Blood Transfusion and Alternatives — MCQs

10 questions

Which of the following is a potential complication of blood transfusion?

In ABO blood grouping, which is False?

In a severely anaemic pregnant patient presenting with cardiac failure, what is the most appropriate choice of transfusion?

Massive blood transfusion complications include all except -

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

Most common cause of febrile non haemolytic transfusion reaction?

Which of the following statements is true regarding the Duffy Fy(a-b-) blood group?

Which one of the following blood fractions is stored at -18°C?

Massive blood transfusion is defined as:

Q10

Which of the following is not a part of basic essential obstetric care?

Blood Transfusion and Alternatives Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is a potential complication of blood transfusion?

A. Hyponatremia
B. Hypercalcemia
C. Increased serum albumin
D. Hyperkalemia (Correct Answer)

Explanation: ***Hyperkalemia*** - Stored red blood cells can release **intracellular potassium** into the storage solution, leading to elevated potassium levels in transfused blood. - Rapid or massive transfusions deliver a significant potassium load, potentially causing **cardiac arrhythmias**. *Hyponatremia* - This is generally not a direct complication of blood transfusions; instead, blood products themselves contain electrolytes, and massive transfusion can disrupt electrolyte balance, but usually not to cause hyponatremia. - Volume overload from transfusion could dilute existing electrolytes, but most commonly, other electrolyte imbalances such as hyperkalemia or hypocalcemia occur. *Hypercalcemia* - Often, the opposite, **hypocalcemia**, is a complication of massive transfusion due to **citrate toxicity**. - Citrate, an anticoagulant in transfused blood, chelates calcium, reducing free calcium levels in the recipient. *Increased serum albumin* - Blood transfusions primarily administer **red blood cells**, plasma, or platelets, not typically albumin in amounts that would significantly increase serum albumin levels in the absence of an albumin-specific infusion [1]. - Low albumin (hypoalbuminemia) is a common finding in critically ill patients, and a blood transfusion usually doesn't correct this unless plasma or albumin is specifically administered [1].

Question 2: In ABO blood grouping, which is False?

A. IgM is most common antibody in ABO
B. ABO are carbohydrate Ag
C. ABO antibodies are natural and present since birth (Correct Answer)
D. Ab are present only if Ag is absent

Explanation: ***ABO antibodies are natural and present since birth*** - **ABO antibodies** are naturally occurring, but they are typically **not present at birth** [1]. - They develop within the **first 3 to 6 months of life** as a response to exposure to similar antigens in the environment (e.g., bacteria). *IgM is most common antibody in ABO* - The primary **ABO antibodies** (anti-A, anti-B) are indeed predominantly **IgM antibodies** [1]. - IgM antibodies are large pentameric structures, and their size prevents them from crossing the placenta [2]. *ABO are carbohydrate Ag* - The **ABO blood group antigens** (A, B, H) are **carbohydrate structures** (glycans) found on the surface of red blood cells and other tissues. - These carbohydrate chains are attached to proteins or lipids. *Ab are present only if Ag is absent* - This statement is a fundamental principle of ABO blood grouping: individuals naturally produce antibodies against the **ABO antigens** they **lack** [1]. - For example, a person with **Type A blood** (A antigen present) will have **anti-B antibodies** (B antigen absent). **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 627-628. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 469-470.

Question 3: In a severely anaemic pregnant patient presenting with cardiac failure, what is the most appropriate choice of transfusion?

