Blood banking:- part 2 – Definition of blood banking, Donor selection, Cross Matching Procedure, and Compatibility test

Sample

1. Patient (recipient) venous blood in the disposable syringe is taken.
2. Take the blood sample from the donor.

History of the blood banking

1. In 1492 blood was taken from three young men and was given to pope innocent VII in the hope of curing him. Unfortunately, all four died.
   1. This was the first time when the blood transfusion was recorded in history.
2. Clotting was the main problem.
3. Attempts to find nontoxic anticoagulants began in 1869, which was recommended sodium phosphate by Braxton and Hicks.
4. Karl Landsteiner, in 1901 discovered the  ABO blood groups in mankind. He also discovered the serious blood transfusion reaction due to the ABO system. He won the Nobel prize.
5. Edward E. Lindemann was the first person who succeeded by carrying out a vein-to vein blood transfusion. This was a time-consuming procedure.
6. Later on, Unger designed a special syringe-valve system that can transfuse the blood without the help of anybody.
7. In 1914, there was a breakthrough when Hustin reported using sodium citrate and glucose as a diluent and anticoagulant solution for the transfusion.
8. In 1915, Lewisohn determined the minimum amount of the nontoxic citrate needed for anticoagulation and transfusion. Then transfusion became more practical and safer for the patient.
9. In 1916, Rous and Turner introduced the dextrose-citrate solution for the preservation of the blood.
10. The common use of glucose was delayed as a preservative for the RBCs.
11. World war II increased research for the preservation of blood and plasma because of the demand.
12. Dr. Charles Drew work in world war II for preserving and transfusing the blood lead to a widespread system of blood banks.
13. In 19041 February, Dr. Charles Drew was appointed the first director of the American red cross society at Presbyterian hospital.
14. In 1943, Loutit and Mollison of England introduced the formula of acid-citrate dextrose solution (ACD).

Definition of blood banking

1. This is the collection, storage, and testing of the blood components and derivatives.
2. There is a therapeutic use of blood components, plasma derivates, and apheresis technology.
3. It includes the collection, storage, and use of hematopoietic and other blood-derived cells.
4. Whole blood may be fractionated into:
   1. Packed RBCs.
   2. Platelets.
   3. Plasma products.
5. Plasma after processing provides:
   1. Albumin.
   2. Blood coagulation factors concentrate.
   3. Immunoglobulins preparation.
      

      Blood banking summary

Purpose of blood cross-matching (Indications):

1. The primary purpose of the crossmatch is to prevent a transfusion reaction.
2. Crossmatch is done before the major surgery.
3. Crossmatch is also done before an operation where there is usually no need for blood, e.g., hysterectomy and cholecystectomy.
4. packed RBCs transfusion:
   1. Anemia when the hemoglobin is <7 G/dL or hematocrit <21% without cardiovascular function complications.
   2. Hb <10 g/dl and HcT <30% in patients with cardiovascular disease, sepsis, or hemoglobinopathy.
5. platelets transfusion:
   1. prophylactically in case of platelets count <10,000/cmm in adults and <50,000/cmm in neonates.
   2. In case of bleeding when platelets are <30,000/cmm.
   3. In the case of postoperative bleeding, when the platelets count is <50,000/cmm.
   4. In the case of the post-cardiopulmonary bypass, when the platelets are <100,000/cmm.
6. Fresh frozen plasma:
   1. When the INR ≥ 2 and in case of bleeding.
   2. In the case of nose bleeds, when the INR is ≥ 6.
   3. In thrombotic thrombocytopenic purpura.
7. Cryoprecipitate:
   1. In the case of dysfibrinogenemia.
   2. When the fibrinogen is <100 mg/dL.
   3. In the case of Von Willibrand disease.

Precautions for the selection of donor (rejection of the donor):

1. Do not  take blood from the donor if:
   1. Blood was donated in less than 8 weeks.
   2. Poor health like cancer, cardiopulmonary disease, and bleeding disorder.
   3. Pregnancy during and after 6 weeks of delivery.
   4. Blood pressure is more than 180/100.
   5. Pulse when 50/min or more than 100/min. The only exception is the athlete, where the pulse is usually slow.
2. Hemoglobin is less than 12.5 g/dL or hematocrit less than 38%.
3. History of infectious agents:
   1. The donor with a history of viral hepatitis like HBV, HCV, and HIV, etc.
   2. The donor with Malaria or coming from a malarial area should avoid giving blood for three years.
   3. The venereal disease should not give blood for at least one year (Syphilis or Gonorrhoea).
   4. A person with rubella or varicella vaccination should not give blood for 4 weeks.
   5. Donor if running fever > 99.5 °C.
   6. The donor with leukemia or lymphoma.
4. History of recent surgery or illness needs to be considered unfit. In case of illness, after the recovery, at least there should be a 2 to 3 weeks interval free of any signs/symptoms.
   1. After the surgery, it depends upon the type of surgery, and if he is under the supervision of a physician should be deferred.
   2. If the donor has a cold, influenza, or tooth extraction, it should be deferred for one week.
5. Donors with a history of allergies and allergies to drugs should be rejected.
6. Donors on drug medication like antihypertensive drugs, antibiotics, and corticosteroids, should be rejected.
7. Donors who have recent vaccination should be deferred at least for one week.
8. If there is H/O drug abuse.

