IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

•
LESSON 1: BLOOD TRANSFUSION PRACTICES

REFERENCE MATERIALS • College of American Pathologists (CAP)

Reference Book: Modern Blood Banking and ▪ American Association
Transfusion Practices 7th Edition ▪ Philippine counterpart is the
(Denise M. Harmening PhD, MT)
Department of Health (DOH)
➔ PowerPoint Presentations
▪ Responsible for the inspection of the
➔ Lecture Discussion of Prof Saltin laboratories to ensure the correct
➔ Passed down transes standards
➔ *Notes from internet
DONOR SELECTION
LEGEND Donor Selection
: Presentations (Main) Is a must in ensuring the safety of the blood products
: Lectures/Discussions (Main) given to the patients
: Passed down transes (Main) • Medical history requirements for the donor
: Reference Book • Partial physical examination
: *Notes from internet • Serologic testing of the donor
: Main topic • Questions to ask:
: Subtopic ▪ Will a donation of approximately 450mL
: Sub-subtopic of whole blood at this time ne harmful to
the donor?
▪ Could blood drawn from this time
GOVERNING AGENCIES potentially transmit a disease to the
Governing Agencies recipient?
Following correct blood practices ensures that all
Registration
blood units and products would be safe for the recipient.
Registration
Governing agencies that are mandated to ensure
that all laboratories follow correct policies, procedures, • Photographic I.D (valid)
▪ Every donor must be checked against a
and standards are the following:
permanent record of previously deferred
• Food and Drug Administration (FDA)
donors
▪ Is responsible for the licensing of
• Name (first, last, MI)
manufacturing companies with the use
• Date and time of donation
of reagents, anticoagulant preservatives
• Address
that are used
• Contact number
• American Association of Blood Banks
• Gender
(AABB)
• Age or date of birth
▪ Sets certain rules, guidelines,
• Consent to donate
policies (requirements for donors, lab
• Additional information
samples, proper collection, dispensing,
and storage) for blood transfusion
Medical History Questionnaire
▪ Every institution has the liberty to
Medical History Questionnaire
make revisions but are not allowed to
contradict the guidelines set by the • In our profession, we explain the questions
AABB

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
1
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

• Was designed to be self-administered by donors ▪ Have you read the educational

but, if preferred may be administered by a materials?
trained donor historian ▪ Have you taken aspirin or anything with
• Conducted on the same day as the donation aspirin in it?
• Donor history questions (DHQ): - Deferral period: 2-3 days
▪ Are you feeling healthy and well today? Contraceptive Pills May donate anytime
▪ Are you currently taking an antibiotic or Penicillin, Aspirin, other - May donate anytime
taking any other medications for an highly allergenic drugs provided the blood
collected will not be
infection?
used to prepare
- Deferral period of antibiotic: platelets
indefinite (allow the donor to - Donor may donate after
donate blood after finishing the 24 hours of taking
medication) medications
▪ Are you taking medication on the Piroxicam Deferred until TB is
completely cured
Medication Deferral List?
▪ Have you been pregnant or are your
- CJD is caused by Prions (bulalo) pregnant now?
manifested by losing sanity - Deferral period: 6 weeks after
- Unlicensed vaccine examples giving birth
are COVID vaccines at the start of ▪ Have you had any vaccination or other
the pandemic as the FDA only shots? Have you had contact with
approved for Emergency Use but it someone who had a small pox
is now known to be approved/known vaccination?
vaccine

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
2
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

• Deferral period for vaccination varies according ▪ Male donors: have you had sexual
to the type of vaccine contact with another male?
▪ 2 weeks deferral: - Deferral period: 12 months/1 year
- Smallpox, Polio, Measles, Mumps, ▪ Female donors: have you had sexual
Influenza contact with a male who had ever had
▪ 4 weeks deferral/1 month: sexual contact with another male?
- German measles, Chickenpox - Deferral period: 12 months/1 year
▪ 12 months deferral/Unlicensed ▪ Have you had sexual contact with a
Vaccine/Hepa B Vaccine: person who has hepatitis? Or lived with
- Rabies vaccine if given after the bite a person who has hepatitis?
of a rabid animal - Deferral period: 12 months/1 year
▪ May donate if afebrile (walang ▪ Have you been treated for syphilis or
lagnat): gonorrhea?
- Diphtheria, Pertussis, Typhoid, - Deferral period: 12 months/1 year
Tetanus, Cholera, Influenza - Are deferred because they are
- 8 weeks or 56 days for allogenic sexually active which puts them at
donation risk for HIV/AIDS infection
▪ Have you been in juvenile detention,
• Donor history questions (DHQ) cont’d: lockup, or prison for more than 72
▪ Have you had a blood transfusion hours?
transplant such as organ, tissue, or - Deferral period: 12 months/1 year
bone marrow graft such as bone or - Deferral period <72 hours: No
skin? deferral
- Deferral period: 12 months/1 year ▪ Have you been outside of the U.S. or
▪ Have you come in contact with someone Canada in the past 3 years?
else’s blood or had an accidental needle ▪ Have you ever been to Mindoro or
stick injury? Had a tattoo or body Palawan?
piercing? - To determine if the person has
- Deferral period: 12 months/1 year travelled to places where malaria,
▪ Have you had sexual contact with leishmaniasis, Creutzfeld-Jakob
anyone who has HIV/AIDS or has had a disease are endemic
positive test for HIV/AIDS? - Deferral period (resident): 3 years
- Deferral period: 12 months/1 year - Deferral period (prophylaxis): 12
▪ Have you had sexual contact with a months/1 year
prostitute or anyone else who takes ▪ Have you ever received a dura mater
money or drugs or other payment for graft?
sex? - Deferral period: Permanent
- Deferral period: 12 months/1 year - These people are infected with
▪ Have you had sex with anyone who has Creutzfeld-Jakob disease
ever used a needle to take drugs or ▪ Have you ever had any type of cancer,
steroids or anything not prescribed by including leukemia?
their doctors? Or has hemophilia or has ▪ Have you ever had problems with heart
clotting factor concentrates? or lungs?
- Deferral period: 12 months/1 year ▪ Have you ever had a bleeding condition
or blood disease?

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
3
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

Physical Examination
Physical Examination
Physicians are the ones that conduct the physical
examinations
• General appearance:
▪ Observe the prospective donor for
presence of excessive anxiety, drug
or alcohol influence, or nervousness
• Age:
▪ At least 17 years old
Example:
• Weight: A. You only weigh 90 lbs. Find the amount of
▪ At least 110 lbs. / 50 kg volume to collect:
• Maximum volume: Solution:
90 𝑙𝑏𝑠.
▪ Maximum volume of 525 mL can be 𝑥 450 𝑚𝐿 = 368.18 𝑚𝐿
collected 110 𝑙𝑏𝑠
B. Matthew, weighing 95 lbs., wants to donate
▪ Maximum of 10.5 mL of blood per kg of
blood for a friend. How much anticoagulant must
donor weight for whole blood (WB)
be removed from the bag?
donation
▪ Volume to collect:
95 𝑙𝑏𝑠.
General Requirements for Blood Donation 𝑥 450 𝑚𝐿 = 388.64 𝑚𝐿
110 𝑙𝑏𝑠
General Requirements for Blood Donation ▪ Reduced volume of anticoagulant:
In theory, we can donate even if our weight is below 388.64 𝑚𝐿
𝑥 63 𝑚𝐿 = 54.46 𝑚𝐿
the allowable limit. 450 𝑚𝐿
You can adjust the blood volume to anticoagulant ▪ Volume of solution to be removed:
ratio 63 mL – 54.46 mL = 8.54 mL
In practice, we do not allow as it is expensive to
Requirements for Blood Donation
remove the anticoagulant in the blood bag which might
also cause contamination Requirements for Allogenic Blood Donation
• Calculate the adjusted blood volume and Age At least 18 years old
Oral temperature <37.5°C or <99.5°F
anticoagulant
Blood pressure ≤180/100 mmHg
• Volume to collect: Hemoglobin ≥12.5g% or g/dL
𝑑𝑜𝑛𝑜𝑟 ′ 𝑠 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔 Hematocrit ≥38%
𝑥 450 𝑚𝐿
50 𝑘𝑔 Pulse 50-100 beats/minute, athlete:
▪ Note!: when weight is in pounds, <50 beats per minute is allowable
substitute the 50 kg with 110 lbs. Weight ≥110 lbs. or ≥50 kg
• Reduced volume of anticoagulant:
𝑣𝑜𝑙𝑢𝑚𝑒 𝑡𝑜 𝑐𝑜𝑙𝑙𝑒𝑐𝑡 Requirements for Allogenic Blood Donation
𝑥 63 𝑚𝐿
450 𝑚𝐿 (Philippine Standards)
▪ Note!: 63 mL is the constant amount of Age 16-65 years old
anticoagulant in a blood bag Temperature ≤37.5°C or ≤99.5°F
• Volume of solution to be removed: Pulse rate 66-100 bpm
63 mL – reduced amount of anticoagulant Blood pressure - Systolic: 90-160 mmHg
- Diastolic: 60-100 mmHg

