The compatibility factor in the transfusion of blood

THE COMPATIBILITY FACTOR IN THE TRANSFUSION OF BLOOD* ANGUS

L.

CAMERON,

M.D.

Northwest Clinic MINOT, NORTH DAKOTA

T

HE transfusion of freshly drawn bIood is stil1 attended by a mortahty and morbidity which shouId be matters of serious concern to everyone engaged in this work. The exact incidence of these tragedies as they occur in the hands of thousands of practitioners who are transfusionists is unknown, because they fai1 to record and pubIish their resuIts. Data concerning only a smaI1 fraction of the transfusions which are currentIy performed are avaiIabIe for study. These reports come for the most part from the better hospitaIs and cIinics where the resuIts are notabIy superior to those which are generaIIy prevaIent. The information even from these sources is often incompIete. TypicaI of these data are the folIowing reports: Hesse and FiIatov’ in 1933 reported from Leningrad a mortaIity of 1.3 per cent among 750 transfusions. According to DeCowin seven deaths occurred among 3,500 titrated bIood transfusions performed at the University of Iowa HospitaI from November, 1933 to JuIy, 1937, an incidence of 0.2 per cent. In 1936, six reactions of incompatibiIity occurred in about 2,000 transfusions performed at BeIIevue HospitaI, New York, during the preceding six years, an incidence of 0.3 per cent.3 In the same year six deaths were reported from one British hospita1 during a period of onIy two and one-haIf years. 4 Among 3,295 transfusions performed at the Mayo CIinic during 1938 the incidence of the definiteIy untoward and severe reactions amounted to 0.4 per cent.j ProbabIy quite typica of many observations is that of Dameshek” who, in December 1938, wrote as foIIows: “Within the past year it has been my sad priviIege to see in consultation at five different hospitaIs in and around Boston as many serious transfusion accidents. The first four were fata1; the fifth undoubtedIy wouId have been had not the surgeon withdrawn the needIe when the reaction occurred. . . . Since this is soIeIy my own experience, it is certain

* From the Departments of Surgery, Northwest Clinic and Trinity Hospital, Minot, North Dakota.

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that other such serious accidents have occurred in this and nearby communities, and that most of them have gone unreported.” In most instances in which freshIy drawn bIood is given the authors admit that these disasters are due to bIood incompatibility. OccasionaIIy, however, an attempt is made to prove the contrary but Iike BordIey’ in 1931 we have not found since that date a singIe case report with “compIete and satisfying evidence to prove that the bIood of the donor was compatibIe with that of the recipient.” SeIdom are transfusion deaths and morbidity any Ionger due to technica errors of the transfusionist or to his empIoyment of dangerous apparatus. The other possibIe or aIIeged causes of troubIe such as aIIergy, tendency toward thermic reactions, susceptibiIity to shock and renaI disease are rareIy if ever proved to be the actua1 or even the probabIe disturbing factors when freshly drawn bIood is grven. It is in the cIinica1 Iaboratory instead of in the operating room or at the bedside that errors are committed which give rise to practicaIIy al1 of the present day transfusion mortaIity and morbidity. The prevaIent technic of administering bIood is highIy satisfactory but the prevaIent technic of examining it is quite unsatisfactory. Because of this, bIood transfusion in most pIaces has not yet been robbed of a11 dangers attending its use. This is particuIarIy regrettabIe because reIiabIe and practica1 Iaboratory tests have been known and given wide if not repeated pubIicity for nearIy a quarter of a century. Thus Lindeman* wrote as foIIows in 1916: “By carefu1, accurate and compIete hemoIysis and aggIutinin tests, when the work is done skiIfuIIy, bIood transfusion is robbed of a11 danger attending its use.” He emphasized the importance of skiIfu1 Iaboratory work and described a technic for compatibiIity determination which he and others since have empIoyed with the utmost satisfaction. Lindeman’s contribution did not cause a genera1 eIimination of the eviIs which existed then in connection with this work and which have persisted in most pIaces up to the present time. They are two, nameIy, unskiIfu1 Iaboratory work and the empIoyment of tests which do not meet a11 the requirements for safety. In many of our better hospitaIs and cIinics, to say nothing of the less favored ones there is a deepIy rooted custom of reIegating the cIinica1 Iaboratory work to individuaIs whose training and experience are not sufficient to enabIe them to perform skiIfuIIy and with safety a11 the tests which are assigned to them. CompatibiIity tests faI1 into a category of Iaboratory procedures which require a con-

