Transfusion-Related Complications — MCQs

10 questions

Which of the following statements about Transfusion-Related Acute Lung Injury (TRALI) is false?

A 62-year-old male patient with heart failure is scheduled for a heart transplant. His renal function test is deranged, and haemoglobin is $6 \mathrm{gm} \%$. The physician ordered 2 units of whole blood. Four hours after transfusion, he developed severe respiratory distress. On examination, he is hypoxemic, has tachycardia and his mean arterial pressure is elevated. Which of the following are the best investigations for the above scenario? 1. Chest X-ray 2. Brain natriuretic peptide (BNP) level 3. Absolute neutrophil count 4. Leucocyte antibodies 5. Platelets

Which of the following is the complication of massive blood transfusion?

Blood transfusion associated acute lung injury occurs due to -

Which of the following is false regarding transfusion-associated anaphylactic reactions?

A CKD patient had to undergo dialysis. His Hb was 5.5. So two blood transfusions were to be given. First bag was completed in 2 hours. Second was started and midway between he developed shortness of breath, hypertension. Vitals: BP 180/120 mm Hg and pulse rate 110/min. What is the cause?

Thrombotic thrombocytopenic purpura is a syndrome characterized by which of the following?

Which of the following is NOT a recognized complication of massive blood transfusion?

Problems which may result from hypotensive anesthesia include:

Q10

Malignant hyperthermia is a rare complication of the use of the following anaesthetic:

Transfusion-Related Complications Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following statements about Transfusion-Related Acute Lung Injury (TRALI) is false?

A. Leucocytes aggregate in the pulmonary vasculature
B. Develops signs of non cardiogenic pulmonary edema
C. Anti-HLA antibodies are never implicated in TRALI. (Correct Answer)
D. Implicated donors are frequently multiparous women

Explanation: ***Anti-HLA antibodies are never implicated in TRALI*** - This statement is **false**, as **anti-HLA antibodies**, specifically anti-HLA class I and II antibodies, are **frequently implicated** in the pathogenesis of TRALI [1]. - These antibodies in donor plasma can react with recipient neutrophils, leading to their activation and subsequent lung injury [1]. *Leucocytes aggregate in the pulmonary vasculature* - This statement is **true**; the aggregation of **activated neutrophils** and other leukocytes in the pulmonary capillaries is a key pathophysiological event in TRALI. - This aggregation contributes to the inflammatory cascade and damage to the **alveolar-capillary membrane**. *Develops signs of non cardiogenic pulmonary edema* - This statement is **true**; TRALI is characterized by **acute respiratory distress** and evidence of **non-cardiogenic pulmonary edema**. - This means the pulmonary edema is not due to elevated left atrial pressure, but rather increased vascular permeability caused by inflammatory mediators. *Implicated donors are frequently multiparous women* - This statement is **true**; **multiparous women** are often implicated as donors in TRALI cases because they are more likely to have developed **anti-HLA antibodies** due to exposure to fetal antigens during pregnancy. - These antibodies, if present in high titers in donor plasma, can trigger TRALI in susceptible recipients.

Question 2: A 62-year-old male patient with heart failure is scheduled for a heart transplant. His renal function test is deranged, and haemoglobin is $6 \mathrm{gm} \%$. The physician ordered 2 units of whole blood. Four hours after transfusion, he developed severe respiratory distress. On examination, he is hypoxemic, has tachycardia and his mean arterial pressure is elevated. Which of the following are the best investigations for the above scenario? 1. Chest X-ray 2. Brain natriuretic peptide (BNP) level 3. Absolute neutrophil count 4. Leucocyte antibodies 5. Platelets

