Purpose: 
To describe the selection of PRBC units by Transfusion Services (TS) at Harborview Medical Center (HMC), including units with special attributes, and alternative ABO/Rh selections when ABO/Rh identical products are unable to be transfused due to inventory management issues.

Policy: 
General Statements:	Related Documents	
1	•	Patients will receive ABO/Rh identical crossmatch compatible PRBC units whenever possible		
2	•	If ABO substitution is necessary, units shall be selected according to the “Alternative ABO Selections for RBCs” Table (table 1).		
3	•	The TS Leads, TS Manager &/or TS Medical Director / Resident / Covering Physician will be involved in RBC selection when the “Alternative ABO Selections for RBCs” Table (table 1) is not applicable		
4	•	Substitution will be utilized to reduce inventory wastage		
5	•	Product selection CANNOT be based on the Puget Sound Blood Center patient history. Serologic results for at least 2 ABO/Rh tests performed by TS at HMC, including 1 during the current HMC patient encounter are required to issue non group O units		
6	•	When emergency RBC transfusion is deemed medically necessary, ABO compatible units will be issued. Rh substitution will be based on patient age and gender 		
Emergency Release Uncrossmatched RBC:		
1	•	For Emergency Release uncrossmatched red  cell (RBC) transfusions,  group O RBCs shall be provided for patients who DO NOT have:  
o	An active type and screen (T&S) OR
o	An ABO/Rh type from their current HMC encounter  AND
o	A total of 2 serologic ABO/Rh type results over all HMC encounters
•	Rh- units shall be provided for females < 50 years old and pediatric patients  ≤ 15 YO &  < 40kg
•	Rh+ units shall routinely be provided for:
o	Males ≥ 15 years old
o	Females ≥ 50 years old
		
Emergency Release Uncrossmatched RBC continued:	Related 
Documents	
2	•	For Emergency Release uncrossmatched RBC transfusion, ABO/Rh type specific units shall preferentially be provided for patients who have:
o	An active type and screen (T&S) OR
o	An ABO/Rh type performed during their current HMC encounter  AND
o	A minimum of 2 ABO/Rh type results over all HMC encounters
•	When ABO identical units cannot be provided based on inventory, alternative selections shall be made according to the choice order in the “Alternative ABO Selections for RBCs” Table (table 1)
•	For Rh- patients, if there is a critical shortage of ABO type specific or compatible Rh- RBC, and only a limited supply of O- RBCs, Rh+ units may be substituted with the approval of the Medical Director or Resident/Covering Physician  for: 
o	Male patients
o	Female patients ≥ 50 years old
•	For Rh- females < 50 years of age, in extremely rare event that NO Rh- ABO type specific or compatible units (including O-) are available, Rh+ units may substituted with the approval of the Transfusion Services Medical Director,/Resident /Covering Physician.  	Table 1	
Crossmatched RBC:		
1	•	An active type and screen + crossmatch is required to issue RBC for routine transfusion
•	For patients with an active type and screen, ABO/Rh identical  units shall preferentially be provided
•	When ABO/Rh identical units cannot be provided due to inventory, alternative ABO compatible units shall be selected according to the choice order in the “Alternative ABO Selections for RBCs” Table (table 1).
•	Rh negative patients must receive Rh negative RBCs 
•	Rh+ patients shall preferentially receive Rh+ RBCs, but may also receive Rh- units if required for inventory management		
Special Product Attributes:	
1	•	Leukoreduced PRBC Units will be routinely provided for:
o	Neonates & Infants < 4 months age
o	Pregnant females
o	HIV positive patients
o	Chronically transfused patients 
•	e.g. sickle cell disease, thalassemia
o	Patient’s with hematologic malignancies 
•	e.g. leukemia, lymphoma, Hodgkin’s disease
o	Hematopoietic progenitor cell (HPC)/”bone marrow”  transplant candidates & recipients
o	Organ donors and potential organ donors
o	Solid organ transplant candidates & recipients 
•	e.g. kidney, liver, heart, lung transplants
o	Patients with bone marrow failure 
•	e.g. severe aplastic anemia
o	Patient’s with congenital immunodeficiencies
o	Patients on cardiac bypass (until 24 hours post op) 
o	Patients on intra-aortic balloon pumps, LVAD, artificial hearts, awaiting cardiac transplant.
o	Intrauterine transfusion		
Special Product Attributes continued:	
2	•	Irradiated PRBC Units will be routinely provided for:
o	Neonates & Infants < 4 months age
o	Patient’s with hematologic malignancies 
•	e.g. leukemia, lymphoma, Hodgkin’s disease
o	Patients receiving fludarabine or other high dose chemotherapy
o	Hematopoietic progenitor cell (HPC)/”bone marrow”/”stem cell”  transplant candidates & recipients
o	Patient’s with cellular immunodeficiencies 
•	e.g. SCID, Di George syndrome
o	Recipients of 
•	Directed donor RBCs 
- e.g. parent, sibling, child, family friend donated unit
•	HLA matched RBCs		
3	•	Patient’s with Sickle Cell Disease/Thalassemia/Other Hemoglobinopathy should receive units that are:
o	Leukoreduced
o	Hemoglobin S negative
o	Irradiated - IF status post hematopoietic progenitor cell transplant (HPC-T), or receiving preparative chemotherapy/treatment for HPC-T 
o	Consider partial antigen matched (C, E, and K negative)		
Selection of RBC Units for Neonatal Transfusion	
1	•	For Neonates and Infants < 4 months of age:
o	Group O, leukoreduced, irradiated, hemoglobin S negative RBCs that are Rh compatible and < 7 days old will be routinely provided
o	Neonates who are group A, B or AB may receive ABO type specific units ONLY  if their initial type and screen demonstrated no maternally derived anti-A or anti-B isoagglutinins directed against a corresponding A &/or B antigen(s).
•	Note: For group A, B, or AB infants with maternally derived anti-A or anti-B directed against their corresponding A/B antigen(s), when subsequent reverse typing demonstrates no residual maternally derived anti-A/anti-B, ABO type specific units may be released 
o	For neonates with passively acquired maternal red cell alloantibodies directed against their corresponding RBC antigen: 
•	If the antibody is clinically significant: AHG crossmatch compatible units negative for the corresponding RBC antigen must be given 
•	Note: For low frequency RBC antigens for which no typing reagent is available, AHG crossmatch compatible units may be given
•	Note: Antigen negative, AHG crossmatch compatible units will no longer be required once subsequent antibody screens become negative
•	If the antibody is Clinically insignificant: Immediate spin compatible units may be provided
o	Units shall be irradiated, unless: 
•	The neonate requires immediate urgent transfusion, and < 7 day old leukoreduced, freshly irradiated RBC are not immediately available 
•	If the patient is receiving massive transfusion and the patient’s physician/pediatrician requests non-irradiated RBC (in order to avoid high dose potassium administration).  		

Table 1: Alternative ABO Selections for RBCs
Recipient ABO	1st Choice	2nd Choice	3rd Choice	4th Choice	
O	O	-	-	-	
 A	A	O	-	-	
B	B	O	-	-	
AB	AB	A	B	O	
 If neonate or infant < 4 months of age, only group O RBCs will be provided. If there are no RBCs in the TSL inventory, Transfusion Services Medical Director/Physician approval is required for ABO substitution.
 If patient is group A2 or A2B subtype with an anti-A1 reactive at 37C, only A2 or O RBCs may be issued.

References: 
AABB Standards for Blood Banks and Transfusion Services, Current Edition. 

AABB Technical Manual, Current Edition.