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siderabIe amount of time and experience under expert supervision for the deveIopment of satisfactory ski11 in their performance. These tests do not permit of unchecked errors without possibIe and probabIy grave consequences to the patient. Now it is a we11 known fact that interns as a cIass spend too IittIe time in the cIinica1 Iaboratory even when under expert guidance to become more than tyros in this work. Yet they aIone are responsibIe for these vita1 tests in many pIaces and as seniors on the Iaboratory service may furnish their juniors with the onIy instruction which they receive in compatibility tests. As already intimated the fauIt here Iies with the briefness of the Iaboratory service and the inferior training and supervision given. Th ese critica remarks are appIicabIe aIso to technicians. We know, however, that the Iatter, as a cIass, with far Iess forma1 Iaboratory training in the basic sciences than the interns have, are capabIe of becoming satisfactoriIy proficient in this work after a period of severa months of intensive training under a competent cIinica1 pathoIogist who is indispensable for any safe and satisfactory pIan. A recent survey of brood transfusions in America conducted by questionnaire maiIed to about 700 hospitals approved for internship under the authority of the BIood Transfusion Betterment Association of New York City, netted 350 rephes which indicate, according to Levine and Katzin that in the selection of donors five depend upon bIood grouping aIone, thirty upon direct matching aIone, of which onIy three incIude cross-matching and 310 empIoy both grouping and direct matching of the donor’s ceIIs with the recipient’s serum. Now a11 of these tests, as usually performed, are unsatisfactory for the detection of hemoIysis. The fact is that they are empIoyed aImost universaIIy for the detection only of red ceI1 cIumping with IittIe if any regard for evidence of red ceI1 destruction. The Iatter evidence as seen in these tests, such as increased transparency of the mixture and the shadow-Iike appearance of red ceIIs is not sufficient for accurate and consistent recognition even by experienced individuaIs. It is unsafe, too, to assume the sufficiency of the aggIutination reaction aIone on the basis of the idea as expressed by MosslO in rgro that “iso-aggIutination may occur independentIy of isohemoIysis but iso-hemoIysis is probabIy aIways preceded or accomContrary to this view there is evidence panied by iso-aggIutination.” of the occurrence of hemoIysis without preceding aggIutination. However this may be, experience has proved the necessity for tests

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for hemolysis which are more reIiabIe than the ones under consideration here. Detection of the hemoIytic factor of incompatibility is of such vita1 importance because practically a11 transfusion deaths as they are now reported are characterized by massive hemoIysis. BIood grouping aIone is quite unsatisfactory for severa other we11 known reasons such as the proneness of the grouping sera to deteriorate in titer and to give rise to errors thereby, its faiIure to provide controis for the checking of errors and the conformation of the test to the erroneous assumption that there are onIy four bIood groups when, as a matter of fact, there are subgroups for the detection of which more accurate tests than standard bIood grouping are necessary and important. Direct matching does not check the reaction between the ceIIs of the recipient and the serum of the donor, a possibIe reaction in vivo, which can not be ignored with safety. Cross-matching obviates this fauIt but Iike direct matching it is a reIativeIy crude test as it is described in most textbooks and as it is performed in most pIaces. A drop of serum is mixed with a drop of red ceI1 suspension. If the aggIutinin titer is Iow and the concentration of red ceIIs is high, no aggIutination is IikeIy to occur even in the presence of factors of incompatibiIity. In view of these severa serious shortcomings of the above tests it is highIy desirabIe to discard them for safer ones such as that described by Lindeman, which has the incomparabIe advantage of being absoIuteIy reIiabIe and at the same time simpIe enough to be performed by any reasonably inteIIigent and properly trained technician. It automaticaIIy excIudes errors resuIting from the crudest kind of technica mistakes in bIood grouping to the more confusing errors theoreticaIIy caused by minor differences within the bIood groups. It thus conforms to a11 the known and unknown groups and subgroups of bIood and reveals at one and the same time in a readiIy detectabIe manner incompatibiIities of both iso-aggIutination and isohemoIysis. This technic was introduced into the cIinica1 Iaboratory of St. Luke’s HospitaI, Chicago, by Dr. Edwin Hirshl’ in rg2q, and into the cIinica1 Iaboratory of Trinity HospitaI, Minot, in 1932 by Dr. P. J. BresIich, who trained under Dr. Hirsch. This method of compatibiIity determination has resuIted in the compIete eIimination in both hospitaIs of serious transfusion reactions in a11 cases in which it has been empIoyed. The number of transfusions performed annuaIIy at