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
4
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

Requirements for Autologous Blood Donation ▪ Involves collecting shed blood from the
Age No age requirement surgical site, a device that utilizes
Hemoglobin 11 g/dL vacuum is used to collect shed blood
Hematocrit 33% ▪ Blood is then washed with saline and
General Patient should have no condition then concentrated to reach hematocrit of
condition predisposing to bacteremia or 50-60%, then reinfusing those cells
any form of severe immediately
cardiovascular/pulmonary
condition • Postoperative Collection
Note!: Single unit is removed at a time, with at least 3 ▪ Infused with or without processing
day intervals ▪ Uses microaggregate filter
▪ Collected from a drainage tube placed
TYPES OF AUTOLOGOUS BLOOD DONATION at the surgical site
Types of Autologous Blood Donation ▪ It is reinfused with or without
• Preoperative Collection processing, via a microaggregate filter
▪ 5-6 weeks immediately preceding a to screen out any debris or small clots
scheduled, elective surgical procedure
• Acute Normovolemic Hemodiilution Directed Donation
▪ ‘Isovolemic Hemodilution’ Directed Donation
▪ Multiple units of blood are being • A directed donation is a unit collected under the
removed from the patient before the same requirements as those for allogenic
surgical procedure and the blood units donors, except that the unit collected is directed
are replaced to maintain the patient’s toward a specific patient
plasma volume with crystalloid or colloid
solutions or plasma expanders such as Apheresis Donation
saline Apheresis Donation
▪ Near the end, the removed blood is • Aphaeresis = “a taking away”
again transfused back to the patient • An effective mechanism for collecting a specific
▪ Order: last unit collected must be the blood component while returning the remaining
first unit to go back in whole blood components back to the patient
▪ Collection of whole blood with the
concurrent infusion of crystalloid or Methods of Centrifugation
colloid solutions Methods of Centrifugation
▪ The idea is that the patient bleeds more • Intermittent Flow Centrifugation
dilute blood during the procedure, and ▪ Only one site of venipuncture
the patient’s heart may pump more ▪ Blood is drawn and reinfused through
efficiently due to decreased blood the same needle
viscosity ▪ Once the desired component is
• Intraoperative Collection separated, the remaining components
▪ Is a medical procedure involving are reinfused to the donor
recovering of blood loss during surgery • Continuous Flow Centrifugation (CFC)
▪ Save and then salvage ▪ Two venipuncture sites are needed
▪ Known form of autotransfusion ▪ Involves withdrawal and processing and
reinfusing of blood to the individual
simultaneously

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
5
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

▪ Standardized RBC mass collection

for erythrocytapheresis is 180- 200 mL
3. WBC pheresis (Leukapheresis)
▪ Given to patients who are severely
neutropenic and unresponsive to
antibiotics
▪ RBC sedimenting agent: Hydroxyethyl
Starch (HES)
- To allow better separation and to
minimize RBC contamination
▪ Corticosteroids will increase the
number of circulating WBCs
• Acid Citrate Dextrose (ACD): primary ▪ Granulocyte colony stimulating factor
anticoagulant in apheresis can also increase the number of WBCs
▪ Though, heparin can also be used ▪ Units are stored for 24 hours at 20-
• Amount of time for a particular procedure can 24°C
range from 45 to 120 minutes ▪ Units require compatibility testing
prior to transfusion as granulocyte
Types of Apheresis products still contain >2 mL of red cell
Types of Pheresis 4. Plasmapheresis
Plateletpheresis (Thrombocytoapheresis) ▪ Equivalent of at least two whole-blood-
RBCpheresis (Eryhthrocytapheresis) derived plasma units
WBC pheresis (Leukapheresis) - Infrequent plasmapheresis:
Plasmapheresis Once in every four weeks
Stem cell apheresis - Frequent or serial:
More than once in every four weeks
1. Plateletpheresis (Thrombocytoapheresis) ▪ FDA recommends 12 L (14.4 for donors
▪ Donor’s platelet count: at least weighing more than 175 pounds) as the
150,000/uL maximum allowable plasma volume
▪ Donor should have not taken aspirin 3 donated per year
days before donation ▪ At least 48 hours should elapse
- Aspirin can affect the platelet before subsequent donation of
function plasmapheresis
▪ Interval of at least 2 days or 48 hours ▪ A maximum of 2 donation in a 7-day
- It should not exceed twice a week period is allowed
or 24 times a year ▪ Plasma and serum should be tested
▪ pH = ≥ 6.2
for total protein and quantitative
▪ Equivalent to 6-8 random donors immunoglobulin
2. RBCpheresis (Eryhthrocytapheresis)
▪ Requirements: Therapeutic Procedures
Height Weight Hct Therapeutic Procedures
Male 5’1” 130 lbs. 40%
• The rationale of therapeutic apheresis (TA) is
Female 5’5” 150 lbs. 40%
based on the following:
▪ Interval is within 16 weeks

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
6
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

▪ A pathologic substance exists in the Therapeutic Plateletpheresis

blood that contributes to a disease Therapeutic Plateletpheresis
process or its symptoms • Thrombocytosis (at least 500,000/uL) can
▪ The substance can be more effectively occur in myeloproliferative disorders Essential
removed by apheresis than by the Thrombocytopenia (ET), Polycythemia Vera
body’s own homeostatic mechanism (PV), Chronic Myelogenous Leukemia (CML) or
as reactive process in response to splenectomy,
Therapeutic Plasma Exchange infection, chronic inflammation or malignancy
Therapeutic Plasma Exchange
• Removal and retention of the plasma with return Therapeutic Leukapheresis
of all cellular components to the patients Therapeutic Leukapheresis
• To remove the agent in the plasma such as an • Elevated levels of WBCs place the patient at
antibody, toxin, or abnormal protein, that is risk for complications associated with
causing the clinical symptoms. leukocytosis, including organ dysfunction due to
▪ These are replaced and changed the formation of microthrombi in the pulmonary
with the substance that is clean and cerebral microvasculature
▪ Used to replace the normal factors or ▪ Blast count is over 100,00/uL of
substances that are missing or deficient blood
from the patient’s plasma • can lead to the formation of microthrombi in the
• It can also remove immune complexes, cerebral and pulmonary microvasculature
alloantibodies, autoantibodies, and antibodies • This is used to treat patients with leukemia
that can cause hyperviscosity of blood
• Removal of inflammatory mediators, protein Erythrocytapheresis (Red Cell Exchange)
bound toxins, excessive lipoprotein and platelet Erythrocytapheresis (Red Cell Exchange)
aggregate factors • Donor RBCs should be ABO and Rh-
Factors Removed by Therapeutic Plasmapheresis compatible, relatively fresh (leukoreduced,
Immune complexes Systemic Lupus negative for hemoglobin S and partially
Erythematosus phenotype-matched for the Rh (C,c,E,e) and K1
Alloantibodies Antibody-mediated transplant antigens
rejection • Done on patients affected by sickle cell
Autoantibodies Guillain-Barre syndrome
disease in order to eliminate the red cells with
Immunoglobulins Waldentstrom’s
causing macroglobulinemia hemoglobin S
hyperviscosity ▪ Remove the sickle blood by blocking the
Protein-bound toxins Amanita mushroom posoning, blood flow and exchange with normal
or drugs barbiturate poisoning red cell
LPPs Familial
hypercholesterolemia,
hypertriglyceridemia
Phytanic acid Refsum’s disease
- Neurologic disorder caused
by accumulation of phytanic
acid found in food that we eat

