Transfusion Reactions (Noninfectious Conplications of Transfusion)

Question 1

What treatment is recommended following a transfusion reaction due to bacterial contamination?

a. epinephrine
b. broad spectrum antibiotics
c. plasma protein fraction
d. aspirin

Answer 1

b. broad spectrum antibiotics

Question 2

A 46 year old woman was transfued with one unit of packed RBCs. The nurse monitoring the transfusion noticed hives on the patient arm and her temperature increased from 98.9 to 99.1 F. what is the choice of treatment for this patient?

a. leukopoor blood
b. diphenhydramine
c. irradiated blood
d. diuretics

Answer 2

b. diphenhydramine

Question 3

What is the physiological mechanism surrounding anaphylactic and anaphylactic reactions?

a. Patient is deficient in IgE and develops IgE antibodies via sensitization from transfusion or pregnancy
b. Antibody in patient serum is detected 3 to 7 days after tranfusion reacting with donor red blood cells
c. Donor plasma has reagins (IgE or IgA) that combine with allergens in patient plasma
d. Patient is deficient in IgA develop IgA antibodies via sensitization from transfusion or pregnancy

Answer 3

d. Patient is deficient in IgA develop IgA antibodies via sensitization from transfusion or pregnancy

Question 4

Which of the following represents the pathophysiologic mechanisms of a febrile non-hemolytic transfusion reaction?

a. PLA1 antibody in patient serum is directed against antigens on donor random platelets
b. HLA antibodies in donor plasma combine with recipient granulocytes causing pulmonary aggregates
c. HLA antibody in patient serum directed against antigens present on donor monocytes, granulocytes, and lymphocytes
d. Red cell antibody in patient serum is directed against antigens present on donor red cells.

Answer 4

c. HLA antibody in patient serum directed against antigens present on donor monocytes, granulocytes, and lymphocytes

Question 5

The treatment in the event of an anaphylactic or anaphylactioid reaction should include all of the following except:

a. immediately administer plasma protein fraction
b. immediately administer epinephrine
c. keep the IV line open with normal saline
d. stop the transfusion

Answer 5

a. immediately administer plasma protein fraction

Question 6

All of the following are consistent with circulatory overload, except:

a. Tachycardia
b. Orthopnea
c. Dyspnea
d. Fever

Answer 6

d. Fever

Question 7

Which of the following might be a cause of an underlying cause of an immediate hemolytic transfusion reaction?

a. A patient with anti-M in serum is transfused with M positive red cells
b. A patient with anti-K in serum is transfused with K positive red cells
c. A patient is transfused with a red cell unit contaminated with E coli
d. Iron overload occurs in a massively transfused patient

Answer 7

b. A patient with anti-K in serum is transfused with K positive red cells

Question 8

How could a potential alloimmunization due to Jk(a) be prevented?

a. washed red blood cells
b. use of third generation bedside leukocyte filters
c. apheresis platelets
d. matching of donor and recipient red blood cell phenotype

Answer 8

d. matching of donor and recipient red blood cell phenotype

Question 9

Which of the following questions should be asked when investigative a transfusion reaction?

a. What methodology was used for serologic testing?
b. What was the donor unit transfused?
c. What time of day was the donor unit collected?
d. How many milliliters of red blood cells were transfused?

Answer 9

d. How many milliliters of red blood cells were transfused?

Question 10

What is the most common preventable error occurring among the nursing and medical staff that results in a transfusion related death?

a. improper patient identification
b. alloantibody misidentified
c. specimen mislabeled
d. incorrect crossmatch procedure

Answer 10

a. improper patient identification

Question 11

What organ may be affected by iron overload?

a. Kidney
b. Heart
c. Liver
d. All of the above

Answer 11

d. All of the above

Question 12

What may be found in the sera of a person who is exhibiting signs of TRALI?

a. Red blood cell alloantibody
b. Antileukocyte antibody
c. Allergen
d. IgA antibody

Answer 12

b. Antileukocyte antibody

Question 13

A delayed hemolytic transfusion reaction is most often the result of:

a. hemosiderosis in a massively transfused patient
b. bacterial contaminated red cells
c. a unit of packed red cells infected with Hepatitis B
d. an anamnestic response from a prior transfusion or pregnancy