Criteria for the selection of the blood donor:

1. History of the donor:
   1. There is no history of viral hepatitis in the last 6 months.
   2. No history of blood transfusion in the last 6 months.
   3. There should be no contact with the patient of viral hepatitis.
   4. Avoid drug addicts.
   5. No history of tattooing in the last 6 months.
   6. Avoid blood positive for HBV or HCV, or HIV.
2. Hemoglobin should be at least 12.5 G/dL. This should be checked before taking the blood.
3. Hct should be 38%, in the normal range.
4. Age: Ideal age between 18 to 65 years.
5. Bodyweight: The donor should weigh at least 50 kg (110 lbs).
6. The temperature should not be >99.6 °C. The purpose of the temperature is to avoid the transfer of the infection to the recipient.
7. The pulse should be 50 to 100 beats/minute. Pulse rate >100/minutes should be further evaluated.
   1. Pulse rate <50/minutes may be found in the athlete.
   2. The donor may have anxiety, so allow him to relax for 10 to 15 minutes, then recheck the pulse.
   3. If still, the pulse is >100/minutes, then defer the donor.
8. Blood pressure systolic should not be >180 mmHg, and diastolic not >100 mmHg. These donors need to be evaluated before these donors are accepted.
9. History of recent immunization: Defer this donor for at least one week till they have no signs and symptoms.
10. Check skin lesions in the antecubital area to rule out habitual drug abuse.
    1. These donors are deferred because of the risk of Hepatitis virus or HIV infection,
    2. Check for psoriasis lesions, skin eruptions like such as poison ivy, and rash.
11. History of malaria: Such donors with a history of malaria should be deferred for at least three years. The people who have traveled to the malarial area should also be deferred for three years.
12. History of donation: Avoid professional donors because they always have low hemoglobin.
    1. The donor should not donate blood more than 4 times a year.
    2. Male should donate more than females.
13. Donors should not donate blood more than 4 times a year.
14. Females should donate less than males because of the menstrual cycle, where they may lose one point of blood donation per year.
15. History of present or recent surgery or illness: Donors with long-standing illnesses should be excluded. Donors with recent surgery or hospitalization should be rejected.
16. Medical history consists of the following questions:
    1. Have you ever have jaundice?
    2. Do you have H/O liver diseases?
    3. Do you have positive tests for viral hepatitis?
    4. Do you have blood donations in the last 12 months?
    5. Do you have organ transplantation?
    6. Do you have acupuncture in the last 12 months?
    7. Do you have close contact with the patient having yellow jaundice or hepatitis?
    8. H/O of malaria or intake of malarial drugs in the past 3 years?
    9. Is there is H/O cancer, blood disease, or bleeding problems?
17. Summary of Donor selection criteria:
    1. 1. In general appearance, the donor should be in good health.
       2. Temperature orally should not exceed 99.6 °C (37.5 °C).
       3. The pulse should be 50 to 100/minutes, and it should not exceed this limit. The Pulse >100/minutes should be further evaluated.
       4. Age of the donor.
       5. Blood pressure systolic should not be >180 and diastolic >100 mm Hg.
       6. Weight of the donor. The ideal weight maybe 110 lb (50 kg)
       7. Level of hemoglobin and Hematocrit (Hct).  Hb at least 12.5 g/100 mL and Hct 38%.
       8. Frequency of blood donation per year.
       9. The medical history of excluding the donors:
          1. Infections of the donor include the history of viral infections, H/O  malaria, or taken antimalarial drugs or  H/O  major surgery or illness.
          2. H/O psoriasis and its treatment.
          3. If there is H/O chest pain, heart disease, or lung disease.
          4. If there is H/O cancer, blood diseases, or bleeding disorder.
          5. If there are H/O convulsions, seizures, or fainting spells.
          6. If the donor has had a vaccination in the last 4 weeks.
          7. H/O extraction of teeth and dental works.
          8. Positive syphilis test in the last 12 months.
          9. If the positive test for AIDS.
             

