BLOOD BANK ROTATION SCHEDULE FOR CLINICAL:PATHOLOGY RESIDENT

I. DONOR AREA

1. Donors: The trainee should become familiar with the standards for drawing donors, the reasons for deferral, and difference in standards for autologous or directed donors. Donor reactions will be reviewed and also the predisposing factors which make such reactions more likely.

   After appropriate introduction and with appropriate supervision, the trainee should completely interview and draw at least two donors.

   After the Donor Room section has been completed, the trainee will review autologous donors requiring M.D. evaluation ("MD auto donors"), under the supervision of a Medical Director.

2. Blood-borne diseases:
   • Basic understanding of the data necessary to compare tests, concepts of specificity and sensitivity, the requirements for improving assays and the nature of the various assays will all be reviewed.
   • AIDS testing methods: Review the epidemiology associated with AIDS and the basis for voluntary exclusion and the technical details of both screening and confirmatory assays for AIDS. Understanding of the specificity and sensitivity is important. Requirements for informing donors should be reviewed. The data on infectiousness of positive confirmed donors should be known. The rationale for the steps taken for initially reactive donors, repeatedly reactive donors and confirmed donors should all be reviewed.
   • Universal precautions and methods of inactivating virus by 10% household bleach and basic safety procedures for handling blood regarding the risk of AIDS should also be reviewed.
   • Hepatitis testing: The method, specificity and sensitivity for hepatitis A, hepatitis B, non-A, non-B should all be reviewed. The epidemiology or risk factors for hepatitis should be reviewed. The sequence of findings for the various markers including antibody to core antigen, antibody to E antigen, and presence of E antigen should also be known, particularly the significance of E as suggesting a chronic infected carrier. Finally, management after exposure to hepatitis should be reviewed.
   • Other diseases: These include CMV, malaria, babesiosis. The evidence that leukopoor or antibody negative blood have equivalent safety in preventing CMV transmission should be reviewed. The risks for malaria should be reviewed, particularly the steps in the donor standards for excluding malaria. Finally, babesiosis should be reviewed as a rare but relevant finding in New England.
3. Platelet collection: The trainee should be familiar with the standards for platelet donors and how they are actually collected. If circumstances permit, the trainee should be introduced to the COBE Spectra to the point where the trainee has a basic understanding of how the collection works and what controls are needed.
4. Outpatient transfusions: The trainee should review considerations which apply in transfusion therapy in the outpatient setting. This includes pre-medication, management of reactions and selection of patients.
5. Apheresis exchange: The trainee will be introduced to principles of therapeutic plasma exchange and stem cell harvesting by appropriate readings during this period of time. The technical aspects of apheresis, patient work-up and follow-up will be taught when patients present that require this service.

II. COMPONENT PREPARATION AND GENERAL BLOOD ORIENTATION

1. Red cells: The trainee should know the different types of red cells, how these are prepared, what the quality control requirements are, the shelf-life and the differences in the anti-coagulants. Current knowledge of red blood cell storage lesion will be reviewed.
2. Standards for testing donor blood: The trainee should be familiar with ABO and Rh typing, the procedures for resolution of inconsistent forward and back types, the procedures for Rh typing including Du typing, and the procedure for syphilis testing.
3. The trainee should be familiar with the standards for the preparation of FFP, cryoprecipitate and the quality control required, and should, in addition, be familiar with the indications for using these products.
4. The preparation of factor concentrates should be reviewed, particularly with reference to the risks of these preparations and the indications for their use. The newer method of sterilization will be reviewed particularly to demonstrate the increased safety this has provided.
5. Albumin: The role of albumin as a plasma expander should be reviewed and the basis for its relative safety as a transfusion product.
6. Immunoglobulin preparations: The specific Immunoglobulin preparations such as H Zig and Gammimmune should be reviewed. The use of IV gammaglobulin will be reviewed.
7. Platelet concentrates: The preparation and standards for platelet concentrates should be reviewed. Different options for storage should be reviewed together with the evidence for which is the correct one.
8. The principles for establishing red cell shelf-life and evaluation of red cell products should be reviewed. This includes both anti-coagulants and survival studies. In particular, the trainee should be familiar with the controversy concerning the use of Adsol and how third generation anticoagulants have extended shelf life.
9. Reasons for leukocyte removal and irradiation will be reviewed.
10. Practical goals: Do specimens for and resolution of typing discrepancies. Analyze Rh typing including sub-typing and Du typing again using known specimens and carry out grouping of the sub-groups of A.

III. INTRODUCTION TO ACCESSION, DISPENSING AREA, PRE-TRANSFUSION TESTING AND TRANSFUSION REACTIONS

The study of pre-transfusion testing will be directed at reviewing the methods by which safe blood is provided to the clinician. This will include understanding the methodology behind antibody screens, the Coomb's crossmatch and the controversy about whether or not it is necessary for safe transfusion, the methods used for resolving incompatible crossmatches, the philosophy behind a type and screen policy and a maximum surgical order schedule. The focus will be to emphasize the relative risks at each level of preparation, and to understand what is necessary in situations where incompatible blood must be given.

Practical goals during pre-transfusion testing will be to understand how to do ABO and Rh typing, type and screen, and crossmatch. The value of albumin and LISS during the crossmatch should be understood. Techniques of RBC phenotyping will be presented. The trainee should read concerning the controversy between immediate spin crossmatch and Coomb's crossmatch. The trainee will also begin reading concerning blood group antigens during this time and will cover specifically the ABO system and, if time permits, begin to read about the Rh system.

Intensive study of transfusion reactions will include classification of transfusion reactions, analysis of their mechanisms and review of strategies to manage the side effects of transfusion therapy.

Many of the topics will be covered incompletely during the introductory week, and will be covered in more detail later in the rotation through study of actual clinical problems.

IV. BASICS OF ANTIBODY AND ANTIGEN IDENTIFICATION

V. PRINCIPLES OF CRYOPRESERVATION AND TRANSFUSION IN TRANSPLANTATION

VI. ADVANCED SEROLOGY

VII. MATERNAL AND FETAL SEROLOGY AND TRANSFUSION PRACTICE

VIII. CLINICAL PROBLEMS IN TRANSFUSION MEDICINE

IX. HLA LABORATORY

X. SPECIAL PROJECTS

XI. CALL SCHEDULE

XII. MORNING REPORT:

XIII. SEMINAR AND JOURNAL CLUB