crossmatch:
• The reagent screening cells should also lack low frequency • Only a validated computer system should be used.
antigens where the corresponding antibodies are not of • The ABO group of the patient should be carried out
clinical significance e.g. Bga. twice.
• The following details should be captured into the computer
Anticoagulants for crossmatch specimens program
For manual compatibility testing, dry tubes are suitable for – ABO and RhD type of patient
the collection of blood samples from patients. However, once – antibody screening results of patient

© 2008 The Authors.

– at least two details by which the patient may be identified ABO blood group and RhD type (as Rh-positive or Rh-negative)
(e.g. name and hospital number) of the intended recipient, the first choice of donor blood, and
– donation number of unit(s) of blood intended for the order of selection of suitable blood of other groups.
transfusion
– type of component intended for transfusion (e.g. red
Points to consider when selecting blood
cell concentrate or platelets)
– blood type confirmed, of blood units selected for • When ABO group compatible blood is to be used instead
transfusion. of ABO group identical blood, it must be low titre and free
• An electronic link between the ABO and RhD type of of ABO haemolysins (see Section 10: Donation testing for
selected units and the ABO and RhD type of the recipient more details). The presence of haemolysins in donor
should be in place to check that they match (are compatible). plasma may cause haemolytic reactions in recipients
• The computer program should alert the operator to any with the corresponding ABO antigens. This is applicable
error, incompatibility or discrepancy. primarily to blood products such as whole blood that
contains plasma.
• RhD positive blood should always be selected for RhD
Type and screen
positive individuals. Although RhD negative blood may
This option is useful when it is not certain that the patient safely be transfused into RhD positive patients, RhD
will need a transfusion. The attending clinician submits a negative units are often in short supply and should be
specimen and crossmatch request form with the under- reserved for use in RhD negative patients.
standing that blood will only be crossmatched if needed, • In most situations, donations that are nearest to their
usually over the next 3 or 4 days. During this time, a telephonic expiry date should be used first.
order for blood may be given to the laboratory. Most type and • If a patient is group AB, and group AB donor blood is not
screen requests are not converted into crossmatches, so rea- available, then group A or B blood may be selected
gents and time are saved and units of blood are not reserved instead, depending on which is more readily available
without being used. (which usually depends on the frequency of the blood
The following laboratory tests are included in a type and group in the donor population).
screen request:
• ABO and RhD type. Table 13·1 Selection of donor blood by ABO group and RhD type for
Determination of the ABO and RhD type of the patient crossmatch
before blood is needed, provides time to check that group
compatible units are available in stock, and if not, to make First choice ABO Group compatible
arrangements to obtain such units from another area. ABO group and group and RhD blood in order
• Antibody screening. RhD type of patient type of donation of selection
Positive antibody screening tests indicate the presence of
irregular antibodies in the serum/plasma of the patient. In A Rh-positive A Rh-positive 1. A Rh-negative
2. O Rh-positive
such cases, antibody identification tests should be carried out
3. O Rh-negative
to determine specificity. Should clinically significant anti-
bodies be identified, the best option for the laboratory is to A Rh-negative A Rh-negative O Rh-negative
proceed with screening donations in order to find compatible B Rh-positive B Rh-positive 1. B Rh-negative
units. If a transfusion is later required, delays may thus be 2. O Rh-positive
avoided. The prescribing clinician should be notified at the 3. O Rh-negative
outset of expected delays in the provision of compatible
B Rh-negative B Rh-negative O Rh-negative
blood.
O Rh-positive O Rh-positive O Rh-negative

O Rh-negative O Rh-negative No other suitable

Selection of blood
AB Rh-positive AB Rh-positive 1. AB Rh-negative
Blood selected for crossmatch should be blood type identical 2. A or B Rh-positive
or if this is not available, group compatible. For example, a 3. A or B Rh-negative
group A patient should be given group A blood. If group A 4. O Rh-positive
blood is not available, then group O blood that does not con- 5. O Rh-negative
tain haemolysing anti-A could be selected instead. Group O
AB Rh-negative AB Rh-negative 1. A or B Rh-negative
red cell concentrates are preferred to whole blood since they 2. O Rh-negative
contain practically no anti-A or anti-B. Table 13·1 gives the

© 2008 The Authors.

• Patients who type as very weak subgroups of A should hospital personnel must be notified should an incompatibility
receive group O blood. Patients who type as weak AB be detected so that the transfusion may be stopped.
should receive group B blood. If the emergency is such that the prescribing clinician
• Group AB Rh-positive patients may be referred to as cannot wait 30 minutes, he/she may take the responsibility
‘universal recipients’ as they may receive blood from all for transfusing blood without crossmatch, in which case
ABO and RhD groups. group O low titre Rh-negative blood should be provided.
• In cases of emergency when Rh-negative blood is Some hospitals keep small stocks of group O blood for
unavailable, Rh-positive blood may be used for Rh- emergency use. It is important that such stocks are controlled
negative male patients. Rh-positive blood must not be by the blood bank, to ensure that they are kept within the
given to Rh-negative female patients with the potential to correct temperature range, and that they are not tampered
bear children. The attending clinician should take respon- with, or removed and then replaced in stock. Records of
sibility for the decision to transfuse Rh-positive blood emergency transfusions from hospital stock are just as
into an Rh-negative recipient. In an attempt to inhibit important for traceability, and details of recipients should
Rh-immunization in case of accidental transfusion of D+ be documented on the same blood request forms as used for
red cells to a D− patient, anti-D immunoglobulin may be other patients.
given to the patient immediately after the transfusion to Whenever blood is used in emergency situations, it should
inhibit anti-D formation. This may however, not be a be crossmatched if possible – if not at the time of transfusion
viable option, due to the volume of anti-D required and – then as soon as possible thereafter.
the prohibitive expense, if the volume of Rh-positive cells A rural hospital may not have access to a compatibility
transfused is large. testing laboratory. Patients may be RhD typed, either at the
• When group identical blood is unavailable, group com- bedside or on admission, using ‘point-of-care’ rapid testing.
patible or group O blood may be provided for a patient of Those who type Rh-positive and need transfusion may then
another group. If group identical blood then becomes be given group O Rh-positive blood units from hospital stock,
available, it may be considered for use if the number of reserving the group O Rh-negative units for Rh-negative
group compatible/group O units transfused to the patient patients. In countries where the majority of the population is
has not exceeded the prescribed number (according to RhD positive, there would likely be a chronic shortage of
local protocols). A crossmatch should be performed using Rh-negative donations and this practice prevents the unneces-
a fresh specimen from the patient to check whether the sary use of Rh-negative blood.
presence of ABO antibodies in this specimen causes blood
of his/her group to be incompatible. If this happens, then
Use of fresh blood
group compatible/group O blood should continue to be
used. Problems like this are more likely to arise when It is standard practice to use stock blood in expiry date order,
whole blood is used instead of red cell concentrates, for routine transfusion requests, so that there is less likelihood
because of the volume of plasma involved. of blood reaching its expiry date and having to be discarded.
• When a massive transfusion has been given, in which the However, because of their clinical status, some patients
volume of blood transfused within 24 hours equals the may require fresh blood. Ideally this should be less than
estimated blood volume of the patient; continuing to 5 days from donation. Fresh blood may be requested in the
crossmatch further units requested, may not be of value. following cases:
When authorized by the clinician, further units for trans- • Infants under the age of 4 months
fusion may be retested to check ABO group only and issued • Patients requiring exchange transfusion
without crossmatch. • Patients undergoing massive transfusions.

