of Harmalol'". 1992.
81, 579-584
A prospective study to determine the safety of omitting the
antiglobulin crossmatch from pretransfusion testing
NANCY M. HBDDLE, PAMELA O'HosK1i JOEL SINGER. JOHN A. MCBRIDE. MAHMOUD A. M. ALI AND
JOHN G. KELTON Dgnrtments of Pathology and laboratory Medicine, McMaster University Medical
Centre, Henderson Hospital, and St Joseph's Hospital. Hamilton, Ontario, and The Canadian Red Cross
Blood Transfusion Service, Hamilton Centre
Received 19 Septemtær 1991: accepted for publication 24 March 1992
Summary. Transfusion medicine laboratories routinely per•
form a series of pretransfusion serological tests Including:
ABO grouping. Rh t.yping. and investigation of the
recipient's serum to detect antibodies against blcod group
antigens (antibody screen), As a final check. most
laboratories also IHfonn a crossmatch in which the
recipient's serum is incubated with the donor's red cells
followed by the addition of an antiglobulin reagent
(antiglobulin crossmatch). The need for the antiglobulin
crossmatch when the screen is negative has
questioned becaue there are few
antibodies that are detected by this test. Such antibodies
are usually directed against low incidence antigens that are
not expressed on the screening cells and in many cases the
clinical importance of these antibMies is uncertain. For
these reasons. we performed a prospective study in which
patients requiring red cell transfusion had a group and
screen #tformed. the antibody screen was negative the
antiglobu-tin crossmatch was omitted. Following the
transfusion of the blood. the antiglobulin crossmatch was
gerformed to took for any potential incompatibility. All
patients were monitored both serologically and clinically.
The primary goal of the transfusion medicine service is to
provide the patient with the safest and most
blood
product. Safety invoives the screening of blcod donors to
minimlæ the risk of transmitting infections plus the Ikrfor-
mance of
tests to ensure blood product compaä-
bility. To ensure compatibility of the red cell concentrates,
several steps are taken. First* the donor and the recipient
are matched for ABO and Rh type. Second. any red cen
alloantibodies in the recipient's serum are detected by
incubating the patient's serum with selected screening cells
Corr—pondence: Nancy Heddle. Room 2N38. McMaster Unlvenity
Medicel Centre, 1200 Main Street
Hamilton. Ontario. Canada
LSN
579
Over the 2•year interval of the study 9128 patients were
entered. There were 8936 patients (97-9%) with a negative
antibody screen and 26 •9% (2404 patients} were transfused
a total of 10899 red cell concentrates. The antiglobulin
crossmatch performed after the transfusion indicated that 1
68 red cell concentrates (l •
would have been incompat-
ible if the antiglobulin crossmatch had been performed
pretransfusion. These 168 red cell concentrates were trans-
fusai to 119 patients during 130 transfusion episodes
(defined as all transfusions administer«} within 24 h). Of the
130 transfusion episodes,
(103/130) were false
positive laboratory resutts. There were 27 transfusion epi-
safes where the antiglobutin crossmatch on blCN'd
was positive due to an IgG antibody. Even though these
transfused red cell concentrates were designated Incompat-
ible by the antiglobulin crossmatch. none of the patients
receiving this blood had clinical or serological evidence of
haemolysis We concluded that tbe antiglobulin phase of the
crossmatch can be omitted from pretransfusion tesäng
without putting patients at risk.
expressing most red cell phenotypes screen),
Finally, the donor's
are
with the recipient's serum
in a procedure called the crossmatch (AABB, 1987). The
traditional crossmatch involves an incubation phase to allow
antibody to bind to the cells followed by an antiglobulin test
to detect the red cell bound IgG. The antiglobulin crossmatch
has been included in the compatibility test to detect antl-
bodiæ directed against low frequency antigens. which could
be present on the donor rd cells. but absent from the red cells
used in the antibody wreen. The need for this test has been
challenged and there heve tken debates
supø)lting and
refuting Its necessity (Issitt. 1985; International Forum.
1982). Most evidence is based on the calculation of risk
determined by retrospectively reviewing Iakoratory records
580 Nancy M. Heddle
to determine how frequently the antiglobulin cros.smatch
is g)siäve when the ant:ibody screen Is negative
& Henry.
1977; Spivak. 1980; Minb et
1982: Oberman et al 1978.
1982: Taswell etal. 1981 Winn et al. 1980), The weakness of
this approach relates to the
study design and the
use of latN)ratory outcome measures. which may not
clinically relevant.
To try end address these issues, we #rformed a
pros#ctive study in which we omitted the antiglobulin
crwsmetch from our routine transfusion practice. The
results of the study demonstrated that the omission of the
antiglobulin cross-match will result In a
percentage of patients
recelving blocxl that is incompatible by
testing. However.
when we analysed the clinical outcome in these pat}ents. we
were unable to and an adverse impact. We also found thet
In patients with a negative antibcO screen. false positive
reactions in the andglobulln crossmatch ere more common
then true positive reactions. Based on these results. we favour
the deletion of the andglobulin crossmatch from routine
compatibility testing.
MATERIALS AND METHODS
Study design. The study was a I-year prospective study
