|IMMUNOHEMATOLOGY

IMMUNOHEMATOLOGY – LECTURE

PRE-TRANSFUSION TESTING

INTRODUCTION
Pre-transfusion testing:
involves: serologic (ABO, Rh, and antibody detection)
non-serologic protocols and testing

objective: preventing an immune mediated

hemolytic transfusion reaction

Testing Standards
● Transfused RBCs should have an acceptable survival
rate, and there should not be significant destruction of
the recipient’s own RBCs.

● Pre-transfusion cannot guarantee normal survival of

transfused RBCs in the recipient’s circulation.
● Although adverse responses to transfusion cannot
always be avoided, results are much more likely to be
favorable if pre-transfusion testing is carefully
performed and if results of laboratory testing show no
incompatibility between donor and recipient.

CLIA ‘88
(Clinical Laboratory Improvement Amendments of 1988)
● gives the US federal government authority to regulate
pre-transfusion testing
● regulated are:
- ABO group
- Rh type
- Antibody detection and identification
- Crossmatch testing
A. Identification of Samples
● Pre-transfusion testing BEGINS and ENDS with the
PROPER IDENTIFICATION and COLLECTION of the
patient sample.
● Those responsible for identifying the patient and
collecting recipient blood must adhere to the strict
standards set forth to ensure recipient safety and
● Strict adherence to and application of each parameter
acceptable survival rates.
of pre-transfusion testing is imperative in managing
safe blood transfusion therapy. Positive Recipient Identification
● Each parameter must also be considered in any Clerical error
comprehensive review of the process used to select - major cause of transfusion-associated fatalities
blood for a recipient. - results in incorrect ABO groupings and transfusion
of ABO incompatible blood
- the greatest threat to safe transfusion therapy
1. misidentification of the recipient when the blood
sample is drawn
2. mix-up of samples during handling in the laboratory
3. misidentification of the recipient when the transfusion
is given.

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
● Exact procedures for proper identification of the
recipient, recipient sample, and donor unit must be
established and utilized by all staff responsible for
each aspect of transfusion therapy.
● To prevent collecting samples from the wrong patient:
1. Recipient ID wristband must always be
compared with the blood requisition form
2. nameplate on the wall or bed labels MUST
NEVER be used to verify identity, as the
patient specified may no longer occupy
that bed.
3. Temporary tie tag
4. Ankle band
5. If no wristband and patient is coherent, it is
permissible to ask the patient to STATE
his/her FULL NAME and to SPELL it out.
6. If the patient is young or is incoherent, some
other reliable professional individual who
knows the patient must confirm the identity
and document this on the requisition form.
● If the date of birth or home address is printed on the
requisition form, the patient might be asked to state
this information.
● Occasional errors can result from 2 patients with the
same name being mistaken for each other.
Phlebotomist should never offer a name and ask
the patient to confirm that it is correct.
(E.g. “Are you Mr. Jones?”)
● Some disoriented patients may answer yes to any
question.
● Commercially manufactured identification systems
using pre-printed tags and numbers are useful in
verifying patients and donors.
● Emerging systems include:
- bar-code readers
- radio frequency identification (RFID)
B.1. Collection of Patient Samples
● After positive identification has been made, blood
samples should be drawn, carefully using a technique
that avoids hemolyzing the sample.
● In vitro hemolysis of recipient samples for
pre-transfusion cannot be used because it can mask
hemolysis caused by antigen-antibody complexes that
activate complement to completion.
● There are patients experiencing in vivo hemolytic
processes (hemolytic anemia) who will do so no
matter how well the collection procedure is performed.
➔ The hemolysis occurs in the patient prior
to collection and cannot be avoided.
➔ Care must be taken to note the extent of
hemolysis present in the patient serum or
plasma and observe for any increases during
each stage of testing.
● Serum or Plasma may be used for pre-transfusion
testing.
Disadvantages to using Plasma:
1. Possible formation of small fibrin clots, which
may be difficult to distinguish from true
agglutination.
2. Plasma anticoagulants may inactivate
complement so that some antibodies may
not be detected.
● Tubes must be labeled before they leave the
recipient’s bedside.
- Labels must be attached to the tubes at the
BEDSIDE in a tamper-proof manner that will
make removal and re-attachment impossible.
- All writing must be legible and indelible.
- Each tube must be labeled with the patient’s
full name, unique ID #, and date of sample
collection.
- Phlebotomist must initial or sign the label.
● To avoid contamination with materials that may cause
confusing serologic results, blood samples should
NOT be taken from IV tubing lines.
- venous samples are to be drawn only from
BELOW the infusion site, NOT ABOVE it
- if a sample must be taken from an IV line,
the line should be disconnected for 5-10
mins, the first 10 mL of blood drawn should
be discarded, and then the sample should be
obtained.
● When a specimen is received in the laboratory, the
blood bank personnel must confirm that the
information on the sample and requisition form agree.
- Receipt of an unlabeled specimen requires
that a new sample be obtained.
● Recipient samples should be tested as soon as
possible after collection.
- if serum is used, the recipient serum should
be separated from the RBCs as soon as
possible after the sample has clotted.
- if testing cannot be performed immediately,
samples should be kept at 1°C – 6°C.
● Antibody production occurs over a predictable range
of time, which varies from patient to patient.
- Specimens used should be ideally collected
during the critical phases of the immune
response.
- Serum obtained from samples fewer than 72
hours after collection must be used for
antibody screening and crossmatch testing if
the patient was pregnant or received RBC
products by transfusion within the last 3
months.
● Patient RBCs can be obtained from either clotted or
anticoagulated samples.
- They can be washed with NSS before use to
remove plasma or serum, which may
interfere with some testing procedures.
- A 2% to 5% saline suspension of RBCs is
used for most serologic testing procedures.
B.2. Collection of Donor Samples
● Samples for donor testing must be collected at the
same time as the full donor unit.
● Clotted or anticoagulated pilot samples are obtained.
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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
● Donor information - The sample used for this testing must be obtained
medical history card from an attached segment on the donor unit.
Pilot samples for processing
collection bag ● Testing the Patient Sample
- must be labeled with the same unique # ABO grouping
before starting the phlebotomy and the Rh type
numbers must be verified again immediately unexpected Ab screening test results
after collection - unusual serologic reactions and the identity
of unexpected antibodies in the patient’s
● RBCs for donor pre-transfusion testing can be serum should be included in the record.
prepared from the segmented tubing through which
the donor blood was collected.
(1) Use a lancet to make a tiny hole in the
segment through which a single drop of
blood can be expressed and then disposing
the lancet in a biohazard sharps container.
(2) Cut the RBC end of the segment tubing with
scissors and use an applicator stick to
remove cells or squeeze the tubing to
express a drop.
(3) Commercially manufactured segment
puncture devices eliminate the need for
scissors/lancets.
● Both donor and recipient samples must be stored for
a minimum of 7 days following transfusion.
- samples must be stoppered, carefully
labeled, and refrigerated at 1-6°C..
- samples should be adequate in volume so
they can be re-evaluated if the patient
experiences any adverse reaction to the
Selection of Appropriate Donor Units
transfusion. ● In almost all cases, the first choice for transfusion is
blood and blood components of the patient’s own
ABO and Rh group. ➔ ABO group-specific
Compatibility Testing Protocols ● When a recipient must be given blood of a different
● Compatibility testing ABO group, only packed RBCs can be given.
- the serologic aspect of pre-transfusion ➔ WB cannot be administered in these
testing situations because incompatible, preformed
- includes every serologic facet, beginning ABO antibodies are present in the
with donor blood and ending with the whole-blood plasma
recipient blood sample. ● If ABO group-specific blood is not available or is in
● Testing the Donor Sample low supply, alternative blood groups are chosen.
Code of Federal Regulations
AABB Standards for Blood Banks and Transfusion
Services