Standard and emergency situations Use of autologous blood

Although it may take less than 30 minutes to crossmatch In cases of elective surgery, patients may donate their own
blood for a patient, logistically, more time is needed, especially blood for transfusion. This facility of preoperative blood
in a busy laboratory. Therefore, approximately 2 hours is donation is mentioned in the discussions on autologous
required for a standard crossmatch. donations in Section 8: Blood donors and Section 9: Blood
If blood is urgently required, then it may be issued after a collection, and describes how the donor/patient gives blood
direct match between patient’s serum/plasma and donor’s red over a period of weeks, and then has these units transfused
cells. In this case, blood could be made available in less than back during or after surgery. Only individuals who are in
30 minutes. Thereafter, compatibility tests that have not been reasonable health and who have the approval of their clinician
completed prior to the issue of the blood are finalized. The are able to participate in such a programme.

© 2008 The Authors.

Other ways in which autologous blood may be used within • If repeated small volume transfusions are anticipated,
the hospital environment, include the following: blood from the same donation should be divided into
• Acute normovolaemic haemodilution by perioperative aliquots and reserved for the infant to reduce the risk of
blood donation: This involves collecting blood from the TTI exposure and to limit exposure to donor red cell
patient immediately before surgery and replacing it with antigens.
fluids to maintain blood volume, which is important for • If a large volume is to be transfused, such as in an exchange
cardiac function and the delivery of oxygen to the tissues. transfusion, it is preferable to use blood that is compara-
The patient becomes anaemic but remains normovolaemic. tively fresh (up to 5 days from the date of collection).
After surgery, when bleeding stops, the blood collected is • For large volume transfusions it may be better to use blood
returned to the patient. Because it is fresh, it contains viable collected into CPDA-1, rather than red cells suspended in
platelets and clotting factors. additive solution.
• Intraoperative blood salvage: Using a special apparatus, • Providing filtered red cells that are leucocyte-depleted,
blood is collected aseptically from where it is shed, within the minimizes the chance of CMV being transfused. Alterna-
surgical area during the operation. It is then anticoagulated, tively, donations that test negative for anti-CMV could be used.
filtered and re-infused either during the operation or after • Irradiating blood prevents graft versus host disease in
surgery. This process is not suitable for procedures involving immunodeficient patients such as infants.
the bowel.
• Postoperative blood salvage: Blood lost after surgery is
Provision of blood in malaria areas
aseptically collected by drainage using a special appa-
ratus, in which it is anticoagulated and filtered before Blood that is collected from donors living in areas where malaria
re-infusion. is endemic is probably best retained for use within that area,
and not transferred to areas where malaria is not endemic.
There are several reasons for this, including the following:
Transfusion in chronic anaemia
• Individuals living in areas where malaria is endemic
Patients with chronic anaemia may require repeated develop a greater resistance to malaria than individuals
transfusions. living in areas where malaria is not endemic.
A special panel of designated, phenotyped blood donors • Clinicians working in these areas are familiar with the
may be put in place for patients starting a chronic transfusion signs and symptoms of malaria and are more likely to
regime, to minimize the chances of development of clinically recognize the infection post-transfusion than clinicians
significant antibodies, which would make the finding of working in areas in which malaria is seldom seen.
compatible blood increasingly difficult. Donors, whose red Many transfusion services attach a label to units of blood
cell antigens match those of the recipient, not only for ABO collected in areas where malaria is endemic in order to draw
and Rh, but for other major immunogens such as K, should the attention of the medical personnel to the fact that the
be selected for such a panel. recipient should be appropriately monitored following the
A side effect of repeated transfusion of red cells is the transfusion.
accumulation of iron in the body. Iron overload can affect Whenever possible, blood collected in malaria areas should
organs such as the pituitary gland, thyroid, heart and/or liver, not be used for infants, pregnant women or other groups of
leading to serious health problems. To enable excess iron to patients that are at higher risk, even if these patients reside
be excreted, ongoing chelation therapy using special drugs in areas in which malaria is endemic.
prescribed by a clinician, may be required. Use of concomitant anti-malaria therapy should be considered
when blood from a malaria area is transfused to a patient who
does not normally reside in a malaria area.
Blood for infants
Blood for transfusion into infants less than 4 months of age
Massive transfusion
requires special consideration and the medical director may
need to be consulted in some cases. Some important points Massive transfusion is usually defined as the replacement of the
in respect of blood for infants are given in the summary patient’s blood volume, or more, within a 24-hour period. Several
following: factors require consideration in massive transfusions:
• If a blood group antibody is detected in the serum/plasma • Massive transfusion may be associated with the develop-
of an infant, it is probably of maternal origin. Blood ment of coagulation abnormalities. Coagulation factor
selected should lack the corresponding antigen and be levels should therefore be monitored, and fresh frozen
crossmatch compatible with maternal serum/plasma, plasma (FFP) or platelets transfused if necessary to correct
using the IAT crossmatch. the situation.

© 2008 The Authors.