Answer 13

d. an anamnestic response from a prior transfusion or pregnancy

Question 14

What is a possible mechanism for TRALI?

a. Histamine is released from basophils decreasing vascular permeability
b. Antileukocyte antibody reacts with leukocytes and activates RES
c. HLA class I or II antibodies in transfused product combine with recipient granulocytes causing aggregation in pulmonary vasculature
d. Histamine is released from mast cells increasing vascular dilation and fluidity to tissues

Answer 14

c. HLA class I or II antibodies in transfused product combine with recipient granulocytes causing

Question 15

What would be the benefit of transfusing washed red cells in circulatory overload?

a. remove allergens
b. reduce the oncotic load
c. remove alloantibody
d. reduce the hematocrit

Answer 15

b. reduce the oncotic load

Question 16

What statement is true regarding the pathophysiology of alloimmunization?

a. upon primary exposure to foreign antigen large amounts of IgG are produced
b. Upon secondary exposure to foreign antigen large amounts of IgG are produced
c. Lymphocyte memory is invoked after the first exposure to foreign antigen
d. Antibody will attach to red cells and activate the complement system

Answer 16

b. Upon secondary exposure to foreign antigen large amounts of IgG are produced

Question 17

Which of the following is an accurate definition of an adverse reaction to a blood transfusion?

a. Any unfavorable transfusion related event occurring in a patient during transfusion of blood components
b. Any favorable transfusion related event occurring in a patient during or after transfusion of blood components
c. Any unfavorable transfusion related event occurring in a patient during or after transfusion of blood components
d. Any unfavorable transfusion related event occurring in a patient after transfusion of blood components

Answer 17

c. Any unfavorable transfusion related event occurring in a patient during or after transfusion of blood components

Question 18

Which of the following antibodies are implicated in a delayed hemolytic transfusion reaction?

a Anti-D, anti-U
b. Anti-Lu(a), anti-Le(a)
c. Anti-d, anti-M
d. Anti-K, anti-JK(a)

Answer 18

d. Anti-K, anti-JK(a)

Question 19

This type of transfusion reaction occurs in about 1% of all transfusions and results in at least a >1 C temperature rise associated with no medical explanation other than blood component transfusion.

a. Delayed Hemolytic
b. TRALI
c. Febrile nonhemolytic transfusion reaction
d. Immediate hemolytic

Answer 19

c. Febrile nonhemolytic transfusion reaction

Question 20

What does the term iatrogenic refer to?

a. Physician caused
b. Respiratory caused
c. Patient caused
d. Research caused

Answer 20

a. Physician caused

Question 21

Anti-PLA1 was identified in a para 3, gravida 3 female. As a result her platelet count fell to 9000/uL. What treatment option is best?

a. Leukoreduced platelets
b. Plasmapheresis
c. Random platelet transfusion
d. Apheresis platelets

Answer 21

b. Plasmapheresis

Question 22

An O patient inadvertently received 2 units of type A red cells. The patient expired as a result of an immediate hemolytic transfusion reaction. A written report must be received by the FDA within how many days of the fatality?

a. 5
b. 2
c. 1
d. 7

Answer 22

d. 7

Question 23

Hemolysis in a delayed transfusion reaction is usually:

a. Extravascular
b. Intravascular

Answer 23

a. Extravascular

Question 24

How many years must a record of an adverse event to blood transfusion be kept according to AABB standards?

a. At least 5 years
b. At least 10 years
c. Indefinitely
d. Permanently

Answer 24

b. At least 10 years

Question 25

Five units of A positve red blood cells were transfused to a patient one day ago. The patients blood type was A postive. The patient spiked a fever >1 C from their baseline reading. There were no clerical errors detected, however the post transfusion DAT was positive with polyspecific and anti-IgG. Hemolysis was also evident in the post transfusion specimen. Anti-Jkb was identified in the post-transfusion plasma. However, the antibody screen on the pre-transfusion specimen was negative. How can the positive DAT be explained? a. Donor cells had a positive DAT b. The recipient cells were likely positive for the Jk(b) antigen and the patient experienced a primary immune response c. The donor cells were likely positive for the Jk(b) antigen and the patient experienced an anamnestic immune response d. The donor cells were polyagglutinable