performai at two Hamilton hospitals. All in-patients end
out-patients receiving
transfusions were eligible for the
study unles.s they were under 16 years ofage or had a
positive direct antigiobulln test. A histocy of previous
pregnancies and past transfusions were documented for all
patients. Patient diagnosis was categorized es surgical.
medical. obstetråcal, heemetological. or trauma on the besis
ofthe primary clinical problem.
Comßlibillty testing. All patients had en ABO group. Rh
type. a direct anäglobulin test and three cell antibody
screen performed on their blood
The three cell antib«iy
screen was rprforrned using a saline antiglobulin technique
(6: I, serum:cells) with a 15-45 min incubation at 37 oc
(Leigb, 1978}, Any patient with a positive antibody screen
was managed by antibody identification, phenotyping of
donor units, and the #tforrnance of the antiglobulin cross-
match to condrm compatlbiJity before blood was transfused.
ABO and Rh compaUble
was
for patlents whose
antibody screen was negative. The blood was Issued after
Eerforrning en immediate spin crossmatch (6: I serum : cells)
to confirm
compatiblllty. Approximately 24-48 h after
the blood had
transfused* an antiglobulin crossmatch
was performed using the pretransfusion sample and a retained
—ment from the transfused donor unit. Polyspecißc antiglobulin
reagent was used for all antiglobulin tests,
Monitoring for transfusion reacåons: serological monitoring.
were obtained from all transfusd petients et
approximaately 24 h a.rud 96 h post-transfuslon to look for
laboratory evidence of haemolys[s. A direct and Indlrect
antiglobulin test (three cell antibody screen) was performed on
all post-transfuslon blood samples collected* [n addltlon. the
following tests were rrformed on all pre- and post-transfusion
samples: plasma haemoglobin, haptoglobin, haemopexin—
beem complex, and metheemalbumln (AH & Vanderlinden,
1977). Intravascular haemolysis was sus-
pected if there was no laboratory evidence of haemolysis
on the pretransfusion sample but three or more of these
tests were positive in addition to a P81tåve direct or Indirect
antiglobulin test on any of the post•transfusion samples,
Total bilirubin wes measured on pre- and post-transfusion
samples ifthe direct or indirect antiglobulin test was
negative pretransfusion but positive on one or more of the
post-transfusion specimens.
Clinical emluation. The hospital charts of every
transfused paåent who had a negative antibody screen but
a posiäve antiglobulin crossmatch were reviewed by two
physicians who were not aware of the ræults of the
laboratory tests. Chacts were also reviewed from a
randomly selected control group of
panents who had a negative antibody
screen pretransfusion and a negatlve antlglobu]n cross-
match. The charts were analysed to look for any adverse
clinical reactions
to the transfusion. Other
clinlca.l endpoints included a prolonged hospital stay due to
adverse effects attributable to the transfusion. and any
addit50naI transfusions that resulted from a drop in heemo-
globin due to the shortened survival of the transfused blood,
The study wes approved by the Ethics Review
Committee ror each hospital.
RESULTS
A total of 9128 patients were eligible for the study. 192
petlents
had a positive antlbody wreen and were
excluded from entering the study. There were 8936 patlents
who had negative antibody screen and 2404
of
th<e patients were trensfuwd. This cohort represented the
axal point ot the study. Some pat:ients were transfused
several units of blood consecutively and/or were u•ansfused
on multiple occasions: therefore. we defined a 'transfusion' as
all red cell concentrates given to a patient within a 24 h
period. The number of red cell concentrates given in these
'transfusion' periods ranged from I to 40 (median — 2). The
2404 transfusd patients with a negative andb«iy screen
ta:elved a total of 10 899 units of red cells which were given
in 4215 transfusions.
The demographlc data of the study pat:ients is shown In
Table r. Males comprised 40' 2% of the study group, Approxi-
mately 39% of petients had been previously ü•ansrused
when entered tnto this study and 59% of the females in the
study had a history of previous pregnancy. The reciplents of
the cell transfusions were as follows: medical patients.
surgical patients,
heematological patients.
obstetrical patients. 6•
and patients with trauma.
All 10 899 units of blood transfused to the patients with a
negaäve antitxxly screen had the antiglobulin crossmatch
perforuned (using the pretransfusion spclmen) following
transfusion of the blood. The anäglobulio crossmatch pto-
duced positive resulb for 168 red cell concentrates {I 5%). These
ted cell concentrates involved 130 transfilskons (some patients
received two or more red cell concentrates within
24 h), adnulnlstered to 119 patients. All of these positive
crossmatch tests were repeated and attempts were made to
idenåfy the an&dles causing the incompatlbillty. Fot 79 •
ofthe
resulb (
the result was a false
 Safety of Omitting the Antiglobulin Crossmatch 581
Table Demographic and clinical data on patients with a
Toble II. ot transfusions in which there was a
negative andglülin crogxnatch in
screen. v.dth a negative
No. Per cent and $#cl.ßcity or the —n
causing the »ltlvity.
966 40+2
Males 143859+8
Fenales 81 True poüve follow-up
P•öents wlth a history of prior transfusion* 853 59+3 Oinlcal slgnlflcance (n—Z7}
Female with hlst«y o' prevlous pregnancyt 1

