Double Failure of the Type and Screen
ELIZABETH A. MITTEN, MT(ASCP)SBB, KAY R. GREGORY, M.S., MT(ASCP)SBB, AND PAUL J. SCHMIDT, M.D.
"Type and Screen" programs have proved effective in reducing
time and cost in the crossmatching laboratories, while still assuring safety when transfusion is necessary. However, there remains the possibility that the program will miss a patient with
an antibody to a low-incidence donor antigen and that such a
patient will receive blood from such a donor. The authors report
on the actuality of that possibility happening twice within two
months in one hospital. (Key words: Blood transfusion; Transfusion reactions; Crossmatching; Type and Screen) Am J Clin
Pathol 1987; 87: 252-253
Southwest Florida Blood Bank, Inc., Tampa, Florida
matches were initiated while two units were being issued, and transfusion
was begun. Thefirstunit was found to be incompatible in the antiglobulin
crossmatch, and that transfusion was stopped. No antibody was found
in tests against a panel of commercial reagent red blood cells. The patient
exhibited no overt clinical ill effects, and the direct antiglobulin test on
a sample drawn two days after transfusion was weakly positive. The
patient and donor samples were then sent to our Reference Laboratory.
THERE IS A REASONABLE move in transfusion medicine toward increased use of the "Type and Screen" protocol. Patients who are to undergo an elective surgical
procedure in which blood is rarely used are tested only
to determine their blood group and type and to confirm
that they do not have preexisting unexpected antibodies.
In the unlikely event that transfusion is needed, the patient
can then receive emergency transfusion with blood chosen
on the basis of ABO group and Rh type only. The crossmatch is done while the transfusion is being given.
The expectation is that the patient will not have an
infrequent unexpected antibody against some infrequent
antigen not present on the reagent red blood cells used in
the screening system. Even if the patient does have the
antibody, it can be expected that the donor blood will not
have the unusual antigen for that rare antibody. Calculations have been made for the frequency of those combinations of events.5 Finally, even if those doubly rare
events were to occur simultaneously, the hope is that the
antigen-antibody reaction would not be clinically significant.
That unlikely series of events happened at one hospital
in Florida in 1982. Then it happened again a second time,
a few weeks later.
Pretransfusion and posttransfusion serum from the first
patient contained anti-Wra. The antibody gave a 3+ reaction with the red blood cells of the involved donor unit
in the albumin to an antiglobulin test with the use of antiIgG reagent. The patient had a negative direct antiglobulin
test pretransfusion; the posttransfusion specimen was
weakly positive with anti-IgG reagent only.
Pretransfusion and posttransfusion serum from the
second patient contained anti-Mia, which gave a 2+ reaction with the involved donor's red blood cells after room
temperature incubation. Direct antiglobulin tests on the
patient specimens had negative results.
Report of Two Cases
Discussion
Case One
A 75-year-old male was scheduled for a transurethral prostatectomy
(TUR). A Type and Screen was ordered, and the transfusion service
detected no unexpected antibody in screening tests in which they used
three screening cells separately by the albumin to antiglobulin technic.
Unexpectedly, blood was needed while the patient was in surgery. CrossReceived March 14, 1986; received revised manuscript and accepted
for publication June 5, 1986.
Address reprint requests to Ms. Gregory: Southwest Florida Blood
Bank, Inc., P.O. Box 2125, Tampa, Florida 33601.
252
Case Two
Two months later, the same urologist scheduled a TUR for a different
patient, a 68-year-old male. He again ordered a Type and Screen, and
the same thorough testing was done. The antibody screening was negative.
Again, unexpectedly, blood was necessary during the surgical procedure,
and two units were released and the crossmatches initiated. The first
unit was incompatible in the antiglobulin crossmatch and that transfusion
was stopped. This patient also exhibited no clinical signs of a transfusion
reaction, and his direct antiglobulin test did not become positive. All
samples were sent to our Reference Laboratory.
Serological Studies
The antibody screening tests that were performed for
those patients are not to be expected to have discovered
either the anti-Wra or the anti-Mia. Such antigens are not
required to be an ingredient of the commerical reagent
cells, and Wra was present in none of 232 lots of two-eel)
reagent red blood cells available commercially in the first
six months of 1985.' Three-cell sets are not designed to
have more of such test antigens, and Wra was present in
none of 52 sets.
Under such circumstances, the risk of transfusion is
the same as if it were given with no compatibility testing
Vol. 87 • No. 2
253
BRIEF SCIENTIFIC REPORTS
for such antigen-antibody combinations. That risk can
be calculated.
