Directed Donation of Blood

Blood donation is a critical process that helps to save millions of lives worldwide. Blood transfusions are required by patients undergoing medical treatment, surgeries, and other medical procedures. Directed blood donation is a type of blood donation where a donor gives blood for a specific individual, usually a friend or family member, who needs a transfusion. In this article, we'll discuss what directed blood donation is, how it works, and why it's important.

What is Directed Blood Donation?

Directed blood donation is a process where a donor gives blood that is reserved for a specific recipient. The blood is collected and tested in the same way as regular blood donations, but it is designated for the specific recipient. The donor and recipient must have compatible blood types, and the donor's blood must meet the requirements for transfusion to ensure that the recipient receives the correct blood type.

How Does Directed Blood Donation Work?

Directed blood donation is a process that involves several steps. First, the donor must be identified and screened to ensure that they are eligible to donate blood. They must also have a compatible blood type with the recipient. Once the donor is identified and screened, the blood is collected and tested for infections and other health conditions.

The collected blood is then labeled and stored specifically for the recipient. The recipient must also undergo screening to ensure that they are healthy enough to receive the transfusion. Once the blood and the recipient are deemed suitable, the transfusion can take place.

Why is Directed Blood Donation Important?

Directed blood donation can be crucial for individuals who require regular transfusions or have rare blood types. In some cases, regular blood donations may not meet the specific requirements of the recipient, and directed donation may be necessary. It can also be essential for patients who have developed antibodies that react to most donated blood, making it difficult to find a suitable match.

Moreover, directed blood donation can offer emotional support to the recipient and their family, as it allows them to have a sense of control over their treatment process. It can also give the donor a sense of satisfaction, as they can see the direct impact of their donation on someone they know and care about.

Is Directed Donation Recommended?

Directed donation is not advised in most cases because it may not provide any additional benefit compared to regular blood donations. Regular blood donations go through extensive testing and processing to ensure they are safe for transfusion to anyone who needs them, regardless of whether they are directed donations or not.

In addition, directed donation can be problematic if the donor's blood is not a good match for the recipient, or if the donor is unable to donate for any reason. This can lead to delays in transfusion and can potentially cause harm to the recipient if they are in urgent need of blood.

Furthermore, some experts argue that directed donation may create a false sense of security among recipients and their families, leading them to believe that directed donation is safer or more effective than regular blood donations. In reality, regular blood donations are the safest and most effective way to ensure a sufficient blood supply for patients in need.

How do I start the process of Directed Donation?

Contact the Blood Bank at the hospital in which the recipient patient will be receiving the possible transfusion. A Blood Bank / Transfusion Medicine Pathologist (A medical doctor) will initiate the beginning stages of the Directed Donation consult and get the ball rolling on the entire process.  Where you donate will be up to what the Blood Bank allows and has set up. Some hospital Blood Banks have their own donation center. Others will allow donors to donate at a local Blood Center and have them ship the blood to the hospital after donation.

What happens to the donated blood if the recipient doesn't need it? 

It will expire on shelf. Directed Donation blood cannot be given to anyone else except for the intended recipient. 

Sickle Cell Disease and Tranfusions

Sickled Cells on a blood smear

What is Sickle Cell Disease

Sickle cell disease (SCD) is a genetic blood disorder that affects millions of people worldwide. It causes red blood cells to become sickle-shaped and stiff, which can block blood flow to various organs and tissues, leading to severe pain, organ damage, and even death.

Sickle cell disease is most common in people of African descent, but it also affects people of Hispanic, Middle Eastern, and Mediterranean descent. There is no cure for sickle cell disease, but treatments can help manage symptoms and reduce complications.  Transfusion therapy can help manage the complications of SCD, but it also poses risks, and its use needs to be carefully considered.

Understanding Sickle Cell Disease and its Complications

SCD is caused by a mutation in the HBB gene that affects the production of hemoglobin, the protein that carries oxygen in red blood cells. Instead of the normal round shape, the hemoglobin molecules in people with SCD form stiff, sickle-shaped structures. These sickle cells can get stuck in small blood vessels, leading to inflammation, tissue damage, and severe pain, particularly in the bones, chest, and abdomen. Repeated episodes of pain can lead to organ damage and increase the risk of infections, stroke, and other complications.