             Criteria for the selection of donor

Approved blood preservatives in use are:

Preservatives name	Abbreviation used are	Storage time limit
Citrate-phosphate-dextrose	CPD CPDA-1	21 days 35 days
Aid-citrate-dextrose	ACD	21 days
Nutricel  (AS-3)	AS-3	42 days
Nutricel (AS-2)	AS-2	35 days
Adsol (AS-1)	AS-1	42 days

Comparison of the allogeneic donors and autologous donors (fitness of the donors):

Clinical parameter	Autologous donor	Allogenic donor
Hemoglobin level	>11 g/dL	>12 g/dL
Hematocrit (Hct)	>33%	>38%
Screening for the infectious disease	Not needed	Needed (HBS, HCV, HIV, Syphilis)
The interval between the blood donation	Only 72 hours	At least 8 weeks
Type of donor	Self (same person, before surgery)	Volunteer

The following tests should be done on the donor’s blood:

• ABO typing.
• Rh typing.
• Hepatitis B surface antigen.
• Hepatitis Core B antibody (HBc-IgM).
• Hepatitis C antibody.
• For Syphilis (VDRL).
• HIV.
• SGPT (ALT).
• If possible, do PCR for HCV and HIV.

To rule out the possibility of infectious diseases:

1. Must do to rule out:
   1. Serologic test for syphilis.
   2. Antibody to HCV (hepatitis C virus).
      1. HCV RNA.
   3. HBS antigen (hepatitis B surface antigen).
      1. Antibody to Core-antigen (antibody to HBV core antigen).
   4. Antibody to HIV-1 and HIV-2.
      1. HIV-1 RNA
   5. West Nile virus RNA
   6. Screening for bacterial infection can do platelets count only.
2. Optional and may be needed in some areas:
   1. CMV antibody.
   2. SGOT/SGPT  for any abnormality in the liver. Sometimes this simple test helps to rule out hepatotropic virus infection.

Procedure for the blood donation:

 Blood bags should not be released  before it is tested for:

Before issuing the blood bag for donation, all blood bags are tested as follows:

1. Advise forward blood grouping (Donor’s RBCs):
   1. ABO typing.
   2. Rh typing, including weak D antigen in the case of D negative.
      1. All Rh0 (D) negative units are confirmed and tested with anti-CD and anti-DE.
      2. D^u tests are performed on all r’ and r” units.
   3. Screening for non- ABO donor antibodies.
2. Advise reverse blood grouping (Donor’s serum):
   1. Antibody screening tests using enzyme and antiglobulin method.
   2. Advise VDRL test for syphilis.
   3. Advise Hbs Ag and HbS Ab test.

Recipient blood screening includes:

1. ABO typing.
2. Rh typing.

Cross-Matching:

Definition of cross-match (compatibility testing):

1. This was introduced by Ottenberg in 1908, the direct compatibility test, or cross-match, between the donor and the recipient (patient), was absolutely important for the safe blood transfusion.
2. The direct cross-match was preceded by antibody screening as part of patients’ pretransfusion testing for several decades.
3. In 1960, phenotyped RBCs were used for this purpose and commercially available.
4. In 1964, Grove-Rasmussen advised the need for the antiglobulin test as part of the crossmatch when antibody testing was negative.
5. Two main functions of the crossmatch are:
   1. This is a final check for the ABO compatibility between the patient and the donor.
   2. This may detect the antibody in the patient’s serum that was not detected in antibody screening.
6. Major crossmatch is much more important than the minor crossmatch.

Procedure:

1. Make Donor’s RBCs suspension in the normal saline.
2. Major-cross match: This is also called a direct crossmatch.
   1. Donor RBC and recipient serum are mixed in the saline phase.
   2. This is followed by an indirect Coombs test, where the above RBC is washed with saline three times, and then Coomb’s serum is added.
      

      Major blood cross match

      

      Blood ABO major crossmatch

3. Minor cross-match:  This is also called the reverse cross-match.
   1. Now take recipient RBC and donor serum.
      

      Minor blood cross match

The result or how to read the crossmatch:

• Negative = No cell clumping or hemolysis should be seen (No agglutination should be observed).
• Positive = Shows agglutination or hemolysis.

