PRETRANSFUSION

TESTING
DEFINITION
Pretransfusion testing can be defined as the use of serologic principles
and tests to ensure compatibility and prevent and immune-mediated
hemolytic transfusion reaction.
Including proper specimen collection, pretransfusion and compatibility
tests, special clinical situations, and patient safety
Specimen collection
• Facilities must strictly follow policies and procedures to identify
patients and collect properly labeled specimens to mitigate
misidentification errors and improve patient safety
Steps in Pretransfusion Testing
• Request for transfusion
• Identification of transfusion recipient and blood specimen collected
• Testing of transfusion recipient’s blood specimen:
- Evaluation of specimen for testing suitability
- ABO group
- Rh type (Weak D testing is optical when testing the patient)
- Screening for unexpected antibodies to red cell antigens
- Antibody identification if unexpected antibodies are detected
- Comparison of current and previous test results ,and any discrepancies shall be
investigated and appropriate action taken before a unit is issued for transfusion
Steps in Pretransfusion
Donor RBC unit testing:
- ABO group confirmation and Rh type confirmation foe Rh-negative RBC units

Donor red blood cell unit selection:

-selection of components of ABO group and Rh type that are compatible with the transfusion
recipient and with any unexpected allogenic antibodies

Compatibility testing (cross match):

-serologic
-Computer or electronic

Labeling of blood or blood components with the recipient’s identifying information and issue.
Positive Patient identification and specimen
labeling
• While pulmonary complications are the leading cause of death associated
with transfusion ,clerical errors and ABO –incompatible transfusion
continue to occur and have potentially serious ,clinical consequences.
• To prevent patient misidentification and administration failures, most
institution require patients to wear a facility-generated ID wristband upon
admission until discharge.
• The wristband must contain two identifiers, typically the patient’s first
name and last name and date of birth and medical record number
• Other information such as drivers license number, social security number,
and photographic ID can be used for further verification
Positive Patient identification and specimen
labeling cont….
• If the patient does not have a wristband or if the patient identity is
unknown, some form of positive identification must be attached to
the patient.
• Acceptable alternatives to wristbands are ankle bands or labels
affixed to an exposed part of the patient’s body such as head or torso
of a draped surgical patient.
• For a patient whose identity is unknown ,a facility-generated fictitious
name with unique number identifier can be assigned and later
merged with the patient’s information.
Positive Patient identification and specimen
labeling cont……
• Prior to specimen collection, the phlebotomist must confirm the
wristband information is accurate and contains all required
information.
• Common practice includes asking the patient to state his or her name
and date of birth, if they are coherent.
• Requests for the testing must be authorized by an ordering provider
and include two unique identifiers to positively identify the patient.
• Wristband information and requests must be legible and indelible.
• Any discrepancies between the two sets of information must be
completely resolved prior to collecting the pretransfusion specimen.
Positive Patient identification and specimen
labeling cont…..
• Once collected, the specimen must be accurately labeled at the bedside.
• Patient information on the label, wristband, and request must be in complete
agreement. Furthermore ,specimen draw date and time and the collecting
individual must be traceable back to the collection of the patient sample.
• Standard operating procedure must be adhered to when the collected
specimen is received into laboratory.
• Testing personnel must confirm that the labeling information on the collected
sample is complete, accurate, and in accordance with the testing requested.
• If the misidentification of the sample is suspected for any reason,the specimen
should be recollected.
Positive Patient identification and specimen
labeling cont….
• Systems such as barcode readers and radio frequency
identification(RFID) are available and can be implemented as part of a
facility-wide patient safety program.
• Commercially manufactured identification systems using preprinted
tags and numbers are useful as well.
• Regardless of system, it is crucial that protocols are in place to
positively identify patients and that phlebotomy procedures are
defined. All personnel involved must be trained and competency
assessed.
Specimen Requirements
• Either anticoagulated or clotted specimens are acceptable for pretransfusion
testing.
• Anticoagulant specimens are often preferred due to ease of handling.
• Red blood cells from an anticoagulated sample are ideal for preparing a uniform
cell suspension for testing.
• Clotted red blood cells may require additional washing steps to minimize
interference in test interpretations.
• In addition, serum may contain small fibrin clots that can be difficult to
distinguish from true agglutination.
• Anticoagulated specimens can inactivate complement-binding antibodies due to
calcium chelation disrupting the complement cascade.
Specimen Requirements cont…
• Intravenous line contamination is unacceptable, the use of hemolyzed
samples should be avoided.
• Iv contamination from the infusion fluid dilute otherwise detectable
antibodies in the specimen and may produce erroneous results.
• If venous access is limited and the specimen must be collected from
the i.v line, the infusion fluid must be stopped and the line flushed.
• The use of hemolyzed specimen could mask antigen-antibody-
mediated hemolysis and create difficulties in evaluating test results.
Specimen Requirements cont…
• The age of the specimen used in pretransfusion testing is very crucial. If a
patient has been transfused or pregnant within the past 3 months or if the
patient’s history is unknown, a specimen must be collected every 3 days for
antibody screening and compatibility testing.
• The 3-day testing window minimizes the risk of an adverse reaction due to
an emerging alloantibody in a recipient that has been recently transfused.
• Pretransfusion specimens and donor unit segments are typically stored at 2
to 8 and must be retained in the event that additional testing is warranted.
• The patient sample and a segment from the donor unit must be must be
retained post-transfusion for at least 7 days.This allows for investigation of
any adverse events related to the transfusion.
Compatibility Tests
• Compatibility tests are performed to prevent an immune-mediated
hemolytic transfusion reaction.