• The rapid infusion of cold blood may cause debilitating commencing the second unit. If this is not done, agglutinates
hypothermia in the massively transfused patient. To avoid of red cells could form beyond the filter and enter the recipient’s
this, blood may be transfused through a blood warming circulation. This precaution is not necessary if only the RhD
device that meets quality and safety standards. group of the units is different.
• There may be toxic effects from citrate in the anticoagulant,
which is infused together with whole blood or FFP, and it Additional note on administration sets
may become necessary for the clinician to administer Blood products should always be administered through an
calcium to counter these effects. This is usually given in appropriate administration set with an in line 170–200 micron
the form of calcium gluconate or calcium chloride, the filter chamber. Other intravenous fluids or drugs should not
dose of which should be carefully calculated. be administered via the blood administration set. For ongo-
• In stored blood, the plasma levels of potassium are ing transfusions, the administration set should be changed
considerably higher than in fresh blood. When given in every 12 hours or after every four units of blood transfused.
large volumes, plasma potassium may be harmful to the
patient, so the use of blood stored for up to 5 days only
should be considered for use.
Alternatives to transfusion
• Microaggregates of white cells and platelets form during Although the products discussed below are not supplied by
the storage of whole blood and if these are not removed the blood transfusion service, information on alternatives to
by filtration, they may be harmful to the patient. transfusion are provided for the benefit of the student.
• One unit of blood contains approximately 250 mg of
iron, mostly contained within the haemoglobin in the red
Replacement fluids
cells. As the body generally excretes only 1 mg of iron per
day, large volumes of blood given to patients can result in Replacement fluids may be used for resuscitation, to limit
a build-up of iron in the body. blood transfusion, or when blood is not readily available.
Replacement fluids may be needed when a large volume of
blood has been lost, such as immediately after trauma, during
Changing blood type during one transfusion episode
surgery or in the treatment of extensive burns. The most
Patients should ideally receive blood that is ABO group identical. important treatment for hypovolaemia is to restore the
However, available stocks of safe blood may be in short supply. circulating blood volume in order to maintain tissue perfusion
It may be necessary, especially in emergency situations, to and oxygenation.
change the ABO group of units transfused during the same
transfusion episode, for several reasons. Replacement fluids are usually crystalloids or colloids
• If a non-group O patient is given large volumes of group • Crystalloids are aqueous (water-based) solutions of low
O blood in an emergency and ABO identical blood sub- molecular mass salts. Glucose may also be added to these
sequently becomes available, crossmatching should be solutions. Crystalloid solutions are isotonic or slightly
performed using a sample drawn after the infusion of the hypotonic and may contain dextrose. They cross the
group O blood. If the donor antibodies passively transferred capillary membrane from the bloodstream into the interstitial
to the patient and circulating in the recipient are not of spaces and are rapidly distributed within the extracellular
sufficient quantity to react with red cells of the same compartment.
ABO group as the patient, then the patient’s own ABO • Colloids contain larger molecular mass molecules in
group can be given. If donor antibodies are detected, it suspension, such as proteins or large glucose polymers.
would be necessary to continue to transfuse group O blood. Colloids do not pass through the capillary membranes
In addition, protocols should be available to determine into the tissues and therefore raise the osmotic pressure of
the maximum number of group O units that can be trans- blood. Colloids may be classified as:
fused prior to changing to another group. – plasma-derived, such as human albumin
• When stocks of blood that match the ABO group of the – synthetic, such as dextrose starches (hydroxyethyl
patient become depleted before the end of the transfusion starches or HES), dextran and gelatines.
episode, it will be necessary to change from ABO identical Crystalloids and colloids used as replacement fluids should
to ABO compatible blood. ideally:
• When there is insufficient Rh-negative blood it may be • Be widely available and cost effective
necessary, in an emergency, to transfuse Rh-positive blood • Be non-toxic and unlikely to cause infection
into a male Rh-negative recipient. • Remain in the intravascular compartment for a sufficient
It is important that if the ABO group of consecutive length of time
units is different, the administration set is changed before • Assist with blood volume expansion

© 2008 The Authors.

• Have no adverse effect on haemostasis Possible clinical uses: red cell substitutes (not to be
– not cause allergic reactions viewed as a recommendation by the authors)
– be metabolized or eliminated in due course from the body. • Replacement at the time of preoperative haemodilution
The benefit of crystalloids is short-lived as they are • Resuscitation after massive blood loss
redistributed extravascularly. Therefore, about three times • Extracorporeal use, such as in bypass or haemodialysis
the volume of blood that was lost is needed for replacement. machines
Crystalloids accumulate in the extravascular space, which • Substitute for blood for patients with multiple antibodies.
may cause interstitial/pulmonary oedema.
Colloids have a longer duration of action but are more Advantages
expensive and may cause volume overload. They may • Reduction or avoidance of human blood use
interfere with haemostasis, cause allergic reactions, risk renal • Immediate benefit for trauma patients before blood is
dysfunction and provide no clinical evidence of being more available
effective than crystalloids for resuscitation. • Preservation of organs for transplantation (perfusion after
harvesting)
Crystalloids • Compatible with patients of all blood groups
• Normal saline (0·9%) • Storage at room temperature
• Other crystalloids are commercially available, such as • Non-immunogenic.
Ringer’s Lactate and Plasmalyte B
• Dextrose-containing crystalloids are only used for main- Disadvantages
tenance, not for volume replacement. • Short half life in vivo
• Costly to produce and provide
Colloids • May be toxic
• Human serum albumin – fractionated from large pool • Not available in countries where they are not licensed.
plasma, and pasteurized
• Gelatines
Recombinants
• Hydroxyethyl starches.
Recombinant products are genetically engineered forms of
FVIII, FIX and FVIIa. As they are not derived from human
Red cell substitutes (oxygen therapeutics)
blood they do not carry the same risk of TTIs. Even though
Alternatives to the red blood cell as a vehicle for the delivery human-derived plasma derivatives are made viral-safe, concern
of oxygen have been under development for decades. It is remains about the risk of transmission of as yet unidentified
recognized that the availability of a red cell substitute would infectious agents. As part of the manufacturing process for
present many advantages, such as universal usage without recombinants, a copy of the human gene for FVIII, FIX or
the risk of ABO mismatch. However, to find a suitable FVII is inserted into a host cell, where copies of the gene
alternative as the carrier and distributor of oxygen has proved continue to be produced. This host cell came originally from
an enormous challenge. a hamster, but now large volumes of ‘factor’ are produced in
Red cell substitutes cannot be used in a country without manufacturing laboratories.
appropriate licensing. Those that are currently available can Recombinant products perform in the same way as human
at best be seen as a bridge to transfusion. When blood is not plasma derivatives, and replace the clotting factor lacking in
available they may be used primarily to treat severe anaemia the patient, in order to stop or prevent bleeding.
and resuscitate patients with hypovolaemia. A small minority of patients develop inhibitors to FVIII or FIX,
They fall into two main categories: which complicates the efficacy of the product, whether of human
origin or a recombinant. Patients who develop inhibitors to
Haemoglobin solutions FVIII or FIX may be treated with recombinant FVIIa. This product
The haemoglobin used for these solutions is either of can also be used to treat patients with a FVII deficiency. At
human, animal (bovine) or microbial origin. Although solu- this stage, patients with von Willebrand’s disease continue
tions may be pasteurized, there are still concerns regarding to be treated, when supplementation of von Willebrand
safety. factor is specifically indicated, with plasma-derived FVIII.
Recombinant clotting factors are provided in powdered
Perfluorocarbons form, for reconstitution with sterile water immediately before
These are synthetic compounds that are solvents for oxygen. use. The products should be stored according to manufacturer’s
They are produced as emulsions and when infused, increase instruction, which is usually for up to 6 months at room
the transportation of gases in vivo. temperature (maximum of +25°C).

