Transfusion Medicine — MCQs
During surgery, a transfusion reaction is manifested as:
Case of trauma in a patient with an unknown blood group. Patient is unstable and requires urgent blood transfusion. Which type of blood should be transfused?
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 blood grouping test shows clumping with Anti-A serum, clumping with Anti-B serum, and no clumping in the control. What blood group does this indicate?
Which of the following is the triad of complications of massive blood transfusion?
Massive blood transfusion is defined as:
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?
Best blood product to be given in a patient of multiple clotting factor deficiency with active bleeding:
Which of the following is the best treatment for refractory ITP?
The following is not true of platelet transfusion -
Transfusion Medicine Indian Medical PG Practice Questions and MCQs
Question 1: During surgery, a transfusion reaction is manifested as:
- A. Hypothermia
- B. Hypotension (Correct Answer)
- C. Bleeding
- D. Increased muscle movement
- E. Tachycardia
Explanation: ***Hypotension*** - **Hypotension** is the most critical and readily detectable sign of an acute hemolytic transfusion reaction during surgery, often resulting from the release of vasodilatory substances and systemic inflammation. - While under anesthesia, many typical signs of transfusion reaction (e.g., fever, chills, back pain) are masked, making changes in vital signs like a sudden drop in **blood pressure** particularly crucial indicators. - In the anesthetized patient, unexplained hypotension during transfusion should immediately raise suspicion of a transfusion reaction. *Hypothermia* - **Hypothermia** is typically associated with massive transfusions of cold blood products, not directly with an acute immunological transfusion reaction. - Although it can occur during surgery due to various factors, it is not a primary manifestation of a direct transfusion reaction. *Bleeding* - **Bleeding** can be a complication of a severe transfusion reaction, specifically due to **disseminated intravascular coagulation (DIC)**, but it's usually a later or more severe manifestation, not the initial presenting sign. - The primary initial clinical sign of an acute hemolytic reaction is often related to cardiovascular instability rather than overt hemorrhage. *Increased muscle movement* - **Increased muscle movement** is unlikely to be a direct manifestation of a transfusion reaction in an anesthetized patient. - While some reactions can cause muscle spasms or rigidity, these are typically masked by paralytic agents or deep anesthesia during surgery. *Tachycardia* - While **tachycardia** can occur as a compensatory response to hypotension, it is less specific and less reliable as an indicator of transfusion reaction in anesthetized patients. - The anesthesiologist primarily monitors for **hypotension** as the key diagnostic sign rather than tachycardia alone.
Question 2: Case of trauma in a patient with an unknown blood group. Patient is unstable and requires urgent blood transfusion. Which type of blood should be transfused?
- A. O- (Correct Answer)
- B. AB+
- C. O+
- D. A+
Explanation: ***O-*** - **O-negative blood** is considered the **universal donor** because it lacks A, B, and Rh (D) antigens, making it safe for transfusion to patients of any blood type in an emergency. - In a critically unstable patient with an unknown blood group requiring urgent transfusion, using **O-negative blood minimizes the risk of a severe acute hemolytic transfusion reaction**. *AB+* - **AB-positive blood** is the **universal recipient** blood type, meaning individuals with AB+ blood can receive blood from any donor. - However, transfusing AB+ blood to a patient with an unknown blood type could lead to a **severe hemolytic reaction** if the patient is not AB+. *O+* - While **O-positive blood** is common and can be given to individuals who are Rh-positive, it contains the **Rh antigen**. - Transfusing O-positive blood to an Rh-negative patient (whose Rh status is unknown in this emergency) could cause **alloimmunization** and a hemolytic reaction. *A+* - **A-positive blood** contains A antigens and Rh antigens. - Giving A-positive blood to a patient with an unknown blood type is risky, as it would cause a **hemolytic reaction** if the patient is B, AB, or O, or if they are Rh-negative.
Question 3: 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 4: A blood grouping test shows clumping with Anti-A serum, clumping with Anti-B serum, and no clumping in the control. What blood group does this indicate?