A. Platelets
B. Packed cells (Correct Answer)
C. Whole blood
D. Exchange transfusion

Explanation: ***Packed cells*** - **Packed red blood cells (PRBCs)** increase **oxygen-carrying capacity** with minimal volume expansion, which is crucial in patients with cardiac compromise [1]. - Slow infusion of PRBCs, often with a **diuretic**, can improve anaemia and cardiac function while preventing **fluid overload**. *Platelets* - **Platelets** are primarily transfused for **thrombocytopenia** or **platelet dysfunction** to prevent or treat bleeding. - They do not address the low haemoglobin and oxygen-carrying deficit directly contributing to cardiac failure in an anaemic patient. *Whole blood* - **Whole blood** contains plasma, which can significantly increase circulatory volume and worsen **cardiac failure** in patients already struggling with fluid balance. - While it does provide red cells, the added volume makes it a less safe option compared to packed cells in this scenario. *Exchange transfusion* - An **exchange transfusion** involves removing a patient's blood and replacing it with donor blood, typically used for severe conditions like **sickle cell crisis** or **severe hyperbilirubinemia** [2]. - This procedure is complex and carries higher risks, and is not the first-line treatment for anaemia-induced cardiac failure in pregnancy.

Question 4: Massive blood transfusion complications include all except -

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

Explanation: ***Hypernatremia*** - **Massive blood transfusions** typically involve transfusing red blood cells suspended in solutions like normal saline, which is **isotonic** or slightly hypotonic, or solutions containing **citrate**, which is metabolized in the liver to bicarbonate. - Therefore, hypernatremia is **not expected** and, in fact, hyponatremia can occur in some circumstances due to dilution or impaired sodium excretion in severely ill patients. *Hypothermia* - **Refrigerated blood products** are typically stored at 1-6°C; rapid infusion of large volumes of these cold products can significantly lower the patient's core body temperature, leading to **hypothermia**. - Hypothermia can worsen **coagulopathy** and cardiac arrhythmias, which are serious complications in critically ill or hemorrhaging patients. *Hyperkalemia* - As red blood cells are stored, there is a gradual leakage of **potassium** from intracellular to extracellular compartments due to reduced activity of the **Na+/K+ ATPase pump**. - During massive transfusion, the infusion of large volumes of blood with elevated extracellular potassium can lead to significant **hyperkalemia**, especially in patients with impaired renal function. *Hypocalcemia* - **Citrate** is an anticoagulant used in blood storage that binds to **ionized calcium** in the patient's blood, effectively chelating it. - Rapid infusion of large amounts of citrated blood can overwhelm the liver's capacity to metabolize citrate, leading to a significant drop in ionized calcium levels and consequently **hypocalcemia**.

Question 5: 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 6: Most common cause of febrile non haemolytic transfusion reaction?

A. Rh mismatch
B. HLA mismatch (Correct Answer)
C. ABO mismatch
D. All of the options

Explanation: ***HLA mismatch*** - **Febrile non-hemolytic transfusion reactions (FNHTR)** are primarily caused by the recipient's antibodies reacting against donor leukocyte antigens (HLAs) [1]. - This reaction leads to the release of **pyrogenic cytokines** from donor leukocytes stored in the blood product, causing fever and chills [1]. *Rh mismatch* - **Rh mismatch** primarily causes **hemolytic transfusion reactions**, characterized by red blood cell destruction, not just fever without hemolysis [1]. - This type of reaction is typically severe and involves antibody-mediated red cell lysis [1]. *ABO mismatch* - **ABO mismatch** leads to the most severe and often fatal **acute hemolytic transfusion reactions**, involving rapid intravascular hemolysis [1]. - This is a direct immune response against incompatible red blood cell antigens, resulting in hemoglobinuria, renal failure, and shock, not just fever [1]. *All of the options* - This option is incorrect because while all listed conditions relate to transfusion, only **HLA mismatch** commonly causes FNHTRs. - **Rh and ABO mismatches** are associated with distinct and more severe hemolytic reactions.

Question 7: Which of the following statements is true regarding the Duffy Fy(a-b-) blood group?