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
7
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

WHOLE BLOOD COLLECTION PROCESS • Amount of blood collected: 450 mL ± 10%

Whole Blood Collection Process • Duration of collection: 7-10 minutes
Once the donor has satisfied requirements of the ▪ Component must be prepared after
screening process and has been registered, whole blood collection
collection can proceed ▪ If >8->10 minutes, component
preparation will be affected such as FFP
Donor Identification and cryoprecipitate.
Donor Identification
Color Coding for Blood Bags
• A numeric or alphanumeric system is used to
link the donor to the donor record, pilot tubes, Color Coding for Blood Bags
blood container, and all components made from FDA (1985) RA 1517
the original collection Blood Type Color Label Blood Type Color Label
A Yellow A Blue
B Pink B Yellow
Blood Collection
AB White AB Pink
Blood Collection O Blue O White
• Aseptic technique developed by Joseph Note!: RA 1517 “National Blood Bank Law”
Lister
• If there is an available water supply, faucet, Post-Donation Instructions
and soap, ask the donor to wash his/her hand Post-Donation Instructions
with soap and water. • Recommended that donors remain in an area
• Primary choice of vein is the median cubital, where they can be observed by the donation
then cephalic, then basilic center staff and be given instructions to follow
• Larger bore needle of gauges 16-18 is used for the next 24 hours
for blood collection ▪ Ask them how are they feeling after
• Note! During the insertion of needle, do not the donation
puncture the vein! Enter the skin first and then ▪ Instruct them with the post-donation
the vein! instructions
• Use aseptic technique - Drink plenty of water
▪ PVP iodine compound or - Avoid sweet drinks
chlorhexidine gluconate and - Avoid alcoholic beverages
isopropyl alcohol (both are used) - Avoid smoking
▪ Scrub site at least 4 cm in all directions - Avoid heavy lifting or vigorous
for 20 seconds exercise for the next 24 hours
▪ Apply tourniquet or blood pressure cuffs:
- Eat food that are rich in iron
40-60 mmHg
▪ Position the needle at 10-20 degrees - Call the blood bank facility or
angle personnel if symptoms occur
• If blood mixer is unavailable, mix the unit
periodically 1-2 times per minute DONOR REACTIONS
Donor Reactions
Most donor reactions will occur during or shortly after
the donation
• Most common reaction is Hematoma

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
8
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals
1. Disengage the hyperventilation
▪ Happens when the needle goes through sequence by conversing with the
the vein donor and having the donor breathe
▪ “Through and Through” cause into a paper bag
subsequent leakage of blood into the - Can be caused by excessive
tissues anxiousness and nervousness
▪ Management: • Nausea or Vomiting
1. Immediately remove the ▪ Management:
tourniquet to reduce the pressure 1. Instruct the donor to breathe slowly
2. Remove the needle 2. Apply cold compress to the
3. Apply gauze and pressure for 7- forehead
10 minutes 3. Turn the donor’s head to one side
4. Apply ice to the site of and provide on appropriate
receptacle
hematoma for 5 minutes to avoid
4. The donor may be given water after
bruising
vomiting has ceased
5. Disengage the blood collection
Moderate Reactions
Mild Reactions
Moderate Reactions
Mild Reactions
• Loss of consciousness
• Syncope or Fainting
▪ Management:
▪ May be idiopathic or may be brought 1. Check vital signs frequently
about by the sight of blood. 2. Administer 95% O2 and 5% CO2
▪ The donor may show signs of
sweating, dizziness, pallor, or Severe Reactions
convulsions Severe Reactions
▪ Management: • Convulsions or Epilepsy
1. Remove the tourniquet and ▪ Management:
withdraw needle 1. Call for help immediately; notify
2. Place cold compress on the donor’s blood bank physician
forehead 2. Try and restrain the donor to
3. Raise the donor’s legs above the prevent injury to self or others
level of the head (to facilitate 3. Ensure an adequate airway
proper circulation of blood to the • Cardiac or Respiratory Difficulties
brain) ▪ Absence of pulse and breathing
4. Loosen tight clothing and secure ▪ Management:
airway 1. Perform CPR until medical help
5. Monitor vital signs arrives
• Hyperventilation, Twitching, or Muscles
Spasms DONOR RECORDS
▪ Donors who are extremely nervous Donor Records
may exhibit sudden twitching or muscle
• Must be retained by the blood collection
spasms
facility as mandated by the FDA and AABB
▪ Management:

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
9
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

• There must be a system to ensure that the

donor’s confidentiality is not compromised and
the donor record must not be altered
• Minimum retention time is 5-10 years
depending on the data or document

DONOR PROCESSING
Donor Processing
• The donor unit collected must tested and
processed by blood bank technologists before it
can be made available for transfusion
• The test performed involves:
▪ ABO typing
▪ Rh typing
▪ Transfusion-Transmitted Infections
(TTIs)
- Malaria
- HIV
- Hepatitis C
- Hepatitis B
- HTLV 1&2

Grades don’t define me as…JOKE. SIMULA PALANG

TO LODS. MADAMI PA SA BABA PADAYON RMT!

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
10
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

LESSON 2: OVERVIEW OF THE ROUTINE BLOOD BANK LABORATORY

DEFINITION OF BLOOD BANK LABORATORY hours of collection (FP24), and

Definition of Blood Bank Laboratory cryoprecipitate
Have different categories ▪ After collection, whole blood is allowed
to cool to room temperature (20-24°C)
• Blood bank center
for platelet concentration preparation
▪ Highest form or type of blood bank
- 1 to 10°C for frozen plasma
unit - FFP must be prepared with 8 hours
▪ Performs blood collection, donor of collection of whole blood
screening, donor’s blood processing, - FP24 may be prepared with 24
component preparation, storage, and hours following collection
dispensing ▪ Apheresis: a donor’s blood is removed,
▪ Blood Bank Centers associated with anticoagulated, and transported directly
hospitals also perform pre-transfusion to an apheresis machine
testing
• Blood Bank Laboratory Blood Banks without Collection Facilities
▪ A facility involved in the collection, Blood Banks without Collection Facilities
storage, processing, and distribution of • Blood banks that depend on an outside source
human blood and blood products for for their blood supplies usually receive their
transfusion products in component form
▪ Secondary type of hospitals does not • However, situations do arise in which products
perform collection must be modified
▪ Republic Act No. 7719 ▪ Patient who is deficient in IgA may
- “National Blood Services act of require washed RBCs
1994” ▪ Uses automated cell washers
• Blood Bank Collection Units • Blood components such as platelet concentrates
▪ Only collects blood units and cryoprecipitate may be received as
individual units but are more easily
Blood Bank Blood Bank Blood Bank administered if pooled before infusion
Center Laboratory Collection
Units DONOR PROCESSING
- donor - collection - collection
screening (Note!: Donor Processing
- blood Secondary type • Before unit of blood can be places in general
collection does not inventory, testing must be performed
- blood perform • Blood processing centers utilize the testing
processing collection) methods that will provide the safest blood
- component - processing
products for patients
preparation - storage
- storage - distribution
- dispensing PRODUCT LABELLING
Product Labelling
Blood Banks with Collection Facilities • Stability requirements:
Blood Banks with Collection Facilities ▪ No discrepancies in the ABO and Rh
• Component preparation testing
▪ Packed RBCs, platelets, fresh frozen ▪ Absence of detectable antibodies in
(FFP), frozen plasma prepared with 24 plasma-containing components
𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
11
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