- A. A
- B. B
- C. O
- D. AB (Correct Answer)
Explanation: ***AB*** - The results show **clumping with both Anti-A and Anti-B serum**, indicating the presence of both A and B antigens on the red blood cells. - The absence of clumping in the control confirms that the **agglutination with Anti-A and Anti-B is due to specific antigen-antibody reactions**, not nonspecific agglutination. - Blood group AB individuals have both A and B antigens on their RBCs and no anti-A or anti-B antibodies in their serum. *A* - Blood group A would show **clumping with Anti-A serum only** and no clumping with Anti-B serum. - This is incorrect because the sample shows clumping with both antisera. *B* - Blood group B would show **clumping with Anti-B serum only** and no clumping with Anti-A serum. - This is incorrect because the sample shows clumping with both antisera. *O* - Blood group O would show **no clumping with either Anti-A or Anti-B serum**, as it lacks both A and B antigens. - This is incorrect because the sample clearly shows clumping with both Anti-A and Anti-B sera.
Question 5: Which of the following is the triad of complications of massive blood transfusion?
- A. Hypocalcemia, hypothermia, coagulopathy
- B. Hyperkalemia, metabolic acidosis, and cardiac arrhythmias
- C. Alkalosis, hyperthermia, coagulopathy
- D. Acidosis, hypothermia, coagulopathy (Correct Answer)
Explanation: ***Acidosis, hypothermia, coagulopathy*** - **Massive blood transfusion** can lead to **metabolic acidosis** due to the citrate in stored blood, which is metabolized to bicarbonate and consumed. - Stored blood is cold, which can cause patient **hypothermia**, while **coagulopathy** arises from dilution of clotting factors and platelets [1]. *Hypocalcemia, hypothermia, coagulopathy* - While **hypocalcemia** can occur due to **citrate toxicity** binding calcium, it is not considered one of the primary components of the classic triad. - The classic triad focuses on the most immediate and profound threats: acidosis, hypothermia, and coagulopathy. *Hyperkalemia, metabolic acidosis, and cardiac arrhythmias* - **Hyperkalemia** can occur due to the release of potassium from lysed red blood cells in stored blood, especially with older units. - However, **cardiac arrhythmias** are a *consequence* of these electrolyte imbalances and not a primary component of the classic triad itself. *Alkalosis, hyperthermia, coagulopathy* - **Alkalosis** is not typically a direct complication; **acidosis** is more common due to the metabolic burden of citrate and hypoperfusion. - **Hypothermia** is a more prominent issue than hyperthermia, as transfused blood is stored cold.
Question 6: Massive blood transfusion is defined as:
- A. Greater than 5 units of blood in 4 hours
- B. Half blood volume in 12 hours
- C. Greater than 10 units of blood in 24 hours (Correct Answer)
- D. Whole blood volume in 24 hours
Explanation: ***Greater than 10 units of blood in 24 hours*** - This is the **most commonly used definition** in clinical practice and medical textbooks for identifying massive blood transfusion. - Receiving more than 10 units of packed red blood cells within 24 hours indicates severe hemorrhage requiring aggressive resuscitation and activation of massive transfusion protocols. - This volume-based criterion is practical, easy to monitor, and widely adopted in trauma and surgical settings. *Greater than 5 units of blood in 4 hours* - While this represents rapid transfusion, it is more commonly used as a **trigger for massive transfusion protocol activation** rather than the definition itself. - This criterion helps identify patients who may progress to massive transfusion and require early intervention with balanced blood product ratios. *Half blood volume in 12 hours* - This is not a standard definition for massive blood transfusion. - Standard definitions focus on either fixed volumes (>10 units) or complete blood volume replacement in a specified timeframe. *Whole blood volume in 24 hours* - Replacement of one complete blood volume in 24 hours is an **alternative definition** of massive transfusion used in some guidelines. - However, the **">10 units in 24 hours"** definition is more practical and universally recognized as it provides a specific numerical threshold. - Average adult blood volume is ~70 mL/kg (~5 liters for a 70 kg adult), and 10 units of packed RBCs (~3000 mL) represents approximately 50-60% of total blood volume, making both definitions closely related in practice.
