Practice questions Blood transfusion II
Practice questions
Blood transfusion II
© Jun Wang, MD, PhD
1. Use this case for the next five questions. A 36-year-old B- woman is undergoing an emergency laparotomy for a ruptured ectopic pregnancy. 2 B- units of packed red blood cells are ordered. Twenty minutes into the transfusion, she develops chills, fever and back pain. Her blood pressure drops from 110/70 mm Hg to 80/50 mm Hg. Her temperature raised from 37°C to 39.5°C. Examination reveals generalized flushing and oozing at the surgical site. Laboratory studies show:
LDH: 1,200 U/L (normal: 100–220 U/L)
Total bilirubin: 4.8 mg/dL
Haptoglobin: <10 mg/dL
What is the most appropriate next step in management of this patient?
B. Antipyretics
C. Broad spectrum antibiotics
D. Clerical check of the patient and blood units
E. Epinephrine
F. Stop transfusion
2. A 36-year-old B- woman is undergoing an emergency laparotomy for a ruptured ectopic pregnancy. 2 B- units of packed red blood cells are ordered. Twenty minutes into the transfusion, she develops chills, fever and back pain. Her blood pressure drops from 110/70 mm Hg to 80/50 mm Hg. Her temperature raised from 37°C to 39.5°C. Examination reveals generalized flushing and oozing at the surgical site. Laboratory studies show:
LDH: 1,200 U/L (normal: 100–220 U/L)
Total bilirubin: 4.8 mg/dL
Haptoglobin: <10 mg/dL
What additional lab test should be used to confirm the diagnosis?
B. Blood culture
C. Direct Coombs test
D. Patient serum IgA levels
E. Repeat ABO and Rh typing
3. A 36-year-old B- woman is undergoing an emergency laparotomy for a ruptured ectopic pregnancy. 2 B- units of packed red blood cells are ordered. Twenty minutes into the transfusion, she develops chills, fever and back pain. Her blood pressure drops from 110/70 mm Hg to 80/50 mm Hg. Her temperature raised from 37°C to 39.5°C. Examination reveals generalized flushing and oozing at the surgical site. Laboratory studies show:
LDH: 1,200 U/L (normal: 100–220 U/L)
Total bilirubin: 4.8 mg/dL
Haptoglobin: <10 mg/dL
Direct Coombs test is positive. What is the most likely cause of these presentations?
B. Allergic reaction
C. Bacterial infection
D. Donor antineutrophil antibodies
E. Excessive circulating volume
F. Immune mediated hemolysis
4. A 36-year-old B- woman is undergoing an emergency laparotomy for a ruptured ectopic pregnancy. 2 B- units of packed red blood cells are ordered. Twenty minutes into the transfusion, she develops chills, fever and back pain. Her blood pressure drops from 110/70 mm Hg to 80/50 mm Hg. Her temperature raised from 37°C to 39.5°C. Examination reveals generalized flushing and oozing at the surgical site. Laboratory studies show:
LDH: 1,200 U/L (normal: 100–220 U/L)
Total bilirubin: 4.8 mg/dL
Haptoglobin: <10 mg/dL
Direct Coombs test is positive. Repeat ABO and Rh typing confirms the patient is B-. forward typing of the used unit of packed red cells reveal agglutination with anti-A but not anti-B reagent. Reverse typing of the used unit of packed red cells reveals agglutination with B cells but not A cells. Rh factor test is negative. What is the most likely cause of this scenario?
B. Clerical error
C. Undetected anti-A in the patient’s blood
D. Undetected anti-B in the patient’s blood
E. Undetected anti-H in the donor’s blood
5. A 36-year-old B- woman is undergoing an emergency laparotomy for a ruptured ectopic pregnancy. 2 B- units of packed red blood cells are ordered. Twenty minutes into the transfusion, she develops chills, fever and back pain. Her blood pressure drops from 110/70 mm Hg to 80/50 mm Hg. Her temperature raised from 37°C to 39.5°C. Examination reveals generalized flushing and oozing at the surgical site. Laboratory studies show:
LDH: 1,200 U/L (normal: 100–220 U/L)
Total bilirubin: 4.8 mg/dL
Haptoglobin: <10 mg/dL
Direct Coombs test is positive. Repeat ABO and Rh typing confirms the patient is B-. forward typing of the used unit of packed red cells reveal agglutination with anti-A but not anti-B reagent. Reverse typing of the used unit of packed red cells reveals agglutination with B cells but not A cells. Rh factor test is negative. What is the diagnosis?