Diagnosis 841
Poentlal for red æll
Surgical 30s 12•7
1
Haematologlcal 34
146 Anti-lk'
Trauma
Obsterics 44•8 1

Medical Anti.Fy*
And-wet
Anu-C1't 1
UnidenUH* 10
DAT donor 4

Total 19

Not known to cause cell Anti-Bß 7

Transfusion history unavaltable on 580 patientx by the antiglobulin crossmatch
t Pregnancy history unavailable on 397 female patients. were reviewed for laboratory evidence of haemolysis. In
the group of 27 transfusions that were consldered to have
a true posltlve antiglobulin crossmatch, the direct
antiglobulin tat on the post-transfusion sample was
positive. A false positive was denned as a test that was initially in only four
positive in the antiglobulin crosstnetch but was negative on
repeat testing performed in duplicate. There were 27 of the
1 30 transfusions in which the positive results or the anåglo-
bulin crossmatch were considered true positive. Eight of the
27 were caused by antibodies that do not cause red cell
destruction (anti-Bg and anti-H). Nineteen were caused by
IgG anåbodies that could potentially cause red cell destruc-
tion. In 10 of the 19 the anåbodles could not be identified of
an insuffcient volume of serum in the pretransfu-Sion
sarnple but were considered significant as they were
demonstrated to
KgG. In four transfusions the positive
antiglobulin crossmatch was caused by IgG sensitizing the
donor red cells (donor red cells had a posltive direct
antiglobulin test). Pive transfusions involved ant.ltx)dies
known to cause red cell destruction, These five
were not detected during the initial antibcxly screen for the
followlng reasons: two were antibodies to low incidence
antigens (Wr and C.I') not expressed on the screening cells:
two
were weakly reactive and not dete&d by the
antibody screen (antl-Pl end anti-Jk4). The and-Pl had
thermal activity at 370C. The antl-jki fai}ed to react with the
screening cells even though one of the screening cells was
homozygous for the Jka antigen. One antibody (anti-Fy*)
was missed due to a technical error (Table II). Therefore,
(95% CI
of transfusions glven to patlents with a
negauve antibody screen had a positive antiglobulin cross-
match. This can also be expressed as 1% OT patients
transfused or one in every 333 red cell concentrates trans-
fused (Table 110.

I&ratorg follow-up
The laboratory tests that were performed on the post-
transfusion samples from all 130 transfusions involving
blood that was
 Anti.Bß+H 1

Toul 8

• AnUbody thermal activity at 376C.

t Antibodies to low Incidenæ antlgens.
* weN demonstrated to IgG but there was
insumcient erum to determine

Table III. Prquency of POGltve antiglobulin crossmntcb in patients

with a negative
xreen.