At the time of collection:

- ABO grouping
- Rh typing (including test for Weak D)
- tests intended to prevent disease transmission

AABB Standards for Blood Banks and Transfusion

Services
- requires a screening test for unexpected antibodies to
RBC antigens on samples from donors who have a
history of transfusion or pregnancy.
- testing is performed by the facility collecting the donor
unit, and results must be clearly indicated on all
product labels appearing on the unit.
- also requires that the transfusing facility confirm the
ABO cell grouping on all units and Rh typing on units
labeled Rh-negative
- Repeat weak-D testing is not required.
- Transfusing facility is not required to repeat any other
testing procedure on donor blood.
Crossmatch Testing
● Crossmatch test
- the testing of the patient’s serum with the
donor RBCs, including an antiglobulin phase
or simply an immediate spin phase to
confirm ABO compatibility.
Compatibility test and Crossmatch
= used interchangeably
- preceded antibody screening as part of
pre-transfusion compatibility testing to check for
unexpected alloantibodies.

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
2 main functions of serologic crossmatch test:
1. It is a final check of ABO compatibility b/w donor and
patient.
2. It may detect the presence of an Ab in the patient’s
serum that will react with antigens on the donor RBCs
but that was not detected in Ab screening because
the corresponding Ag was lacking from the screening
cells.
● AABB Standards state that tests to detect ABO
incompatibility are sufficienty if no clinically significant
Abs were detected in the antibody screening process
and if no historical record exists of clinically significant
unexpected antibodies being detected.
● “Type and screen” – involves elimination of advanced
crossmatch testing
● Serologic Crossmatch Tests
- mixing the recipient’s serum with donor’s
RBCs
- immediate spin and antiglobulin crossmatch
- objective: to select donor units that can
provide maximal benefit to the patient
● Immediate Spin Crossmatch
- mixing the recipient’s serum with donor RBCs and
centrifuging immediately (immediate spin)
- absence of hemolysis or agglutination indicates ABO
compatibility
1. Testing the patient’s blood sample for ABO, Rh, and
clinically significant antibodies.
2. Patient sample is then stored in the blood bank
refrigerator for future crossmatch if blood is needed
for transfusion.
- application of type-and-screen:
● for patients undergoing many elective
procedures who may need blood (because
the process may not always require
transfusion, the crossmatch is not performed
until necessary.)
- type and screen + immediate spin crossmatch
= ABBREVIATED CROSSMATCH
- a safe and effective method of
pre-transfusion testing
- 99.9% effective in preventing
occurrence of an incompatible
transfusion
- does not detect all ABO incompatiblities
- false reactions may be seen :
a. in the presence of other immediate
spin-reactive Abs (autoanti-I)
b. in patients with hyperimmune ABO
antibodies,
c. when the procedure is not performed
correctly (delay in centrifugation or reading)
d. when rouleaux is observed
e. when infants’ specimens are tested.
- adding EDTA to the test system reportedly eliminates
some of the false (+) reactions, thus improving the
sensitivity of the immediate spin crossmatch
● Antiglobulin Crossmatch
- begins in the same manner as the immediate
spin crossmatch, continues to a 37 0C
incubation, and finishes with an antiglobulin
test.
- enhancements:
1. albumin
2. LISS (Low ionic strength solution)
3. polyethylene glycol
4. polybrene
AHG reagent - for greatest sensitivity
- containing both anti-IgG and
anti-complement may be selected for the
final phase of this crossmatch method
Autocontrol – consisting of the patient’s own cells and serum
AABB Standards no longer requires an autocontrol, some
technologists still find it useful.
● Resolution of Incompatibilities in the Serologic
Crossmatch
- requires explanation
- the recipient should not receive a transfusion
until the cause of the incompatibility has
been determined
- the result of the autocontrol and antibody
screening test should be reviewed to
identify patterns that may help determine the
cause of the problem.
Causes of Positive Results in the Serologic Crossmatch
1. Incorrect ABO grouping of the patient or donor.
2. An alloantibody in the patient’s serum reacting with
the corresponding Ag on donor RBCs
3. An autoantibody in the patient’s serum reacting with
the corresponding Ag on donor RBCs.
4. Prior coating of the donor RBCs with protein, resulting
in a (+) AHG test.
5. Abnormalities in the patient’s serum
6. Contaminants in the test system
Causes of Positive Pre-transfusion Tests
● suggestions for investigating causes of
pre-transfusion tests
- Table 10-4, p. 250
Pre-Transfusion Testing in Special Circumstances
1. Emergencies
2. Transfusion of Non-Group-Specific
3. Intrauterine transfusion
4. Neonatal transfusion
5. Massive Transfusions
6. Specimens with Prolonged Clotting time
7. Pre-operative Autologous Blood
Limitations of Compatibility Testing Procedures
● No current testing procedure can guarantee the fate
of a unit of blood that is to be transfused.
● Even a compatible crossmatch cannot guarantee that
the transfused RBCs will survive normally in the
recipient.
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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
● Despite careful and meticulous in vitro testing, some
compatible units will be hemolyzed in the patient.
● In some cases, even limited survival of donor cells
may help to maintain a patient until the patient can
begin to produce his/her own cells.
Certainly NO PATIENT should be denied a transfusion if
he/she needs one to survive, and donor cells that appear
incompatible by in vitro testing procedures may, in fact,
survive quite well in vivo.
Positive Antibody Screen, Incompatible Crossmatches, Positive
Autocontrol, Positive DAT
● Alloantibody causing either a delayed serologic or
hemolytic transfusion reaction.
● Passively acquired autoantibody (e.g., intravenous
immune globulin).
● Cold- or warm-reactive autoantibody.
● Rouleaux formation.

Causes of Positive Pre-Transfusion Tests

Negative Antibody Screen, Incompatible Immediate Spin

Crossmatch

● Donor RBCs are ABO incompatible.

● Donor RBCs are polyagglutinable.
● Anti-A1 is the serum of an A2 or A2B individual.
● Other alloantibodies reactive at room temperature
(e.g., Anti-M).
● Rouleaux formation.
● Cold autoantibodies (e.g., Anti-I).
● Passively acquired anti-A or anti-B.

Negative Antibody Screen, Incompatible Antiglobulin

Crossmatch
● Donor RBCs have a positive direct antiglobulin test.
● Antibody reacts only with RBCs having strong
expression of a particular antigen (e.g., dosage) or
variation in antigen strength (e.g., P1).
● Antibody to a low-incidence antigen on the donor
RBCs.
● Passively acquired Anti-A or Anti-B.

Positive Antibody Screen, Compatible Crossmatches

● Autoanti-H or Anti-LebH and non-group O units are
selected.
● Antibodies dependent on reagent RBC diluent.
● Antibodies demonstrating dosage and donor RBCs
are from heterozygotes (i.e., expressing a single dose
of antigen).
● Donor unit is lacking corresponding antigen.