© 2008 The Authors.

patient, blood of the same group as the patient should be

Modified red cells
crossmatched to avoid incompatibilities as a result of anti-H.
Conversion to group O • The patient and laboratory records should be checked for
Research has been ongoing on the conversion of group A (or B) errors that may have occurred.
blood to group O. This has been performed by using bacterial • A direct antiglobulin test (DAT) should be performed on
enzymes that are able to remove sugar molecules from the red the red cells of the patient to check for sensitization. If the
cell surface, thus removing the A (or B) terminal sugars that DAT is positive it may indicate that the patient has a
determine blood group. The conversion of group B to group haemolytic anaemia, or has suffered a delayed transfusion
O has also been achieved by using recombinant coffee bean reaction to blood already transfused. The cause of the
alpha-galactosidase. If research of this nature proves successful, positive DAT may be unknown (patients who are HIV positive
it may eventually lead to the availability of universal red cells frequently have a positive DAT).
that may be transfused into patients of any ABO group. This • An autoantibody test should be performed to determine
research does not include the RhD antigen, so Rh-negative whether the incompatibility could be the result of auto-
blood would still be required for Rh-negative recipients. antibodies. However, a positive autoantibody test may
mask clinically significant antibodies.
Cultured red cells • Further units should be crossmatched, particularly if only
Cord cell derived CD34+ stem cells are used as the starting a small proportion of blood units originally crossmatched,
material to culture and develop mature red blood cells that were incompatible. Further compatible units should not
function normally. During the process of conversion, CD34+ be difficult to find, particularly if the patient has an anti-
cells are mixed with erythropoietin and interleukin-3. There- body to a low frequency antigen. Crossmatch compatible
after, the stem cells are cultured on cell stroma extracted from blood may then be issued.
bone marrow or fetal liver with the addition of cytokines. The • Antibody identification should be performed using the
mature red cells that are produced have the same lifespan as technique by which the incompatibility was detected and
red cells in vivo (120 days), which is a major advantage. The additional techniques to determine the clinical signifi-
biggest disadvantage is the cost of producing these ‘designer’ cance of the antibody.
red cells, and the size of the operation that would be needed • Typing the patient’s red cells to determine which red cell
to produce sufficient stocks. antigens the patient lacks can be a guide to the possible
specificity of the antibodies.
• The IAT phase of the crossmatch should be repeated without
Incompatibilities using an additive solution or low ionic strength medium,
i.e. doing a saline IAT.
Dealing with incompatibilities efficiently and
Once the specificity of the antibody is known, various
effectively
options are available:
If donor red cells are sensitized, agglutinated or haemolysed • Appropriate antigen negative blood may be available in
by the patient’s serum/plasma during any stage of the cross- the stock of phenotyped blood, and may then be selected
matching procedure the incompatibility needs to be investigated for crossmatching.
as a matter of urgency. The clinician should be notified • Commercial reagents may be required to screen for antigen
immediately should there be an anticipated delay in providing negative blood in the available stock that can then be
compatible blood, checking beforehand that there is crossmatched using the patient’s serum/plasma.
sufficient sample remaining in the specimen from the patient. • The patient’s serum/plasma may be used to screen for
If not, a further specimen should be requested at the same blood units. Those that test negative should be typed to
time. Ongoing communication between senior technologist confirm that they do not have the antigen towards which
and prescribing clinician is important for optimum patient care. the patient’s antibody is directed.
If the incompatibility was detected after the blood was issued If the reason for the incompatibility cannot be established
on emergency, the clinician should be notified immediately or the antibodies cannot be readily identified, a medical
and the transfusion stopped. decision may be made to transfuse the patient with the least
Every laboratory should have clear guidelines on how to incompatible unit if the patient’s care will be compromised
deal with incompatibilities efficiently and effectively so that by withholding or delaying a blood transfusion.
good patient care is not compromised.
Steps taken should include:
Antibodies to high incidence antigens
• Checking the ABO group of the patient and the donor
blood to ensure that the ABO groups are compatible. If If all units crossmatched are incompatible, antibodies to high
group O blood has been crossmatched for a group A, B or AB incidence antigens should be suspected. The patient’s serum/

© 2008 The Authors.

plasma should be tested against the panel cells used for antibody obtained. If the patient is known to suffer from an autoimmune
identification and additional panels if available. The strength haemolytic anaemia and warm reacting autoantibodies are
of the reaction and the technique by which the antibodies react detected, all blood crossmatched will be incompatible. If the
should be noted as this may give an indication of the specificity patient’s red cell type, particularly the Rh phenotype, is
of the antibodies. If the antibodies cannot be identified readily known or the patient’s red cells can be typed, it is preferable
in the laboratory, the patient’s sample should be transferred to transfuse phenotype-matched blood. If the patient has been
to a reference laboratory for identification, if possible. transfused previously, additional tests should be performed
When investigating apparent antibodies to high incidence in the appropriate laboratory to determine whether the auto-
antigens, the possibility of a mixture of antibodies of various antibodies are masking clinically significant alloantibodies
specificities should be considered. Therefore the degree of (autoadsorptions/alloadsorptions/titrations/tests against rare
agglutination and the techniques by which the incompatibilities high frequency antigen negative cells may be required).
were detected is significant. Units that are negative for a com-
bination of antigens may be difficult to source (e.g. if the patient
has anti-e, anti-Fya and anti-Jkb antibodies, screen first for R2R2
Patient records
units and then screen those R2R2 units for Fy(a–) and Jk(b–) The crossmatch register should contain all the details on
units). This can be extremely time-consuming. If the antibodies patients for whom a request was received for blood or blood
are clinically significant antibodies to very high frequency products. This register could be hard copy or electronic, or
antigens it may be necessary to obtain blood from a rare donor both. The details recorded should be taken from the informa-
registry where blood donations from individuals with rare tion provided on the request form, including the following:
antigen negative blood types may be stored frozen. The units • Unique crossmatch number allocated by the laboratory
are stored frozen using special techniques, at extremely low • Title (Mr, Ms or newborn/infant)
temperatures for a greatly extended shelf life (see Section 11: • Last name, followed by first name
Blood processing for more details). If blood is needed, it must • Gender
be thawed and deglycerolized before use. Shelf life post-thawing • Age (or date of birth)
is limited to 24 hours when a manual process is used, and may • Hospital
be extended to 2 weeks depending on the validation of the auto- • Hospital number/social security/ID number
mated process used. There are also substantial costs involved. • Hospital ward (if applicable)
• Date and time of receipt of patient’s sample
• ABO and RhD type of patient
Cold agglutinins
• Details on issue of ABO non-identical blood, if applicable
During the crossmatch procedure if all units tested are • Comments on crossmatch difficulties or irregular antibodies
incompatible in the immediate spin phase and not in the IAT • Type of product and number of units requested
phase, cold agglutinins can be excluded by warming the tests • Type of crossmatch (emergency, standard, or type and
to +37°C and rereading. The autoantibody controls should be screen)
set up and read at the same time. • Prescribing clinician
If the patient is suffering from cold haemagglutinin disease • History of transfusions.
(CHAD) or has pathologically high cold haemagglutinins
reactive above +30°C (high cold agglutinin titre) the patient’s
Repeat blood orders
sample may be autoagglutinated on arrival at the laboratory.
A free suspension of cells can usually be obtained by washing The crossmatch request form should contain information
the patient’s cells in warm saline. In severe cases it may be about previous transfusions a patient received, such as where
necessary to obtain a sample from the patient and keep it at the transfusion was given, and when. Every effort should be
+37°C continuously until the serum/plasma and cells have made by laboratory personnel to trace the details of previous
been separated in the laboratory. transfusions, and note these on the request form. When the
The prescribing clinician should be informed of the pres- blood type of the patient is determined, it should be compared
ence of cold agglutinins in the patient, as it may be necessary with the one on record. Any blood type anomalies should be
to warm the blood as it is being transfused using a validated brought to the attention of the senior technologist and the
blood warmer specifically designed for that purpose. prescribing clinician as soon as possible. The best course of
action would be to take another specimen from the patient to
confirm the blood group.
Haemolytic anaemias
Difficulty in the provision of compatible blood for a
If the patient’s cells are sensitized in vivo (DAT positive) and patient, such as when a clinically significant irregular
all units tested are incompatible, the patient’s history must be antibody is present, should be documented in detail so that the