Answer 25

c. The donor cells were likely positive for the Jk(b) antigen and the patient experienced an anamnestic immune response

Question 26

A 50 year old male with a 4 year history of Hairy cell leukemia is scheduled to undergo a hip replacement. He has not previously required transfusion. At the end of the operative procedure the patient's platelet count is 40,000/ uL. The transfusion service provides a pool of five platelet concentrates that are transfused in the recovery room. All other vital signs are stable with the exception of an elevated blood pressure from 126/82 to 158/88 mmHg. The patient is treated with a antipyretic and his fever promptly resolves. What type of reaction is evident in this case? a. Febrile non-hemolytic b. Immediate hemolytic c. Bacterial contamination d. Delayed hemolytic

Answer 26

a. Febrile non-hemolytic

Question 27

A 38 year old male with pancreatic cancer is undergoing chemo with a requirement for frequent red cell and platelet transfusions. While being transfused 6 units of platelets the patient suddenly develops a high fever accompanied by rigors, shock, facial flushing, abdominal cramping, nausea, and vomiting. This is reflective of what type of reaction? a. TRALI b. Bacterial contamination c. Febrile nonhemolytic d. Circulatory overload

Answer 27

b. Bacterial contamination

Question 28

A "white out" on radiographs is usually associated with what type of transfusion reaction? a. TRALI b. Bacterial contamination c. Febrile nonhemolytic d. Circulatory overload

Answer 28

a. TRALI

Question 29

A group A patient with CML receives a stem cell transplant from his group O sister. What type of ABO mismatch is this? a. Major b Minor c. Bidirectional d. None of the above

Answer 29

b Minor

Question 30

What may be employed in the event of a significant antibody to a high frequency antigen to predict if a patient would have a transfusion reaction to receiving the corresponding antigen via blood transfusion. a. Reticulocyte harvest b. Acid elution c. Monocyte Monolayer assay D. W.A.R.M.

Answer 30

c. Monocyte Monolayer assay

Question 31

A 65 year old male was transfused with one unit of apheresis platelets after surgery. The patients blood type was A positive and the platelet type was O positive. One hour after transfusion the patient became hypotensive, had chills, and a temperature of 103 F. The baseline temperature was 99.2 F. The blood bag was sent down to the blood abk and a post-transfusion DAT was performed and found to be negative. There were no discrepancies noted in the clerical check. These results are consistent with: a. Acute hemolytic reaction b. Delayed hemolytic reaction c. Bacterial contamination d. TACO

Answer 31

c. Bacterial contamination

Question 32

A 61 year old woman received 2 units of FFP to correct an INR of 2.5. She had no history of transfusino, however was currently on Coumadin for venous thrombosis. Her blood type was O positive. The 2 FFP units were AB negative. Halfway through the second unit she became cyanotic, dyspenic, and tachycardic. Her temperature increased slightly from 99.1 to 99.3. F. Oxygen saturation was 71%. These symptoms are consistent with: a. TACO b. TRALI c. Acute hemolytic d. Anaphylactic

Answer 32

b. TRALI

Question 33

An 81 year old woman received 327 mL of RBCs (B Pos) for anemia. She presented with seizures 20 minutes after the transfusion was completed. Her blood pressure decreased from 147/71 before transfusion to 131/71 at completion of transfusion. Temperature decreased from 99.1 F to 98.8 F. The post transfusion DAT was negative and urine blood was negative. Clerical check was ok. These symptoms and results are consistent with: a. Allergic reaction b. Symptoms not related to transfusion c. Bacterial contamination d. TRALI

Answer 33

b. Symptoms not related to transfusion

Question 34

A 49 year old male received 3 units of RBCs and 3 units of FFP for anemia and prolonged PT and APTT. His blood type was O positive. The 3 RBCs were O positive and FFPs were O positive as well. FFPs were transfused successfully without incedent, however into the 3rd transfusion of RBCs the patient became tachycardic and hypertensive. Oxygen saturation was 65% on room air. The post transfusion DAT was negative, clerical check ok and urine blood negative. BNP was elevated. These results are consistent with: a. TRALI b. TACO c. Anaphylactic reaction d. Air embolism