ABO donor and recipient compatibility:

Donor’s blood group	Antigen	Antibody	Recipient blood group
Blood group O	None	Anti-A and B	O, A, B, AB
Blood group A	Antigen- A	Antibody- B	A, AB
Blood group B	antigen-B	Antibody- A	B, AB
Blood group AB	Antigen-A and B	None	A, B

Blood Grouping and compatibility:

		Donor blood group
		O (universal donor)	A	B	AB
Recipient blood groups	O	Compatible	Incompatible	Incompatible	Incompatible
	A	Compatible	Compatible	Incompatible	Incompatible
	B	Compatible	Incompatible	Compatible	Incompatible
	AB (universal recipient)	Compatible	Compatible	Compatible	Compatible

Blood components:

Whole blood:

1. Proper storage of the blood is crucial:
   1. Whole blood needs to be stored at 4 °C (± 1 °C).
   2. At this temperature, bacterial growth and cell metabolism slow down.
2. Some researchers say that a temperature of 2 °C is better, but disadvantages are:
   1. White blood cells and platelets become irreversibly clumped at this temperature.
   2. Also, at 2 °C, RBCs are swollen due to the presence of dextrose, become fragile, and maybe hemolyzed.
   3. At temperature >10 °C:
      1. Bacterial growth is enhanced.
      2. Cell survival is decreased, around 20%.

When blood is stored for some time, then changes seen are:

1. Blood deterioration starts when stored in Citrate phosphate dextrose anticoagulant (CPD) or Acid Citrate Dextrose anticoagulant (ACD) within the collection of a few days.
2. RBCs will lose their ability to metabolize glucose.
3. The cells suffer the loss of K⁺ to plasma.
4. The osmotic and mechanical fragility is increased.
5. There is a loss of membrane lipids.
6. The survival of the RBCs is lost in vivo:
   1. 5% after the first week.
   2. 10 to 15% after 2 weeks.
   3. 15 to 30% after 3 weeks.
7. The addition of the Adenine (Adenine+CPD)  will prolong the shelf life of RBCs to 35 days.
8. There is a decrease in the 2,3-diphosphoglycerate (2,3-DPG) and Adenosine triphosphate (ATP) on storage.
   1. The concentration of the 2,3-DPG is better maintained in the CPD than the ACD.
9. Blood stored at 4 °C, the transport of the Na⁺ and K⁺ across the RBCs membrane is stopped.
   1. If storage is continued, then:
      1. In that case, Na⁺ and K⁺ intracellular and extracellular concentrations continued to maintain the balance.
   2. After the blood transfusion in CPD, Na⁺ is corrected within 24 hours.
   3. But the K+ level does not become normal, and it takes >6 days.
      

      Equilibrium of sodium and potassium when stored in CPD bags

10. Uses of the whole blood:
    10. It is advised in patients where there is enough acute loss of blood leading to hypovolemia.
    11. This may be given in patients with severe anemia, preferably give packed RBCs.

Fresh frozen plasma (Plasma):

1. Plasma is separated from the RBCs by centrifugation at 4 °C and is frozen as rapidly as possible.
   1. This is stored at -30 °C for a maximum period of one year.
   2. At -20 °C can store for 3 months.
2. On storage of fresh frozen plasma, deterioration takes place for labile clotting factors.
3. Use of the fresh frozen plasma:
   1. It is used for the deficiency of labile coagulation factors.
   2. With concentrated RBCs and frozen plasma.
   3. Stored plasma is useful in the treatment of protein replacement or to increase blood volume.
      1. Stored plasma is also used in burns, hypovolemic shock, coagulation factors deficiencies ( except factor V and VIII), and an anticoagulant reversal.

Packed red blood cells:

1. 1. When Red blood cells concentrate is prepared in a closed atmosphere, the cells’ sterility is not affected.
   2. In this way, you can avoid bacteria proliferation.
   3. These are used to avoid disturbing Hct and circulatory overload.
   4. This will also avoid the reaction because of the donor antibodies.
   5. Uses of packed RBCs:
      1. This is indicated where the Hct needs to be increased without affecting the blood volume, e.g, anemia.
      2. Packed cells advantages over the whole blood are:
         1. This will minimize circulatory overload.
         2. This will reduce the reaction due to the donor antibodies.
         3. It will reduce the quality of anticoagulants and electrolytes transfused in whole blood.
         4. It will minimize the reaction due to plasma components.