Percentage with a posidve

cross•natch (95% Cl)

Patse True All peitlvee

(t.rue/fat*)

Transfusion* 0-6{0.4-08)
Patients
Unfis of blcxxi
transfused

& negative reactlon when repeetsd in duplicate.

antibody was e

t B)itive reacton in which a 8ßdfic

or the reaction was
to
IgGr
A transfusion was as all
concenü*tæ given to a
patient during 24 b perid.

casö. Two or these cases were due to weak IgG

which the laboratory was unable to identify. The remaining
two casæ involved anti-Fy• and anti-Jk'. [n all four cases the
laboratory tests for haemolysis were normal, None of these
patients
additional transfusions due to a fatl in
haemoglobin that could
with immune mediated
cell destruction.
Laboratory tests for haemolysis were reviewed for the
103 transfusions involving the false xjsitjve antiglobulin
cross-matches. One patient developed a weakly B)sltive
direct antiglobulin test 3 d
Antl•K was detected in
582 Nancy M. Heddle et al
Table 'V. Summary of patients with a positive follow-up antiglobulin
laboratory evidence of haemolysis or clinical
Result of the retroepctlve
Study antLgtobuI'n cr«smetch
100762 True positive (anti-F*)
20108) True positive (antl-Jk')
True positive (no Identißcatlon)
201704 me positive (no Identißcatlon)
201089 True pmitive
201 Palse positive
Patse positive
201740 False lx•sidve
201004 Fale xxitive
Negative (control group}
Neptlve (control group)
Note. the DAT and haemolytic screen were negative in alt patlents pretransfusion.
• [hect antiglobulin test.
t Haemolytic scræn (consideral pmit.ive I' thre or more of the rollowing wEe abnormal:
haptoglobin, plasma heenwglobin. metheemalbumln, haemorxin—haem).
DAT was posiüve 3 d pwt&ansfusi0D due to transfuioe
the post-transfusion sample but not detected
pretransfusion. This patient bad no other laboratory or
clinical evldence ot haemolysis. Two patients had negative
direct antlglobuLin test. laboratory evidence ot beemolysis.
but no clinical evidence of an adverse effect (Table
Clinical follow-up
The review of the hospital charts Identified four patients who
had clinical ev#dence of an adverse reaction to the red cell
n•ansfusions. Three of the four had signs and symptoms of a
febrile transfusion reaction. Two of these three
were
in the group who had a vositive antiglobulin crosmatch: one
was a false
and the other was due to anti-Bg. The
third panent was in the control group. The fourth patient
with
evldence ot a transfusion reaction was also in
the control group and had chills and hypotension. No
patient with a positive antiglobulin crosxnatch due to an
IgG antibody that had the potential to cause increased red
cell de8truction had any morbidity. None of the pat.ients
had an increaæd hospital stay or required additional blood
trans-fusions that could be attributable to the transfusion of
which was reacäve by laboratory tßting.
DISCUSSION
The principle of transfusion medicine is to provide the
patient with the safest and most neded
product. In an ever-
Increasing attempt to provide safer blood products. laborator-
ies have
more and more serological tests. There is no doubt about
the importance of ensuring ABO compaObIIIty ABO
mismatch«l transfusions can produæ serious end
sometirnes fatal adverse affects (Treacy. 1980). Rh
testing. especially in young women. also is imrortant to
and control who had
evidence of an adveræ e&ct pod-transfusion.
Laboratory test result
dlnicel evidence ot
DAT' HSt diverse
No
Yes (%brile reaction)
No
No
No
Yes (febrile tcacüon)
Yes (febrile reaction)
Yes (chills, hym)tenslon)
alloimmunintion (anti-K).
prevent alloimmunization to the D antigen (Case, 1980).
There also is agræment that paoeots with red
alloanå-
Endies. detected by the antibody screen. should receive bloui
that Is phenotypically compatible (AABB. 1990). However,
es our study demonstrated. patients with
are a
small minority (2% of patients). less is known about the
overall imprtance of some of the other minor blood group
antigens æpecially race blood group antigens. Indeed.
increasing evidenæ suggats that IgG medj8td
cell
destruction alone produces little morbidity. Physicians can
intentionally induce a mild haemolytic state by adrninister-
ing anti-D to D Ix:jsitive individuals as a treatanent of immune
thromtncytopenia with minimal or no adverse effects (Bussel
1991).
In addition to ABO grouping. Rh typing and performing
the antibody scren. most transfusion medicine laboratories
Incubate the patient's semm with the donor red cells. wash
to remove unbound IgG, then add the antiglobulin reagent
(antiglobulin "osmatch} (Wilson & &senstaedti 1989). This
test should detect any rwtential reactivity with uncommon
enågens
by the donor red cells that would not have
detæted using the screening cell. Rationale for omitång
this test includs: the low probability of a
reaction
when the antibody screen is negative: the add«l expense: the
potential of false positive reactions: and dnally. the uncer-
tainty about the biological relevance of many or theæ
antigen—antibody interactions. Indeed. given the fact that
rnany of these antibodies are IgG and have li.rnlted ability to
activate complement, and given the addence that ome IgG
antibodies fail to cause red cell destrucuon. the neceslty of
the antiglobulln a•osmatch is uncertain.
The intent ot the study
In this
was to try
and resolve this imm)rtant Issue. We perforrned a .2•year
 related to the
prospecåve study in which two general hospitals provided
retrospective studies (Boral & Henry, 1977: Minuet al. 1982:
blood following performance ot the ABO group. Rh type. populations.
screen and immediate spin crossmatch. The imme- prospctive design of our study or differences in patient
lin test perforrned on cells collected 24 and 96 h after the All of
diate spin crossmatch was performed to the patients plus the controls had a direct anäglobu-
ABO with a true
compatibility. Following transfusion of the blood, we per- transfusion. Positive results were seen in four of the patients
anäglobulin crossmatch including those
formed the traditional antiglobulin crossmatch to identify
caugd by anti-Fy•. and anti-lk*. and two unidentiHed IgG
those units that might have been deemed 'incompatlbler by
laboratory tests, yet were administered to patients. The
Impact of omitting the antiglobulin crossmatch was analysed
in three ways. First. we looked Tor serological evidence of e
transfusion reaction by
a direct and indirect
antiglobulin test on 24 and 96 h post-transfusion specimens.
we investigated