Positive Antibody Screen, Incompatible Crossmatches, Negative

Autocontrol
● Alloantibody(ies)

Positive Antibody Screen, Incompatible Crossmatches, Positive

Autocontrol, Negative DAT
● Antibody to ingredient in enhancement media or
enhancement-dependent autoantibody.
● Rouleaux formation.

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IMMUNOHEMATOLOGY – LECTURE
TRANSFUSION PRACTICE
GOVERNING AGENCIES
U.S. Food and Drug Administration (FDA)
- a regulating agency
- its regulations for donor screening are outlined in the
Code of Federal Regulations (CFR)
- blood is regarded both as a biologic and a drug
- in the early 1990s, it began to treat blood
establishments the same as any drug manufacturer,
requiring strict compliance toward all aspects of
transfusion medicine, including donor selection and
screening.
- establish and maintain the regulations and inspect
blood-collection and processing centers
- responsible for licensing the collection and processing
facilities, the blood products and derivative, and the
reagents used in the processing and testing of those
products.
Center for Biologics Evaluation and Research (CBER)
- formed in 1988
- responsible for regulating the collection of blood and
blood components used for transfusion and for the
manufacture of pharmaceuticals derived from blood
and blood components.
- develops and enforces quality standards
- inspects blood establishments
- monitors reports of errors, accidents, and adverse
clinical events
American Association of Blood Banks (AABB)
- established in 1947
- an international association of blood centers,
transfusion and transplantation services, and
individuals involved in transfusion medicine.
- provides a voluntary inspection and accreditation
program for its member institutions that meets the
requirement of CMS (Centers for Medicare and
Medicaid Services) and the CLIA ‘88.
mission:
to establish and provide the highest standard of
care for patients and donors in all aspects of
transfusion medicine
- has published books on transfusion medicine:
(1) AABB Standards for Blood Banks and
Transfusion Services
(2) AABB Technical Manual
College of American Pathologists (CAP)
- also provides a voluntary inspection and accreditation
program for its member institutions.
|IMMUNOHEMATOLOGY
DONOR SCREENING
● Encompasses:
1. medical history requirements for the donor
2. (mini) physical examination
3. serologic testing of the donor blood
● The medical history information and the physical
examination are designed to answer 2 questions:
1. Will donation of approximately 450 mL of
whole blood at this time be harmful to the
donor?
2. Could blood drawn from this donor at this
time potentially transmit a disease to the
recipient?
REGISTRATION
- Blood collection facilities must confirm donor identity
and link the donor to existing donor records.
- Most facilities require a photographic identification
such as a driver’s license, passport, or school
identification card.
- To prevent an ineligible donor from donating again,
every donor must be checked against a permanent
record of previously deferred donors.
- List of information used by the collection facility in the
registration process and is kept on record as a single
donation record form or electronically:
● Name (first, last, MI)
● Date and time of donation
● Address
● Telephone
● Gender
● Age or date of birth (min. age: 16 and 17 yrs)
* No upper age limit.
* For autologous donation, there is NO AGE
RESTRICTION.
● Consent to donate
* Give educational materials informing
them of the signs and symptoms associated
with HIV infection and AIDS, etc.
● Additional information:
* The name of the patient for whom the
blood is intended (directed donation)
* Race of the donor for unique phenotypes
* CMV status (neonates require
CMV-negative blood)
MEDICAL HISTORY QUESTIONNAIRE
- A standardized medical history questionnaire was
developed by a task force that included
representatives from the AABB, the FDA, and the
blood and plasma industry.
- The questionnaire was designed to be
self-administered by the donor but if preferred may be
administered by a trained donor historian.
- The questions are designed so that a simple “yes” or
“no” can be answered but elaborated if indicated.
- The medical history is conducted on the same day as
the donation.
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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
Summary of the DHQ (Donor History Questionnaire)
Are you feeling healthy and well today?
Are you currently taking an antibiotic or taking any other
medication for an infection?
Donors currently taking antibiotics for an infection or
for prophylaxis after dental surgery may be deferred
temporarily until the donor has completed the
prescribed antibiotic regimen and the infection has
cleared up.
Donors who have taken tetracyclines or other
antibiotics used to treat acne are acceptable for
donation.
Are you now taking or have you ever taken any medication
on the Medication Deferral List? ➔ Figure 13-4, p. 297
Have you read the educational materials?
In the past 48 hours, have you taken aspirin or anything
with aspirin in it?
In the past 6 weeks, have you been pregnant or are you
pregnant now?
Following termination of pregnancy – deferred for 6
weeks
For autologous donation (complications are
anticipated at delivery) – no deferral
1st trimester or 2nd- trimester abortion or miscarriage
– not a cause for deferral
if the woman received transfusion during her
pregnancy
- deferred for 12 months
In the past 8 weeks, have you donated blood, platelets, or
plasma?
In the past 16 weeks, have you donated a double unit of
red cells using an apheresis machine?
time interval b/w allogeneic WB donations = 8 weeks
(56 days)
if donor has participated in an apheresis donation
= at least 48 hours must pass before
donating WB
Infrequent plasma apheresis = 4-week deferral
Double red cell unit apheresis = 16 weeks deferral
In the past 8 weeks, have you had any vaccinations or
other shots? Have you had contact with someone who had
a smallpox vaccination?
if donor has received a live, attenuated or bacterial
vaccine (measles, mumps, oral polio, typhoid, yellow
fever) = 2 weeks
if donor has received a live attenuated vaccine for
German measles or chickenpox = 4-week deferral
No deferral for toxoids or killed or synthetic viral,
bacterial, or rickettsial vaccines (diphtheria, hepatitis
A, Hepatitis B, influenza, Lyme disease,.
Pneumococcal; polysaccharide, polio injection,
anthrax, cholera, pertussis, plague, paratyphoid,
rabies, Rocky Mountain spotted fever, tetanus, or
typhoid injection).
For smallpox vaccination = 14-21 days or until the
scab has fallen off
In the past 12 months, have you had a blood transfusion; a
transplant such as organ, tissue, or bone marrow; or a
graft such as bone or skin?
If yes = deferred for 12 months
In the past 12 months, have you come in contact with
someone
else’s blood or had an accidental needle-stick injury? Had
a tattoo? Had ear or body piercing?
If yes = deferred for 12 months
In the past 12 months, have you had sexual contact with
anyone who has HIV/AIDS or has had a positive test for
HIV/AIDS?
If yes = deferred for 12 months from the time of
sexual contact
In the past 12 months, have you had sexual contact with a
prostitute or anyone else who takes money or drugs or
other payment for sex?
If yes = deferred for 12 months from the time of
sexual contact
In the past 12 months, have you had sex with anyone who
has ever used a needle to take drugs or steroids or
anything not prescribed by their doctor? In the past 12
months, have you ever had sex with anyone who has
hemophilia or has used clotting factor concentrates?
If yes = deferred for 12 months from the time of
sexual contact
Female donors: Have you had sexual contact with a male
who has ever had sexual contact with another male?
if yes even once since 1977 = deferred for 12 months
In the past 12 months, have you had sexual contact with a
person who has hepatitis? Have you lived with a person
who has hepatitis?
if yes = deferred for 12 months followed by
discontinuation of “close contact”
In the past 12 months, have you been treated for syphilis
or
gonorrhea?
if yes = deferred for 12 months
Have you been in juvenile detention, lockup, or prison for
more
than 72 hours?
if yes = deferred for 12 months from the last date of
the incarceration
In the past 3 years, have you been outside of the country?
Malaria = deferred for 1 year ff. departure from the
endemic area, provided the donor has showed no s/s
of malaria infection
= if has resided for at least 5 consecutive
years
= deferred for 3 years from the time
of departure and remain symptom
free
In the past 3 years, have you been outside of the country?
CJD and vCJD = deferred indefinitely
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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
Leishmaniasis = 12-month deferral from the date of
departure from the area
*From 1980 through 1996:
Did you spend time that adds up to 3 months or
more in the United Kingdom?
if yes = deferred indefinitely
Were you a member of the U.S. military, a civilian
military employee, or a dependent of a member of
the U.S. military?
= deferred indefinitely
if traveled since 1977 and received a blood
transfusion or other medical treatment with a
blood product
= deferred indefinitely
Had sexual contact with anyone who was born in
or lived in Africa?
if yes = indefinite deferral
Have any of your relatives had Creutzfeldt-Jakob
disease?
with history = permanently deferred unless
diagnosis of CJD was confidently excluded.