© 2008 The Authors.

record reflects the actions that were taken. This will provide
Issue of blood
guidance on how to approach the problem in future. Some
clinically significant antibodies are transient in nature, such as At the time of issue of blood, the blood bank technologist
anti-Jka. When the record states that the patient has anti-Jka, should carefully check all the details on the request form, on
Jk(a–) units of blood should be selected for crossmatch, the blood bag label and on the request slip presented by the
even if the antibody screening tests are negative using Jk(a+) hospital representative, to ensure that they match. However,
red cells. if blood is to be delivered by the blood bank to the hospital
During a single transfusion episode, requests for additional ward, then there would be no additional request slip against
units to be crossmatched for a patient are sometimes received which to check. A laboratory error would occur at the time
by the blood bank. The same crossmatch sample may con- of issue if the wrong request form was retrieved and a unit of
tinue to be used, provided that there is sufficient specimen blood relating to that incorrect request form, issued. If the
remaining for the testing required. However, the sample used wrong request form is used, the unit of blood issued will not
should not be more than 72 hours old from the date of the first relate in any way to the patient for whom the hospital is
transfusion; a fresh sample should be requested if additional expecting blood to be issued. If the hospital personnel do
units are required to be crossmatched after this period of time. not detect the error, by checking the blood bag label against
the patient’s details just prior to transfusion, then blood
Confidentiality of communication that does not relate in any way to that patient, will be
• All communication with the hospital regarding patients administered.
should be clearly documented on the crossmatch request The blood bank technologist who issues the unit of blood
form, together with dates and times, by the blood bank is also responsible for carefully inspecting the blood bag, to
technologist receiving the message. confirm the following:
• Any information regarding patients and their records is • Blood has not reached its expiry date.
confidential and should not be divulged to anyone not in • There is no evidence of damage or leakage.
authority to receive it, which includes family members. • The contents are not discoloured, or haemolysed or have
Any communication with the family regarding results of any other sign of contamination.
laboratory tests, and other details with regard to cross- Once the unit of blood has left the blood bank, it usually
match requests, should be performed by the clinician. becomes the responsibility of the medical/nursing personnel
in the hospital ward. It is very important that the blood is
given to the correct patient. As with any other medicinal
Transplantation leading to change in blood type
drug, blood can have serious side-effects if given to the wrong
Bone marrow transplantation is sometimes the treatment of patient. Bedside identification of patient, and matching with
choice for patients suffering from diseases such as leukaemia. the blood bag label is therefore of utmost importance.
These patients may have had many transfusions, and their
blood type therefore noted in laboratory records. Blood bank
Starting the transfusion
personnel may not always be informed when such a patient
receives a bone marrow transplant. If the transplanted material Checking patient identification at the bedside, by matching
was from a donor with a different blood type, then the blood his/her wristband information (which could be bar-coded
type of the recipient will change to that of the transplant. and include a photograph), with a portable electronic device
Should a post-transplant blood sample be received by the such as a ‘palm held’, reduces the chance of misidentification
laboratory, it will no longer reflect the blood group on record. further, provided that the blood bag label is linked into the
The technologist should query any such anomaly and record checking process.
the reason for the anomaly. Clinicians prescribing transfusion should be provided with
information on the correct procedure for administering
blood, and handling reactions, for all blood products issued.
Retention of specimens and transfused units
Checking procedures should include the following instructions
In case of an untoward transfusion reaction, specimens used for to medical and nursing personnel regarding:
crossmatch and units transfused may need to be investigated • Blood containers, that should be inspected for:
and tests repeated. It is therefore very important that specimens – evidence of damage or leakage
used for crossmatches are retained by the blood bank. It is just as – evidence of discoloration, contamination or haemolysis
important that the hospital retains the remains of all transfused of contents
units. The length of time that specimens and transfused units – expiry date, which should not have been reached
should be retained depends on the available storage space at – details on the compatibility label, which should match
+4°C ± 2°C, but this should be for a minimum of 24 hours. those of the patient.

© 2008 The Authors.

• Storage conditions: at +4°C ± 2°C for red cells and FFP, – haemoglobinuria (blood in urine)
and that FFP and platelets should be transfused on receipt – anuria or oliguria (no urine or reduced output of urine)
from the blood bank. – unexplained bleeding (may indicate disseminated
• Warming of blood: this should be performed only when intravascular coagulation).
absolutely necessary, such as for exchange or massive Untoward reactions should be investigated to establish
transfusion, and then by using an approved blood warmer their cause, and all findings documented and analysed to
specifically designed for that purpose. determine what actions could be initiated to prevent their
• Addition of medication and solutions: no additives should recurrence.
be transfused with blood; the only exception being sterile
normal saline.
Transfusion reaction investigation
• Blood administration sets: an appropriate administration
set fitted with a 170–200 micron filter should be used When notified of a transfusion reaction, crossmatch labora-
whenever blood products are transfused. tory personnel should request the return of all blood bags
• Used blood containers: after transfusion, empty containers from which blood was transfused during the transfusion
and administration sets used should be kept at +4°C ± 2°C episode, together with a post-transfusion blood specimen for
for a minimum of 24 hours, in case of adverse reaction investigation. Transfusion reaction investigations should
and subsequent investigations that may be required. always be carried out immediately on receipt and discrepancies
For at least the first 30 minutes of any blood transfusion, detected should immediately be brought to the attention of
the patient should be carefully observed for any signs of an the technologist in charge of the crossmatching laboratory
untoward reaction. The blood should be administered slowly and the consultant haematologist.
at first, if feasible, because the amount of blood transfused is
often proportional to the severity of reaction. Clerical check
On receipt of the reaction report and post-transfusion speci-
mens, the first step is a clerical check of all transfusion doc-
Transfusion reactions and haemovigilance umentation to ensure that the correct blood was issued and
If a reaction is observed, the nursing personnel responsible that there was no misinterpretation of the laboratory results
for the observation of the patient should stop the transfusion or any other errors made. The reaction report form submitted
immediately and alert the medical personnel. The patient by the clinician should also be checked against the original
should be immediately treated for the reaction. crossmatch request form to ensure that the patient identifi-
Thereafter, the prescribing clinician should complete and cation details match. The signs and symptoms noted by the
submit a reaction form provided by the blood bank, in which clinician should be checked as they may assist in identifying
the following information is documented: the type of reaction.
• Details of the patient (name, hospital, number and ward,
diagnosis, state of consciousness) Visual check
• Details of the blood product (type, container number, The serum/plasma from the patient’s pre- and post-transfusion
blood group, volume transfused) samples should be examined for any sign of haemolysis or
• Details of the reaction (time transfusion started, time of jaundice and evidence of either, documented. If the post-
start of reaction) transfusion sample appears haemolysed or jaundiced the
• Clinical signs and symptoms should be indicated, and clinician should be informed and the reason established.
these may include the following, especially in the case of Further testing to determine the bilirubin levels would probably
a haemolytic transfusion reaction: not be performed in a crossmatching laboratory.
– nausea The bags from which blood was transfused are returned and
– headache the partially or empty bags must be examined for haemolysis,
– back pain discoloration or untoward appearance.
– chest pain
– shock ABO group
– urticaria (rash) It is most important to verify that blood of compatible ABO
– anxiety (restlessness) group was transfused. Therefore, the ABO groups of both
– flushing (redness, particularly in the face) pre- and post-transfusion specimens, plus all units of blood
– fever/rigors (raised temperature/severe trembling) transfused, are tested to confirm ABO compatibility, or
– tachycardia (increased heart rate) discover if there was an ABO mismatched transfusion. It
– hypotension (low blood pressure) should never be presumed that only the last unit transfused
– bronchospasm (difficulty in breathing) was the cause of the reaction.

© 2008 The Authors.

RhD type was not transfused within the last 3 months (in which case
Likewise, RhD typing is repeated on the pre-transfusion transfused red cells will be present).
specimen, and performed on the post-transfusion specimen
plus units of blood transfused to determine whether or not Haemoglobin
there was RhD incompatibility between patient and units A failure of the haemoglobin level to be raised post-transfusion
transfused. may be an indication that transfused cells were rejected
(because of an undetected and clinically significant antibody),
Antibody screen and that the cells transfused were removed from the patient’s
The antibody screen test is repeated using the serum/plasma circulation. The patient may be suffering a delayed transfusion
of both pre- and post-transfusion specimens and the same reaction.
batch of screening cells as used in the initial crossmatch
procedure. This is to determine whether an irregular antibody Tests on urine
has become detectable in the post-transfusion specimen and A pooled 24-hour urine specimen should be collected and
to check that an irregular antibody was not present during then tested for the presence of haemoglobin, as this is an
initial testing. indication of a haemolytic transfusion reaction. This test is
not necessarily performed at the blood bank.
Immediate ‘spin’ crossmatch
Saline crossmatches between the serum/plasma of both Tests for bacteria
pre- and post-transfusion specimens and red cell suspensions A culture may be performed on the blood remaining in the
prepared from the transfused units are carried out. These bags of blood transfused. It is important to identify the type
immediate ‘spin’ tests are performed without an incubation of micro-organism if it is found that the bag is contaminated.
period. Their main purpose is to check for ABO compatibility If the transfusion reaction was as a result of bacterial
but also to detect IgM reacting irregular antibodies in the contamination of blood transfused, this is extremely serious
serum/plasma of the patient. and life-threatening. In the event of possible contamination
it is important to establish the conditions under which the
IAT crossmatch bag was stored prior to it being returned to the blood bank.
An IAT crossmatch is performed using both pre- and post- If components were prepared from the original donation
transfusion specimens against the red cells of the units all components should be traced and tested for bacterial
transfused. This is to determine whether an irregular antibody contamination.
against a donor derived antigen has become detectable in the
post-transfusion specimen, and to check that an incompati-
Haemovigilance
bility as a result of an IgG antibody was not present during
initial testing – an antibody may have been present but was The process of monitoring and evaluating all incidents and
below the detectable level. Any incompatibility found is accidents related to the transfusion chain is part of haemov-
investigated to identify the specific cause. igilance, first discussed in Section 9: Blood collection, as
haemovigilance relates also to blood donors. Haemovigilance
Direct antiglobulin test as it relates to transfusion hazards and reactions is described
A DAT is performed on the red cells of both pre- and post- in more detail in Section 14: Benefits and risks of transfusion.
transfusion specimens and on units transfused to detect
sensitization of the recipient cells or the red cells of the units
transfused. Where relevant, an EDTA specimen may be
Quality control
requested from the recipient to prevent complement becoming All blood banks should have a defined quality control (QC)
cell bound, leading to a false positive result. programme in place. All QC should be carried out according
to a defined plan and results should be subject to periodic
Antibody identification review. If QC results do not satisfy predefined criteria, the
Antibody identification should be performed if there is any product or test results should not be released until the problem
incompatibility between the serum/plasma of the patient and has been satisfactorily identified and resolved.
the red cells of transfused blood, or if the antibody screen The main objective of crossmatching is to transfuse the
tests are positive. If a clinically significant antibody is correct blood type and component into the patient. This
identified, the red cells of the unit(s) transfused, should be means that important steps along the process of identifying
phenotyped to determine whether the corresponding antigen that a patient needs a transfusion, until the time that the
is present. The patient’s pre-transfusion sample should also transfusion is given, should be carried out in a disciplined
be typed for the relevant antigen providing the patient way, according to documented SOPs. It also means that all

© 2008 The Authors.