Walker reports the possibility of a random donor having
the Wra antigen to be 0.0007 and the antibody frequency
in a random patient to be 0.0200. He calculated an apparent incompatibility frequency of antigen and antibody
meeting by chance, which is what happened in our first
patient, as 0.000014.5
For the Mi" antigen, the frequency is 0.0014 but the
antibody is more common, i.e., 0.01.3 The incompatibility
for Mia found in our second patient is to be expected
therefore, also with a frequency of 0.000014.
Despite the fact that each of these events could be expected to happen only once in every 71,429 transfusions,
two such transfusions were given in one 230-bed hospital
in a two-month period.
What is the future of the Type and Screen at that hospital? Although other examples of anti-Wra and anti-Mia
have been said to cause acute hemolytic reactions,2 in
both of our cases the antigen-antibody reaction was clinically insignificant. But if you were the urologist, would
you continue to order the Type and Screen? As a consequence of these cases and the frequent use of blood for
patients with TURs, that procedure has been dropped
from the Type and Screen program at that hospital.
The potential cumulative "incompatibility" frequency
for Cw, Lua, Kpa, Jsa, Wra, V , V, Toa, Pta, Wb, Rd, W ,
Moa, Hey, and Mg has been calculated by Walker5 as
0.000508. That can be translated to the ten million red
blood cell transfusions given in the United States yearly
as saying 5,080 such events would be expected if anti-
globulin crossmatching were not done. We report on two
such events happening in one hospital involving one surgeon in the space of a few months. Fortunately, no clinical
ill effects were realized.
The practical matter is different now. Since October of
1984, it is allowable practice to omit the antiglobulin cross
match completely even when there is an expected need
for blood if the antibody screening is and has been negative.4 A survey in September of 1985 of 2,254 transfusion
services that do compatibility testing routinely showed
that 181 (8%) had adopted that system.1 For their patients,
events such as we report would not have been noticed
because they caused no clinical ill effects. Is that an acceptablerisk?We think so, and in our transfusion service
we use a Type and Screen protocol and omit routine antiglobulin in testing when a crossmatch is performed.
Acknowledgments. The permission of Dr. Charles E. Johnson, Jr., and
Karen Todd to publish these cases is acknowledged. Dr. Richard H.
Walker made helpful suggestions on the calculations of risk.
References
1. Comprehensive Blood Bank Survey Report J-C, College of American
Pathologists, October 1985
2. Molthan L: Intravascular hemolytic transfusion reaction due to antiVw + Mi" with fatal outcome. Vox Sang 1981; 40:105-108
3. Rouger P: Do you think that the crossmatch with donor red cells
can be omitted when the serum of a patient has been tested for
the presence of red cell alloantibodies with a cell panel? Vox Sang
1983;43:165-166
4. Standards for blood banks and transfusion services, eleventh edition.
Arlington, American Association of Blood Banks, 1984
5., Walker RH: Is a crossmatch using the indirect antiglobulin test
necessary for patients with a negative antibody screen? Safety in
transfusion practices. Edited by HF Polesky, RH Walker. Skokie,
College of American Pathologists, 1982, 101
Transfusion Reactions in Patients with Cancer
YANG O. HUH, M.D. AND BENJAMIN LICHTIGER, M.D., PH.D.
In general, the true incidence of transfusion reactions is difficult
to determine with certainty. In patients with cancer, it becomes
even more complex to define. During a four-year study period
in which 100,177 units of red blood cell transfusions were given
to 25,744 cancer patients, 245 episodes of transfusion reactions
were reported. The incidence of overall reaction was 0.3% of all
transfused units, which is significantly lower than other studies.
Febrile nonhemolytic reactions and allergic urticarial reactions
Received March 4, 1986; received revised manuscript and accepted
for publication August 11, 1986.
Address reprint requests to Dr. Huh: Blood Bank, Division of Laboratory Medicine, U.T.M.D. Anderson Hospital and Tumor Institute,
6723 Bertner Avenue, Houston, Texas 77030.
Division of Laboratory Medicine, The University of Texas
M.D. Anderson Hospital and Tumor Institute, Houston, Texas
were the most frequently noted, constituting 51.3% and 36.7%,
respectively, of total reactions. There were only 17 hemolytic
reactions (four immediate and 13 delayed-type). The incidence
of delayed hemolytic reactions in cancer patients is significantly
lower than that reported for patients in non-oncology hospital
settings. This could result from the inability of cancer patients
to produce alloantibodies against blood group antigens as frequently and efficiently as can those with non-neoplastic conditions. (Key words: Transfusions; Transfusion reactions; Cancer;
Febrile reactions; Allergic reactions; Hemolytic reactions) Am
J Clin Pathol 1987; 87: 253-257 "