B. Acute hemolytic transfusion reaction due to Rh incompatibility
C. Delayed hemolytic transfusion reaction due to ABO incompatibility
D. Delayed hemolytic transfusion reaction due to Rh incompatibility
E. Febrile non-hemolytic transfusion reaction
F. Severe allergic transfusion reaction
6. Use this case for the next four questions. A 42-year-old B- woman presents to Urgent Care with worsening fatigue and dark-colored urine. She has a history of beta thalassemia major and has been receiving blood transfusions regularly. She received 2 units of B- RBC 3 days ago. Physical examination reveals a temperature of 37°C. Her other vital signs are within normal range. She has mild scleral icterus and non-tender splenomegaly. Laboratory test results include:
Reticulocyte count: 10% (0.5-2.5%)
Total bilirubin: 4.0 mg/dL (0.2-1.3 mg/dL)
LDH: 800 U/L (140-280 U/L)
Haptoglobin: 15 mg/dL (30-200 mg/dL)
Direct Coombs test: Positive
Peripheral blood smear reveals target cells and many RBCs without central pallor area. What is most likely the cause of her current condition?
B. Anti-ABO antibodies causing intravascular hemolysis
C. Cytokine-mediated inflammation process
D. IgE-mediated hypersensitivity to plasma proteins
E. Non-ABO antibodies causing extravascular hemolysis
F. Non-ABO antibodies causing intravascular hemolysis
7. A 42-year-old B- woman presents to Urgent Care with worsening fatigue and dark-colored urine. She has a history of beta thalassemia major and has been receiving blood transfusions regularly. She received 2 units of B- RBC 3 days ago. Physical examination reveals a temperature of 37°C. Her other vital signs are within normal range. She has mild scleral icterus and non-tender splenomegaly. Laboratory test results include:
Reticulocyte count: 10% (0.5-2.5%)
Total bilirubin: 4.0 mg/dL (0.2-1.3 mg/dL)
LDH: 800 U/L (140-280 U/L)
Haptoglobin: 15 mg/dL (30-200 mg/dL)
Direct Coombs test: Positive
Peripheral blood smear reveals target cells and many RBCs without central pallor area. What is most likely the cause of her lab test results?
B. Hepatitis virus infection
C. Iron deficiency
D. Parvovirus B19 infection
E. RBC membrane protein defects
8. A 42-year-old B- woman presents to Urgent Care with worsening fatigue and dark-colored urine. She has a history of beta thalassemia major and has been receiving blood transfusions regularly. She received 2 units of B- RBC 3 days ago. Physical examination reveals a temperature of 37°C. Her other vital signs are within normal range. She has mild scleral icterus and non-tender splenomegaly. Laboratory test results include:
Reticulocyte count: 10% (0.5-2.5%)
Total bilirubin: 4.0 mg/dL (0.2-1.3 mg/dL)
LDH: 800 U/L (140-280 U/L)
Haptoglobin: 15 mg/dL (30-200 mg/dL)
Direct Coombs test: Positive
Peripheral blood smear reveals target cells and many RBCs without central pallor area. Review of her medical record reveals presence of anti-K and negative agglutination during her cross-match tests before transfusion. The unit transfused is K negative, and Kidd negative. What is most likely the cause of her hemolysis?