Transfusion therapy for Sickle Cell Disease

Transfusion therapy can help manage the complications of SCD by providing healthy red blood cells that can improve oxygen delivery and prevent sickling. The goals of transfusion therapy for SCD include reducing the frequency and severity of pain episodes, preventing or treating strokes, and reducing the risk of acute chest syndrome, a potentially life-threatening complication that can occur when sickle cells block blood vessels in the lungs.

However, transfusion therapy also carries risks, including the development of alloantibodies, iron overload, and infections. Alloantibodies are antibodies produced by the immune system in response to foreign red blood cells from donors. In SCD patients who receive frequent transfusions, alloantibodies can accumulate and make it difficult to find compatible blood for transfusion. Iron overload can occur when the body absorbs too much iron from the transfused blood, leading to organ damage, particularly in the heart and liver. Finally, chronic transfusions can increase the risk of infections and other transfusion related sequela. 

Transfusion needs in SCD patients

The decision to transfuse SCD patients depends on various factors, including the severity of their symptoms, the presence of complications, and their overall health. In general, SCD patients with a hemoglobin level below 6 g/dL or with evidence of tissue damage or organ dysfunction may benefit from transfusion therapy. However, transfusions should be used judiciously and tailored to the individual patient's needs to minimize the risks of complications.

Rh and Kell Antigen Screening

SCD patients require Rh and Kell antigen screening before receiving transfusions. Rh and Kell antigens are present on the surface of red blood cells and can cause alloimmunization, which is the production of antibodies against these antigens. As many SCD patient's are chronically transfused, they are at a higher risk of developing alloantibodies, the most common being antibodies in the Rh system such as D,C, or E and also Kell. If SCD patients with Rh or Kell antibodies receive blood containing these antigens, their immune system will attack the donor red blood cells, leading to a severe transfusion reaction. Therefore, SCD patients require Rh and Kell antigen-negative blood to avoid these complications.

HgbS Negative Blood

SCD patients also require blood that is tested to be HgbS negative. HgbS is the abnormal hemoglobin that causes sickling of red blood cells in SCD patients. If SCD patients receive blood containing HgbS, their red blood cells will still sickle, and they will not benefit from the transfusion. Therefore, SCD patients require blood that is tested to be HgbS negative.

Transfusions and Sickle Cell Trait

Individuals with sickle cell trait typically do not require blood transfusions. Sickle cell trait is a genetic condition where a person inherits one normal hemoglobin gene and one abnormal hemoglobin gene. While individuals with sickle cell trait may have some symptoms related to the abnormal hemoglobin gene, these symptoms are usually mild and do not require blood transfusions.

What is a Type and Screen?

A type and screen is a blood test that is used to determine a person's blood type and screen for antibodies in their blood that may react with transfused blood. The test is typically performed before a person receives a blood transfusion, surgery, or other medical procedure that may require a blood transfusion.

First off...

What is a Blood Type?

During a type and screen, a sample of blood is collected from the person and sent to a laboratory for analysis. The blood is first tested to determine the person's blood type, which is based on the presence or absence of certain antigens on the surface of the red blood cells. There are four major blood types: A, B, AB, and O.

Additionally, The Rh factor is a protein that is found on the surface of red blood cells. Specifically, the Rh factor refers to a group of antigens known as the Rhesus antigens, with the most important of these antigens being the D antigen. People who have the D antigen are considered Rh positive (Rh+), while those who do not have the D antigen are considered Rh negative (Rh-).

The D antigen is determined by an individual's genetics. The gene that controls the D antigen is located on chromosome 1. If an individual inherits the dominant D gene from one or both parents, they will be Rh positive. If they inherit two recessive d genes, they will be Rh negative.

Most people (about 85%) are Rh positive, while the remaining 15% are Rh negative. Rh factor is important in pregnancy because if a woman who is Rh negative becomes pregnant with a fetus who is Rh positive, there is a risk that the woman's immune system may produce antibodies against the Rh factor of the fetus, which can lead to complications in future pregnancies. To prevent this, Rh-negative women who become pregnant with an Rh-positive fetus may be given a medication called Rh immune globulin (RhoGAM). RhoGAM works by blocking the woman's immune system from producing antibodies against the D antigen of the fetus.