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St. Luke’s Hospital is approximateIy 600 and at Trinity HospitaI 200; a11 told, therefore, about 9,000 blood transfusions have been given at St. Luke’s Hospital and 1,600 at Trinity HospitaI without the occurrence of a singIe disaster. Lindeman’s technic of hemoIysis and aggIutinin tests as empIoyed at St. Luke’s and Trinity HospitaIs has been modified somewhat but not in any of its essentia1 details. It reveals in test tubes a11 the noteworthy reactions of incompatibility which occur when saIine suspensions of red cells are mixed with different diIutions of serum and are permitted to stand at room temperature for one and onehaIf hours. Cross-examinations are carried out in this fashion between the red cells and sera of both the patient and the recipient. Control reactions are run between red cells and saIine solution aIone, and between the red ceIIs and serum of the same individual. Preliminary typing or bIood grouping is carried out routineIy for the purpose onIy of selecting for the actua1 compatibility tests individuaIs of the same blood group as the patient. Only members of the same group are so tested. Since blood grouping in our hands is never reIied upon for the actual selection of donors, an error in this regard causes the patient no troubIe, where otherwise it might cost him his Iife. It is necessary to determine compatibility before each transfusion when it is repeated regardIess of whether the same or other donors are to be used because of the occasional occurrence foIIowing transfusion of incompatibIe factors which otherwise wiII not be discovered. BIood in the amount of IO cc. is withdrawn for the examination. It is divided and to 2 cc. are added oxaIate crystaIs to prevent clotting. The serum from the remaining portion is recovered after separation from the clot. The oxaIated blood is centrifuged and the ceIIs removed. They are washed in physiologica saIine soIution three times to rid them of serum. The fina packed cell mass in the centrifuge tube is converted into a 5 per cent suspension by the addition of saline solution. Ten test tubes are arranged in numerical order in a rack. (Fig. I .) Into each of tubes I, 2, 3, 4 and 5 is pIaced o. I cc. of a 5 per cent saline suspension of the donor’s erythrocytes. To each of tubes I, 2 and 3 is added the recipient’s serum in the following amounts, respectiveIy: 0.1, 0.2, and 0.4 cc. Four-tenths of a cubic centimeter of the donor’s serum is added to tube 4. Into each of tubes 6, 7, 8, g and IO is placed o. I cc. of a 5 per cent saline suspension of the

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recipient’s erythrocytes. To each of tubes 6, 7 and 8 is added the donor’s serum in the folIowing amounts, respectiveIy: o. I, 0.2 and 0.4 cc. Four-tenths of a cubic centimeter of the recipient’s serum is

FIG. I. Photograph of the rack of ten test tubes sometime after completion of the mixtures. FinaI reading for agglutination and hemoIysis is made only after the expiration of one and one-half hours.

added to tube g. PhysioIogicaI saIine soIution is added to the IO tubes in amounts sufficient to make the content of each equa1 to I cc. In tubes I, 2,3,6,7 and 8 occur the cross reactions between the serum of both the donor and the recipient in three different diIutions and their erythrocytes. In tubes 4,5, g and IO occur contro1 reactions between serum and erythrocytes of the same origin in saIine SOIUtion and the erythrocytes alone of both the donor and the recipient. CHART Tubes No. Donor’s erythrocytes I-zodilution.............................~.~~.~ Donor’sserum............................. Recipient’s erythrocytes I-zodilution............................. Recipient’sserum...........................o.10.20.4... PhysioIogicalsaIinesoIution . . . .._......_.._.. This chart shows the exact content patibility test.

I I 2 3 -___---.---

4

5

6

7

8

9

10

0.10.10.1 . ..0.4...0.10.20.4 .__ . . . . . .