B. Alloimmune anti-D
C. Alloimmune anti-Duffy
D. Autoimmune anti-D
E. Autoimmune anti-Duffy
9. A 42-year-old B- woman presents to Urgent Care with worsening fatigue and dark-colored urine. She has a history of beta thalassemia major and has been receiving blood transfusions regularly. She received 2 units of B- RBC 3 days ago. Physical examination reveals a temperature of 37°C. Her other vital signs are within normal range. She has mild scleral icterus and non-tender splenomegaly. Laboratory test results include:
Reticulocyte count: 10% (0.5-2.5%)
Total bilirubin: 4.0 mg/dL (0.2-1.3 mg/dL)
LDH: 800 U/L (140-280 U/L)
Haptoglobin: 15 mg/dL (30-200 mg/dL)
Direct Coombs test: Positive
Peripheral blood smear reveals target cells and many RBCs without central pallor area. Review of her medical record reveals presence of anti-K and negative agglutination during her cross-match tests before transfusion. The unit transfused is K negative, and Kidd negative. What is the diagnosis?
B. Anaphylactic transfusion reaction
C. Delayed hemolytic transfusion reaction
D. Febrile non-hemolytic transfusion reaction
E. Transfusion related iron overload
F. Urticarial transfusion reaction
10. Use this case for the next two questions. A 65-year-old man presents to Emergency Department for upper gastrointestinal bleeding. One unit of packed red blood cells for symptomatic anemia. About one hour after the transfusion started, he develops fever (38.9°C), chills, and mild malaise. He denies chest pain, back pain, dyspnea, or dark urine. His vital signs are otherwise stable, and physical examination is unremarkable. The transfusion is stopped. His laboratory test results include:
Total bilirubin: 1.2 mg/dL
LDH: 190 U/L
Haptoglobin: normal
Direct antiglobulin (Coombs) test: negative
Urinalysis: negative for hemoglobin
Peripheral blood smears reveal no significant morphological abnormalities. What is the most likely cause of his presentations?
B. Allergic reaction to donor plasma components
C. Cytokines and pyrogens in donor plasma
D. Donor antibodies against patient’s leukocytes
E. Excessive circulating load
11. A 65-year-old man presents to Emergency Department for upper gastrointestinal bleeding. One unit of packed red blood cells for symptomatic anemia. About one hour after the transfusion started, he develops fever (38.9°C), chills, and mild malaise. He denies chest pain, back pain, dyspnea, or dark urine. His vital signs are otherwise stable, and physical examination is unremarkable. The transfusion is stopped. His laboratory test results include:
Total bilirubin: 1.2 mg/dL
LDH: 190 U/L
Haptoglobin: normal
Direct antiglobulin (Coombs) test: negative
Urinalysis: negative for hemoglobin
Peripheral blood smears reveal no significant morphological abnormalities. What is the diagnosis?
B. Anaphylactic transfusion reaction
C. Delayed hemolytic transfusion reaction
D. Febrile non-hemolytic transfusion reaction
E. Transfusion associated circulatory overload
F. Urticarial transfusion reaction
12. Use this case for the next four questions. A 27-year-old woman presents to the clinic for blood transfusion. She has a history of beta thalassemia major and need regular blood transfusion. One unit of crossmatched packed red blood cells is prepared for her. Approximately 15 minutes after the transfusion starts, she develops itching and a rash over her arms and chest. She does not have shortness of breath, chest pain, or abdominal discomfort. Her vital signs are within normal ranges. Physical examination reveals multiple erythematous, raised wheals over her trunk and upper limbs. What is the most appropriate next step?
B. Antipyretics
C. Broad spectrum antibiotics
D. Clerical check of the patient and blood units
E. Epinephrine
F. Stop transfusion
13. A 27-year-old woman presents to the clinic for blood transfusion. She has a history of beta thalassemia major and need regular blood transfusion. One unit of crossmatched packed red blood cells is prepared for her. Approximately 15 minutes after the transfusion starts, she develops itching and a rash over her arms and chest. She does not have shortness of breath, chest pain, or abdominal discomfort. Her vital signs are within normal ranges. Physical examination reveals multiple erythematous, raised wheals over her trunk and upper limbs. Transfusion is stopped immediately. What is the most appropriate next step?
B. Antipyretics
C. Broad spectrum antibiotics
D. Clerical check of the patient and blood units
E. Epinephrine
14. A 27-year-old woman presents to the clinic for blood transfusion. She has a history of beta thalassemia major and need regular blood transfusion. One unit of crossmatched packed red blood cells is prepared for her. Approximately 15 minutes after the transfusion starts, she develops itching and a rash over her arms and chest. She does not have shortness of breath, chest pain, or abdominal discomfort. Her vital signs are within normal ranges. Physical examination reveals multiple erythematous, raised wheals over her trunk and upper limbs. Transfusion is stopped immediately. What is the most appropriate next step?