Answer 34

b. TACO

Question 35

A patient presenting with a hemolytic transfusion reaction contained both anti-Jka and anti-K in their serum. While phenotyping had been done to establish that the patient was Kell negative in the previous admissions phenotyping had not been done for the Jka antigen. How many days must you wait before performing a reticulocyte harvest after the patient has been transfused. a. 1 b. 2 c. 3 d. 4

Answer 35

c. 3

Question 36

A 65 year old male with kidney disease was admitted to the hospital with bleeding varices. Blood work revealed a PT of 19 seconds and PTT of 30 seconds; Hgb 7.2 g/dL and Hct 21%. His platelet count was 132,000/uL. He was transfused 3 units of FFP and 4 units of RBCs. All units were O positive to match his blood type. During transfusion the patient became hypertensive with difficulty breathing and transfusions were terminated. The clerical check revealed no discrepancies, post transfusion DAT was negative, post transfusion urine hemoglobin was negative as was the plasma hemoglobin. The post transfusion ABO/Rh, and antibody screen was O pos and negative, respectively. What type of reaction is present in this case? a. TRALI b. symptoms unrelated to transfusion c. TACO d. Acute Hemolytic

Answer 36

c. TACO

Question 37

A 75 year old female was admitted for anemia and joint paint. She had no history of transfusion and had no children. Medical history revealed a diagnosis of Lupus at age 33 and she was currently on ACE inhibitors. Her hemoglobin was 8.5 g/dL and hematocrit was 25.2%. ABO and Rh revealed the patient was A positive and antibody screen negative. Two unit of packed RBCs were ordered. The units were A positive. Minutes into the first transfusion the patient was markedly hypotensive necessitating administration of epinephrine. The transfusion was stopped and lab investigation initiated. The clerical check revealed no discrepancies. Baseline temperature was 37.2 C and increased to 37.9. The post transfusion DAT was negative with no hemoglobin evident in a post transfusion urine sample or plasma. What could be the pathophysiology of this reaction? a. increased braykinin b. decreased bradykinin c. circulatory overload d. increased prekallikrein

Answer 37

b. decreased bradykinin

Question 38

The most commonc cause of fatal tranfusin reactions relate to: a. clerical errors involving misidentification of patients b. emergency release of uncrossmatched units c. misidentification of autoantibodies d. bacterial contamination

Answer 38

a. clerical errors involving misidentification of patients

Question 39

Regarding the part of the transfusion investigation of examining a post-transfusion urine sample for free hemoglobin, such a finding indicates that there is a large amount of free hemoglobin in plasma which exceeds the binding capacity of: a. Homocysteine b. Haptoglobin c. albumin d. cobalamin

Answer 39

b. Haptoglobin

Question 40

Most lawsuits involving blood banks or donor centers are: a. civil in nature b. criminal in nature c. always settled d. cannot be appealed

Answer 40

a. civil in nature

Question 41

What is the basis of state blood statutes in the United States? a. blood product manufacture provides for sale between blood centers and firms b. blood product manufacture is procured under governmental regulations and thus cannot impose a charge on hospitals c. blood product manufacture is deemed a service d. blood product manufacture is a for profit enterprise

Answer 41

c. blood product manufacture is deemed a service

Question 42

The failure to exercise reasonable prudent care in a like circumstance is: a. tort b. negligence c. certiorari d. strict liability

Answer 42

b. negligence

Question 43

Death associated with acute hemolytic transfusion reaction is most commonly a result of: a. Pretransfusion testing errors b. Clerical Errors c. Undetected RBC alloantibodies d. Abnormally high ABO isoagglutinin titers

Answer 43

Clerical Errors

Question 44

Hemosiderosis is an unfavorable effect of longer term transfusion therapy. Which of the following are administered to remove excess iron from the body? a. Furosemide b. Diazapam c. Deferoxamine d. Nitrofurantion

Answer 44

Deferoxamine is an iron chelator, which will remove free iron from the peripheral blood stream.