A. 3 and 5
B. 4 and 5
C. 1 and 2 (Correct Answer)
D. 2 only

Explanation: ***1 and 2*** - A **Chest X-ray** would help identify signs of **pulmonary edema** and **cardiomegaly** [1], which are characteristic of transfusion-associated circulatory overload (**TACO**) due to his underlying heart failure exacerbated by fluid from the transfusion. [2] - An elevated **Brain Natriuretic Peptide (BNP) level** is a key biomarker for heart failure [1] and would support a diagnosis of **TACO** by indicating increased ventricular stretch and volume overload. *3 and 5* - An **absolute neutrophil count** is primarily relevant for assessing infection or inflammatory conditions, which are not the primary focus given the acute respiratory distress post-transfusion in a heart failure patient. - **Platelets** are important for coagulation assessments but do not directly explain acute respiratory distress and hypoxemia in the context of post-transfusion events like TACO. *4 and 5* - **Leukocyte antibodies** (such as anti-HLA antibodies) are typically investigated in cases of **transfusion-related acute lung injury (TRALI)**, but the elevated blood pressure and underlying heart failure point more strongly towards **TACO**. - **Platelets** are not a primary investigation for acute respiratory distress following transfusion in a patient with heart failure. *2 only* - While an elevated **BNP level** is highly indicative of heart failure exacerbation and TACO [1], a **Chest X-ray** is also crucial for visualizing the pulmonary edema and assessing the extent of circulatory overload [2]. - Relying solely on BNP might miss co-occurring pulmonary issues or provide an incomplete picture of the patient's acute respiratory distress.

Question 3: Which of the following is the complication of massive blood transfusion?

A. Respiratory alkalosis
B. Metabolic acidosis
C. Respiratory acidosis
D. Metabolic alkalosis (Correct Answer)

Explanation: ***Metabolic alkalosis*** - **Citrate**, an anticoagulant in stored blood, is metabolized by the liver into **bicarbonate**, which can accumulate with massive transfusion. [2] - This bicarbonate excess leads to a rise in blood pH, causing **metabolic alkalosis**. [2] *Respiratory alkalosis* - This typically results from **hyperventilation**, leading to excessive CO2 exhalation. [1] - It is not a direct complication of the chemical constituents or physiological effects of massive blood transfusions. *Metabolic acidosis* - While sometimes seen in early phases due to reduced tissue perfusion or hypothermia in massive transfusion, the predominant and later complication (especially with adequately functioning liver) is metabolic alkalosis due to citrate metabolism. - **Lactic acidosis** can occur in shock or hypoperfusion states, but the buffering capacity and citrate metabolism often shift towards alkalosis. *Respiratory acidosis* - This results from **hypoventilation** or impaired CO2 removal, leading to CO2 retention in the blood. [1] - It is not directly caused by the components of a massive blood transfusion itself.

Question 4: Blood transfusion associated acute lung injury occurs due to -

A. Nosocomial infections
B. Auto-immune disorder
C. Genetic susceptibility
D. HLA-mediated reaction (Correct Answer)

Explanation: ***HLA-mediated reaction*** - Transfusion-related acute lung injury (TRALI) is primarily caused by **antibodies** in the donor plasma (usually anti-HLA or anti-HNA antibodies) reacting with the recipient's **neutrophils** [1]. - This interaction leads to neutrophil activation and sequestration in the pulmonary vasculature, causing **endothelial damage** and increased capillary permeability [1]. *Nosocomial infections* - Nosocomial infections are **hospital-acquired infections** and are not a direct cause of TRALI. - While infections can lead to lung injury, the mechanism of TRALI is distinct and immunologically mediated by donor antibodies. *Auto-immune disorder* - An autoimmune disorder involves the body's immune system attacking its own tissues, which is not the primary mechanism of TRALI. - TRALI is an **alloimmune reaction** where donor antibodies react with host antigens, rather than a pre-existing autoimmune condition. *Genetic susceptibility* - While genetic factors might sometimes play a role in an individual's general inflammatory response or susceptibility to certain conditions, they are **not the direct or primary cause** of TRALI. - The acute lung injury in TRALI is triggered by specific **antibody-antigen interactions** during the transfusion.

Question 5: Which of the following is false regarding transfusion-associated anaphylactic reactions?

A. Different from allergy
B. Epinephrine is the drug of choice
C. Washed blood products prevent it
D. Seen in IgG deficient individuals (Correct Answer)

Explanation: ***Seen in IgG deficient individuals*** - Transfusion-associated **anaphylactic reactions** are most commonly seen in **IgA-deficient individuals** who develop **anti-IgA antibodies** and receive blood products containing IgA. - Anaphylaxis occurs when these pre-formed IgA antibodies react with donor IgA, leading to mast cell degranulation and severe allergic symptoms. *Different from allergy* - Transfusion-associated **anaphylactic reactions** are a severe form of allergic reaction, often distinguished by their **rapid onset** and life-threatening nature [1]. - While all allergies involve an immune response to an allergen, anaphylaxis represents the most extreme systemic manifestation. *Epinephrine is the drug of choice* - **Epinephrine** is indeed the **first-line treatment** for acute anaphylaxis, regardless of its cause, including transfusion-associated reactions [2]. - It acts rapidly to counteract the systemic effects of histamine and other mediators by acting on α and β adrenergic receptors [3]. *Washed blood products prevent it* - **Washing blood products** (e.g., packed red blood cells or platelets) is an effective strategy to **remove plasma proteins**, including IgA. - This is particularly crucial for patients with a known **IgA deficiency and anti-IgA antibodies** to prevent severe anaphylactic reactions.