*From 1980 to the present, did you:

Spend time that adds up to 5 years or more in
Europe?
If yes = deferred indefinitely as donors of
WB, blood components, or leukocytes
No deferral for plasma.
Receive a blood transfusion in the U.K. or
France?
if yes = deferred indefinitely

*From 1977 to the present, have you:

Received money, drugs, or other payment for
sex?
if yes = permanently deferred
Male donors: Have you had sexual contact with
another male, even once?
if yes = permanently deferred

Have you ever:

Had a positive test for HIV/AIDS virus?
if yes = indefinite deferral
Used needles to take drugs, steroids, or anything
not prescribed by your doctor?
if yes = indefinite deferral
Used clotting factor concentrates?
if yes = 12-month deferral
Had hepatitis?
- history of hepatitis after their 11th birthday,
(+) HBsAg, anti-HBc = deferred indefinitely
- if hepatitis before age of 11 years = deferred
temporarily until the circumstances are
investigated and medical opinion concludes
there is no history or diagnosis of viral
hepatitis after age 11.
Had malaria?
with history of malaria = deferred for 3 years
ff treatment and being asymptomatic
Had Chagas’ disease? Had babesiosis?
if yes = indefinite deferral
Received a dura mater (or brain covering) graft?
if yes = indefinite deferral
Had any type of cancer, including leukemia?
if yes = indefinite deferral
Had any problem with your heart or lungs?
cardiovascular, coronary, or rheumatic heart
disease active pulmonary tuberculosis
Had a bleeding condition or a blood disease?
if yes = indefinite deferral
Been in Africa?
if born or lived since 1977 = deferred
indefinitely

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE

THE PHYSICAL EXAMINATION

● General Appearance
- observe for excessive anxiety, drug or
alcohol influence, or nervousness
- done in a gentle manner so as not to deter
the donor from donations in the future.

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
● Weight
- maximum of 10.5 mL of blood/kg of donor AUTOLOGOUS DONORS
weight for WB collection inclusive of pilot
● Autologous donor
tubes for testing.
- one who donates blood for his/her own use
- if donor weighs less than 100 pounds
- referred to as the donor-patient
➔ the amount of blood collected must be
● Most autologous blood is used to treat surgical blood
proportionately reduced as well as that of the
loss in very specific situations where there is a
anticoagulant
reasonable opportunity to avoid homologous
- formulas to calculate the adjusted volume of
transfusions or when compatible allogeneic blood is
blood to be collected and anticoagulant to be
not available.
used
Advantage: decreased risk of disease transmission,
transfusion reactions, and alloimmunization
Volume to collect = (donor’s weight in Kg/50) X 450 mL
Disadvantages:
Volume to collect/450 X 63 mL = reduced volume of
1. There is still a risk of:
anticoagulant
a. bacterial contamination
63 mL – above calculated volume = amount of solution to
b. circulatory overload
be removed
c. cytokine-mediated reactions, and
Temperature
d. misidentification of the product or patient
- must be less than or equal to 37.5 0C or 99.5 0F.
2. higher cost due to added administrative processes
- donors are not asked to drink coffee or hot beverages
3. special labeling requirements to ensure that units
while waiting to donate.
get transfused to the proper patient.
- Oral temperatures that are lower than normal are not
cause for deferral.
Good for:
Pulse
1. those with very rare blood types
- should be b/w 50 and 100 bpm
2. those with multiple antibodies where compatible
- athletic donor = less than 50 bpm (not a cause for
units in the general blood supply may be difficult or
deferral)
impossible to find
- should be counted for at least 15 seconds; any
irregularities should be evaluated by a blood bank
● There is a high percentage of wasted units
physician.
(30-50%), because patients end up not requiring
Blood Pressure
any or all of the units donated.
- systolic pressure = less than or equal to 180 mm Hg
AABB Standards do not permit “crossing
diastolic pressure = less than or equal to 100 mm Hg
over” of unused autologous units into the
- readings above these levels should be evaluated by a
general inventory, except in exceptional
blood bank physician
circumstances.
Hemoglobin
- should be greater than or equal to 12.5 g/dL
- Hematocrit level – should be greater than or equal to Methods and techniques for obtaining autologous blood:
38%
- for autologous donation:
1. Pre-operative collection
*Hb = greater than or equal to 11 g/dL - occurs during the 5-6 weeks immediately preceeding
*Hct = greater than or equal to 33% a scheduled, elective surgical procedure unless the
Skin Lesions RBCs and plasma are scheduled to be frozen.
- Evidence of skin lesions is cause for indefinite - procedures that might use this:
deferral. a. Orthopedic procedures
- Skin disorders that are not cause for deferral include: b. Vascular surgery
*poison ivy c. Cardiac or thoracic surgery
*other rashes d. Radical prostatectomy
e. During pregnancy for unforeseen
complications
INFORMED CONSENT - when the mother has multiple
AABB Standards mandates that informed consent of antibodies to high-frequency
allogeneic, autologous, and apheresis donors be antigens
obtained before donation. - risk for placenta previa
● The donor must be informed of the risks of the - risk for intrapartum hemorrhage
procedure and of the tests that are performed to
reduce the risk of infectious disease transmission to - requires both an order from the patient’s physician
the recipient. and an approval from the blood bank medical director
● The donor must be able to ask questions concerning - MSBOS (Maximal Surgical Blood Order Schedule)
any element of the collection or testing process. can provide guidance for surgical procedures to
● If the donor is a minor or is unable to comprehend the estimate the number of units needed for transfusion.
informed consent protocol, applicable state law - the last blood collection should occur no later than 72
provisions will intercede. hours (3 days) before the scheduled surgery to allow
➔ Figure 13-5, p. 301 (Sample of Informed Consent for volume replacement.
Form)