▪ Non-reactive viral marker tests • Is the problem-solving section of the transfusion

▪ Non-reactive syphilis test service
• Blood Bag label includes: • Goal:
▪ Appropriate ABO and Rh type ▪ To ensure that any discrepancies
▪ Expiration date detected during the routine testing
▪ Stored at proper temperature are resolved in an accurate and
▪ Time collected timely manner
▪ Volume of blood • San Lazaro Hospital – STD AIDS Central
Cooperative Laboratory (SACCL)
▪ National reference laboratory for
HIV/AIDS, Hepatitis, Syphilis, and other
STIs

PERSONNEL REQUIREMENTS
Personnel Requirements
• Clinical Laboratory Improvement Amendments
of 1988 (CLIA ’88) established personnel
qualifications for laboratories performing certain
types of testing
▪ Gel technologies
▪ Solid phase RBC adherence
• There are blood bank proficiency and
certificates given
MAIN LABORATORY
• Malarial identification proficiencies
Main Laboratory
• Other proficiency testing related to blood
• Sample collection and acceptance
bank laboratory
▪ Proper patient identification
• Routine testing
STANDARD OPERATING PROCEDURES
▪ Type and screen
Standard Operating Procedures
- Blood typing and antibody
• These manuals, usually located at the
screening
workbench and accessible to all personnel,
▪ Type and crossmatch
contain information outlining the operations of
- Blood type and crossmatching the laboratory; details on how, when and
▪ Prenatal evaluation why particular activities are done; and
▪ Postpartum evaluation procedures for all tests performed
▪ Cord blood studies • SOP manuals are integral components of any
• Request for other blood components blood bank laboratory’s quality assurance
• Issue blood products program along with other laboratory
departments
REFERENCE LABORATORY
• They are reviewed at least annually and
Reference Laboratory updated on a regular basis to reflect changes in
• It is an entity separate from the main laboratory operations and implementation of new
or an integrated part regulations

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
12
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

EQUIPMENT 5. Blood Bags

Equipment
1. Blood Storage Refrigerator

6. Plasma Expressor

▪ Where we store blood products

▪ Depending on temperature
requirements
2. Donor Couches

7. Platelet Incubator

3. Tube Sealer

8. Platelet Agitator

▪ Seals the blood bags

4. Blood Mixer and Collector

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
13
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

9. ELISA Reader with Washer 14. Centrifuge

10. Pipette
15. Specialized Centrifuge and Incubator for Gel
Technology

11. Plasma Thawer

16. Sterile Connecting Device

12. Blood Bank Thermometer

17. Tube Welder

13. Automatic Cell Washer

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
14
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

18. Agglutination Viewer

19. Rh View Box

20. Microscope

Meron ka bang lemon? Gusto…na yata kita.

Ehe PADAYON RMT!

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
15
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

LESSON 3: DONOR SELECTION AND PROCESSING

COMPONENT PREPARATION Platelet Concentration
Component Preparation Platelet Concentration
• If you intend to produce platelet
concentration, the whole blood sample must
spin in centrifuge at a light spin (3200xg for 2-3
minutes)
• After centrifugation, the platelet rich
plasma will separate from the red cell
• The platelet rich plasma, after heavy
centrifugation (5000xg for 5 minutes), will
separate into platelets and plasma
• The plasma will have the fate of becoming
either FFP (if prepared within 8 hours and
stored at -18°C for 1 year or -60°C for 7
years) or it can become a cryoprecipitate

Packed Red Cell Preparation

Packed Red Cell Preparation
• If you intend to produce packed red cell, the
whole blood sample must spin in centrifuge at a
heavy spin (5000xg for 5 minutes)
Procedure: • After centrifugation, the packed red cell will
separate into the platelet poor plasma
▪ It became platelet poor due to the
speed of the spinning

TRANSFUSION THERAPY
Transfusion Therapy
• Blood and blood products are considered drugs
because of their use in treating diseases
• Transfusion therapy is used primarily to treat
two conditions:
▪ Inadequate oxygen-carrying capacity
Summary: because of anemia or blood loss
▪ Insufficient coagulation proteins or
platelets to provide adequate
hemostasis

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
16
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

COMPONENT THERAPY
Note!:
Component Therapy
• Within 12 hours prior to blood transfusion,
• Component therapy was introduced to blood allow the pack red cells to settle at the
banking to address the problem in circulatory bottom leaving the plasma above
overload • Upon transfusion, only use the portion of the
• The patient receives only the specified packed red cells leaving a small number of
blood product red cells attached to the plasma

Whole Blood
Packed Red Blood Cell
Whole Blood
Packed Red Blood Cell
• Whole blood should be used to replace the
• RBCs are indicated for increasing the RBC
loss of both RBC mass and plasma volume
mass in patients who require increased oxygen-
• A definite contraindication to the use of whole
carrying capacity
blood is severe chronic anemia
• The decreased RBC mass may be caused
Indication To increase volume and RBC
by:
mass
Storage 1-6°C ▪ Decreased bone marrow production
Transport 1-10°C (leukemia or aplastic anemia)
Shelf-life Acid Citrate Dextrose (ACD), ▪ Decreased RBC survival (hemolytic
Citrate Phosphate Dextrose anemia)
(CPD), Citrate Phosphate
Dextrose 2 (CPD2): 21 days ▪ Surgical or traumatic bleeding
• Transfusion of RBCs is contraindicated in
CPDA-1: 35 days patients who are well compensated for the
anemia
CPDA-2/S: 42 days
Indication To increase RBC mass
Heparin: 2 days/48 hours Storage 1-6°C
Transport 1-10°C
Note!: In cases where the patient has low red cell Shelf-life Open system: 24 hours (due to
exposure to bacterial
mass but normal red cell volume, and if there is no contamination)
packed red cell unit, you can request for modified Closed system: Same as whole
whole blood blood
• Modified whole blood is prepared by Dosage Increase Hb by 1g/dL
inverting the blood bag and upon storage Increase Hct by 3%
must be in this position: QC ≤ 80% Hct

Leukocyte Reduced Red Blood Cell

Leukocyte Reduced Red Blood Cell
• Donor leukocytes may cause:
▪ Febrile nonhemolytic transfusion
reactions
▪ Transfusion-associated graft-versus-
host disease (TA-GVHD)
▪ Transfusion-related
immunosuppression
𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
17
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