What is an Antibody Screen?

The blood is also screened for antibodies that may react with transfused blood. Alloantibodies are antibodies produced by an individual's immune system in response to exposure to foreign antigens from transfused blood. In other words, alloantibodies are antibodies that are directed against antigens that are not present on a person's own red blood cells. These antibodies can develop when a person is exposed to red blood cells that have different blood group antigens than their own.

Alloantibodies

Alloantibodies can cause serious complications during blood transfusions. When a person receives a transfusion of blood that contains foreign antigens, their immune system can produce alloantibodies against those antigens. If the person receives another transfusion with incompatible blood in the future, their immune system can recognize the foreign antigens and initiate an immune response, resulting in a transfusion reaction. The A and B antigens are the most commonly known antigens on a persons Red Blood Cells that are used for compatibility. This is where we get the blood types A, B, O, and AB. However there are DOZENS more known antigen systems on Red Blood Cells. It is not routine for labs to screen for these antigens on a patient due to time and cost, but if they create an alloantibody they will then need tested for these antigens that they create an antibody towards.

Alloantibodies may also be made during the stages of pregnancy. Alloimmunization in pregnancy occurs when a woman's immune system produces antibodies against foreign blood group antigens present in the blood of her developing fetus. This can occur when the mother has a different blood type from the fetus, and the fetus inherits blood group antigens from the father that are foreign to the mother.

If the mother is Rh-negative and the fetus is Rh-positive, for example, the mother's immune system may produce Rh antibodies that can cross the placenta and attack the fetal red blood cells. This can result in hemolytic disease of the newborn (HDN), a condition in which the fetus or newborn experiences the destruction of red blood cells and can lead to anemia, jaundice, and other serious complications.

Alloantibodies are often detected through a blood test called an antibody screen, which is performed prior to a blood transfusion to ensure that the donor blood is compatible with the recipient's blood type. If alloantibodies are detected, the transfusion process must be carefully managed to avoid a transfusion reaction. In some cases, it may be necessary to use blood from a special donor source or to perform additional testing to identify compatible blood products.

What is a Crossmatch?

You may hear the term Type and Cross, which is a bit of a misnomer. A crossmatch is a test performed using the Type and Screen specimen. A crossmatch involves mixing a sample of the recipient's blood serum with a sample of the donor's red blood cells and observing whether there is agglutination (clumping) of the cells. If the recipient's antibodies react with the donor's cells, this indicates that the blood is incompatible and a transfusion could result in a severe transfusion reaction.

There are two main types of crossmatches: the immediate spin crossmatch and the full crossmatch. The immediate spin crossmatch involves mixing the donor's cells with the recipient's serum and observing for agglutination at room temperature. The full crossmatch is a more comprehensive test that involves incubating the donor's cells with the recipient's serum at 37°C to mimic the conditions inside the body and observing for agglutination.

Patient's with a proven history of a negative antibody screen may be eligible for an "Electronic Crossmatch" in which the laboratory information system scans the unit of blood through the patient's history and agrees that the unit is "electronically" compatible based on the correct choice of Blood Type and negative antibody history. This saves time and efficiency for the lab worker and the patient as no physical testing needs to be performed. Patient's with blood typing issues or antibodies are not eligible for electronic crossmatch.

The crossmatch is a critical step in ensuring safe blood transfusion and is performed for every blood product that is transfused to a patient. If an incompatible crossmatch is detected, the transfusion must be halted immediately, and alternative compatible blood products must be obtained.

Jehovah's Witnesses and Blood Transfusion

Blood And Jehovah's Witnesses 

Jehovah's Witnesses are a denomination of the Christian faith with almost 9 million followers worldwide. They are known for keeping a firm ethical code. One of many of these moral conditions in which a follower must subscribe to involves the refusal of blood products. A follower who outright agrees to receiving blood products is generally shunned from their congregation, as this is seen as a renouncement of their religious faith that the higher powers can and will preside over their life. Even in emergent situations, it is generally expected that a follower will deny the use of blood product
transfusion. 

