2. There are various considerations taken in performing crossmatching. Describe each: a.

Transfusion request Requests for transfusion may be submitted electronically or on paper and must contain sufficient information for positive recipient identification. Standards requires two independent identifiers to identify the patient. These identifiers could be the patients first and last names, an identification number unique to that individual, a birth date, or other identifying system. Other information necessary to process the request includes identification of the component needed, the quantity, any special requests such as irradiation, gender and age of the recipient and the name of the responsible physician. The diagnosis and the recipients history of transfusion and pregnancy may be helpful in problem- solving. Each facility should have a written policy defining request acceptance criteria. Blood requests that lack the required information, are inaccurate, or are illegible should not be accepted. Telephoned requests are acceptable in urgent situations but should be documented, for example, in a telephone log; a subsequent request as a written authorization is to be made within 30 days. b. Patient identification Collection of a properly labeled blood sample from the intended recipient is critical to safe blood transfusion. Most hemolytic transfusion reactions result from errors in sample or patient identification. The person drawing the blood sample must identify the intended recipient in a positive manner. Each facility must develop and implement policies and procedures for patient identification and specimen collection. Most hospitals identify patients with an identification wristband. Ideally, this wristband is placed on the patient before specimen collection and remains on the patient until discharge. The same identifying information on the specimen tube submitted for testing will be used to label blood components and this information will be compared against the patients wristband at the time of transfusion. Some hospitals use an internally generated or commercially available identification band with a substitute or additional blood bank number as the unique patient identifier. Commercial systems vary in design: color-coded numbers on wristbands, tubes, and units; a wristband with an embosser for label printing; and a system for barcoding that provides positive sample and patient identification. Hospital policies generally require phlebotomists to collect blood specimens only from patients who have an attached patient identification wristband. However, in some circumstances, it may not be possible for the patient to wear an identification wrist- band, and an alternative means of positive patient identification may be needed. The use of wristbands is difficult when the patient has total body burns, when the patient is an extremely premature infant, or when the wristband is inaccessible during surgery. Some facilities allow identifying information to be placed on a patients ankle or forehead. Intraoperative patient identification procedures may allow the use of an alternative identification process in lieu of an inaccessible wristband. It is important to remind clinical personnel that transfusions should not be administered to a patient who lacks positive identification. When the patients identity is unknown, an emergency identification method may be used. This patient identification must be attached to the patient and affixed or reproduced on blood samples. This identification must be cross referenced with the patients name and hospital identification number or code when they become known. When hospitals allow the use of confidential or alias names, the facility must have policies and procedures that govern their use.

Outpatients may be identified with the use of a patient wristband for the purpose of blood sample collection. Alternative methods of positive patient identification include a drivers license or other photographic identification. Whenever possible, the patient should be asked to state his or her name and to provide confirmation of birth date and address. If a discrepancy is noted, the sample must not be collected until the patients identity has been clarified. c. Sample labeling Before leaving the patient, the phlebotomist must label the blood sample tubes with two independent patient identifiers and the date of collection. Either hand- written or imprinted labels may be used as long as the information on the label is identical to that on the wristband and request. There must be a mechanism to identify the phlebotomist; this certification may be placed on the label of the tube, placed on the requisition, or documented in a computer system. d. Confirming sample identity in the laboratory When a sample is received in the laboratory, a trained member of the staff must confirm that the information on the label and on the transfusion request is identical. If there is any doubt about the identity of the patient, a new sample must be obtained. It is unacceptable for any-one to correct identifying information on an incorrectly labeled sample. Each laboratory should establish policies and procedures that define identifying information and describe how to document receipt of mislabeled specimens. e. Appearance of blood samples The appearance of the serum or plasma may create difficulties in detecting antibodyinduced hemolysis. Whenever possible, a hemolyzed sample should be replaced with a new specimen. Test results observed with lipemic serum can be difficult to evaluate. On occasion, it may be necessary to use hemoglobin-tinged or lipemic serum or plasma. If hemolyzed samples are used, it should be noted in the patient testing re- cords to differentiate hemolysis as a result of anantigen-antibody reaction. Each institution should have a procedure describing the indications for using hemolyzed and lipemic specimens. f. Age of sample Blood samples intended for use in cross- matching should be collected no more than 3 days before the intended transfusion unless the patient has not been pregnant or transfused within the preceding 3 months. If the patients transfusion or pregnancy history is uncertain or unavailable, compatibility tests must be per- formed on blood samples collected within 3 days of RBC transfusions. This is to ensure that the sample used for testing reflects the recipients current immunologic status because recent transfusion or pregnancy may stimulate production of unexpected antibodies. Because it is not possible to predict whether or when such antibodies will appear, a3-day limit has been selected as an arbitrary interval expected to be both practical and safe. It is short enough to reflect acute changes in immunologic status but long enough to allow the results of preadmission testing completed on Friday (day 0) to be used for surgical cases performed on Monday(day 3). The 3-day requirement applies only to patients who have been transfused or pregnant within the last 3 months, but many laboratories prefer to standardize their operations by setting a 3-day limit on all specimens used for pretransfusion testing.

Each institution should have a policy that defines the length of time samples may be used. Testing of stored specimens should be based on the specimen storage limitations in the reagent manufacturers information circulars. Lack of appropriate storage space may also limit the length of time specimens are stored. g. Retaining and storing of blood samples The recipients blood specimen and a sample of the donors red cells must be stored at refrigerator temperature for at least 7 days after each transfusion. Donor red cells may be from the remainder of the segment used in the crossmatch or a segment removed before issuing the blood. If the opened crossmatch segment is saved, it should be placed in a tube labeled with the unit number and sealed or stoppered. Keeping the patients and donors samples allows repeat or additional testing if the patient experiences adverse effects. h. Reading and interpreting reactions during serologic testing In serologic testing, the hemolysis or agglutination that constitutes the visible end- point of a red cell antigen-antibody inter- action must be observed accurately and consistently. The strength of agglutination or degree of hemolysis observed with each cell sample should be recorded immediately after reading. All personnel in a laboratory should use the same interpretations and notations and be consistent in grading (eg, 0-4+) reactions. Some laboratories prefer to use a numeric scoring (eg, 0-12) system to indicate reaction strength. An optical aid such as a concave mirror enhances visualization in reading tube tests. Microscopic observation is not routinely recommended in manufacturers inserts for enhancement media. A microscope can be useful in distinguishing rouleaux from true agglutination. Microscopic reading may also allow for the detection of specific patterns of agglutination that are characteristic of some antibodies. For example, anti-Sda typically produces small refractile agglutinates in a sea of free red cells, giving the appearance of a mixed-field appearance. If gel or solid phase is used, the manufacturers directions must be followed for reading and interpreting positive and negative reactions. i. Comparison with previous records Results of ABO and Rh tests on a current specimen must be compared with previous transfusion service records if there has been prior testing during the past 12 months, and the comparison must be documented. Errors in identification and/ or testing may be detected when discrepancies are found between previous and current ABO and Rh results. Records are also to be reviewed for the presence of clinically significant red cell antibodies, for difficulties in testing, for the occurrence of significant adverse reactions, and for special transfusion requirements. Clinically significant red cell alloantibodies may become undetectable in a recipients serum over time. Between 30% and 35% of antibodies become undetectable within 1 year and nearly 50% become undetectable after 10 or more years. AABB Technical Manual pp. 407-413