• In addition, human leukocyte antigens (HLA) Frozen Red Blood Cells

are responsible for HLA alloimmunization Frozen Red Blood Cells
• Leukocytes may harbor cytomegalovirus • Freezing RBCs allows the long-term
(CMV) storage of rare blood donor units, autologous
• Intended for individuals that have previous units, and units for special purposes, such as
exposure for transfusion which developed febrile intrauterine transfusion
NHTR or to neonates to prevent CMV infection • We use our freezing agent which is glycerol
Indication To increase RBC mass in patient • The blood unit should undergo
with severe and or recurrent febrile deglycerolization which will be replaced with
non-hemolytic transfusion reaction
saline
(NHTR) due to leukocyte antibody;
prevent CMV Indication Storage of rare blood and
Storage 1-6°C autologous units
Transport 1-10°C Storage -65 or -120°C
Shelf-life Open system: 24 hours (due to Shelf-life 10 years
exposure to bacterial
contamination) Cryoprecipitate
Closed system: Same as whole Cryoprecipitate
blood • Cryoprecipitate is used primarily for
Dosage Increase Hb by 1g/dL
fibrinogen replacement
Increase Hct by 3%
QC ≤ 85% RBC recovery • It is also used for coagulation factor
WBC ≤ 5x106 deficiency
• The AABB requires that at least 150 mg of
Washed Red Blood Cells fibrinogen be in each unit of cryoprecipitate
Washed Red Blood Cells Indication Fibrinogen deficiency, Hemophilia
• Patients who have severe allergic A, vWF disease, Factor XIII
(anaphylactic) transfusion reactions to deficiency
Storage ≤ -18°C
ordinary units of RBCs may benefit from
Content Fibrinogen: 150 mg
receiving washed RBCs
Anti-hemophilic factor (AHF, FVIII):
• The washing process removes plasma 80 IU
proteins, the cause of most allergic reactions vWF, FXIII
• Washed RBCs are used for the rare patient Shelf-life 1 year
Notes White mass of precipitate in 15 mL
who has had moderate to severe allergic
plasma
transfusion reactions and has anti-IgA
antibodies because of IgA deficiency
Fresh Frozen Plasma
Indication To increased RBC mass in patient
Fresh Frozen Plasma
with allergic, anaphylaxis, febrile
and urticarial reactions Indication Correct multiple coagulation
Storage 1-6°C deficiency (liver disease)
Transport 1-10°C Reverse effect of warfarin
Shelf-life Open system: 24 hours (Coumadin)
Dosage Increase Hb by 1g/dL Storage ≤ -18°C or ≤ -65°C
Increase Hct by 3% Shelf-life 1 to 7 years
QC ≤ 70% Hct Notes Thawed at 37°C
▪ Thawed plasma stored at
1-6°C used within 24
hours
𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
18
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

Factor VIII Concentrate Shelf-life 5 years

Factor VIII Concentrate Contents 96% albumin
4% globulin
• Patients with hemophilia A or factor VIII
deficiency have spontaneous hemorrhages that
Plasma Protein Fraction (PPF)
are treated with recombinant or human plasma–
Plasma Protein Fraction
derived factor VIII replacement
• Same as Normal Serum Albumin with the
• Factor VIII is treated by different methods,
difference of the contents
such as pasteurization, nanofiltration, and
Indication Replace lost colloids in
solvent detergent, to ensure sterility for HIV,
hypovolemic shock or severe
hepatitis B virus, and hepatitis C virus (HCV) burns
Indication Prevent or control bleeding in Storage 2-6°C
Hemophilia A Shelf-life 5 years
Storage 1-6°C, lyophilized Contents 80-85% albumin
15-20% globulin
Factor IX Concentrate
Factor IX Concentrate Granulocyte, Pheresis
• Factor IX complex (prothrombin complex) Granulocyte Pheresis
is prepared from pooled plasma using various • Newborn infants may develop overwhelming
methods of separation and viral inactivation infection with neutropenia because of their
• The prothrombin complex contains factors II, limited bone marrow reserve for neutrophil
VII, IX, and X; however, the product is production
recommended for factor IX–deficient patients ▪ In addition, neonatal neutrophils have
(hemophilia B), patients with factor VII or X impaired function
deficiency (rare), and selected patients with • For an adult or a child, the usual dose is one
factor VIII inhibitors or reversal of warfarin granulocyte pheresis product daily for 4 or more
overdose days
Indication Prevent or control bleeding in ▪ For neonates, a portion of a
Hemophilia B
granulocyte pheresis unit is usually
Storage 1-6°C, lyophilized
given once or twice
Normal Serum Albumin (NSA) Indication Neutropenia, granulocyte
dysfunction
Normal Serum Albumin
Storage 20-24°C
• Albumin is prepared by chemical and Shelf-life 24 hours
physical fractionation of pooled plasma QC 1x1010 granulocytes
• Albumin is available as a 5% or a 25%
solution, of which 96% of the protein content is Irradiated Blood Components
albumin 22 Irradiated Blood Components
• Albumin may be used to treat patients Indication Prevent Transfusion-Associated
requiring volume replacement Graft-Versus-Host Disease (TA-
GVHD)
• Albumin can also be used in the treatment Recipients of components
of burn patients to replace colloid pressure collected from a blood relative or
Indication Replace lost colloids in HLA-matched donors
hypovolemic shock or severe Radiation Cesium (137 Cs)
burns source Cobalt (60 Co)
Storage 2-6°C Shelf-life 28 days from irradiation
𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
19
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

Platelets
Platelets
• Platelets are essential for the formation of
the primary hemostatic plug and
maintenance of normal hemostasis
• Patients with severe thrombocytopenia
(low platelet count) or abnormal platelet
function may have petechiae, ecchymoses, and
mucosal or spontaneous hemorrhage
• Platelet transfusions are indicated for
patients who are bleeding because of
thrombocytopenia or abnormally functioning
platelets
Random Donor Single Donor
Indication Thrombocytopenia, Platelet
Disseminated refractories
Intravascular
Coagulopathy (DIC)
Myeloproliferative
disorder
Bleeding
Storage 20-24°C with constant agitation
1-6°C
Shelf-life 5 days
Dosage Increase platelet Increase
count by 5000- platelet count
10000/uL by 30000-
60000/uL
QC ≥ 5.5x1010 ≥ 3.5x1011
Note!: Platelet agitation is done to promote gas
exchange and prevent platelet aggregation and
activation

Dami ‘no? Buti pa ako, ikaw lang isa ang pipiliin sa

araw-araw PADAYON, RMT!

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
20
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

LESSON 4: ADVERSE EFFECTS

ADVERSE EFFECTS 3. Neonatal RBC Transfusion
Adverse Effects ▪ Preferred blood is less than 7 days old
1. Positive identification ▪ Reduce the risk of hyperkalemia and
2. Venous access maximize 2,3-DPG level in blood
3. Intravenous infusion device ▪ Blood to be transfused is O negative or
4. Clot-screen filters blood compatible with the mother
5. Vital signs ▪ It should be Cytomegalovirus (CMV)
6. Blood warmers negative and leukoreduced
7. Rate and Length of transfusion 4. Exchange Transfusion
▪ Used as a treatment for newborn infants
Reissue of Unit and for treatment of anemia and
Reissue of Unit hyperbilirubinemia
The blood can be reissue given that the sample is: - Characterized or related to
1. Closed or closure must not have been entered in Hemolytic Disease of the Fetus
any way and the Newborn (HDFN)
2. Kept at 1-10 degrees Celsius ▪ Small amounts of blood are removed
3. Pilot tube or sealed segment of donor tube must and is replaced with donor blood
be attached to the container ▪ Replacement of antibody-coated red
4. Blood must not be away for more than 30 cells with compatible donor cells
minutes - Removes bilirubin to prevent
5. Record must be available that verify all kernicterus
inspection 5. Intrauterine Transfusion
▪ Transfusion was done when the baby
Special Consideration in Transfusion was still inside the mother’s womb
▪ Diseases associated are severe
Special Consideration in Transfusion
anemia due to anemia associated
1. Emergency Transfusion
with Hemolytic Disease of the Fetus
▪ Cases when the ABO and Rh group of a
and the Newborn (HDFN)
patient cannot be immediately identified
▪ Done by injection of RBC into the fetal
▪ Thes safest route is to transfuse the
peritoneal cavity or intraperitoneally
patient with Blood Group O, Rh
▪ Cordocentesis can also be performed
Negative red cells
- Donor RBCs are directly injected
- Group O is a universal donor
2. Massive Transfusion
TRANSFUSION REACTION
▪ Administration of enough blood or
components within less than 24 hours Transfusion Reaction
▪ Constitutes a complete volume • A transfusion reaction is defined as any
replacement transfusion-related adverse event that occurs
▪ Can cause citrate toxicity during or after the transfusion of whole blood,
▪ Can induce hypoglycemia, blood components or human-derived plasma
hypothermia, depleted 2,3-DPG levels products.
and, depletion of coagulation factors
and platelets
▪ Accumulation of biochemicals and
microaggregates
𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
21
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