What Types of Blood Do Jehovah's Witnesses Refuse?

It is generally understood that Jehovah's Witnesses will refuse the four main types of blood products that can be simply harvested without extra manipulation. This includes:

• Red Blood Cells
• Platelets
• Plasma
• White Blood Cells (granulocytes)

Jehovah's Witnesses will also typically refuse autologous blood, which is blood that they themselves donate to keep on shelf for potential use during an upcoming surgery. 

This is why Blood Transfusion Consent is so important to have on file. If a Jehovah's Witness adherer receives blood products against their wishes, or without being informed properly of the possible need for blood (such as prior to surgery, etc), the hospital can be liable for damages for not properly following the patient's religious wishes. 

Why Do Jehovah's Witnesses Refuse Blood Transfusions?

The main reason of refusal lies in that portions of the New and Old Testaments lay out that one should not take in the blood of other beings. Additionally, it is seen as disobedient to God to receive blood products as "blood is considered life" and "God gives life".  

Blood Substitutes for Jehovah's Witnesses

What, if anything, can Jehovah's Witnesses due in the event of requiring blood products?

Jehovah's Witnesses will usually allow certain manufactured blood components, such as Albumin, antibody preparations, Recombinant Factor solutions, fibrinogen concentrate, cryoprecipitate, etc. 

Other options include trying to raise blood counts through the use of other mechanisms, such as Iron supplementation (if indicated), giving Erythropoietin (tells the bone marrow to make more Red Blood Cells), etc. 

Surgical procedures may elect to perform "Bloodless Surgery" which involves the use of procedures to minimize bleeding such as using lasers and/or electrocautery to stop active bleeding, minimally invasive surgical techniques, etc.  

Blood Transfusion Consent

Importance of Blood Transfusion Informed Consent

What is Blood Transfusion Consent? Blood transfusion consent is the process through which a patient agrees to receive a blood transfusion after being fully informed about the procedure. This medical procedure involves the intravenous delivery of blood or blood products to a patient.

Informed Consent: The Core of the Process

• Essential Information: Patients, or their legal representatives, must be thoroughly informed about the transfusion's benefits, risks, and any alternative options available.
• Discussion and Questions: The healthcare provider will detail why the transfusion is necessary, the procedure's potential risks and benefits, and address any questions or concerns from the patient.

Steps Following Consent:

• Verification: After obtaining consent, the patient's identity and blood type are verified to ensure the transfusion's safety and suitability.
• Administration: A trained healthcare professional then performs the transfusion in a sterile setting.

The Importance of Informed Consent in Transfusions:

• Informed consent is a critical aspect of the transfusion process, ensuring patients are well-informed and agree to their treatment plan. This process empowers patients to make educated decisions regarding their healthcare.

By emphasizing informed consent, the medical field prioritizes patient autonomy and understanding, reinforcing the significance of clear communication and patient education in healthcare decisions.

Emergent Transfusion and Consent

Navigating Emergency Transfusions: In emergencies requiring immediate blood transfusions, if a patient cannot give informed consent, healthcare providers may proceed without explicit approval. These critical situations demand swift action to safeguard the patient’s health, guided by established medical protocols and ethical guidelines.

Legal Frameworks and Ethical Considerations:

• Legal Protections: Many jurisdictions have laws enabling emergency medical interventions without prior consent to prevent harm and preserve life.
• Efforts to Obtain Consent: Providers are expected to attempt to secure consent from the patient or their legal representatives as soon as the emergency stabilizes.

Decision-Making in Consent's Absence:

• In the absence of patient consent, decisions may be informed by the patient’s medical history, existing advance directives, or the input of family members and caregivers.

The Rarity of Consent-Less Transfusions:

• Instances where transfusions occur without consent are exceptional. Medical professionals strive to respect patient autonomy, prioritizing informed decision-making and patient welfare.

This framework ensures that, even in urgent scenarios, the principles of patient care, ethical conduct, and legal adherence are maintained, balancing immediate medical needs with respect for individual rights and preferences.

Examples of Transfusion Consent Forms:

Blood Consent from UCLA

Blood Consent from Kaiser Permanente