B. Send the blood unit for bacterial culture
C. Test for IgA deficiency
D. Administer corticosteroids and epinephrine before resuming transfusion
E. Begin broad-spectrum antibiotics
15. A 27-year-old woman presents to the clinic for blood transfusion. She has a history of beta thalassemia major and need regular blood transfusion. One unit of crossmatched packed red blood cells is prepared for her. Approximately 15 minutes after the transfusion starts, she develops itching and a rash over her arms and chest. She does not have shortness of breath, chest pain, or abdominal discomfort. Her vital signs are within normal ranges. Physical examination reveals multiple erythematous, raised wheals over her trunk and upper limbs. Transfusion is stopped immediately. What is the diagnosis?
B. Anaphylactic transfusion reaction
C. Transfusion related circulatory overload
D. Transfusion related acute lung injury
E. Urticarial transfusion reaction
16. Use this case for the next three questions. A 45-year-old man presents to the Emergency Department after falling from a bridge. He has a history of IgA deficiency. His blood pressure is 95/65 mmHg, and heart rate is 110 beats per minute. Physical examination reveals pale skin and mucosa and a 10 cm laceration on the left leg with active bleeding. His CBC reveals a hemoglobin of 7.5 g/dL. His white cell count, platelet count and coagulation panels are within normal ranges. Forward typing reveals agglutination with anti-A but not anti-B reagent. Reverse typing reveals agglutination with B cells, but not A cells. Rh factor test is positive. Routine antibody screening test is negative. What blood product is needed for him?
B. Type A+ red cells
C. Type AB- fresh frozen plasma
D. Type B+ fresh frozen plasma
E. Type B+ red cells
F. Type O+ red cells
17. A 45-year-old man presents to the Emergency Department after falling from a bridge. He has a history of IgA deficiency. His blood pressure is 95/65 mmHg, and heart rate is 110 beats per minute. Physical examination reveals pale skin and mucosa and a 10 cm laceration on the left leg with active bleeding. His CBC reveals a hemoglobin of 7.5 g/dL. His white cell count, platelet count and coagulation panels are within normal ranges. Forward typing reveals agglutination with anti-A but not anti-B reagent. Reverse typing reveals agglutination with B cells, but not A cells. Rh factor test is positive. Routine antibody screening test is negative.
2 units of A+ RBC are prepared. He develops dyspnea and perioral edema 5 minutes after transfusion started. His blood pressure dropped to 75/45 mmHg. His heart rate is 130/min and respiratory rate is 26/min. He does not have fever. Physical examination reveals bilateral wheezing. The transfusion is immediately stopped. What is most likely causing his presentations?
B. Cytokine release from donor leukocytes during storage
C. Donor antibodies attaching recipient neutrophils
D. Recipient anti-Kidd antibodies attacking donor RBC
E. Recipient anti-IgA antibodies reacting to donor IgA
18. A 45-year-old man presents to the Emergency Department after falling from a bridge. He has a history of IgA deficiency. His blood pressure is 95/65 mmHg, and heart rate is 110 beats per minute. Physical examination reveals pale skin and mucosa and a 10 cm laceration on the left leg with active bleeding. His CBC reveals a hemoglobin of 7.5 g/dL. His white cell count, platelet count and coagulation panels are within normal ranges. Forward typing reveals agglutination with anti-A but not anti-B reagent. Reverse typing reveals agglutination with B cells, but not A cells. Rh factor test is positive. Routine antibody screening test is negative.
2 units of A+ RBC are prepared. He develops dyspnea and perioral edema 5 minutes after transfusion started. His blood pressure dropped to 75/45 mmHg. His heart rate is 130/min and respiratory rate is 26/min. He does not have fever. Physical examination reveals bilateral wheezing. The transfusion is immediately stopped. What is the diagnosis?