The difference between the whole blood and packed cells:

Characteristic features	Packed cells	Whole blood
Hct %	70 ± 5	40 ± 5
Volume of transfusion	300 ± 25 mL	500 ± 25 mL
Plasma volume	100 ± 25 mL	300 ± 25 mL
RBC volume	200 ± 25 mL	200 ± 25 mL
Albumin contents are	4 to 5 grams	10 to 12 grams

Human serum albumin:

1. This is prepared from the normal human plasma.
2. Human albumin is prepared by the cold ethanol plasma fractionation and is available in a concentration of 5% or 25% concentrate.
3. 25%  albumin is stored at 2 to 8 °C and should not be frozen.
4. 5% albumin is stored at room temperature, and the temperature should not exceed 37 °C and should not be frozen.
5. The shelf life for both products is 3 years; expiry dates should not be ignored.
6. Storage has no effect if it is stored at the proper temperature and used before the expiry dates.
7. Uses of the human albumin:
   1. It is used in the case of shock due to hemorrhage or surgery.
   2. This can be used as a fluid replacement during manual or automated therapeutic plasma exchange.
   3. In the case of neonatal hyperbilirubinemia.
   4. A complication of human albumin are:
      1. The patient may have a pyogenic or allergic reaction.
      2. There may be a hypotensive reaction.
      3. The above S/S disappear when the infusion is slowed down or stopped.
      4. The patients may have dilutional anemia.
      5. It should not be given in patients with contraindications in a rapid increase in the volume affecting the health.

Gamma Globulin (Immune serum Globulin):

1. Immune serum globulins are stored at 2 to 8 °C for 2 years without any deterioration.
2. Uses of the immunoglobulins are:
   1. These are given to boost passive immunity (passive antibody) and protect exposure to some diseases.
   2. In congenital immune deficiency disorders.
   3. These immunoglobulins are effective in:
      1. Measles.
      2. Hepatitis A infection.
      3. Hypogammaglobulonemia.

Antihemophilic factor (Factor VIII concentrate):

1. Factor VIII concentrate is obtained from the pooled fresh frozen plasma.
2. This is in lyophilized form, and it should be stored at 2 to 8 °C and should not be frozen.
3. This can be stored at room temperature for a short limited period of time.
4. Cruprecipitate factor VIII is prepared from a single donation of fresh blood by cold precipitation.
5. Uses of the antihemophilic factor VIII:
   1. This is used in the case of hemophilia A (congenital factor VIII deficiency).
   2. In the cases of acquired factor VIII inhibitors.

Platelet-rich plasma or platelet concentrate:

1. Platelet-rich plasma concentrate can be stored for up to 72 hours at room temperature with constant agitation.
2. Effect of storage: With time, there is a progressive decrease in their hemostatic efficiency.
   1. After 72 hours, the pH falls to 6.0, where the platelet’s hemostatic activity is lost or decreased.
   2. Now plastic bags (O2 diffusible) are available where the platelet activity remains for 5 days.
3. Uses of platelets concentrate:
   1. It is used to treat or prevent thrombocytopenia.
   2. These are used for the treatment of bleeding disorders due to platelets functional disorders.

Blood components and their indications:

Components	Composition	Indications
Stored whole blood	The whole blood is stored.	Acute blood loss
Fresh whole blood	Whole blood	Acute blood loss requiring massive replacement
Packed RBCs	Only RBCs without plasma	For the treatment of anemia Hemolytic disease of the newborn
Washed red blood cells	Washed red blood cells	To prevent a severe allergic reaction.
Fresh frozen plasma	Plasma separated and frozen in 8 hours of collection.	Used to control bleeding in coagulation factors deficiency
Cryoprecipitate	Prepared by thawing fresh frozen plasma at 1 to 6 °C, the precipitate is collected and again refrozen.  Cryoprecipitate <25 mL contains fibrinogen 150 mg and 80 units of factor VIII.	Used in deficiency of fibrinogen Deficiency of factor XIII. Deficiency of factor VIII DIC.
Platelets concentrate	Platelets are separated from a single unit of blood, suspended in40 to 60 mL of plasma. Stored at 20 to 24 °C.	Indicated in thrombocytopenia  due to any cause, and prevents bleeding in low platelets count
Granulocytes collected by apheresis	granulocytes are collected by apheresis.	In neutropenia and infection. It is more effective in infants than adults.
Platelets collected by apheresis	platelets collected by apheresis and volume is 200 to 300 mL	Used as platelets concentrate
Leucocyte poor blood	Blood where leucocytes are removed	For patients with leucocytes antibodies
Factor IX concentrate	Contains factor IX	In factor IX deficiency
II, VII, X, IX concentrate	concentrate on factors	Correction of vitamin K-dependant factors deficiency
Gamma globulins	Contains gamma globulins	In hypogammaglobulinemia
Serum albumin	Contains albumin	In burns, protein depletion, and blood volume restorer