of haemolysis including the patients for laboratory evidence

plasma haetnoglobin, the measurement of bllirubin. free

haem. and haptoglobin. methaemalbumin. haemolkxin—

Third. the charts ot patients trans-
fused with 'incompatible'
and charts from a control
group were reviewed to I(X'k for any clinical evidence of a
r•ansfusion reaction or adverse effects resulting from the
transfusion.
Over the 2 years of the study, a total of 10899 red cell
c.oncentrates were transfused and 168 (1 • 9.5% CI
were 1
testing. the majority of these positive reactions (79

• 2%) were
in the antiglobulin phase. On
reagents gave negative results). This rate of false positive falsethespecificitypositives

of(repeatcurrenttestingantiglobulinwithtwo different anäglobulin concentratesreacäons(I•2%}wereis

serologicallynotunexpectedincompatible.indeedpredictableasdefindgivenbya

patient received more n one incompatible unitof blood

Wefound that 35of the 10 899 (0'3%)transfused red cell

represent 27 ü•ansfuslons where one or more incompatible

positive antiglobulin crossmatch. In some situations a
period. These transfusions repreE11t the focal
durlng a 24 h peHod; hence. these 35 red cell concentrates
of the
units of
Tor antigens that do not cause
were transfused to a patient within a 24 h
cell destruction {anti-Bg
study (Table 11). In eight transfusions.
results, but subsequently the donor red cell units were shown
were specific
involved red cell concentrates that were positive in the
and anti-H). Four transfusions gave positive crossmatch
determined trcause sumcient patient serum was not avall-
to be reactive in the direct antiglobulin test. Ten transfusions
Therefore. in our study one in every 100 patients with a
gaveantiglobulintruepositivecrossmatchreactionbut anintheibodyantiglobullnspecificity

crossmatchcouldnot. abThlse forlaborchatoryracteriskization of the srHficlty of the alloantibody.

negatlve antibody screenishigherwas transfusthanthetd reporta3withbloodby whlchother

p. 283. American
Taswell et al. 1981 Banks. Arllngton. Va.
This represents one in every 333 units or
This difference may transfused.
Safety of Omitting the Antiglobulin Crossmatch 58 This study wag supported by a grant from the Ontario
Ministry of Health and the Medical Research Council
antibcxlies, One additional patient gave a positive
result on the 96 h post-transfusion sample: however. of Canada.
subsequently this patient was shown to have a »itive
direct antiglobulin test due to alloimmunlzaåon REFERENCES
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The results of our study demonstrate that the
antiglobulin phase of the crossmatch can be omitted
from pretransfusion testing provided the patient has a
negative antibcx!y screen. This omission will evotd
unnecessary work. because the majority (80%) of
positive crossmatch results in this group will
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The risk associated with
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units of blood having a true
antiglobulin test (O' 3% or 1/3 33
units)
will
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cell
haemolysis
in the recipient. Our study did not address this Issue in
children nor can our results necessarily
extrapoiated to
the
paediatric population tEcause of
differences
in
reticuloendothelial cell functlon and the risk of
alloimmuni-
zatjon.

ACKNOWLEDGMENT
584 Nancy M. Heddle et al

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