B. Anaphylactic transfusion reaction
C. Transfusion associated circulatory overload
D. Transfusion related acute lung injury
E. Urticarial transfusion reaction
19. Use this case for the next two questions. A 60-year-old woman develops fever, chill, and dyspnea approximately 30 minutes after the transfusion of 2 unit of packed RBCs is started. She is hospitalized for elective hip replacement surgery. She receives packed red blood cells for blood loss during surgery. She has no significant past medical history. She has a temperature of 38°C, heart rate of 102/min, respiratory rate of 25/min, and blood pressure of 115/70 mm Hg. Her blood oxygen saturation is 88% on room air. Physical examination reveals bilateral crackles on auscultation. No jugular vein distension nor hepatosplenomegaly are noted. Chest X-ray reveals bilateral pulmonary infiltrates. What is the most likely cause of her presentations?
B. Cytokine release from donor leukocytes during storage
C. Donor antibodies attaching recipient neutrophils
D. Excessive circulatory volume
E. Recipient anti-Kidd antibodies attacking donor RBC
F. Recipient anti-IgA antibodies reacting to donor IgA
20. A 60-year-old woman develops fever, chill, and dyspnea approximately 30 minutes after the transfusion of 2 unit of packed RBCs is started. She is hospitalized for elective hip replacement surgery. She receives packed red blood cells for blood loss during surgery. She has no significant past medical history. She has a temperature of 38°C, heart rate of 102/min, respiratory rate of 25/min, and blood pressure of 115/70 mm Hg. Her blood oxygen saturation is 88% on room air. Physical examination reveals bilateral crackles on auscultation. No jugular vein distension nor hepatosplenomegaly are noted. Chest X-ray reveals bilateral pulmonary infiltrates. What is the diagnosis?
B. Anaphylactic transfusion reaction
C. Febrile non-hemolytic transfusion reaction
D. Transfusion associated circulatory overload
E. Transfusion related acute lung injury
F. Urticarial transfusion reaction
21. Use this case for the next three questions. An 89-year-old hospitalized woman develops dyspnea approximately 2 hours after receiving 2 units of RBCs. She has history of anemia, chronic renal disease and COPD. She was admitted because of elective hip replacement surgery. She has a heart rate of 105/min, blood pressure of 160/85 mmHg, and oxygen saturation of 87% at room air. She does not have fever. Physical examination reveals jugular vein distension and bilateral crackles. Chest X-ray reveals bilateral basilar infiltrate and widened cardiac silhouette. What additional blood test is likely to be elevated?
B. D-dimer
C. Indirect bilirubin
D. LDH
E. Total iron binding capacity
22. An 89-year-old hospitalized woman develops dyspnea approximately 2 hours after receiving 2 units of RBCs. She has history of anemia, chronic renal disease and COPD. She was admitted because of elective hip replacement surgery. She has a heart rate of 105/min, blood pressure of 160/85 mmHg, and oxygen saturation of 87% at room air. She does not have fever. Physical examination reveals jugular vein distension and bilateral crackles. Chest X-ray reveals bilateral basilar infiltrate and widened cardiac silhouette. What is most likely causing her presentations?
B. Cytokine release from donor leukocytes during storage
C. Donor antibodies attaching recipient neutrophils
D. Excessive circulatory volume
E. Recipient anti-Kidd antibodies attacking donor RBC
F. Recipient anti-IgA antibodies reacting to donor IgA
23. An 89-year-old hospitalized woman develops dyspnea approximately 2 hours after receiving 2 units of RBCs. She has history of anemia, chronic renal disease and COPD. She was admitted because of elective hip replacement surgery. She has a heart rate of 105/min, blood pressure of 160/85 mmHg, and oxygen saturation of 87% at room air. She does not have fever. Physical examination reveals jugular vein distension and bilateral crackles. Chest X-ray reveals bilateral basilar infiltrate and widened cardiac silhouette. What is the diagnosis?
B. Anaphylactic transfusion reaction
C. Febrile non-hemolytic transfusion reaction
D. Transfusion associated circulatory overload
E. Transfusion related acute lung injury
F. Urticarial transfusion reaction
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