A. lacks H- antigen
B. lacks A-antigen
C. All of the options
D. lacks Fy(b) antigen (Correct Answer)

Explanation: ***lacks Fy(b) antigen*** - The **Duffy Fy(a-b-)** phenotype indicates absence of both Fya and Fyb antigens on red blood cells. - Since the phenotype is **Fy(a-b-)**, it definitively lacks the **Fyb antigen** (indicated by the "b-" notation). - This phenotype is common in people of **African descent** and confers natural **resistance to Plasmodium vivax malaria**, as these antigens serve as receptors for the parasite to enter RBCs. *lacks H- antigen* - The **H antigen** belongs to the **H/h blood group system** and is a precursor to A and B antigens in the ABO system. - The absence of H antigen (Bombay phenotype - Oh) is completely **unrelated to the Duffy blood group system**. - Duffy antigens are on the **DARC (Duffy Antigen Receptor for Chemokines)** protein, distinct from the H antigen. *lacks A-antigen* - The **A antigen** is part of the **ABO blood group system** and defines blood types A and AB. - The Duffy blood group system is **genetically and structurally independent** from the ABO system. - Having Fy(a-b-) phenotype does not affect A antigen expression. *All of the options* - This is incorrect because the Duffy Fy(a-b-) phenotype **specifically refers only to the absence of Duffy antigens** (Fya and Fyb). - It has **no relationship** with A, B, or H antigens, which belong to different blood group systems controlled by different genes on different chromosomes.

Question 8: Which one of the following blood fractions is stored at -18°C?

A. Packed red cells
B. Human albumin
C. Platelet concentrate
D. Cryoprecipitate (Correct Answer)

Explanation: ***Cryoprecipitate*** - **Cryoprecipitate** contains high concentrations of **Factor VIII**, **von Willebrand factor**, **Factor XIII**, and **fibrinogen**, which are unstable at room temperature [1]. - Storage at **-18°C or colder** is essential to maintain the activity and stability of these coagulation factors for up to one year. *Packed red cells* - **Packed red cells** are typically stored at **2-6°C** for up to 42 days, not frozen, as freezing would damage the red blood cells. - Their primary function is to increase **oxygen-carrying capacity** in patients with anemia or acute blood loss. *Human albumin* - **Human albumin** is a stable protein and is typically stored at **room temperature (2-25°C)**, as freezing is not required to preserve its function. - It is used for **volume expansion** and to maintain **oncotic pressure** in conditions like hypovolemia or hypoalbuminemia. *Platelet concentrate* - **Platelet concentrates** must be stored at **20-24°C** with continuous agitation for up to 5-7 days to maintain their viability and function [2]. - Freezing would irreversibly damage the platelets, making them ineffective for treating **thrombocytopenia** or platelet dysfunction [2]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 582-583. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 581-582.

Question 9: 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 10: Which of the following is not a part of basic essential obstetric care?

A. Blood transfusion (Correct Answer)
B. Administration of parenteral antibiotics
C. Administration of parenteral sedatives for eclampsia
D. Administration of parenteral oxytocic drugs

Explanation: ***Blood transfusion*** - While important in many obstetric emergencies, **blood transfusion** is considered part of **Comprehensive Essential Obstetric Care (CEmOC)**, not basic care. - **Basic Essential Obstetric Care (BEmOC)** focuses on the capability to perform key life-saving interventions but generally lacks the capacity for blood storage or transfusion. *Administration of parenteral antibiotics* - This is a crucial component of **Basic Essential Obstetric Care (BEmOC)**, used to manage infections such as **puerperal sepsis**. - It addresses one of the major causes of maternal mortality. *Administration of parenteral sedatives for eclampsia* - The management of **eclampsia** with parenteral anticonvulsants (e.g., magnesium sulfate) is a fundamental aspect of **Basic Essential Obstetric Care (BEmOC)**. - This intervention prevents and controls seizures, a severe complication of pre-eclampsia. - Note: While the question refers to "sedatives," the correct medical classification is **anticonvulsants**. *Administration of parenteral oxytocic drugs* - The use of **parenteral oxytocic drugs** (e.g., oxytocin) to prevent and treat **postpartum hemorrhage** is a core function of **Basic Essential Obstetric Care (BEmOC)**. - Postpartum hemorrhage is a leading cause of maternal death, and timely oxytocin administration is critical.

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