Question 6: A CKD patient had to undergo dialysis. His Hb was 5.5. So two blood transfusions were to be given. First bag was completed in 2 hours. Second was started and midway between he developed shortness of breath, hypertension. Vitals: BP 180/120 mm Hg and pulse rate 110/min. What is the cause?

A. Allergic
B. FNHTR
C. Transfusion related circulatory overload (TACO) (Correct Answer)
D. TRALI

Explanation: ***Transfusion related circulatory overload (TACO)*** - The patient's presentation with **shortness of breath**, **hypertension**, and **tachycardia** following blood transfusion, especially in a **CKD patient** with likely compromised cardiac and renal function, is highly suggestive of **TACO** [1]. - **Fluid overload** from the transfused blood, exacerbated by pre-existing renal impairment, leads to acute pulmonary edema and cardiovascular stress. *Allergic* - Allergic reactions typically manifest with **urticaria**, **pruritus**, **bronchospasm**, or **anaphylaxis**, often without severe hypertension or primary respiratory distress in this manner [1], [2]. - While mild allergic reactions can occur, the prominent hypertension and acute respiratory distress point away from a simple allergic response. *FNHTR* - **Febrile non-hemolytic transfusion reaction (FNHTR)** is characterized by a temperature increase of at least 1°C, chills, and rigors, usually without significant respiratory distress or marked hypertension [1]. - The patient's symptoms are dominated by respiratory and cardiovascular overload rather than fever. *TRALI* - **Transfusion-related acute lung injury (TRALI)** is characterized by acute respiratory distress with **hypoxemia** and **bilateral pulmonary infiltrates** due to non-cardiogenic pulmonary edema, typically associated with hypotension, not hypertension. - The prominent hypertension and the patient's underlying CKD make TACO a more likely diagnosis than TRALI.

Question 7: Thrombotic thrombocytopenic purpura is a syndrome characterized by which of the following?

A. Thrombocytopenia, anemia, neurological abnormalities, progressive renal failure and fever (Correct Answer)
B. Thrombocytopenia, anemia, neurological abnormalities, progressive hepatic failure and fever
C. Thrombocytopenia, normal anemia, neurological abnormalities, progressive renal failure and fever
D. Thrombocytopenia, anemia, no neurological abnormalities, progressive renal failure and fever

Explanation: ***Thrombocytopenia, anemia, neurological abnormalities, progressive renal failure and fever*** - Thrombotic thrombocytopenic purpura is characterized by **thrombocytopenia** and **microangiopathic hemolytic anemia**, along with neurological and renal complications [1][2]. - The presence of **fever** and other systemic symptoms is consistent with this **thrombotic microangiopathy** syndrome [1]. *Thrombocytosis, anemia, neurologic abnormalities, progressive renal failure and fever* - This option incorrectly lists **thrombocytosis** rather than **thrombocytopenia**, which is a hallmark of thrombotic thrombocytopenic purpura (TTP) [1]. - While it includes anemia, the absence of thrombocytopenia makes it inconsistent with TTP's classic presentation [2]. *Thrombocytopenia, anemia, neurologic abnormalities, progressive hepatic failure and fever* - Although it correctly states **thrombocytopenia** and **anemia**, it incorrectly identifies **progressive hepatic failure** instead of **renal failure**, which is a key feature of TTP [1]. - The presence of neurological abnormalities and fever does align with TTP; however, the hepatic failure aspect is misleading. *Thrombocytosis, anemia neurologic abnormalities, progressive renal failure and fever* - Again, this option incorrectly notes **thrombocytosis**, contradicting the characteristic finding of **thrombocytopenia** found in TTP [1]. - While other features align with TTP's clinical picture, the thrombocytosis excludes this option from being correct [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 947-948. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 667-668.