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
- medical history and physical requirements are less
stringent
● there is no minimum or maximum age
requirement (so long as the donor should be
able to tolerate the donation)
● for younger donors, limit the age to children
whose veins can accommodate the
phlebotomy needle and who can understand
the procedure.
● min. Hg level: 11 g/dL Hct level: 33%
● BP and pulse r – same with allogeneic
donors
● temp. – should not be elevated or indicate
any sign of possible infection
- units are a standard 450 or 500 mL +/- 10%
● If donor weighs <50 kg (110 lb), the total
amount of blood collected must be reduced
proportionately.
● if the amount of blood to be collected is
determined to be 300 to 405 mL, the unit
must be labeled as LOW VOLUME
➔ no requirement to reduce the volume
of anticoagulant-preservative solution
➔ the plasma is not suitable for
transfusion
● if the unit must be less than 300 mL
➔ anticoagulant-preservative must be
adjusted and the approval of the BB medical
director is required.
- testing requirements are somewhat less stringent.
= ABO and Rh determination
● antibody screening is optional
● if the collection facility and the transfusion
facility are the same, viral marker testing is
not required
● if different, collecting facility must test for:
a. HBsAg f. HIV 1-RNA
b. Anti-HBc g. Anti-HTLV-I/II
c. Anti-HCV h. WNV RNA
d. HCV RNA i. STS
e. Anti-HIV ½
= transfusing facility must re-confirm the ABO and Rh
of the unit, crossmatch is optional
● units must be labeled appropriately
● label includes:
a. Patient’s full name
b. Medical record # or ID #
c. Expiration date of the unit
d. Name of the facility where the
donor-patient will be transfused
- label must clearly state “FOR AUTOLOGOUS USE
ONLY”
- have a distinct green label linked correctly with the
donor-patient and to make the BB technologists
aware that certain patients have autologous units on
the shelf that must be transfused before allogeneic
units
- the oldest units should be transfused first
2. Acute Normovolemic Hemodilution (ANH)
- results in the collection of whole blood with the
concurrent infusion of crystalloid or colloid solutions,
thus maintaining a normal blood volume but
decreasing the patient’s hematocrit.
- ratio of replacement is 3:1 for crystalloids
1:1 for colloids
- the number of units collected depends on the patient’s
ability to tolerate the decrease in Hgb/Hct.
- limited hemodilution will reduce the Hct to 28%
- severe dilution will reach 21% or less
- recommended: start with a Hgb of at least 12 g/dL
- performed in surgery immediately prior to beginning
the surgical procedure and is managed by
anesthesiology.
- the blood is collected in random blood bags
containing anticoagulant or preservative and is stored
in the room at room temp.
- blood is normally re-infused to the patient during or
immediately following the surgery, but within 8 hours
of collection, thus maintaining the viability of both plts.
and coagulation factors.
- blood units are re-infused in the reverse order of
collection so that the last unit re-infused carries the
highest hematocrit level.
- because the blood does not leave the OR, the units
are not tested, labeled, or tracked, and the BB is
generally not involved.
- if the blood is not transfused during surgery, it can be
stored for up to 24 hours in a monitored BB
refrigerator if refrigerated within the first 8 hours.
- if the units leave the OR and are stored, they must be
appropriately tested and labeled as with pre-deposit
autologous units.
3. Intra-operative Collection
- involves collecting shed blood from the surgical site
1. processing the blood through an instrument
that washes it with saline to remove tissue
debris, free Hgb, and plasma that may
contain activated coagulation factors
2. concentrating the residual red cells (to a Hct
of 50%-60%)
3. re-infusing those cells immediately
- this process is repeated continually during the
surgical procedure
used in:
a. Cardiothoracic surgery
b. Major orthopedic surgery
c. Cardiac surgery
d. Vascular surgery (liver transplantation)
Advantage: it may be used in cases where pre-operative
donation is not possible due to urgency of the surgery or the
patient cannot be scheduled for multiple pre-operative
donations.
Disadvantages:
a. High cost of the instrumentation involved
b. Training of the personnel to run the instrument
c. The amount of blood that is collected is not sufficient
for the patient’s total needs, and allogeneic blood may
still need to be given
d. Counterindicated if there is potential for contamination
of the surgical site by bowel contents, amniotic fluid,
urine, clotting agents, or where there is a risk of
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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
bacterial contamination or activation of coagulation
factors.
- blood does not leave the OR
- if some of the blood is to be stored post-operatively, it
must be labeled with the patient’s full name, medical
record number, date and time of collection, and with
“FOR AUTOLOGOUS USE ONLY.”
- blood may be stored at room temperature for up to 6
hours or at 1 0C-6 0C for up to 24 hours from the end
of collection.
4. Post-Operative Blood Salvage
- collected from a drainage tube placed at the surgical
site
- It is re-infused, with or without processing, via a
microaggregate filter to screen out any debri.
- this blood is characterized as being dilute, partially
hemolyzed, and defibrinated.
- recommended: no more than 1, 400 mL be re-infused
- procedures that have used this method:
a. Orthopedic surgery (arthroplasty)
b. Cardiac surgery
- blood must be re-infused within 6 hours of collection
or it is to be discarded.
Advantages:
a. very low cost
b. Can be used in conjunction with other autologous
blood collection procedures to avoid the need for
allogeneic blood transfusions.
- blood does not leave the patient’s bedside, so no risk
of the blood being transfused to the wrong patient.
Disadvantages:
a. does not yield a large volume of blood and by itself
would not generally produce enough blood for the
patient’s needs
b. Carries a significant risk of producing transfusion
reactions due to the presence of activated coagulation
factors, FDPs, and cytokines.
DIRECTED DONATION
- a unit collected under the same requirements as
those for allogeneic donors, except that the unit
collected is directed toward a specific patient.
- when a friend or family member needs blood, the
donor center will accommodate these directed
donations so that the required testing may be done as
soon as possible.
- if the blood is compatible, it can be used by the
patient.
- tag is a distinct color (YELLOW, SALMON) to
differentiate it from autologous tags.
- if the donor is a blood relative, the unit must be
irradiated to prevent graft-versus-host disease so
that viable T cells from the donor that enter the
patient’s circulation do not mount an attack against
patient’s cells and tissue.
APHERESIS DONATION
- an effective mechanism for collecting a specific blood
component while returning the remaining whole blood
components back to the patient.
- use an automated cell separator device whose
centrifugal force separates blood into components
based on differences in density
- can be used to collect platelets, plasma, WBCs,
RBCs, and stem cells.
- designed to collect large volumes of the intended
component
- the only effective method for collecting leukocytes and
stem cells
- donor requirements are generally the same as for
whole blood donation; however, there are some
differences, depending on the component that is to be
collected.
- with whole blood donation, the process is regulated
by the FDA, and both the AABB and the American
Society for Apheresis provide comprehensive
guidelines and standards.
- Types:
a. Plateletpheresis
b. Plasmapheresis
c. Leukapheresis
d. Double RBC Pheresis
WHOLE BLOOD COLLECTION
DONOR IDENTIFICATION
- a numeric or alpha-numeric system is used to link the
donor to the donor record, pilot tubes, blood
container, and all `components made from the original
collection.
- care must be taken to avoid duplicate numbers,
voided numbers, or other mistakes in the labeling
system.
- AABB Standards:
* trained phlebotomist must identify the
donor record and
*ensure that the donor name and ID
numbers match
ASEPTIC TECHNIQUE
- most blood centers use an iodine compound such as
PVP-iodine or polymer iodine complex
- the area is scrubbed at least 4cm in all directions from
the site for a minimum of 30 seconds
- the area is then covered with a dry sterile gauze pad
until the venipuncture is performed.
- donors who are allergic or sensitive to iodine
compounds may use chlorhexidine gluconate and
isopropyl alcohol.
POST DONATION INSTRUCTIONS
- recommended that donors remain in an area where
they can be observed by the donation center staff and
be given instructions to follow for the next 24 hours
- most blood centers have a designated post donation
area where donors can sit and replenish their fluids.
DONOR REACTIONS
MILD REACTIONS
- encompass one or more of the ff:
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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE

Syncope or fainting - caused by the needle going through and through the
vein, with subsequent leakage of blood into the tissue.
- may be brought about by the sight of blood
what to do?
s/s:
a. Remove the tourniquet and needle from the donor’s
sweating pallor
arm.
dizziness convulsions
b. Apply pressure with sterile gauze pads for 7-10
minutes, with the donor raising his/her arm above the
what to do?
heart.
a. Remove the tourniquet and withdraw the needle.
c. Apply ice to the area for 5 minutes.
b. Place cold compresses on the donor’s forehead.
c. Raise the donor’s legs above the level of the head.
d. Loosen tight clothing and secure airway. DONOR RECORDS
e. Monitor vital signs

Twitching / Muscle spasm

- due to extreme nervousness
- try to disengage the hyperventilation sequence by
conversing with the donor and having the donor
breathe into a paper bag.
- not advised to give oxygen to these donors.

Nauseated / vomits
a. Instructs the donor to breathe slowly.
b. Apply cold compresses to the forehead.
c. Turn the donor’s head to one side and provide an
appropriate receptacle.
d. The donor may be given water after vomiting has
ceased.
DONOR PROCESSING
MODERATE REACTIONS
-include any of the reactions previously mentioned in
addition to loss of consciousness
- donor may have a decreased pulse rate, may
hyperventilate, and may exhibit a fall in systolic
pressure to 60 mm Hg.
what to do?
a. Check vital signs frequently.
b. Administer 95% oxygen and 5% carbon dioxide.

SEVERE REACTIONS Tests performed on donor blood include:

-a donor experiencing convulsions 1. ABO/Rh 6. Anti-HIV-1/2 and NAT
-convulsions can be caused by cerebral ischemia, 2. Antibody Screen 7. Anti-HTLV-I/II
marked hyperventilation, or epilepsy. 3. HBsAg 8. WNV RNA
- cerebral ischemia is associated with vasovagal 4. Anti-HBc 9. Syphilis
syncope or reduced blood flow to the brain owing to 5. Anti-HCV and NAT 10. T. cruzi (Chagas’ Disease)
the shock symptoms 11. Platelet Bacterial Detection
- hyperventilation is caused by marked depletion of
carbon dioxide Component preparation
what to do?
a. Call for help immediately; notify the BB physician.
b. Try and restrain the donor to prevent injury to self or
others.
c. Ensure an adequate airway.

- In the event of cardiac or respiratory difficulties, the

donor room staff should perform CPR until medical
help arrives.

HEMATOMAS
- a localized collection of blood under the skin, resulting
in a bluish discoloration.
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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE

Centrifuge: Storage/Shelf-Life & Other Considerations

1. Light / Soft Spin – at 3200 g for 2-3 minutes
2. Heavy / Hard Spin - at 5000 g for 5 minutes

Components and their Uses

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE

1. Whole blood
2. Red blood cells
3. RBC Aliquots
4. RBCs Irradiated
5. RBCs Leukoreduced
6. Frozen, Deglycerolized RBCs
7. Platelet concentrates
8. Platelet Aliquots
9. Platelets Leukoreduced
10. Single-Donor Plasma
11. Thawed Plasma and Liquid Plasma
12. Cryoprecipitated Antihemophilic Factor
13. Granulocyte Concentrates

Whole blood
- contains RBCs and plasma
- Hct: 38%
- WB transfusion provide both oxygen-carrying capacity
and volume expansion
- platelets, WBCs, and labile clotting factors do not
survive in stored WB

Red Blood Cells

- prepared from WB by centrifugation or sedimentation,
or directly by apheresis
- the amount of plasma removed is dependent on the
anticoagulant-preservative solution used
● if CPDA-1 is used = 200-250 mL plasma is
removed (Hct=65%-80%)
● if AS = 200-250 mL + 50 mL can be removed
- (Hct = less than 80%)
- (final Red cell volume = 160-275
mL)
- indicated in patients who require an increase in RBC
mass and oxygen-carrying capacity
- useful when the patient is at risk of circulatory
overload

PLASMA DERIVATIVES
1. Activated Factor VII (Factor VIIa)
2. Factor VIII Concentrates (FVIII)
3. Factor IX Concentrates
4. Factor XIII Concentrates
5. Immune Serum Globulin
6. Normal Saline Albumin
7. Plasma Protein Fraction
8. Rh0 (D) Immune Globulin
9. Synthetic Volume Expanders
10. Antithrombin III Concentrates

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 |IMMUNOHEMATOLOGY
IMMUNOHEMATOLOGY – LECTURE
Incidence of Adverse Reactions to Transfusion
Transfusion-Associated Fatalities
POST-TRANSFUSION (transfusion fatalities associated with adverse events)
ADVERSE EFFECTS TO TRANSFUSION

INTRODUCTION
● Blood transfusion is not, and likely never will be,
without risk.
● ADVERSE EVENTS are an inevitable consequence
of blood transfusion in spite of the myriad processes,
physical barriers, and software safeguards in place to
ensure safe transfusion.
● An ADVERSE EVENT is an unintended and
deleterious occurrence associated with blood
component transfusion.
- may occur before, during, or after a
transfusion
- include incidents and adverse reactions

● Incident – any error that could affect the quality or

effectiveness of a blood product or could have led to
an adverse reaction to a transplant recipient.
● Adverse reaction – a harmful effect observed in a
transfusion recipient that is temporally associated with
a blood component transfusion.

RISK OF TRANSFUSION RECOGNITION AND EVALUATION OF

Incidence of Adverse Reactions to Transfusion
Incidence of Transfusion-Related Adverse Reactions
(estimates)
TRANSFUSION REACTIONS
Involves 2 critical components:
1. Clinical recognition by the person administering the
transfusion (usually a nurse or physician) that a
suspected transfusion reaction may be occurring or
has occurred and an initial evaluation by a physician
as to the likelihood that the signs and symptoms
observed may be related to transfusion.
● First step: immediately stop the transfusion if
the infusion is still in process.
● Next step: follow a standard procedure to
send appropriate specimens to the
laboratory for a transfusion reaction
investigation
2. Laboratory investigation of a transfusion reaction.

main objective: To identify a possible hemolytic transfusion

reaction
a. checking for appropriate identification of the
component bag, label, paperwork, and the recipient’s
pretransfusion specimen;
b. repeating ABO testing on the posttransfusion sample;
c. visual inspection of the pre- and post-transfusion
specimens for hemolysis; and
d. performing a direct antiglobulin test (DAT) on the
post-transfusion specimen

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE

● main tasks and responsibilities in investigation of a

suspected transfusion reaction

Lists of signs and symptoms that may be observed in

transfusion reactions

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE

REGULATORY AND ACCREDITATION REQUIREMENTS SIGNS AND SYMPTOMS:

