A blood banker in Florida is interested in learning whether/when/how other pediatric facilities address crossmatching for infants who are older than four months of age, including older children in the setting of large volume operative or post-operative transfusions, particularly those that require ongoing large volumes of blood components over several days. The cardiovascular surgery program at his hospital is expanding in both numbers and complexity, and they are encountering more patients who remain on bypass post-operatively or otherwise require massive transfusion support. The inquiring blood banker wonders if it is truly necessary to keep requesting additional samples for crossmatching to comply with AABB Standard 5.12.3.2 which states that "If the patient has been transfused in the preceding 3 months with blood or a component containing allogeneic red cells, has been pregnant within the preceding 3 months, or if the history is uncertain or unavailable, a sample shall be obtained from the patient within 3 days of the scheduled transfusion. Day 0 is the day of draw". The inquiring blood banker is of the opinion that after having administered a large volume of blood products, that a significant percentage of what is present in the patient's plasma is actually of donor origin. (Editor's NOTE: As e-networkers consider this question, please keep in mind that IgM and IgG antibodies are continually synthesized and that an anamnestic response to transfusion, if one occurs, can trigger the production of specific anti-red cell antibodies at a measurable rate).

A resource of related guidelines for Pediatric Transfusion is now available for review in this forum. E-Network members are encouraged to submit useful additions to this resource by contacting the e-Network Forum Editor & Moderator.

The following replies were submitted in response to the above:

ADDENDA June 2, 2002

1. A blood banker from a Sunbelt state reported that at her hospital once a massively bleeding patient's blood volume is exchanged (their guide is 100ml/kg body weight) they merely perform an ABO confirmation of each donor unit and issue group-compatible blood. At 72 hours from the initial type and crossmatch they would receive a new sample and perform a new ABO/Rh, antibody screen and crossmatche(s). They do not need additional samples for additional donor unit transfusions until 72 hours has elapsed. (That is their rule for how good a T&C is good.) She concedes that it is theoretically possible for donor plasma, FFP, platelets, etc. to have some unusual antibody effect or development. Even though blood centers test and screen the products, there could be something missed or something that is activated by the infusions over a period of time.

2. A New York physician blood banker thinks that getting a new sample every 3 days or so is a reasonable approach in this setting and not unduly taxing to the clinical staff, patient or blood bank. He has seen primary responses within 10 days of transfusion in one child. With the possibilities of alloimmunization from undocumented previous transfusions or exposure to maternal red cells during delivery, one needs to worry about anamnestic responses even in children with negative antibody screens initially, as was pointed out by the e-Network Forum Editor & Moderator. With massive transfusion in patients with no preexisting alloantibodies, the New Yorker just uses an electronic crossmatch until the bleeding is under control, getting no new samples, then they go back to samples every 3 days and immediate spin crossmatches. The New Yorker boldly exclaims that if their computer were up to it, they would use the electronic crossmatch for everyone all the time.

ADDENDA June 3, 2002

3. A blood banker from Northern California reports that she has seen antibodies in patients as young as 3 months of age. Therefore, her hospital follows the same AABB guidelines for specimens from pediatric patients that they would use in multitransfused adults.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator