Test Device for Blood Transfusion Safety

How Acoustics Can Help Preventing Any Red Cells Incompatibility

Karine Charrière

, Jean-François Manceau

, Pascal Morel

, Véronique Bourcier

, Wilfrid Boireau

Lionel Pazart

and Bruno Wacogne

1,2

INSERM CIC 1431, Besançon University Hospital, 25000 Besançon, France

FEMTO-ST Institute, Univ. Bourgogne Franche-Comté, CNRS, 25030 Besançon cedex, France

Etablissement Français du Sang Bourgogne/Franche-Comté, 25000 Besançon, France

Hemovigilance Service, Besançon University Hospital, 25000 Besançon, France

Keywords: Red Cells Incompatibility, Blood Transfusion, Microsystem, Medical Device, Transfusion Safety, Acoustic

Mixing, Acoustic Detection.

Abstract: During red cells concentrates transfusion, red cells incompatibilities still occur despite the laboratory

controls based on immuno-hematologic techniques. Red cells incompatibilities appear when patient’s

antibodies bind to red cells to be transfused. Up to now, all pre-transfusion testing are addressed using

techniques based on immunology. This is time consuming, expensive and some incompatibility situations

cannot be addressed at the patient’s bedside. In this position paper, we propose a completely novel

paradigm. Our hypothesis is that red blood cells sensitized by the patient’s antibodies see their deformability

greatly reduced. This induces changes of the rheological properties of the “red cells concentrate /patient’s

blood” mixture. Studies described in this position paper aim at characterizing these modifications by

measuring the characteristics of acoustic waves propagating in the mixture and to produce a mobile and

automated acousto-micro-fluidic device which would allow detecting any incompatibility at the patient’s

bed side.

1 INTRODUCTION

In most countries, a crossmatch (a compatibility test

between blood for transfusion and the receiver's

blood) is carried out in a laboratory prior to

transfusion, but is of no use when an error occurs

after the blood has been transfused. The current

techniques for carrying out a crossmatch are either

manual, with blood reagents and samples being

mixed in tubes or being placed on gel columns

before centrifuging (e.g. Across Gel® Cross Match,

from Dia Pro or ID-Card 50531 from Bio-Rad), or

automated (e.g. the Qwalys analysers from Diagast).

As far as these automated systems are concerned, the

analysers may only be used in the laboratory and are

difficult to adapt for use at the patient's bedside, in

particular because of the need to treat the blood

samples before they are analysed.

Many countries are thus looking at solutions at

the patient's bedside in order to reduce the rate of

transfusional accidents related to avoidable

immunological incompatibilities. Currently, the final

pre-transfusional test at the patient's bedside consists

exclusively of an identity check (identity of the

blood pouch and identity of the patient). This

method cannot guarantee that there will be no

transfusional accident because 50% of the reported

adverse effects are due to human error (SHOT,

2011). Therefore, in spite of increasingly effective

safety systems, it is currently impossible to eliminate

entirely the risks due to human error, both in the

laboratory and at the time of the transfusion.

A few countries, including France, carry out a

second ABO compatibility test at the patient's

bedside immediately before the blood transfusion,

using control charts requiring several handling

procedures. These tests makes allows us to limit

fatal transfusional accidents in France, but does not

completely prevent human error, which is the main

cause of transfusional error (Linden, 2000 - Myhre,

206

Charrière, K., Manceau, J-F., Morel, P., Bourcier, V., Boireau, W., Pazart, L. and Wacogne, B.

Test Device for Blood Transfusion Safety - How Acoustics Can Help Preventing Any Red Cells Incompatibility.

DOI: 10.5220/0006635702060211

In Proceedings of the 11th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2018) - Volume 1: BIODEVICES, pages 206-211

ISBN: 978-989-758-277-6

2000 - Sazama, 2003). These errors can occur during

the test procedure at the patient's bedside, in

particular when the hemagglutination reaction is

read and interpreted (Henneman, 2007 - Myhre,

2000).

In this position paper, we propose a conceptual

and technical innovative approach which will

address any red cells incompatibility in a mobile and

easy to use medical device.

The scientific hypotheses can be summarized as

follows. Red cells are nucleus-free cells with an

average diameter of 7.2 µm. Their cytoplasm is rich

in haemoglobin. Their membrane is extremely

flexible. This makes them deformable enough to

propagate in the much smaller blood capillary

network (Kim, 2015 – Tomaiuolo, 2014 –

Mohandas, 2008). Physiological aging or various

pathological situations jeopardize this deformability

(Franco, 2013 – Mourao, 2016 – Chien, 1987).

Among the factors, deformability is reduced when

red cells are covered in antibodies. More

importantly, a loss in red cell deformability results in

a significant increase of blood viscosity (Kim,

2015).

When the red cells concentrate is compatible

with patient’s blood, antigens at the surface of the

red cells to be transfused are not complementary to

antibodies present in the patient’s blood. No

antigen/antibody reaction occurs and deformability

of the red cells to be transfused is not modified.

Transfusion is then allowed.

On the contrary, when the red cells concentrate is

incompatible, antigens at the surface of the red cells

to be transfused are recognized by the patient’s

antibodies. This induces an immune reaction whose

consequences are more or less critical

(alloimmunization, haemolytic reaction, patient’s

death). Our hypothesis is that fixation of antibodies

on the red cells to be transfused reduces their

deformability and alters the rheological properties of

the “red cells concentrate (blood bag)/patient’s

blood” mixture. This alteration can be measured

using acousto-fluidic interactions. In this case, no

supplementary reagent is required and any immune

incompatibility situation can be detected.

This communication is organized as follows. In

section 2, we present a schematic representation of

the foreseen medical device. In part 3, we present

preliminary results obtained concerning acoustic

mixing, activation and detection of liquid

rheological modifications. In part 4, and in line with

the scope of a position paper, we present scientific

and socio-economic impacts such a device could

address.

2 DESCRIPTION OF THE

FORESEEN DEVICE

The device under development includes studies on

microfluidics, acoustic mixing, acoustic activation

and acoustic detection. Examples of acoustic

manipulation of liquids will be presented in section

3. In this section, we detail the biological and

technological studies currently under investigation.

At the cellular level, deformability of red cells is

investigated using conventional techniques: Atomic

Force Microscopy, possibly optical tweezers and

quantitative phase imaging (Kim, 2015).

Experiments are conducted in condition as close as

possible to real clinical conditions. For example, we

are setting up experiments with compatibility or

incompatibility situations induced by natural and/or

unexpected antibodies against red cell antigens.

Variations of the rheological properties of the bag’s

cell/patient’s blood mixture will be investigated

using a device such as the one described in figure 1

in the case of an incompatibility.

Figure 1: Schematic representation of the foreseen device.

(a) Driving the samples to the mixing chamber. (b)

Reaction activation either by acoustic activation or

heating. (c) Acoustic detection of incompatibilities.

Patient’s blood and bag’s red cell will be

transferred to a mixing chamber (part (a) in figure

1). The goal is to make the mixture as homogeneous

as possible in order to optimize recognition of the

red cell antigens by antibodies from the patient.

Mixing by diffusion would be too long for a

practical use at the patient’s bed side. Therefore,

acoustic mixing comparable to what is presented in

section 3 will be employed.

Test Device for Blood Transfusion Safety - How Acoustics Can Help Preventing Any Red Cells Incompatibility

207

The blood mixture will be transferred in a

reaction chamber as illustrated in part (b) of the

figure. In order to reduce the time required for the

antigen/antibody reaction, this chamber may have to

be temperature controlled and/or equipped with an

acoustic activation device as presented in the next

section.

Once the antigen/antibody reaction is completed,

the mixture is then transferred into a test chamber

equipped with acoustic transducers (part (c) in the

figure). The transducer generates acoustic waves

(Lamb waves in this case) which propagate through

the mixture and are detected by the acoustic

detector. This detector will detect variations of the

rheological properties of the mixture through

measurement of both amplitude and phase by means

of an integrated network analyzer. In this case,

measurement obtained with the acoustic detector

will have to be compared to values obtained in the

case of compatibility. This may become an issue

since referenced or calibrated measurement are

difficult to perform in an automated way at the

patient’s bed side. Also, Lamb waves only interact

with liquid in the vicinity of the membrane. A more

bulky architecture may be required in order to

enhance the sensor’s sensitivity.

A possible simpler architecture is describe in

figure 2. Here only one chamber and only one

transducer is used. Red cells to be transfused and

patient’s blood are injected in the chamber and the

piezoelectric transducer is driven with frequencies

and amplitudes suitable for either fluid mixing,

activation or reaction sensing. The acoustic

transducer may be patterned so that several acoustic

modes can be generated. Natures of the most

suitable acoustic modes will have to be defined for

the aimed function. Next, the same transducer is

used to monitor the time-dependent evolution of the

acousto-fluidic properties of the mixture during the

antigen/antibody reaction. This make the method

potentially reference or calibration free.

We already mentioned that the age of red cells

influences their membrane deformability (Franco,

2013). If needed, micro-filtration units will be added

to the device in order to remove aged red cells.

These units will be inserted in the circuitry

employed to transfer the red cells to be transfused

and the patient’s blood to the mixing chamber (part

(a) in figure 1). However, a device similar to the one

we propose for blood incompatibility could be used

in order to qualify the age of red cells contained in

transfusion bags. This constitutes one of the

scientific impacts we describe in section 4.

Figure 2: Simplified architecture with one sensor/actuator.

3 ACOUSTIC INTERACTIONS

WITH FLUIDS

In section 3, we mentioned that acoustic

manipulation is used for fluid mixing,

antigen/antibody reaction activation and rheological

properties monitoring. In what follows, we present

preliminary results concerning acoustic fluids

manipulations which can be directly adapted for

blood compatibility assessment.

3.1 Acoustic Mixing

We demonstrated acoustic mixing using patterned

acoustic transducers (Kardous, 2014). This structure

allowed exciting different acoustic modes in a liquid

droplet as illustrated in figure 3.

Figure 3: (a): Generation of acoustic mode (5.5). (b)

Generation of a degenerated mode (1,3)+(3,1). Figure

adapted from (Kardous, 2014).

Mixing various viscous fluids have been tested.

Liquids to be mixed are rhodamine in water and

40% glycerol in water. Fluorescence of rhodamine is

used to visualize the mixing of these two liquids.

The result is shown in figure 4. In this figure,

negative times indicate that no acoustic activation is

applied. For positive times, acoustic mixing is

BIODEVICES 2018 - 11th International Conference on Biomedical Electronics and Devices

208

applied. It can be noted that the two liquid phases

are completely mixed after about 3-5 min.

Acoustic mixing was also demonstrated in order

to homogenize blood red cells in a physiological

serum droplet. This is illustrated in figure 5. Note

that acoustic manipulation can also be used for

reversible concentration/dispersion of micro-

particles in liquids. This is not shown here because it

is out the scope of this communication.

Figure 4: Acoustic mixing of water and glycerol solution.

Rhodamine is used to visualize mixing using fluorescence.

Figure adapted from (Kardous, 2014).

Figure 5: Acoustic homogenization of red cells in a

physiological serum droplet.

3.2 Acoustic Activation

Antigen/antibody recognition can be enhanced using

acoustic activation during antibodies immobilization

step (Kardous, 2011). Monoclonal antibodies

A9H12 were deposited in droplets of 400 nL at the

surface of membrane compatible with Surface

Plasmon Resonance imaging (SPRi) experiments.

Five antibodies spots were deposited. The

corresponding antigen was LAG-3 proteins. Figure 6

shows SPR images of the biochip were (a)

corresponds to the capture of LAG-3 without

acoustic activation and (b) corresponds to the same

spots when acoustic activation is used.

Amplification of the bio-recognition ranges from 1.5

to 3. This is illustrated in figure 6(c) and it highlights

the efficiency of acoustic mixing regarding

antigen/antibody reaction.

Figure 6: Acoustic activation of antigen/antibody

recognition. (a) LAG-3 antigens captured by A9H12

antibodies on a SPRi biochip without acoustic activation.

(b) The same experiment using acoustic activation. (c)

Amplification rate obtained for 2 values of the antibodies

concentrations. Figure adapted from (Kardous, 2010).

3.3 Acoustic Sensing

Acoustic sensing of a fluid may be achieved using

the Lamb waves. Various Lamb waves exist such as

symmetric modes noted S

and the anti-symmetric

modes noted A

. A

and S

are shown in figure 7(a).

Figure 7: Acoustic sensing. (a) Anti-symmetric and

symmetric Lamb waves modes. (b) Sensing solutions of

varying concentrations in sodium chloride.

Each mode exhibits its own resonant frequency

and penetration depth in the liquid under

Test Device for Blood Transfusion Safety - How Acoustics Can Help Preventing Any Red Cells Incompatibility

209

investigation. An example of acoustic sensing is

given in figure 7(b). Here, resonant frequencies of

the modes are about a few MHz. Lamb waves were

used to monitor the concentration in sodium

chloride. Addition of sodium chloride increases the

density of water. This results in shifts of the resonant

frequency of the acoustic mode. The figure clearly

shows that acoustic sensing allows measuring the

sodium chloride concentration (i.e. the viscosity)

when A

mode is excited. S

mode does not

experience frequency shifts due to its inadequate

penetration depth.

4 SCIENTIFIC AND SOCIO-

ECONOMICAL IMPACTS

As mentioned above and in the scope of a position

paper, we present the scientific and socio-economic

impacts such a device potentially produce in the next

section.

The new paradigm which constitutes the acoustic

detection of immuno-incompatibilities potentially

allows detecting any cause of incompatibility. Given

the increasing exchanges of populations and the

increasing number of multiple transfusions, some

unexpected antibodies against red cell antigens are

not currently detected or identified. The acoustic

technique we propose here would detect

incompatibility without the need of prior

identification.

Outside the field of transfusion safety, studies are

ongoing concerning the effect of the age of the red

cells concentrates on the transfusion efficiency

(Vallion, 2015 – Lacroix, 2015 – Lapierre, 2007 –

Desmarets, 2016). In 2008, Luten et al. showed that

about 30% of bag’s red cell are eliminated by the

organism within 24 hours after transfusion, probably

because of the loss in membrane deformability

(Luten, 2008). Therefore, a device like the one we

propose could be adapted in order to perform a

selection of the red cells based on the detection of

the less deformable cells at the moment of blood

donation. This potentially would improve blood

transfusion efficiency.

By changing the principle of incompatibility

detection, this acousto-fluidic device will be a

technological advance because no expensive

antibodies will be used (human IgGs). The foreseen

cost of the disposable part of the device is estimated

to about 5$.

Technology development related to this device

will considerably simplify ultimate compatibility

controls by proposing a mobile device which can be

used by non-trained staff at the patient’s bed side. In

most countries, organization of care will benefit

from this technological and conceptual

breakthrough. In countries where the transfusion

chain (from donation to transfusion) is well

organized, this device will contribute to the

harmonization of pre-transfusion controls as

advocated by the World Health Organization. In

countries where the transfusion chain is not or

partially organized, such a device will offer a cost-

effective solution to enhance blood transfusion

safety. In the future, this device could be proposed

for every red cell concentrates transfusion which

means at least 17 million tests in Europe, 20 million

in the US and 140 million worldwide.

In the world, only 62% of countries have a

legislation and care organization concerning the

quality and the security of blood transfusions. In

2016, 40 countries admit that no qualification of the

blood donation is performed due to the lack in

qualified staff and economic issues (WHO

factsheets).

The World Health Organization highlights the

need for international standardization of safety

processes, in particular for what concerns blood

incompatibilities. Simplifying the blood transfusion

safety controls would improve the access to safe and

cost-effective blood transfusions in more countries

than it is today and to the benefit of a rapidly

increasing population.

5 CONCLUSIONS

In this position paper, we have described how

immuno-erythrocytic incompatibilities can have

severe or lethal consequences. We pointed out that

there exists no method to address all the

incompatibility situations.

Here, we propose a new paradigm based on the

use of acoustic sensing to detect incompatibilities.

The hypothesis is that when red cells from the red

cells concentrate are covered in antibodies issued

from the patient’s blood, the deformability of their

membrane is strongly reduced. As a consequence,

rheological properties of the mixture red cell

concentrate/patient’s blood are modified and these

modifications can be acoustically detected.

Furthermore, this acoustic detection is independent

of the immunologic origin of a possible

incompatibility. Examples of already demonstrated

acoustic mixing, activation and sensing using other

fluids have been presented. The preliminary results

BIODEVICES 2018 - 11th International Conference on Biomedical Electronics and Devices

210

demonstrate the feasibility of the method we

propose. Experimental studies are currently ongoing

using whole blood samples issued from donators and

red cell concentrates.

When completed, these studies will lead to a

global solution able to address any incompatibility

situation which can be used by non-specialized staff

directly at the patient’s bed side. This

incompatibility detection has to be coupled to an

identification of the antibody / antigen responsible of

the immunological reaction. This technology will

reinforce transfusion safety in countries where the

transfusion chain is already organized. At the same

time, such a device will offer an affordable solution

to enhance blood transfusion safety in other

countries.

ACKNOWLEDGEMENTS

This work is partially funded by the “translational

PEPS call” from the CNRS. Operation 2017.

REFERENCES

Chien, S. 1987, Red Cell Deformability and its Relevance

to Blood Flow. Annu. Rev. Physiol. Vol. 49, pp. 177–

192.

Desmarets, M., Bardiaux, L., Benzenine, E., Dussaucy, A.,

Binda, D., Tiberghien, P., Quantin, C. and Monnet, E.,

2016, Effect of storage time and donor sex of

transfused red blood cells on 1-year survival in

patients undergoing cardiac surgery: an observational

study, Transfusion, Vol. 56, pp. 1213–1222.

Franco, R.S., Puchulu-Campanella, M.E., Barber, L.A.,

Palascak, M.B., Joiner, C.H., Low, P.S. and Cohen,

R.M., 2013, Changes in the properties of normal

human red blood cells during in vivo aging. Am. J.

Hematol., Vol. 88, pp. 44–51.

Henneman, E.A., Avrunin, G.S., Clarke, L.A., Osterweil,

L.J., Andrzejewski, C., Jr, Merrigan, K., Cobleigh, R.,

Frederick, K., Katz-Bassett, E., Henneman, P.L., 2007.

Increasing patient safety and efficiency in transfusion

therapy using formal process definitions. Transfus.

Med. Rev. 21, 49–57. doi:10.1016/j.tmrv.2006.08.007.

Kardous, F., Rouleau, A., Simon, B., Yahiaoui, R.,

Manceau, J.F. and Boireau, W., 2010, Improving

immunosensor performances using an acoustic mixer

on droplet microarray, Biosens. Bioelec., Vol. 26, pp.

1666-1671.

Kardous, F., Yahiaoui, R., Aoubiza, B. and Manceau, J.F.,

2014, Acoustic mixer using low frequency vibration

for biological and chemical applications, Sens. Act. A,

Vol. 211, pp. 19-26.

Kim, J., Lee, H. and Shin, S., 2015, Advances in the

measurement of red blood cell deformability: A brief

review. J. Cell. Biotechnol., Vol. 1, pp. 63–79.

Lacroix, J. et al., 2015, Age of transfused blood in

critically ill adults. N. Engl. J. Med., Vol. 372, pp.

1410–1418.

Lapierre, V., Aupérin, A., Robinet, E., Ferrand, C.,

Oubouzar, N., Tramalloni, D., Saas, P., Debaene, B.,

Lasser, P. and Tiberghien, P., 2007, Immune

modulation and microchimerism after unmodified

versus leukoreduced allogeneic red blood cell

transfusion in cancer patients: results of a randomized

study - Transfusion - Wiley Online Library. Available

at: http://onlinelibrary.wiley.com/doi/10.1111/j.1537-

2995.2007.01344.x/full.

Linden, J.V., Wagner, K., Voytovich, A.E., Sheehan, J.,

2000. Transfusion errors in New York State: an

analysis of 10 years’ experience. Transfusion (Paris)

40, 1207–1213.

Luten, M., Roerdinkholder-Stoelwinder, B., Schaap, N.P.,

de Grip, W.J., Bos, H.J. and Bosman GJ., 2008,

Survival of red blood cells after transfusion: a

comparison between red cells concentrates of different

storage periods, Transfusion, Vol. 48, pp. 1478–1485.

Mohandas, N. and Gallagher, P. G., 2008, Red cell

membrane: past, present, and future, Blood, Vol. 112,

pp. 3939–3948.

Mourão, L.C., Roma, P.M., Sultane Aboobacar Jda, S.,

Medeiros, C.M., de Almeida, Z.B., Fontes, C.J.,

Agero, U., de Mesquita, O.N., Bemquerer, M.P. and

Braga, É.M., 2016, Anti-erythrocyte antibodies may

contribute to anaemia in Plasmodium vivax malaria by

decreasing red blood cell deformability and increasing

erythrophagocytosis, Malar. J. Vol. 15, pp. 397.

Myhre, B.A., McRuer, D., 2000. Human error-a

significant cause of transfusion mortality. Transfusion

(Paris) 40, 879–885.

Sazama, K., 2003. Transfusion errors: scope of the

problem, consequences, and solutions. Curr. Hematol.

Rep. 2, 518–521.

SHOT, 2011. Annual SHOT report 2011.

South, S.F., Casina, T.S., Li, L., 2012. Exponential error

reduction in pretransfusion testing with automation.

Transfusion (Paris) 52, 81S–87S. doi:10.1111/j.1537-

2995.2012.03816.x.

Tomaiuolo, G. 2014, Biomechanical properties of red

blood cells in health and disease towards

microfluidics, Biomicrofluidics, Vol. 8, pp. 51501.

Vallion, R., Bonnefoy, F., Daoui, A., Vieille, L.,

Tiberghien, P., Saas, P. and Perruche, S., 2015,

Transforming growth factor-β released by apoptotic

white blood cells during red blood cell storage

promotes transfusion-induced alloimmunomodulation,

Transfusion, Vol. 55, pp. 1721–1735.

World Health Organization, Blood safety and availability.

Available at: http://www.who.int/mediacentre/

factsheets/fs279/en/.

Test Device for Blood Transfusion Safety - How Acoustics Can Help Preventing Any Red Cells Incompatibility

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