Question 45

A patient receives 3 units of FFP without incedent. 1 hour after infusion of a 4th unit of FFP the patient experiences dyspnea, hypotension, and an increase in temperature of 2 C. The radiological picture is of bilateral pulmonary infiltrates without evidence of cardiac compromise. The most likely cause is: a. allergic reaction b. patient has HLA antibodies c. TRALI d. Fluid overload

Answer 45

c. TRALI The key here is pulmonary infiltrates without evidence of cardiac compromise. In TRALI, the donor plasma contains antibodies which react with leukocytes in the patient. This antibody reaction stimulates the complement system to produce C3a and C5a. The proteins then stimulate the tissue basophils and platelets to release histamine and serotonin, resulting in leukocyte emboli which aggregate in the lungs. Because there is no cardiace compromise, here, we can rule out volume overload. Allergic reactions will often manifest with hives as well as respiratory distress.

Question 46

Which of the following is an established indication for the use of leukocyte reduced blood components? a. to guard against the immunomodulary effect of transfusion b. prevent graft vs host disease c. prevention of TRALI d. prevention of CMV transmission

Answer 46

d. prevention of CMV transmission CMV is a leukocyte associated virus, and reducing the leukocytes to less than 5 X 10^6 has been shown to prevent CMV transmission.

Question 47

A patient is being transfused with an autologous whole blood. After approximately 30 ml of bloo has been infused, the patient complains of fever, chills, pain and nausea. The nurse stops the transfusion and contacts the blood bank. The most likely cause of this transfusion reaction is: a. an IgG antibody was missed in the pretransfusion antibody screen. b. the patient is having an allergic reaction to the anticoagulant in the whole blood unit. c. the patient is having a febrile reaction d. the wrong unit was transfused

Answer 47

d. the wrong unit was transfused Therese are classic signs of a hemolytic transfusion reaction. Remember that most transfusion fatalities are caused by clerical mistakes. Therefore, the choice "the wrong unit was transfused" is the most likely cause of an HTR. The presence of an undetected IgG antibody would not cause such as immediate reaction, nor would it matter if the unit truly were the correct autologous unit. An allergic reaction would also likely involved hives and respiratory distress. If the unit were the correct autologous unit, then we would not expect a febrile reaction in this patient.

Question 48

What is the most common cause of transfusion associated mortality reported to the FDA? a. Post-transfusion purpura (PTP) b. Transfusion-associated graft-vs-host disease (TA-GVHD) c. Hemolytic transfusion reactions (HTRs) associated with ABO incompatibility. d. Transfusion-related actute lung injury (TRALI) e. Transfusion-associated circulatory overload (TACO)

Answer 48

d. Transfusion-related actute lung injury (TRALI)

Question 49

Which of the following is the second most common cause transfusion-associated mortality reported to the FDA? a. PTP b. TA-GVHD c. Hemolytic transfusion reactions associated with ABO incompatibility. d. TRALI e. TACO

Answer 49

e. TACO

Question 50

Which of the following is the most preventable root cause fatal transfusion reaction? a. Errors in the performance of donor disease testing. b. Errors in patient or specimen identification. c. Errors in the interpretation of serologic reactions. d. Antibodies of the Kidd blood group system. e. Antibodies of the Rh blood group.

Answer 50

b. Errors in patient or specimen identification.

Question 51

When a fatality occurs in association with blood collection or transfusion, how should the Director of the Office of Compliance and Biologics Quality of the FDA be notified? a. Telephone or email only, as soon as possible. b. Written report only, within 7 days. c. Written report only, within 30 days. d. Telephone or email as soon as possible and written report within 7 days. e. Telephone or email as soon as possible and written report within 30 days.

Answer 51

d. Telephone or email as soon as possible and written report within 7 days.

Question 52

A 60 year old male with bladder cancer is undergoing chemotherapy and required frequent Red Blood Cell and platelet transfusions. During the transfusion of 6 units of pooled platelet concentrates, the patient suddenly develops a high fever accompanied by rigors, shock, facial flushing, abdominal cramping, nausea, and vomiting. What does this constellation of symptoms most likely suggest? a. An intravascular HTR b. FNHTR c. TRALI d. A bacterially contaminated unit e. TACO

Answer 52

d. A bacterially contaminated unit

Question 53

A 4-year old female with a metastatic tumor is admitted to the hospital for surgical evaluation of her disease. She received multi-agent chemotherapy and is now anemic, with a hematocrit of 20%. She receives a 150 mL aliquot of RBCs after admission without incident. Within 30 minutes of a second RBC transfusion (also 150 mL) 24 hours later, the patient begins to cough and has increasing difficulty breathing. She also develops a fever with a temperature elevation of 2 C. All other vital signs are stable including heart rate and blood pressure. Eventually, the child requires intubation secondary to increasing respiratory effort and poor oxygenation. What is the most likely diagnosis. a. TRALI. b. An anaphylactic transfusion reaction. c. A hemolytic transfusion reaction. d. TACO. e. A manifestation of the patient's underlying clinical condition.