Question 8: Which of the following is NOT a recognized complication of massive blood transfusion?

A. Hypokalemia
B. Hypothermia
C. Hypocalcemia
D. Hypernatremia (Correct Answer)

Explanation: ***Hypernatremia*** - Massive transfusions, especially of packed red blood cells (PRBCs) preserved in solutions like **CPDA-1**, actually tend to cause **hyponatremia** due to the low sodium content of the transfusion products relative to plasma. - While PRBCs have some sodium, the net effect of large volumes is a dilutional effect on plasma sodium and the infusion of sodium-poor fluids, making hypernatremia an unlikely complication. *Hypokalemia* - Although stored blood products accumulate extracellular potassium (leading to hyperkalemia), **hypokalemia** can occur post-transfusion due to the rapid uptake of potassium by metabolically active cells. - This is particularly true if the patient has pre-existing conditions or is on certain medications that can shift potassium intracellularly. *Hypothermia* - Stored blood is refrigerated, and rapid infusion of large volumes of cold blood can significantly lower the patient's **core body temperature**. - **Hypothermia** can exacerbate coagulopathy and lead to cardiac arrhythmias. *Hypocalcemia* - The citrate anticoagulant used in blood products chelates calcium, reducing the amount of **ionized calcium** available in the patient's bloodstream. - Massive transfusions overwhelm the liver's ability to metabolize citrate, leading to significant **hypocalcemia**.

Question 9: Problems which may result from hypotensive anesthesia include:

A. Deep vein thrombosis
B. Reactionary hemorrhage
C. Retraction anemia
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - Hypotensive anesthesia is a technique used to reduce **blood pressure** during surgery, aiming to decrease **blood loss** and improve the **surgical field visibility**. - While beneficial, it carries inherent risks including **deep vein thrombosis (DVT), reactionary hemorrhage**, and complications like **retraction anemia** if not managed properly. *Deep vein thrombosis (DVT)* - While hypotension might seem to reduce the risk by lowering **blood flow velocity**, prolonged immobility and potential for **venous stasis** during any surgery, especially under hypotension, can increase DVT risk. - The combination of **endothelial dysfunction** and **hypercoagulability** often seen in surgical patients, coupled with reduced peripheral blood flow due to hypotension, can contribute to DVT formation. *Reactionary hemorrhage* - This is a common post-operative complication where bleeding restarts hours after surgery. With hypotensive anesthesia, **blood vessels** are constricted and may not be actively bleeding during the surgery. - As the patient's **blood pressure** returns to normal post-operatively, these previously undetected bleeds can manifest as significant **hemorrhage** due to the increased pressure. *Retraction anemia* - This term is less commonly used in medical literature. However, it likely refers to the complications arising from prolonged tissue retraction during surgery, which, when combined with reduced **perfusion** from hypotensive anesthesia, can lead to **tissue ischemia** or damage akin to anemia in the affected area. - The reduced **oxygen delivery** to tissues during hypotensive states, especially when further compromised by retraction, may result in localized tissue injury or contribute to systemic complications if severe or prolonged.

Question 10: Malignant hyperthermia is a rare complication of the use of the following anaesthetic:

A. Thiopentone sodium
B. Halothane (Correct Answer)
C. Ether
D. Ketamine

Explanation: **Halothane** - **Halothane** is a potent volatile anesthetic and a classic trigger for **malignant hyperthermia** due to its effect on ryanodine receptors, leading to excessive calcium release from the sarcoplasmic reticulum. - While its use has declined, it remains a critical example of an anesthetic agent known to induce this life-threatening genetic disorder. *Thiopentone Sodium* - **Thiopentone sodium** is an intravenous barbiturate anesthetic and is **not associated** with triggering malignant hyperthermia. - It is often used for induction of anesthesia and has a different mechanism of action involving GABA receptors. *Ether* - **Diethyl ether** was one of the earliest general anesthetics but is **not a trigger** for malignant hyperthermia. - Its use has largely been discontinued due to its flammability and adverse side effects, but it doesn't cause MH. *Ketamine* - **Ketamine** is a dissociative anesthetic that acts as an NMDA receptor antagonist and is **not a trigger** for malignant hyperthermia. - It is often used for its analgesic and sedative properties and is considered safe in patients susceptible to MH.

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