tests performed in the crossmatching laboratory should be being determined by the quality procedure in place. The use
properly controlled to ensure that results may be interpreted of anti-A,B as a grouping reagent in addition to anti-A and
with confidence; and that random checks be carried out daily, anti-B, is optional.
to confirm that crossmatches were carried out correctly. • Anti-D
QC refers in general to a procedure that is carried out at the RhD typing reagents should be tested daily with D+ and
time a test is performed and that provides feedback about the D– reagent red cells; the frequency of this QC being deter-
state of the test. QC should be designed to test the materials, mined by the quality procedure in place.
equipment and technique used in the procedure. If discrep- • Antihuman globulin
ancies are found, the test result should be disregarded until The addition and reactivity of the AHG reagent is controlled
the matter has been resolved For example, when controlling by the addition of sensitized control cells to all apparent
ABO grouping reagents, they should be tested against negative IAT tests (see Section 4: Principles of laboratory
reagent red cells of known ABO groups to check that they techniques for details). In addition the antihuman globulin
are both sensitive and specific. It is essential to record the may be tested with every batch of IAT tests, by including a
QC test results actually observed and not the results as they weakly reacting type IgG antibody as a positive control, and
ought to be. serum without irregular antibodies as a negative control,
together with reagent screening cells.
Should any reagent control results not give results as
Critical control points
expected, the problem should immediately be reported to the
These are steps considered critical to the successful outcome senior technologist and blood should not be issued until the
of the crossmatching process. Failure to carry out these steps problem is resolved.
correctly could result in harm to the patient. These critical
control points include the following:
Random QC
• Correct identification of the intended recipient at the time
of taking the blood sample for crossmatching. According to agreed quotas, every day a certain number of
• Checking that the ABO and RhD type of the recipient is crossmatches should be randomly selected and the com-
correct. patibility tests repeated. The results should be compared with
• Checking records to ascertain in the case of repeat trans- those obtained originally and any anomalies brought to
fusions, that the recipient blood grouping results correlate the immediate attention of the technologist in charge. Blood
with those on record. crossmatched in cases where mistakes or incompatibilities
• Testing the serum/plasma of the recipient for the presence are detected only by random QC should be withheld for use
of irregular and possibly clinically significant irregular until the true results are confirmed. The added value of random
antibodies. QC is that no technologist knows which crossmatches will be
• Confirmation of ABO group of blood selected for subject to repeat.
crossmatch, and RhD group in the case of Rh-negative
recipients. This is not necessarily performed at the time of
the crossmatch and may be performed on receipt of the
Summary of section: Compatibility
blood stock or by the supplying blood centre.
testing
• Crossmatching as appropriate, between serum/plasma of Tabulated summaries of tests performed during crossmatching
the recipient and red cells of units selected for transfusion. and investigating transfusion reactions, are given below,
• Correct labelling of crossmatched components that are followed by general points to summarize this section. Table 13·2
found compatible and suitable for the recipient. summarizes routine crossmatching laboratory tests. Table 13·3
• Checking all details on the crossmatch request form and summarizes the initial investigation of a transfusion reaction.
component labels at the time of issue and confirmation Any anomaly, discrepancy or incompatibility should imme-
that the correct blood is being issued for the patient diately be brought to the attention of the technologist in
concerned. charge of the crossmatching laboratory, and the medical
director if appropriate.
Reagent controls
The reagents that are in daily use in the compatibility testing
Summary of other points in section:
laboratory include the following
compatibility testing
• Anti-A and anti-B • The major crossmatch involves testing the serum/plasma
ABO grouping reagents should be tested daily with group of the intended recipient with the red cells of each unit of
A, B and O reagent red cells; the frequency of these QC tests blood selected for transfusion.

Table 13·2 Summary of routine crossmatching laboratory tests

Test description Comments

ABO group 1. Correct ABO grouping of the patient is critical, and every step should be taken to avoid patient misidentification that could
lead to blood of the incorrect ABO group being transfused.
2. Only one crossmatch should be handled at a time, and a crossmatch specimen should never be centrifuged with another
crossmatch specimen.

RhD type 1. Patients are RhD typed so that Rh-positive blood is transfused only to Rh-positive recipients.
2. If the patient’s cells type weak D, the guidelines for the particular anti-D reagents in use should be followed. If the D type is very
weak, Rh-negative blood may be selected for transfusion, particularly if the patient is a female and of childbearing potential.
3. If Rh-negative blood is not available, then in cases of extreme emergency, and with the approval of the medical director of
the transfusion service and the prescribing clinician, Rh-positive blood may be given to Rh-negative male recipients, provided
that a full crossmatch is performed, there is no evidence of anti-D in the recipient and transfusion is absolutely necessary.

Antibody screening 1. A set of reagent group O red cells for antibody screening, should be used to screen potential transfusion recipients for irregular
antibodies.
2. Ideally the reagent cells should contain all the commonly encountered clinically significant antigens in the local population.
3. Antibodies detected during screening should be identified to determine their specificity and potential for causing transfusion
reaction.
4. Donations that test negative for the antigen to which a clinically significant antibody is directed, should be located and used
for crossmatch and transfusion into patients with such antibodies.

Immediate spin crossmatch The immediate spin crossmatch is performed by testing the serum/plasma of the recipient with the red cells selected for
transfusion, to check for ABO compatibility (i.e. no agglutination or haemolysis).

IAT crossmatch 1. The IAT crossmatch is usually performed using a LISS medium to detect irregular antibodies in the recipient against
corresponding antigens on the donor cells selected for transfusion.
2. The LISS environment provides for increased uptake of antibody onto red cells with the corresponding antigen, together with
a reduced incubation time, both factors being advantageous in crossmatching.
3. Not all laboratories use LISS. If this is the case, a saline IAT crossmatch is performed, or various additive solutions are used.

Table 13·3 Summary of initial investigation of transfusion reaction

Test description Comments

Clerical check A clerical check of all transfusion documentation is performed to ensure that the correct blood was issued and that there are no
errors on the crossmatch request form

Visual check Patient’s pre- and post-transfusion samples are checked for haemolysis and/or jaundice
The appearance of returned units/bags is checked

ABO group ABO group of pre- and post-transfusion specimens, plus all units of blood transfused, are checked to determine ABO compatibility

RhD type RhD type of pre- and post-transfusion specimens is determined and all units of blood transfused are also RhD typed

Antibody screen The antibody screen test is repeated using the same screening cells as used in the initial crossmatch

Crossmatch 1. The immediate spin crossmatch is performed or repeated, using both pre- and post-transfusion specimens

2. The IAT crossmatch is performed using both pre- and post-transfusion specimens

Direct antiglobulin test A DAT is performed on pre- and post-transfusion specimens and units transfused, and positive results investigated

Antibody identification Antibody identification should be performed if there is any incompatibility between the serum/plasma of the patient and the red
cells of transfused blood, or if the antibody screen tests are positive

Haemoglobin A low Hb may be indicative of in vivo red cell destruction as in the case of a haemolytic transfusion reaction

Tests on urine Hb in the urine is an indication of a haemolytic transfusion reaction. This test is not necessarily performed at the blood bank

Tests for bacteria A culture may be performed on the remains of the blood transfused to determine the likelihood of bacterial contamination having
caused the reaction