• Increase respiratory distress shortly after

TRANSFUSION REACTION transfusion
IMMEDIATE (Acute) - DELAYED- after 24 • Cause: anti-leukocyte antibodies act on
signs and symptoms hours of transfusion endothelial cells of lungs; emboli form
presenting within 24
• Remedy: Leukopoor RBCs
hours of transfusion.
Immunologic Non- Immunologic Non-
immunologic immunologic Non-immunologic: Acute
- Hemolytic - Bacterial - Hemolytic - Transfusion
- Febrile contamination - TA-GVHD associated- Non-immunologic: Acute
- Allergic - Circulatory - Post hemosiderosis A. Bacterial Contamination
- TRALI overload transfusion - Disease
- PCITR purpura transfusion • Contamination of blood products from donors
with transient bacteremia during phlebotomy,
Immediate or Acute Transfusion Reactions preparation and processing, thawing.
Immediate or Acute Transfusion Reactions • Cause: endotoxins of psychrophilic organisms; -
• Is caused by incompatible blood transfused ▪ Yersinia enterocolitica
patient ▪ Escherichia coli
• Occurs soon after the transfusion or during the ▪ Pseudomonas spp.
transfusion of the blood • Prevention: Aseptic techniques, visual
• Sign and symptoms: fever, back pain, inspection and infusion within 4 hours.
• Considered as a medical emergency and • Treatment: Administration of broad-spectrum
transfusion must be stopped immediately. antibiotic intravenously
• Diuresis must be administered by administering
mannitol and other diuretic agents. B. Physical or Chemical Induced Transfusion
Reactions (PCITR)
Immunologic: Acute • Causes: mechanical damage (Infusion through
Immunologic: Acute small bore), osmotic or chemical change,
thermal trauma, citrate toxicity
Allergic Anaphylactic
Definition Reaction between Afebrile reaction • Physical damage of RBC due to intravascular
recipient antibody that occurs only lysis caused by hypertonic/hypotonic solution
and transfused after infusion of • Heat damage (more than 37 degree Celsius)
donor plasma only few mL of • Damage during shaking
proteins blood • Freeze damage due to absence of
Cause Donor plasma with IgA deficient
cryoprecipitate
foreign proteins patient with anti-
IgA
Remedy Washed RBC Washed RBC C. Transfusion Associated Circulatory Overload
Signs and Hives and pruritus Clinical signs are (TACO)
Symptoms seen suddenly • Associated with rapid infusion of large volumes
after exposure to of blood products.
blood (IgA
• Children, elderly patients and cardiac disease
protein) often
before 10 mL patients Physical or Chemical Induced
Transfusion Reaction (PCITR)
A. Transfusion-Related Acute Lung Injury (TRALI) • Causes: mechanical damage (infusion through
• Attributed to the administration of donor plasma small bore), osmotic or chemical damage,
containing high concentrations of thermal trauma, citrate toxicity
leukoagglutinins

𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
22
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

Delayed or Anamnestic Transfusion Reactions ▪ Thalassemia major

Delayed or Anamnestic Transfusion Reactions ▪ Sickle cell anemia and
• Associated with patients that were previously Hemoglobinopathies
sensitized by transfusion, pregnancy and 1. Iron chelating agent like desferrioxamine can
transplant be used for therapy
• May be diagnosed only 7-10 days (3-7 days)
after the transfusion B. Transfusion-Transmitted Diseases
• Signs and symptoms: jaundice and decreasing 1. Hepatitis B, C, D
hematocrit levels ▪ Inflammation of the liver
• Kidd blood group is implicated in delayed ▪ Symptoms: jaundice, dark urine,
hemolytic transfusion hepatomegaly, anorexia, malaise, fever,
etc.
Immunologic: Delayed Hepatitis Route of Transmission
A Fecal/oral
Immunologic: Delayed
B Parenterally
A. Transfusion-Associated Graft vs. Host Disease C Parenterally
(TA-GVHD) D Parenterally
• Certain susceptible recipients with E Fecal/oral
compromised immune systems are G Parenterally
transfused with blood or blood components
containing immunocompetent lymphocytes Hepatitis A
which engraft in recipient’s tissue and multiply. 2. Picornaviridae
• Cause: Proliferation of T cells that reacts 3. Small, non-enveloped, single stranded
against foreign tissue of the host recipient enterovirus RNA
• Prevention: Irradiated blood components 4. Most common
Hepatitis B
B. Post-Transfusion Purpura • Hepadnaviridae
• Previously immunized patients to platelet • A partially double stranded circular DNA virus
antigens through pregnancy or transfusion • Diagnosis:
produce antibodies once stimulated, destroying ▪ HBV DNA is the first marker to appear
the patient's own platelets. (PCR testing)
• Seen in multiparous women ▪ HBsAg - appears 2 to 12 weeks post-
• Cause: Platelet antibodies (anti-Human platelet exposure during acute stage;
A1or anti HPA-1A) undetectable in 12-20 weeks after the
• Therapy: Exchange transfusion, corticosteroids, development of anti-HBsAg
intravenous immunoglobulin - Permanent deferral
▪ HbeAg - appears after the HBsAg in
Non-immunologic: Delayed recovering patients. Disappears before
HbsAg.
Non-immunologic: Delayed
▪ HbcAg - is present in the serum but is
A. TA-Hemosiderosis
undetectable.
• Iron overload: accumulating in the mitochondria
Hepatitis C
of cells, in organs like liver, heart and endocrine
• Flaviviridae
gland
• RNA virus
• Seen in patients who are chronically
dependent to transfusion

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
23
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