Answer 53

a. TRALI.

Question 54

Which of the following plasma products have been implicated in cases of TRALI? a. Fresh Frozen Plasma (FFP) b. Plasma Frozen Within 24 Hours after Phlebotomy (PF24). c. Liquid Plasma d. Plasma, Cryoprecipitate Removed. e. All of the above.

Answer 54

e. All of the above.

Question 55

Which of the following is a defining feature of TRALI? a. Preexisting acute lung injury before transfusion. b. Onset of symptoms within 6 hours of transfusion. c. Evidence of left atrial hypertension. d. Presence of HLA antibodies in the transfused blood component. e. A higher mortality rate in comparison with other types of acute lung injury.

Answer 55

b. Onset of symptoms within 6 hours of transfusion.

Question 56

Which of the following licensed pharmacologic products can be used to mitigate TRALI risk? a. Solvent/detergent (SD) treated plasma. b. Three-factor protein complex concentrates. c. Four-factor protein complex concentrates. d. All of the above. e. None of the above.

Answer 56

d. All of the above.

Question 57

A 65 year old woman is in the operating room for a complicated spinal surgical procedure. Multiple red cell units are expected to be required. The patient is group O. During the transfusion of the third unit of blood, the anesthesiologist notes that the patient is producing red urine. All vital signs are stable. The transfusion is stopped and a transfusion reaction investigation ensues. Which of the following is the LEAST likely explanation of this patient's reaction? a. Intravascular hemolytic transfusion reaction b. Bacterial contamination of the third unit. c. Mechanical damage to red cells secondary to use of a cell saver device. d. Bladder irritation from catheterization causing hematuria.

Answer 57

b. Bacterial contamination of the third unit. The question asks which is LEAST likely. The patient is not experiencing any of the common clinical signs of bacterial infection such as increase in temperature, hypotension, rigors.

Question 58

A 2 y ear old child has a complex congenital heart defect in need of surgial repair. The procedure will require extracorpeal bypass and multiple units of blood will be needed. Near the end of the surgical procedure, a unit is transfused. Shortly thereafter the anesthesiologist notes the development of red urine. A blood sample is obtained for intraoperative lab testing also reveals red serum. All vital signs are stable. The transfusion reaction investigation is negative (ie clerical check is fine, pre and post transfusion DAT testing is nonreactive, and repeat ABO typing demonstrates no discrepancy) exvept for the visual inspection (ie red serum). This child likely experienced what type of reaction? a. Intravascular hemolytic transfusion reaction. b. Delayed hemolytic transfusion reaction. c. No hemolysis; red serum and red urine are unrelated to transfusion. d. Mechanical hemolysis attributable to the bypass circuit.

Answer 58

d. Mechanical hemolysis attributable to the bypass circuit. A causative antibody is not likely since the DAT is negative. So we then suspect mechanical cause of hemolysis.

Question 59

A 60 year old male was transfused with 4 units of ABO/Rh matched RBCs over a period of 6 hours. The patient is now exhibiting the following symptoms: coughing, difficulty breathing, cyanosis, edema, hypertension and a severe headache. The patient does not have a fever. Which of the choices below represents the most likely type of transfusion reaction? a. TRALI b. Circulatory Overload c. Allergic d. Febrile

Answer 59

b. Circulatory Overload To differentiate, it helps to know which conditions involve fever. Conditions due to blood group antibody or immune processes and bacterial contamination typically involve fever. SO things like Febrile, TRALI, HTR, Bacterial Contamination, GVHD all involve fever. Conditions like circulatory overload and allergic reactions do NOT involve fever. The patient is showing cyanosis (blue cast to skin), difficulty breathing, coughing and a headache. These are all sings of circulatory overload. There is no fever, and no mention of pulmonary infiltrates, so we are not thinking TRALI. Also, TRALI typically has HYPOtension, and this patient has HYPERtension.