. ..o.Io.I 0.10.10.1 . . . . . . . . . . . . 0.4 o.8o.7o.5o.5o.go.8o.7o.5o.o.g of each of the ten tubes employed in the com-

After preparation, the tube mixtures are aIIowed to stand for one and one-haIf hours. DeIayed reactions are not uncommon. IncompatibiIities, if present, are usuaIIy apparent within forty minutes but, for absoIute safety, the ful1 one and one-haIf hour observation period

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is necessary. In approximately 4 per cent of tests between bIoods of the same group incompatibiIity is found which is usuahy due to agglutination unreveaIed by the bIood grouping tests but occasionaIIy to hemoIysis. If the macroscopic evidence of aggIutination is at a11 doubtfuI-a rare event-a microscopic examination may be carried out. In no case, however, has the microscopic examination in our hands given additional information, but several hemoIytic and agghrtination reactions were demonstrated in the test tubes macroscopicaIIy which were not found upon microscopic examination. CompatibiIity determination by means of this technic requires more time and effort than do the procedures in common use. The time eIement, however, is not greatIy in excess of that required for the necessary preIiminary examination for syphilis. The factor of time is important onIy in so far as it concerns the weIfare of the patient. It is high time that cIinicians concede this point and act accordingIy by ceasing their unreasonabIe demands for speed in the Iaboratory which precIudes the use of safe methods in these preIiminary tests. Their reasonable and wise anticipation of the possible or probable necessity for bIood transfusion before an emergency occurs wiI1 avoid in most instances the unexpected necessity for immediate bIood transfusion without sufficient time for safe and accurate Iaboratory tests. Where provisions of this kind are impossible, temporary substitutes for blood, like saline soIution, is in our opinion much better for the patient often times than is bIood which has been hastiIy examined by a faIIible method. Too often such examinations are performed by nervous and improperly trained interns and technicians whose incompetence is accentuated appreciabIy by the unreasonabIe demands for speed made by the clinician. Of course it is conceded that the condition of the patient does at times necessitate the immediate administration of bIood with acceptance of the risks which this procedure involves. This fact, however, does not justify the disregarding of vita1 safeguards whenever it can be avoided with greater safety to the patient. CONCLUSIONS

A noteworthy percentage of severe and fata reactions stil1 the transfusion of freshIy drawn blood. 2. These reactions are practicaIIy a11 due to factors of incompatibility. 3. The prevalent methods of examination for these factors are not sufficiently accurate to reveal their presence invariabIy. I.

attend

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4. Lindeman’s technic of “carefu1, accurate and compIete hemolysis and aggIutinin tests, when the work is skiIfuIIy done”8 aIways reveaIs the presence of these factors when they occur. 5. Lindeman’s technic is practica1 of appIication and because of this and its incomparabIe superiority shouId replace a11 other methods of compatibiIity determination now in genera1 use. BIBLIOGRAPHY 1. HESSE, E. and FILATOV, A. ExperimenteIle Untersuchungen iiber das Wesen des hamolytischen Schocks bei der BIutransfusion und die therapeutische BreinAussung desselben: 1. Die Nierenfunktions stiirungen im akuten Experiment. Ztscbr. J. d. ges. exper. Med., 86: 211-230, 1933. Quoted by DeGowin, E. L., Qsterhagen, H. T. and Audersch, M., Arch. Int. Med., 59: 432-444, 1937. z. DEGOWIN, E. L. Grave sequelae of blood transfusions; a clinical study of 13 cases occurring in 3500 blood transfusions. Ann. Int. Med., I I: 1777-1791, 1938. 3. GOLDRING, W. and GRAEF, I. Nephrosis with uremia foIIowing transfusion with incompatibIe blood. Arch. Znt. Med., 58: 825-845, 1936. 4. PLUMMER, N. S. BIood transfusion. A report of six fataIities. Brit. Med. J., 2: I 186 I 189, 1936. 5. LUNDY, J. S., TUOHY, E. B., ADAMS, R. C. and MOUSEL, L. H. AnnuaI report for 1938 of the section on anesthesia; incIuding data on blood transfusion. Proc. StajT Meet., Mayo Clinic, 14: 273-284, 1939. 6. DAMESHEK, W. Transfusion of incompatibIe bIood. New England J. Med., 219: 929-930, 1938. 7. BORDLEY, J. Reactions folIowing transfusion of blood with urinary suppression and uremia. Arch. Int. Med., 47: 288-315, 1931. 8. LINDEMAN, E. Reactions following blood transfusion by the syringe cannuIa system. J. A. M. A., 66: 624-626, 1916. 9. LEVINE, P. and KATZIN, E. M. A survey of bIood transfusion in America. J. A. M. A., IIO: 1243-1248, 1938. IO. Moss, W. L. Studies on iso-agglutination and iso-hemolysis. Bull. Jobns Hopkins Hosp., 21: 63-70, 1910. I I. HIRSCH, E. Persona1 communication.