● Fever with chills or rigors
● pain to the flanks, lower back, abdomen, or infusion
site
● hypotension
● shock
● acute kidney injury – elevated BUN and creatinine,
absent/decreased urine output
● renal dysfunction – shock + DIC

TREATING AHTR: Early and aggressive fluid resuscitation and

blood pressure management
- preventing hypotension, shock, and acute kidney
failure

Differentiate DIC from other pre-existing coagulation

abnormalities:
aPTT. D-dimer
PT. fibrinogen
NON-INFECTIOUS TRANSFUSION REACTIONS Thrombin time platelet count
ALLOIMMUNIZATION TO RBC ANTIGENS
ALLOIMMUNIZATION 2. DELAYED HEMOLYTIC AND SEROLOGIC TRANSFUSION REACTION
- is the development of non-ABO antibodies following
RBC transfusion, pregnancy, or transplantation. (DHTR / DSTR)
DHTR – defined as having a positive DAT 24 hours to
1. ACUTE HEMOLYTIC TRANSFUSION REACTION (AHTR) 28 days after transfusion with either a positive eluate
or a newly identified alloantibody in the plasma or
- is the accelerated destruction of transfused RBCs due
serum AND evidence of hemolysis
to antibody-mediated incompatibility
- combination of signs and symptoms associated with
evidence of hemolysis:
hemolysis, biochemical evidence of hemolysis, and
- inadequate rise in hemoglobin after transfusion
serologic evidence of RBC incompatibility occurring
- a rapid drop in hemoglobin to the pre-transfusion level
during or within 24 hours after transfusion.
- appearance of spherocytes on peripheral blood smear
- occurs within minutes after the start of transfusion or
examination
within a few hours after the transfusion is completed.
- biochemical evidence of hemolysis
- The vast majority of AHTRs is due to RBC
transfusion, but they can occur with incompatible
DSTR – defined as the same serologic findings as
plasma-containing products.
DHTR but without evidence of hemolysis

● Most cases of DHTR appear 7-10 days

post-transfusion.
● Some cases, especially in transfused
postsurgical patients, will be unsuspected, because
postoperative anemia is attributed to other causes.
● Furthermore, there is often incomplete
laboratory evaluation to substantiate the presence of
hemolysis, other than unexplained anemia.
● In these cases, the diagnosis of DHTR is left as
PROBABLE or POSSIBLE.

3. TRANSFUSION-RELATED ACUTE LUNG INJURY (TRALI)

- a rare event associated with acute respiratory
distress but a leading cause of mortality due to
adverse reactions to transfusion.
- there is NO DIAGNOSTIC TOOL for TRALI.
- the diagnosis of TRALI is primarily made
according to clinical criteria that support the diagnosis
and, importantly, the exclusion of other possible
causes of acute lung injury.

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
The NHSN Hemovigilance definition includes 4. TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD (TACO)
(1) the absence of acute lung injury (ALI) prior to
- an adverse reaction characterized by respiratory
transfusion,
distress from pulmonary edema caused by increased
(2) ALI during or within 6 hours after transfusion,
intravascular volume due to excessive transfused fluid
(3) evidence of hypoxemia by blood gas or oxygen
and/or too rapid of an infusion rate and the inability of
saturation testing,
the patient to accommodate the volume of the
(4) radiographic evidence of bilateral pulmonary edema,
transfused products due to impaired pulmonary,
and
cardiac, or renal function.
(5) exclusion of circulatory overload and other causes of
- NHSN Hemovigilance definition specifies the
pulmonary edema.
presence of 3 or more features (Table 17-7 [next
slide])of fluid overload occurring within 6 hours after
transfusion.

- signs and symptoms frequently seen in TACO

generally occur within 2 hours after the start of
transfusion but may take up to 6 hours to be seen.
- 2nd most common cause of transfusion-related
deaths
there are 2 alternative diagnoses to TRALI:
1. “Possible TRALI” – designated when the criteria TREATMENT:
(previous slide) are present but another cause of ALI - Stopping the transfusion
is also identified - placing the patient in a more upright posture
2. “Delayed TRALI” – when the criteria for TRALI are - administering supplemental oxygen
present but the onset is 6- 72 hours after transfusion - stopping infusion of other intravenous fluids
- administering diuretic medications
clinical presentation:
- acute respiratory distress (dyspnea, tachypnea, 5. TRANSFUSION-ASSOCIATED DYSPNEA
hypoxemia)
DYSPNEA – could be seen in allergic reactions,
- fever - hypothermia
TACO, or TRALI
- rigors - hypotension
- diagnosed when dyspnea occurs within 24 hours after
- tachycardia
transfusion and all other diagnoses are excluded.
- transient leukopenia and thrombocytopenia – in about
- pathophysiology is unknown
25% of patients
- diagnosis should almost always be made with a
qualification as “PROBABLE” or “POSSIBLE.”

6. HYPOTENSIVE TRANSFUSION REACTION

HYPOTENSION – defined by NHSN criteria in adults
as a drop in the systolic BP of > 30 mmHg and systolic BP <
80 mmHg.
- in children: a 25% drop in the baseline systolic BP
- cause: increased bradykinin levels in stored blood
products
- pathophysiology of hypotensive transfusion reactions
are not understood.

7. FEBRILE NONHEMOLYTIC TRANSFUSION REACTION (FNHTR)

- one of the most common adverse transfusion
reactions
- generally mild and self-limited