Question 7: 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 8: Best blood product to be given in a patient of multiple clotting factor deficiency with active bleeding:
- A. Whole blood
- B. Packed RBCs
- C. Cryoprecipitate
- D. Fresh frozen plasma (Correct Answer)
Explanation: ***Fresh frozen plasma*** - **Fresh frozen plasma (FFP)** contains all coagulation factors, including labile factors V and VIII, making it the best choice for patients with multiple clotting factor deficiencies and active bleeding. - It rapidly replenishes clotting factors, which is critical in scenarios of **acute hemorrhage** due to global coagulopathy. *Whole blood* - **Whole blood** contains red blood cells, plasma, and platelets, but its clotting factor concentration is lower than FFP and deteriorates over storage. - It is preferred for massive hemorrhage with significant blood volume loss, but less effective for isolated clotting factor deficiencies without substantial volume depletion. *Packed RBCs* - **Packed red blood cells (PRBCs)** are primarily used to increase oxygen-carrying capacity by raising hemoglobin levels in anemic patients. - They lack significant amounts of clotting factors and are therefore not effective in treating active bleeding due to coagulation factor deficiencies. *Cryoprecipitate* - **Cryoprecipitate** contains specific clotting factors, namely factor VIII, von Willebrand factor, fibrinogen, and factor XIII. - While useful for deficiencies in these specific factors (e.g., hemophilia A, DIC with low fibrinogen), it does not provide a broad spectrum of all clotting factors needed for general multiple factor deficiencies.
Question 9: Which of the following is the best treatment for refractory ITP?
- A. Platelet transfusion
- B. Azathioprine
- C. Prednisolone
- D. Splenectomy (Correct Answer)
Explanation: ***Splenectomy*** - **Splenectomy** is considered the most effective treatment for **refractory immune thrombocytopenic purpura (ITP)**, especially in patients who have failed multiple lines of medical therapy [1]. - The spleen is the primary site of **platelet destruction** and **antibody production** against platelets in ITP, so its removal can lead to a sustained increase in platelet count [1]. *Platelet transfusion* - While platelet transfusions can temporarily increase platelet counts, they are generally reserved for **acute, life-threatening bleeding** in ITP, not as a definitive treatment for refractory cases. - Transfused platelets are rapidly destroyed by the same **autoantibodies** that target endogenous platelets, making their effect short-lived. *Azathioprine* - **Azathioprine** is an **immunosuppressant** that can be used in ITP, but it is typically a **second-line** or **third-line agent** and its response takes time [1]. - It is not considered the "best" treatment for refractory ITP compared to splenectomy, which offers a more immediate and often sustained response [1]. *Prednisolone* - **Prednisolone** (corticosteroids) is often the **first-line treatment** for ITP due to its rapid immunosuppressive effects. - However, for **refractory ITP** (meaning it has not responded adequately to initial treatments), corticosteroids alone are usually insufficient to achieve long-term remission [1].
Question 10: The following is not true of platelet transfusion -
- A. Used in DIC
- B. Useful in ITP
- C. Effective for 9-10 days (Correct Answer)
- D. Effects decrease with repeated usage
Explanation: ***Effective for 9-10 days*** - Platelets have a normal lifespan of about 7-10 days in the circulation, but **transfused platelets** are effective for a much shorter duration, typically **3-4 days** at most. - This short post-transfusion lifespan is due to various factors including immediate consumption, destruction, and removal from the circulation. *Used in DIC* - Platelet transfusions are often indicated in **Disseminated Intravascular Coagulation (DIC)**, especially if there is significant bleeding and a platelet count below 50,000/microL [1]. - DIC involves widespread activation of the coagulation cascade, leading to the consumption of platelets and clotting factors, resulting in both **thrombosis** and **hemorrhage** [1]. *Useful in ITP* - Transfusions are generally **not useful in Immune Thrombocytopenic Purpura (ITP)**, except in severe, life-threatening hemorrhage. - In ITP, platelets are rapidly destroyed by **autoantibodies**, so transfused platelets would also be quickly destroyed, providing only a transient, minimal benefit. *Effects decrease with repeated usage* - With repeated transfusions, patients can develop **alloimmunization** to HLA antigens on donor platelets, leading to refractoriness. - This means subsequent transfusions may have a **diminished or no therapeutic effect**, as the immune system rapidly destroys the transfused platelets.
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