• The electronic crossmatch involves the use of an appro- • There are several options for the use of autologous blood,
priate computer program to issue blood to the patient, including preoperative donation, acute normovolaemic
without performing a serological crossmatch. haemodilution, intraoperative and postoperative blood
• Patient misidentification is the single most common and salvage.
life-threatening challenge in the provision of safe blood • Patients on repeated transfusions may accumulate iron
to patients. and this leads to iron overload, a condition that may
• An ABO mismatched transfusion may lead to a serious adversely affect major organs.
haemolytic transfusion reaction. • There may be toxic effects as a result of massive transfu-
• Every step of the process of compatibility testing should sion, as a result of the volume of anticoagulant involved.
be checked and checked again, to make doubly sure that A massive transfusion is one that is equivalent to the
errors are uncovered. entire blood volume of the patient, transfused within a
• There should be no interruptions or distractions during 24-hour period.
critical steps, from the time of taking the specimen from • When ABO group has to be changed during one transfusion
the patient, until the time of transfusion. episode, the administration set should be changed to
• Most laboratories do compatibility tests using a LISS prevent small agglutinates resulting from their inter-reaction,
method so that IAT incubation time is reduced and anti- entering the bloodstream of the patient.
body uptake onto cells is increased. • Crystalloids or colloids are replacement fluids that may be
• Some laboratories use anti-IgG antiglobulin reagent for used to restore blood volume or resuscitate. Crystalloids
compatibility testing by IAT, whereas others use a broad do not remain in the vascular space, but seep into the
spectrum antiglobulin reagent containing anti-IgG and tissues, whereas colloids with a larger molecular mass are
anti-C3. able to more effectively maintain osmotic pressure in the
• The abridged or abbreviated crossmatch is frequently bloodstream.
performed, using antibody screening for the detection of • Alternatives to red cells, for use when suitable blood of
irregular antibodies in the recipient, rather than the IAT human origin is unavailable, have been under development
crossmatch. The saline crossmatch is always performed to for decades. Red cell substitutes, also known as oxygen
check for ABO mismatch. therapeutics, cannot be used in a country without appropriate
• When a patient has irregular antibodies, IAT compatibility licensing. They fall into two main categories, haemo-
testing should always be included. globin solutions and perfluorocarbons.
• The type and screen facility is used when it is not certain • Recombinant products are genetically engineered forms
that a patient will need a blood transfusion. A specimen of FVIII, FIX and FVIIa. As they are not derived from
from the patient is submitted to the laboratory for blood human blood they do not carry the same risk of TTIs. A
type and antibody screening. If and when blood is small minority of patients develop inhibitors.
required, compatibility testing is performed without delay. • Research is being carried out to convert group A or B red
• Anomalous results on type and screen samples are inves- cells to group O by using bacterial enzymes. The con-
tigated to save time should blood be needed, and the cli- version of group B to group O has also been researched by
nician informed of possible delays in finding compatible using recombinant coffee bean alpha-galactosidase. If
blood. this research is successful, it may eventually lead to the
• Blood group identical components are best for the recipi- availability of universal red cells.
ent and if these is not available, then group compatible • Research is also being performed on cord cell derived stem
blood that is free of ABO haemolysins is selected for use. cells as the starting material to culture and develop
• Once large volumes of group O blood have been trans- mature red blood cells that function normally, but are not
fused, it may not be advisable to revert to the group of the group A or B specific. It is hoped that in the future, red
recipient within the same transfusion episode. cells cultured in this way may be suitable for transfusion
• Blood ordered on emergency should be available within into patients of any ABO group.
30 minutes of request, whereas because of logistics, espe- • It is very important that patient records are comprehen-
cially in a busy crossmatching laboratory it takes about sive and easily accessible. As with all patient records, they
2 hours to prepare blood on standard crossmatch. should be kept confidential.
• In some instances, fresh blood should be used for patients. • Transplantation may lead to a change in blood type that
For example, infants requiring exchange transfusion outdates laboratory records for the transplant patient.
should be given blood that is less than 5 days old. Blood • Compatibility testing laboratories should have clear
for infants should be fresh, leucocyte-depleted (to avoid guidelines on how to deal with incompatibilities effi-
CMV) and irradiated if from a first degree relative (to ciently and effectively so that care of the patient in not
prevent graft versus host disease). compromised.

• When a patient has antibodies to high incidence antigens, • All such events should be recorded in detail as part of
finding compatible blood may be very difficult and it ongoing haemovigilance, with a view to analysis of problems
may be necessary to obtain blood from a rare donor and introduction of preventive measures to overcome
registry. them in the future, as part of continuous improvement.
• Specimens from patients with cold agglutinins should be • Quality control is an integral part of compatibility testing.
kept at body temperature until the serum/plasma is separated, Critical control points receive special attention and docu-
to prevent spontaneous agglutination and the resultant mented procedures should be in place. All personnel
complications in compatibility testing. Blood units provided involved in the transfusion process should be trained and
may need to be warmed at the time of transfusion, using have demonstrable competency before being given the
a blood warmer designed for the purpose. responsibility of working unsupervised.
• It may not be possible to find compatible blood for • Random QC checks, by repeating crossmatches already
patients with haemolytic anaemia. To establish the completed, are invaluable in helping to maintain standards
specificity of antibodies responsible, autoadsorptions in the compatibility testing laboratory.
or alloadsorptions, titrations, and tests against rare
high frequency negative cells may need to be performed.
If compatible blood cannot be found, it may be neces-
Additional learning activities
sary to issue the least incompatible blood, provided (1) It is suggested that students use a medical dictionary
that the clinician agrees to this in the interests of patient and/or the Internet to clarify the meaning of words and
care. phrases and to add to the information provided in this section.
• When a unit of crossmatched blood is issued from the A list of key words that may be useful in this regard is
laboratory to the hospital ward, it is the last chance for the provided below.
technologist to find an error that may compromise patient • Blood transfusion
safety. • Crossmatching blood
• When the transfusion is to be started, it is the last chance • Autologous blood for transfusion
for the hospital personnel to check that the correct unit of • Patient identification for transfusion
blood is to be given to the patient. • Blood bank specimen collection
• A patient receiving a transfusion should be monitored • Patient wristband ID
during the procedure, and especially for the first (2) How many crossmatches are handled in the crossmatch-
30 minutes, for any sign of an untoward reaction, in ing laboratory during a month? Are there busy months and
which case the transfusion should immediately be stopped other times when demand for blood is low? If so, can the
and the clinician notified. reasons for this be determined?
• Specimens used for crossmatch and blood remaining in
used blood bags should be kept for at least 24 hours (and
Conflicts of interest
longer if facilities allow) in case an investigation is needed,
such as in the case of a transfusion reaction. Each contributing author of this section on Compatibility
• In the event of an untoward reaction, the clinician should testing (BA, ES and RW) has not received grants, speakers
notify the crossmatch laboratory immediately, and a fees, etc., from any commercial body within the past 2 years.
transfusion reaction investigation should be initiated. These authors have no potential conflicts.

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ISBT Science Series - 2008 - Armstrong - Compatibility testing

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ISBT Science Series - 2008 - Armstrong - Compatibility testing

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ISBT Science Series (2008) 3, 197–215

© 2008 The Authors.

B. Armstrong, R. Wilkinson & E. Smart

– provision of blood in malaria areas

• Transfusion of blood into the wrong patient (bedside

© 2008 The Authors.

© 2008 The Authors.

• The crossmatch test tubes, into which the serum/plasma

© 2008 The Authors.

© 2008 The Authors.

O Rh-negative O Rh-negative No other suitable

© 2008 The Authors.

Standard and emergency situations Use of autologous blood

© 2008 The Authors.

© 2008 The Authors.

© 2008 The Authors.

© 2008 The Authors.

patient, blood of the same group as the patient should be

© 2008 The Authors.

© 2008 The Authors.

© 2008 The Authors.

© 2008 The Authors.

© 2008 The Authors.

© 2008 The Authors.

Table 13·2 Summary of routine crossmatching laboratory tests

Test description Comments

Table 13·3 Summary of initial investigation of transfusion reaction

Test description Comments

© 2008 The Authors.

© 2008 The Authors.

© 2008 The Authors.

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