Case 1:

Labor and delivery orders 4 units of packed red blood cells stat on a 32-year-old white
female with the following results:
ABO/Rh Antibody screen:
Blood type A no unexpected antibodies detected
Rh: Positive(+)

History: No unexpected antibodies in two previous deliveries at this facility, no previous

red cell transfusion recorded.
1. What crossmatch options do they have?
2. Which do you choose and why?
 I. Introduction
Compatibility testing is a necessary part of transfusion medicine and is done by
testing of the patients serum with the donor RBCs including an antiglobulin phase or
simply an immediate spin phase to conrm ABO compatibility. The call for compatibility
testing according to the Code of Federal Regulations and the American Association of
Blood Banks (AABB) Standards, ABO and Rh grouping is intended to prevent Hemolytic
transfusion reactions which can occur when the recipient's immune system encounters
antigens from donor blood. Antibodies may form in response to these antigens, resulting
in destruction of donor red blood cells (RBCs), with sequelae leading to clinical
manifestations of fever, hypotension, rigors, acute respiratory failure, and acute renal
failure.
The type and screen are the first pretransfusion compatibility tests performed and
are used to identify the patient's ABO group and Rh type and to detect expected and
unexpected antibodies in the patient's serum, respectively. The crossmatch is the final
step of pretransfusion testing as a routine procedure. A portion of donor blood is combined
with patient plasma or serum and is checked for agglutination, which would signify
incompatible blood. This important step, also known as major crossmatch, serves as the
last guard to ensure a safe transfusion The crossmatch is routinely used as the final step
of pretransfusion compatibility testing. It serves 2 purposes: (1) to serve as a final check
of ABO compatibility between donor RBCs (RBCs) and patient plasma or serum and (2)
to detect clinically significant antibodies that may have been missed by the antibody
screening test.
 II. PATIENT DATA

Personal data:

Name: Not stated

Age: 32 years old
Gender: Female
Race: Caucasian

History:

Gravida 3 with no history of unexpected antibodies in two previous deliveries in the

same facility, no previous red cell transfusion recorded.

Laboratory results:

ABO/Rh Antibody screen:

Blood type A no unexpected antibodies detected
Rh: Positive(+)
 III. Definition of the case

the patient had 2 previous deliveries in the same facility presented with no immediate
medical concerns upon serologic screening and checking the patients history.The
previous determination of ABO/Rh and antibody screen including the fact that there had
been no transfusion of red cells in the previous deliveries bares no immediate medical
concern. The crossmatching option available includes immediate spin, AHG crossmatch
and Computer crossmatching.
 IV. Discission

A. What crossmatch options does the patient have?

1. Immediate Spin Crossmatch

When no clinically signicant unexpected antibodies are detected and there are no
previous records of such antibodies, a serologic test to detect ABO incompatibility is
sufcient. This is accomplished by mixing the recipients serum with donor RBCs and
centrifuging immediately (i.e., immediate spin). Absence of hemolysis or agglutination
indicates compatibility. The type and screen process involves testing the patients blood
sample for ABO, Rh, and unexpected antibodies. The patient sample is then stored in the
blood bank refrigerator for future crossmatch if blood is needed for transfusion. This
process has application for patients who may need blood but, because the process may
not always require transfusion, the crossmatch is not performed until necessary. The type
and screen, coupled with an immediate spin crossmatch, is referred to as an abbreviated
crossmatch. Studies of the use of an abbreviated crossmatch show that it is a safe and
effective method of pretransfusion testing. It has been calculated to be 99.9 percent
effective in preventing occurrence of an incompatible transfusion. A study done by
walker(1989) was able to show that the frequency with which an incompatible antiglobulin
crossmatch follows a negative screen is very low: 0.06 percent.
However, the immediate spin does not detect all ABO incompatibilities.although
rare in the Philippine setting, it is important to consider the patient is Caucasian. False
reactions may be seen in the presence of other immediate spin-reactive antibodies (e.g.,
autoanti-I), in patients with hyperimmune ABO antibodies, when the procedure is not
performed correctly (i.e., delay in centrifugation or reading), when rouleaux is observed,
or when infants specimens are tested. Adding ethylenediaminetetraacetic to the test
system has been reported to eliminate some of the false-positive reactions, thus
improving the sensitivity of the immediate spin crossmatch.