• Diagnosis: ▪ Once the RNA has been transcribed into

▪ Depends on biochemical changes DNA, it is integrated randomly into the
suggestive of HCV host cell's genome.
- Detection of HCV RNA or anti-HCV ▪ What's integrated into the DNA, the
in serum provirus can either complete its
▪ EIA, ChLIA and RIBA (Recombinant replication cycle or remain latent for
Immunoblot Assays) many years.
Hepatitis D, E, G • HTLV-1 was the first retrovirus to be associated
• HDV is a defective, single-stranded RNA virus with a human disease ○ Association was with
▪ Found only in the patients with HBV adult t-cell lymphoma/leukemia (ATL), highly
infection aggressive for mature T-cell non-Hodgkin
- It requires HBsAg in order to lymphoma with a leukemic phase.
synthesize an envelope protein.
- It was previously called the delta 5. Human Immunodeficiency Virus (HIV)
antigen. • Retrovirus
- If HBV and HDV are contracted • Spherical in shape
concurrently, this results in co- • Approximate diameter of 100 nm.
infection. • It consists of an envelope of glycoproteins, and
• HEV is a member of Calciviridae an inner core of viral RNA and reverse
▪ Non-enveloped RNA virus transcriptase.
• GB Virus C (GBV-C) and Hepatitis G Virus ▪ Infection with the virus causes a slowly
(HGV) progressing immune disorder.
▪ Are two genotypes of the same ▪ The causative viruses, HIV-1 and HIV-2
enveloped RNA virus that belongs to the are similar in structure, varying primarily
family Flaviviridae in the envelope proteins.
▪ The use of very sensitive serologic
testing in screening the blood supply
2. Cytomegalovirus (CMV) has resulted in an extremely low risk of
• Herpesvirus group
• CMV can remain latent in the tissues and HIV transmission.
leukocytes for years, with reactivation occurring ▪ Positive screening tests are repeated in
due to severe immune system impairment. duplicate, and if at least one of the
duplicates also tests positive, WB or
3. Epstein-Barr Virus (EBV) immunofluorescent antibody assay is
• EBV has been called the “kissing disease” used for confirmation.
because the virus usually replicates in the cells ▪ Expansion of donor screening protocols
of the oropharynx, possibly in infected B cells. in 1996 to include p24 core antigen
• The virus is shed in the saliva and is most testing reduced the window period from
frequently associated with infectious an estimated 22 days to 16 days.
mononucleosis.
6. Treponema pallidum (Syphilis)
4. Human T-Cell Lymphotropic Virus (HTLV) 1 • Treponema pallidum, the causative agent of
and 2 syphilis, is a spirochete.
• HTLV-1 and HTLV-2 causes a T cell proliferation • It is usually spread through sexual contact but
with persistent section can be transmitted through blood transfusion.
𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
24
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

7. Plasmodium spp. ▪ Ss
• Malaria, another intraerythrocytic protozoan ▪ Duffy
infection, may be caused by several species of
the genus plasmodium (P. malaria, P. Pathogenesis
falciparum, P. vivax, and P. ovale).
▪ Natural transmission occurs through the
bite of a female Anopheles mosquito,
but infection may also occur following
transmission of infected blood.

8. Babesia microti
• Babesiosis, a zoonotic disease, is usually
transmitted by the bite of an infected deer tick.
• Infection is caused by the protozoan parasite,
Babesia, which infects the RBCs.
• Babesia infection may also be acquired by
blood transfusion and solid organ transplant

9. Trypanosoma cruzi
• Trypanosoma cruzi is a flagellate protozoan that
is the etiologic agent of Chagas disease
(American trypanosomiasis).
• The reduviid bug bite produces a localized
nodule, referred to as a chagoma.

10. Toxoplasma gondii

HEMOLYTIC DISEASE OF THE FETUS AND THE

NEWBORN (HDFN)
Hemolytic Disease of the Fetus and the Newborn
(HDFN)
• Destruction of the RBCs of the fetus and Note!:
neonate by the antibodies produced by the • Begins with an Rh negative mother bearing
mother a child that is Rh positive
• Only the antibodies if the immunoglobulin G • Main foundation is that mothers do not
(IgG) class are actively transported across the possess the antigens that the fetus carries
placenta. • During the cutting of umbilical cord, there is
▪ IgG Subclass 1 contamination of fetal blood into the mother’s
▪ IgG Subclass 3 circulation
• Blood groups associated with HDFN: • The moment the fetal red cell starts
circulating into the mother, it is called
▪ Rh – most immunogenic
fetomaternal hemorrhage
▪ Kell
▪ Kidd – delayed HTR and mild
HDFN
𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
25
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

4. Fetal DNA Testing

Note!:
5. Antibody Titers
• The immune system of the mother
recognizes it as a foreign antigen, attacking
Serologic Testing of the Newborn Infant
the antibody of the fetal red cell causing
Serologic Testing of the Newborn Infant
cellular lysis due to the neutralization which
• ABO
will be scavenged and is transported into the
spleen where it will be discarded • Rh
• The body of the mother will produce • DAT
memory B cells producing antibodies ▪ By running DAT, it is possible to
against it detect in-vivo sensitization
▪ The first pregnancy is successful but ▪ HDFN leads to a positive DAT
the subsequent pregnancies would • Elution
be dangerous ▪ Done to separate the antibodies that are
attached/coats the fetal red cells
▪ The eluated serum which contains the
Characteristics of HDN antibody will be the specimen for
Characteristics of HDN antibody testing
• Anemia
▪ Compensated anemia (increased RhIg (Rh Immunoglobulin) / Rhogam
immature RBCs = erythroblastosis RhIg/Rhogam
fetalis)
• Commercially available treatment
▪ The bone marrow detects that there
• Allowing the Rh immunoglobulin to precoat
is insufficient red cell in the circulation
the fetal red cell
• Generalized edema and cardiac feature
• Active immunization induced by RBC antigen
(hydrops fetalis)
can be prevented by the concurrent
• Increased urinary bilirubin
administration of the corresponding RBC
▪ Due to simultaneous hemolysis antibody
▪ Intravascular hemolysis ▪ This principle has been used to prevent
• Deposition in brain tissue (kernicterus) immunization D antigen by the use of
• Hepatosplenomegaly (extramedullary high-tittered RhIg
hematopoiesis) ▪ Prevention of hemolytic disease of
▪ As we are experiencing the fetus and newborn
compensated anemia, the liver and ▪ Should be administered within 72
spleen will also work more to hours following delivery or as soon as
compensate by doing extramedullary possible
hematopoiesis ▪ Usually given IV, intramuscularly
▪ They are enlarged due to the • Mechanism
increased work load ▪ The administration of Rh
immunoglobulin would allow the
Serologic Testing of the Mother attachment of RhIg to the fetal Rh
Serologic Testing of the Mother positive red cell in the maternal
1. ABO, Rh, Antibody Screen circulation
2. Antibody Identification ▪ The administered RhIg attaches to the
3. Paternal Phenotype and Genotype fetal Rh-positive RBCs in the maternal
𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
26
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

circulation. Another way to calculate for FMH:

▪ The antibody coated RBCs are removed FMH = Fetal Cell Percentage x 50
by the macrophages in the maternal FMH = 1.3% x 50
spleen. FMH = 65 mL
▪ The RBC antigens are thus unavailable
for dendritic cells to present antigen to T Sample Problem 2:
helper cells. With the amount of FMH determined on the
▪ The amount of antibody necessary to problem above (FMH=65mL), how many vials of RhIg
prevent alloimmunization has been should be administered to the mother within 72 hours of
determined experimentally and is known childbirth?
to be less than that required to saturate No. of Rhogam vials = FMH/30 or 15
all D antigen sites.
• Use 30 for whole blood sample and 15 if
Calculations sample is packed red cell
Calculations • Standard Dose: 300 ug of Rhogam can
• After 2000 cells are counted, the percentage of neutralize 30mL of the D-positive fetal whole
fetal cells is determined, and the volume of fetal blood; 15mL if D-positive fetal red cells/purely
hemorrhage is calculated using the formula: red cells.
• Each 300 ug of Rhogam is adequate for 30
platelet concentrate units or 3 plateletpheresis.
𝑵𝒖𝒎𝒃𝒆𝒓 𝒐𝒇 𝒇𝒆𝒕𝒂𝒍 𝒄𝒆𝒍𝒍𝒔 𝒙 𝑴𝒂𝒕𝒆𝒓𝒏𝒂𝒍 𝒃𝒍𝒐𝒐𝒅 𝒗𝒐𝒍𝒖𝒎𝒆
• If it is not specified whether whole blood or
𝑵𝒖𝒎𝒃𝒆𝒓 𝒐𝒇 𝒎𝒂𝒕𝒆𝒓𝒏𝒂𝒍 𝒄𝒆𝒍𝒍𝒔 purely packed RBCs, use the 30 being the
= 𝑽𝒐𝒍𝒖𝒎𝒆 𝒐𝒇 𝒇𝒆𝒕𝒐𝒎𝒂𝒕𝒆𝒓𝒏𝒂𝒍 𝒉𝒆𝒎𝒐𝒓𝒓𝒉𝒂𝒈𝒆 constant dose.
• The calculated volume of fetomaternal • Solution:
hemorrhage is the divided by 30 to determine No. of Rhogam vials = 65 mL/30 = 2.17
the number of required vials of RhIg Final No. of Rhogam vials: 3 vials
• This formula is used to determine the dosage
needed by a pregnant woman Dose and Administration
• Another way to calculate for FMH: Dose and Administration
Volume of FMH (mL) = Fetal cell percentage x 50 • 15 mL of packed RBCs or 30 mL of whole blood
• This is equal to 300 g of the World Health
Sample Problem 1:
Organization (WHO) reference material.
A Kleihauer-Betke acid elution stain for
postpartum fetomaternal hemorrhage (FMH) is reported,
Kleihauer-Betke Test and Rosette Test
percent fetal cells of 1.3%. What is the total volume of
Kleihauer-Betke Test and Rosette Test
fetomaternal hemorrhage?
• Test done to determine the percent of fetal cells
Solution: present in the mother’s circulation.
𝟏. 𝟑% 𝒙 𝟓𝟎𝟎𝟎 Kleihauer-Betke Test
= 𝟔𝟓 𝒎𝑳 • A maternal blood smear is treated with acid and
𝟏𝟎𝟎
then stained with counterstain.
FMH = 65 mL ▪ Fetal cells contain fetal hemoglobin
Note!: (HgB F) that is resistant to acid and will
• 5000 is the average maternal blood volume. remain pink.
• 5000 and 100 are constant
𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
27
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