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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
- defined as fever greater than 100.4°F (38°C) or a
change of at least 1.8°F (1.0°C) from the
pre-transfusion level occurring during or within 4
hours after the end of the transfusion or chills and/or
rigors are present.
- diagnosed after the patient’s underlying condition and
medications are excluded as a cause.
- Fever usually occurs with chills or rigors, but chills or
rigors without fever can still be diagnosed as FNHTR
despite the absence of fever.
other symptoms:
headache, cold feeling, mild dyspnea, mild
nausea/vomiting
- Symptoms typically begin toward the end of the
transfusion, but 5% to 10% do not appear until 1 to 2
hours after the end of the transfusion
- The change in temperature is usually modest (less
than 2°C/3.6°F), but when it is greater than 2°C,
transfusion-transmitted bacterial infection must be
excluded by visual inspection of the product for
discoloration or clots and culture of the implicated
product.
treatment: Anti-pyretics
8. ALLERGIC TRANSFUSION REACTIONS
- most common reactions seen with platelet and
plasma transfusions, occurring in about 2% of
transfused platelets, and are 2nd to FNHTRs in RBC
transfusions.
- The terms “allergic,” “anaphylactoid,” and
“anaphylactic” are used to generally categorize ATRs.
● allergic reactions - generally mild to moderate
reactions and refer to signs and symptoms limited to
the skin and gastrointestinal tract
● anaphylactoid reactions - moderately severe
reactions that include oral and throat symptoms, more
severe GI symptoms, and respiratory complaints.
● anaphylactic reactions - severe, life-threatening
reactions in which there is profound hypotension and
shock.
- The NHSN Hemovigilance definition of ATRs includes
only anaphylactoid and anaphylactic signs and
symptoms.
- A definite diagnosis of ATR includes the appearance
of signs and symptoms during or within 2 hours after
the end of transfusion and the exclusion of other
possible drug, environmental, and dietary causes.
- The clinical signs and symptoms of ATRs can be
categorized into mucocutaneous, gastrointestinal,
respiratory, and cardiovascular
treatment:
● diphenhydramine – for mild cutaneous reactions
● steroids – more severe urticarial reactions or those
accompanied by oropharyngeal or upper respiratory
symptoms
● epinephrine
● antihistamines – used prior to transfusion to prevent
ATR
9. TRANSFUSION-ASSOCIATED GRAFT-VERSUS-HOST DISEASE
- The NHSN definition of TA-GVHD is a clinical
syndrome developing from 2 days to 6 weeks after
transfusion characterized by the typical skin rash
seen and other forms of GVHD, diarrhea, fever,
enlarged liver, elevated liver enzymes, marrow
aplasia, and/or pancytopenia.
- A definite diagnosis is made by skin or (occasionally)
liver, biopsy showing characteristic histological
features.
- A probable diagnosis of TA-GVHD is made when the
clinical criteria are met but a biopsy is negative or was
not performed.
The most common symptoms:
rash, fever, increased liver enzymes, pancytopenia,
and diarrhea.
- The first symptoms appear on average 11 days from
the implicated transfused unit, but there is a wide
range of disease onset.
- Uncommonly, symptoms can occur over 6 weeks after
transfusion.
- Death occurs in about 90% of patients with a median
of 24 days after the implicated transfusion.
- Mortality is associated with older age, whole blood
transfusion, local reduced product, and short storage
duration (fresh or less than 48 hours old).
- The rash begins as a maculopapular rash that starts
over the trunk and then spreads to the limbs.
- It is indistinguishable from viral and drug-induced
rashes.
- The histological features of GVHD are well described
in the skin, but the leukocyte chimerism (the presence
of donor lymphocytes and recipient tissue) can be
tested for when biopsy findings are equivocal.
- Analysis of microsatellite DNA polymorphisms has
also been used to diagnose TA-GVHD by
demonstrating replacement of recipient WBCs by
donor WBCs in peripheral blood.
- The treatment for TA-GVHD is immunosuppressive
medications.
- Hematopoietic stem cell transplantation has been
reported to be successful, but only a small number of
patients have been treated so far.
- Irradiation of cellular blood components is successful
in preventing TA-GVHD.
TRANSFUSION-TRANSMITTED BACTERIAL INFECTIONS
● is the most frequent infection associated with
transfusion
● Despite strict donor screening, stringent collection
and storage techniques, and bacterial detection
methods, bacterial contamination of blood products
remain a significant risk of transfusion, especially for
platelets.
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IMMUNOHEMATOLOGY 2ND SEMESTER | LECTURE
● The NHSN Hemovigilance definition of TTBI requires
laboratory evidence of the pathogen in the recipient
and demonstration of the pathogen in at least one or
more of the following:
a. the transfused component
b. the donor at the time of collection
c. an additional component prepared from the
same donation, or
d. an additional recipient of a component from
the same donation.
● A definitive diagnosis of TTBI also requires that the
recipient did not have evidence of infection with the
same pathogen prior to the transfusion
Clinical symptoms begin during transfusion of the
contaminated product and include:
- high fever (>38.5°C/101.5°F)
- tachycardia
- rigors
- nausea
- hypotension
- vomiting
- Pain (back, abdominal, or infusion site) and
respiratory complaints can also occur.
- Septic shock, acute kidney failure, and
disseminated intravascular hemolysis are
common complications
● The predominant bacteria associated with RBC
contamination are gram-negative rods in the
Enterobacteriaceae family.
● most bacteria in contaminated platelets are due to
gram-positive cocci and are from normal skin flora
introduced into the product during venipuncture.

Atido. P.v.c. | 7
 SUMMARY: ACUTE TRANSFUSION REACTIONS

SYMPTOMS DIAGNOSIS TREATMENT PREVENTION

AIHTR Fever/chills DAT positive Discontinue transfusion Follow standard operating
(Acute Immune Hemolytic Back pain Decreased Hemoglobin Maintain vascular access procedures for identification of
Transfusion Reaction) Hemoglobinemia Increased LDH Maintain blood pressure the patient
Hemoglobinuria Increased Bilirubin Maintain renal blood flow
Hypotension, renal failure Decreased haptoglobin Treat DIC if present
Shock DIC
ANIHTR Asymptomatic DAT negative Discontinue transfusion Follow standard operating
(Acute Non-Immune Hemolytic Hemoglobinuria Maintain vascular access procedures for equipment
Transfusion Reaction) Maintain renal blood flow operation
FNHTR Fever/chills DAT negative Treat with antipyretics Pre-storage leukoreduction of
(Febrile Non-Hemolytic Nausea/vomiting For rigors, treat with meperidine PRBC and platelets
Transfusion Reaction) Tachycardia
Tachypnea
Increased blood pressure

Allergic, Non-severe Erythema Clinical diagnosis Temporary discontinue For repeated reactions, consider
Pruritus DAT not required transfusion premedication with
Treat with antihistamines antihistamines
If symptoms improve, restart
transfusion
Allergic, Severe Angioedema DAT negative Discontinue transfusion For IgA absolute deficient
Wheezing IgA deficiency workup when Maintain vascular access patients, provide IgA deficient
Hypotension indicated Treat with subcutaneous blood components
Anaphylaxis epinephrine
Maintain blood pressure
Provide respiratory support
TRALI Severe hypoxemia CXR: bilateral infiltrates Discontinue transfusion Use male only plasma
(Transfusion-Related Acute Lung No evidence of left atrial Donor test for HLA/HNA Maintain vascular access Exclude or screen female platelet
Injury) hypertension antibodies Supplemental oxygen donors
Recipient test for HLA/HNA Mechanical ventilation
antigens
 TACO Severe hypoxemia CXR: Pulmonary edema, Upright posture Slower transfusion rate
(Transfusion-Association Increased Blood pressure cardiomegaly, distended Supplemental oxygen Transfuse in smaller volumes
Circulatory Overload) Jugular vein distension pulmonary artery Diuresis
Increased venous pressure Brain Natriuretic Peptide (BNP)

SUMMARY: DELAYED TRANSFUSION REACTIONS

SYMPTOMS DIAGNOSIS TREATMENT PREVENTION

DSHTR Asymptomatic Positive Antibody screen/DAT As needed Accurate record-keeping
(Delayed Serologic Hemolytic Fatigue Decreased Hemoglobin Transfuse antigen-negative, AHG- Obtain transfusion history
Transfusion Reaction) crossmatched compatible PRBC Limit transfusions
DHTR Flulike symptoms Decreased Hemoglobin As needed Accurate record-keeping
(Delayed Hemolytic Transfusion Pallor Increased Total bilirubin Transfuse antigen-negative, AHG- Obtain transfusion history
Reaction) Jaundice crossmatched compatible PRBC Limit transfusions
TA-GVHD Rash Pancytopenia Not available Gamma irradiation of cellular blood
(Transfusion-Associated Graft- Fever Identify donor engraftment components as indicated
versus-Host Disease) Diarrhea
Iron overload Multiorgan failure High ferritin levels Use of iron-chelating agents Prophylactic use of iron-chelating
agents
Red cell exchange