2. Antiglobulin Crossmatch
The antiglobulin crossmatch procedure begins in the same manner as the
immediate spin crossmatch, continues to a 37 Degrees Celcius incubation, and nishes
with an antiglobulin test. Several enhancement media may be applied to enhance
antigen-antibody reactions. These may include albumin, low ionic strength solution
(LISS), polyethylene glycol, and polybreneFor greatest sensitivity, an antihuman globulin
(AHG) reagent containing both anti-IgG and anticomplement may be selected for the nal
phase of this crossmatch method.
 3. Computer Crossmatch
Electronic (computer) crossmatch to detect ABO incompatibilities is as safe as the
serologic immediate spin test. Many believe that the computer crossmatch is safer than
the immediate spin because the of the integrity of the computer software to detect ABO
incompatibility between the sample submitted for pretransfusion testing and the donor
unit. The computer crossmatch compares recent ABO serologic results and
interpretations on le for both the donor and the recipient being matched and determines
compatibility based on this comparison. Annual savings, reduced sample requirements,
reduced handling of biologic materials, and elimination of false reactions associated with
the immediate spin crossmatch are additional benets identied when using the computer
crossmatch.

B. Which do you choose and why?

In the practical setting, the procedure that is followed is the one that is used in the
laboratory SOP, in this case however, I choose the immediate spin crossmatching method
because practically, is fast and effective, it is also widely used across laboratories and is
sufficient since there had been no raised concern for unexpected antibodies. Computer
cross matching may be faster and possibly be more accurate, however is not that
common in the Philippines.
Case 2:
Pretransfusion testing results on a presurgical patient with a 3-unit crossmatch order are
as follows:
ABO/Rh B positive
Unexpected antibody screen no unexpected antibody detected
3 rbc units crossmatched
Unit 1: compatible at AHG
Unit 2: compatible at AHG
Unit 3: incompatible using gel column methodology

1. What can account for the incompatible unit? Explain?

2. How would you resolve this situation?
 I. Introduction
The primary objective of the crossmatch test is to detect the presence of antibodies
in the recipients serum, including anti-A and anti-B, that could destroy transfused
RBCs. A positive result in the crossmatch test requires explanation, and the recipient
should not receive a transfusion until the cause of the incompatibility has been
determined. When the crossmatch test result is positive, the results of the autocontrol
and antibody screening test should be reviewed to identify patterns that may help
determine the cause of the problem.
 II. PATIENT DATA

Patient is for surgery needing 3 units of type B, Rh positive red cell units.

Upon cross matching, the results show:

Red Method Result
cell
unit
UNIT 1 AHG COMPATIBLE
UNIT 2 AHG COMPATIBLE
UNIT 3 Gel Column INCOMPATIBLE

Unexpected antibody screen revealed no unexpected antibody detected

 III. Definition of the case
Gel technology is applicable to a broad range of blood bank tests, and it offers
several advantages over routine tube testing. Standardization is one of the major
advantages, inasmuch as there is no tube shaking to resuspend the RBC button. Tube
shaking techniques vary among technologists, which results in variation in the reading,
grading and interpretation of the test. The gel technique provides stable, welldened
endpoints of the agglutination reaction. It includes simple standardized procedures,
no wash steps, and no need for antiglobulin control cells. These factors combine to
produce more objective, consistent, and reproducible interpretation of the test results.
Because the gel technology offers objective, consistent results, it is ideally suited to
individuals who have been cross trained to work in the blood bank. Other advantages
include the decreased sample volume needed for testing and the enhanced sensitivity
and specicity of gel technology. Finally, gel technology offers improved productivity,
standardization, and ability to meet regulatory requirements when compared with
traditional tube testing. That being said the main concern in this case is to explain why
there had been incompatibility upon crossmatch upon using gel technology even after
screening.
 V. Discission

A. What can account for the incompatible unit? Explain?

There could be a multitude of reasons for this to happen, however it is important
to note that screening should have picked up the incompatibility, however in cases
like this, it could be narrowed to a few possibilities:

a. Screening errors

I. Methodology error

It may be possible that upon the screening, common practice does not
include serum testing for antibody and upon the gel column crossmatching,
where the serum is tested hence the incompatible result.

II. Limitation error

Antibody to low incidence antigen
Antibodies to low-incidence antigens will be difficult to test for since most
screen and panel cells do not have these antigens on the testing cells.
Further testing may be needed at a reference laboratory where a larger
selection of antibody panels are available to locate cells positive for these
antigens.

Suspect an antibody to a low-incidence antigen if:

crossmatch is incompatible and

Other causes have been ruled out (positive donor DAT, ABO
incompatibility)

B. How would you resolve this situation?

The very first step is to recheck every procedure and look for error, if theres no
apparent mistake in the methodology, then it is good to consider other possibilities
such as low incidence antigen. The very first step is to repeat all procedures in all
three units from the antibody screening up to crossmatching,screening should include
the addition of the patients serum to all screening cells. Test should be done including
test determining for low incidence antigen, then transfuse antigen negative,
crossmatching compatible units to the patient.