▪ The maternal cells will appear as Immune Hemolytic Anemia

ghosts. Immune Hemolytic Anemia
▪ Usually, used to quantitate FMH • Shortened RBC survival mediated through
happening in the baby. immune response specifically by humoral
Rosette Test antibody
• Qualitative screening test for FMH that detects • Associated with the presence of
fetal D+ red cells in maternal Rh negative blood. autoantibodies that would agglutinate, sensitize,
• Falsely positive if the mother is weakly D or lyse one’s own RBCs.
positive and may be falsely negative if the 1. Alloimmune- Patient produces
baby is weakly D positive alloantibodies to foreign or non-self RBC
• The rosette screen will be positive if there is a antigens introduced into the circulation,
FMH of 10mL or more. most often through transfusion or
• Treatments: pregnancy.
a. Premature labor 2. Autoimmune- Patient produces
b. Intrauterine transfusion antibodies against his or her own RBC
c. Exchange transfusion antigens
d. Phototherapy 3. Drug-induced- production of antibodies
to a particular drug or drug complex with
Comparison of ABO vs. Rh HDN ensuing damage to the individual’s
Comparison of ABO vs. Rh HDN RBCs.
Characteristics ABO Rh • Mechanisms Involved:
Antibody Non- Immune IgG I. Drug-dependent (Immune Complex/
immune/Immune anti-D Innocent Bystander) Mechanism
IgG, anti-A, B - The antibody (IgG or IgM)
Blood Group Mother- O Mother- Rh
produced recognizes determinants
Baby- A/B/AB negative
Baby- Rh on the drug.
positive - If the patient ingests the same drug
Obstetric First pregnancy First pregnancy (or a drug bearing the same
history and subsequent not affected; haptenic group) after immunization,
pregnancies may rare the formation of a drug-antidrug
be affected complex may occur
Disease No Yes
- The complement cascade may be
predicted by
titers activated because of this antigen-
Bilirubin at Normal Elevated antibody interaction.
birth - RBCs are thought to be involved in
Anemia at birth No Yes this process only as “innocent
DAT Weakly Positive bystanders.”
positive/Negative - The soluble drug-antidrug complex
Spherocytosis Yes Rare nonspecifically adsorbs loosely to
Therapy Phototherapy Phototherapy,
the RBC surface.
exchange /
intrauterine - Complement, when activated,
transfusion sensitizes the cell, leading to the
Note!: both ABO and Rh can cause HDFN. ABO is formation of the membrane attack
usually mild cases and Rh is severe cases complex (MAC) and may cause
lysis.
𝕬𝖈𝖎𝖉𝖎𝖈, ʀᴍᴛ
28
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

II. Drug-independent (Autoantibody Autoimmune Hemolytic Anemia

Formation) Autoimmune Hemolytic Anemia
III. Drug Adsorption (Hapten 1. Warm Autoimmune Hemolytic Anemia
Mechanism) (WAIHA)
- Unlike drugs acting through the ▪ DAT: Positive
immune complex mechanism, drugs ▪ Donath- Landsteiner test: Negative
operating through the drug- ▪ Antiglobulin: IgG antibody
adsorption mechanism bind firmly ▪ Optimal temperature: 37 degrees
to proteins, including the proteins of Celsius
the RBC membrane. ▪ Most common blood group: Rh, Kell
- Presumably because of their ability ▪ Induces extravascular hemolysis;
to bind to proteins, these drugs are splenic (involves the spleen)
better immunogens. 2. Cold Hemagglutinin Disease
IV. Membrane modification (Non- ▪ DAT: Positive
immunologic Protein Adsorption) ▪ Donath- Landsteiner test: Negative
- It is hypothesized that the ▪ Antiglobulin: IgM
cephalosporins, especially ▪ Optimal temperature: 0-4 degrees
cephalothin (Keflin), both operate Celsius
through the drug-adsorption ▪ Most common blood group: I blood
mechanism and are able to modify group
RBCs so that plasma proteins (e.g., ▪ Induces extravascular hemolysis in
IgG, IgM, IgA, and complement) can the liver (hepatic)
bind to the membrane. ▪ Mycoplasma pneumoniae
3. Paroxysmal Cold Hemoglobinuria
▪ DAT: Positive
▪ Donath-Landsteiner test: Positive
▪ Antiglobulin: Biphasic IgG
- Reaction requires 2 different
phases: cold and warm phase
▪ Optimal temperature: 0-4 degrees
Celsius; 37 degrees Celsius
- Colder temperature (0-4C):
antibody will attach to the antigen.
Sensitization occurs
- Warmer temperature (37C):
complement cascade will be
stimulated. Production of MAC
▪ Most common blood group: P blood
group
▪ Hemolysis only occurs in PCH If
exposed to both and cold and warmer
environment
▪ Intravascular hemolysis

𝕱𝖊𝖘𝖆𝖑𝖇𝖔𝖓, ʀᴍᴛ
29
 IMMUNOHEMATOLOGY MODULE

05
LECTURE
Professor: Joana Rose Saltin
2nd Semester, Finals

WHAT TO DO WHEN THINGS GO WRONG?

What to do when things go wrong?

Bedside Procedures
Bedside Procedures
Note!: Bedside procedures are done by a nurse
1. Stop transfusion
▪ Done most especially if the reaction was
immediate or acute, which is considered
an emergency.
2. Keep intravenous line open with physiologic
saline
3. Notify patient’s physician and blood bank
4. Take care of the patient per physician’s order
5. Perform bedside clerical checks
▪ Look into the possibility of clerical errors
during transfusion
6. Specimens to be submitted:
▪ Post-transfusion venous blood
▪ First voided urine
▪ Blood bags
7. Document reaction that occurred during
transfusion

Transfusion Reaction Investigation Work Up

Transfusion Reaction Investigation Work Up
1. Clerical Checks
2. Visual Inspection
3. Direct Antiglobulin Test (DAT)
4. Repeat ABO/Rh
5. Repeat Compatibility Testing
6. Repeat Crossmatch
7. Bilirubin test in Blood
8. Urine Test
9. Hemoglobin and Hematocrit

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30