• Compatibility tests include: determining the recipient’s ABO group

and Rh type, screening for any unexpected antibodies, and
crosshatching the donor unit with the recipient’s plasma
Recipient Testing
• ABO grouping
• Rh typing
• Screening for unexpected antibodies must be performed within 3 days
prior to the scheduled transfusion except in the previously mentioned
for which the pretransfusion testing window may be extended.
• An accurate medical history including current medications, recent
blood transfusions, and previous pregnancies may be helpful in
explaining any unusual results.
ABO GROUPING, Rh typing and Antibody
Screening
• ABO GROUPING

• Rh Typing

• Antibody Screening
Selection of Donor Units/Donor units testing
• Blood suppliers and transfusion services is to provide a safe and
efficacious blood component that benefits the intended recipient.
• Test performed are ABO grouping, Rh typing, a weak D test if the
initial Rh typing results is negative.
• Screen for antibodies to common blood group antigens
• Infectious disease testing on donor units include HBV DNA, HBsAG,
HBc antibodies,HIV-1 RNA,HTLV 1/II antibodies, WNV RNA, and a
serologic test for syphilis. In addition ,each donor must be tested for
at least once antibodies to trypanosoma cruz
Selection Criteria
• ABO group selection order for Transfusion of RBCs

Recipient 1st choice 2nd choice 3rd choice 4th choice

ABO Group
AB AB A B O
A A 0
B B 0
O O
Antigen-Negative
• If a patient has a history of, or has detectable clinically significant
antibodies, donor units selected for transfusion must be negative for
the corresponding antigen(s).
• In certain clinical situations, it might be necessary to phenotypically
match red cells in order to prevent antibody production or decrease
the need for costly workups in the future.
Platelets, Thawed Plasma, and
Cryoprecipitate
• No compatibility testing is required for the transfusion of platelets, thawed plasma
and cryoprecipitate. Either a current or a historical ABO grouping is sufficient.
• Rh typing is ignored because these components contain very few red blood cells as
a result of collection methods or frozen storage.
• ABO-identical platelet units should be selected whenever possible to ensure
adequate platelet survival.
• Plasma units should be compatible with the recipient’s ABO red blood cell antigens
• However, many facilities provide group A thawed plasma emergently to trauma
patients with an unknown blood type due to the lack of group AB plasma available
Crossmatch Test
• Serologic crossmatch: consists of mixing recipient plasma with cells
directly obtained from the donor unit to detect ABO or blood group
antibody incompatibilities.
• A nonreactive serologic crossmatch indicates the donor unit is compatible
and safe for transfusion
• Possible reasons for incompatibilities
- Incorrect ABO grouping of recipient or of donor unit selected.
- Cold-reactive allo-or autoantibody in the plasma not detected in antibody
detection test
- Abnormalities in the recipient;s plasma
Agglutination crossmatch
• Once a clinically significant antibody has been detected, an antiglobulin cross match is
required.
• The donor unit selected should be antigen-negative for the corresponding alloantibody
identified
• The antiglobulin crossmatch consists of an immediate spin crossmatch with the recipient’s
plasma and cells from the donor unit.
• The test system is then incubated at 37oC and completed with the antiglobulin test.
• Antiglobulin crossmatching may be performed in tube tests,typically with the addition of
LISS or PEG enhancements or in column agglutination and solid phase red cell adherence
tests.
• Observable reactivity and/or hemolysis at any phase of testing indicate incompatibility.
Special circumstances
• Emergent Transfusion
• Massive transfusions
• Neonatal Transfusion
• Intrauterine Transfusions
Emergent transfusions
• Urgent situations may arise may arise when it is medically necessary to
transfuse blood components.
• The transfusion service must have policies addressing the selection of
appropriate donor units to prevent transfusion delays.
• If the blood type of the recipient is unknown, group O red cells are
required.
• ABO group-specific red cells may be issued once a blood type is
obtained.
• Rh – negative red blood cells units are preferred but may be limited to
women of childbearing age in order to conserve inventory
EMERGENT TRANSFUSION CONT…
• Issuing group A thawed plasma to traumatically injured patients where
ABO grouping is unknown is becoming widespread practice.
• Group A thawed plasma is readily available at most facilities, and its use
in the initial resuscitation showed no increase in mortality.
• Emergently released units must clearly indicate that compatibility
testing has not been completed at the time of issue.
• Pretransfusion testing must be completed expeditiously and any
incompatibility reported to the medical director.
• An emergency release waiver signed by the ordering provider accepting
responsibility for the transfusion due to critical needs is required.
Massive Trnsfusion
• Is defined as the administration of 8 to 10 red cell units to an adult
patient in less than 24 hours or acute admintration of 4 to 5 units
within 1 hour.
• The goal of treatment is to restore blood volume rapidly to a level
adequate to maintain hemostasis,oxygen-carrying capacity, oncotic
pressure,and biochemical parameters.
Neonatal transfusion
• Pretransfusion may be abbreviated in infants less than 4 months of age.
• ABO grouping only ant-A and anti-B reagents are required
• Either the infants or the mother’s blood plasma may be used for the antibody screening
and any necessary compatibility testing.
• If a clinically significant antibody is identified ,the donor unit selected must be either
antigen-negative for the corresponding antibody or antiglobulin crossmatch compatible
until the antibody is no longer demonstrable in the infant’s plasma.
• If an infant has a negative antibody screen and will only receive group O red cell
transfusion
• Non- group O group red blood cells may be issued to a non-group O infant.
• However ,an antiglobulin test to detect passively acquired maternal anti-A and /or anti-B
is required.