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CHAPTER 49

Blood Transfusion

MULTIPLE CHOICE QUESTIONS


11. Which of the following is better indicator of need for
BLOOD TRANSFUSION transfusion? (AIIMS 80, UPSC 87)
1. MC blood transfusion reaction is: (All India 2008) a. Urine output b. Hematocrit
a. Febrile non-hemolytic transfusion reaction c. Colour of skin d. Clinical examination
b. Hemolysis 12. Massive blood transfusion is defined as: (PGI 95)
c. Transmission of infections a. 350 ml in 5 min b. 500 ml in 5 min
d. Electrolyte imbalance c. 1 litre in 5 min d. Whole blood volume
2. All of the following infections may be transmitted via blood 13. How long can blood stored with CPDA? (JIPMER 2003)
transfusion, except: (AIIMS May 2009, All India 2002) a. 12 days b. 21 days
a. Parvo B-19 b. Hepatitis G c. 28 days d. 48 days
c. Dengue virus d. Cytomegalovirus 14. Massive transfusion in previous healthy adult male can
3. Which of the following is the least likely complication after cause hemorrhage due to: (PGI 98)
massive blood transfusion? (AIIMS May 2009) a. Increased t-PA
a. Hyperkalemia b. Citrate toxicity b. Dilutional thrombocytopenia
c. Hypothermia d. Metabolic acidosis c. Vitamin K deficiency
d. Decreased fibrinogen
4. Fresh hold blood transfusion is done with in how much time
of collection? (DNB 2006) 15. Arterial blood gas analysis in a bottle containing heparin
a. Immediately b. 1 hours causes a decrease in value of:
c. 4 hours d. 24 hours a. pCO2 b. HCO3
c. pH d. All of the above
5. Which of the following investigations should be done
immediately to best confirm a non matched blood transfusion 16. Massive blood transfusion is defined as:
reaction? (All India 2010) a. Whole blood volume in 24 hours (Recent Questions 2013)
a. Indirect Coombs test b. Half blood volume in 24 hours
b. Direct Coombs test c. 40% blood volume in 24 hours
c. Antibody in patients serum d. 60% blood volume in 24 hours
d. Antibody in donor serum
6. Blood components products are: (PGI Dec 2005)
a. Whole blood b. Platelets BLOOD TRANSFUSION COMPLICATIONS
c. Fresh frozen plasma d. Leukocyte reduced RBC
17. After blood transfusion the febrile non-hemolytic transfu-
e. All of the above
sion reaction (FNHTR) occurs due to?
7. A man is rushed to casualty, nearly dying after a massive a. Alloimmunization
blood loss in an accident. There is not much time to match b. Antibodies against donor leukocytes and HLA Ag
blood groups, so the physician decides to order for one of the c. Allergic reaction
following blood groups. Which one of the following blood d. Anaphylaxis
groups should the physician decide: (AIIMS June 2004)
18. Blood grouping and cross-matching is must prior to infusion
a. O negative b. O positive
of:  (MHPGMCET 2007)
c. AB positive d. AB negative a. Gelatin b. Dextran
8. One unit of fresh blood arises the Hb% concentration by: c. Albumin d. FFP
a. 0.1 gm% b. 1 gm% (All India 2003) 19. Blood grouping and cross matching is must prior to infusion
c. 2 gm% d. 2.2 gm% of: (MHPGMCET 2008)
9. Which of the following statements about acute hemolytic a. Gelatin b. Albumin
blood transfusion reaction is true? (PGI June 2004) c. Dextran d. Hemaceal
a. Complement mediated hemolysis is seen 20. Collection of blood for cross matching and grouping is done
b. Type III hypersensitivity is responsible for most cases before administration of which plasma expander?
c. Rarely life threatening a. Hydroxyl ethyl starch b. Dextran(MHSSMCET 2007)
d. Renal blood flow is always maintained c. Mannitol d. Hemacele
e. No need for stopping transfusion
21. Mismatched blood transfusion in anesthetic patient presents
10. True about blood transfusions: (PGI June 98) is:
a. Antigen D determines Rh positivity a. Hyperthermia and hypertension (PGI June 2000)
b. Febrile reaction is due to HLA antigens b. Hypotension and bleeding from site of wound
c. Anti-d is naturally occurring antibody c. Bradycardia and hypertension
d. Cryoprecipitate contains all coagulation factors d. Tachycardia and hypertension

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22. All of the following are major complications of massive c. Coagulation factor levels are equal to Plasma
transfusion except: (All India 2006) d. None of the above
a. Hypokalemia b. Hypothermia 29. Stored plasma is deficient in: (PGI 79, DNB 90)
c. Hypomagnesaemia d. Hypocalcaemia a. Factors 7 and 8 b. Factors 2 and 5
23. Massive transfusions results in: (PGI 88) c. Factors 5 and 8 d. Factors 7 and 9
a. DIC b. Hypothermia 30. With reference to fresh frozen plasma (FFP), which one of
c. Hypercalcemia d. Thrombocytopenia the following statement is not correct? (UPSC 2008)
a. It is used as volume expander
b. It is stored at 40C to 50C
RED BLOOD CELLS c. It is a source of coagulation factors
24. The maximum life of a transfused RBC is: d. It is given in a dose of 12-15 ml/kg body weight
 (JIPMER 80, DNB 89) 31. In cholecystectomy, fresh frozen plasma should be given:
a. One hour b. One day a. Just before operation  (UPPG 2008)
c. 15 days d. 50 days b. At the time of operation
E. 100 days c. 6 hours before operation
d. 12 hours after operation
32. Half life of factor VIII is: (PGI 88)
PLATELETS a. 4 hours b. 8 hours
25. Platelets can be stored at: (AIIMS Nov 2005) c. 34 hours d. 48 hours
a. 20-24C for 5 days b. 20-24C for 8 days 33. Rosenthals syndrome is seen in deficiency of factor:
c. 4-8C for 5 days d. 4-8C for 8 days a. II b. V (AIIMS 81, DNB 91)
26. Blood platelets in stored blood do not remain functional c. IX d. XI
after: (PGI 88, 81, AIIMS 86)
Section 10: Others

a. 24 hours b. 48 hours CRYOPRECIPITATE


c. 72 hours d. 96 hours
34. Cryoprecipitate contains: (MCI March 2009)
a. Factor II b. Factor V
PLASMA c. Factor VIII d. Factor IX

27. Indication of fresh frozen plasma is/are: (PGI Nov 2011) 35. Cryoprecipitate is a rich source of: (PGI 79, AIIMS 85)
a. Hypovolemia a. Thromboplastin b. Factor VIII
b. Nutritional supplement c. Factor X d. Factor VII
c. Coagulation factor deficiency 36. Which one of the following blood fractions is stored at
d. Warfarin toxicity -40C? (UPSC 2006)
e. Hypoalbuminemia a. Cryoprecipitate b. Human albumin
28. True about FFP (Fresh frozen plasma) is the following c. Platelet concentrate d. Packed red cells
except: (MHPGMCET 2009) 37. Cryoprecipitate contains all except: (AIIMS Nov 2007)
a. Good source of all coagulation factors a. Factor VIII b. Factor IX
b. Prepared from single unit of blood c. Fibrinogen d. VWF

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EXPLANATIONS
BLOOD TRANSFUSION
1. Ans. a. Febrile non-hemolytic transfusion reaction (Ref: Harrison 18/e p954-956)

Febrile non-hemolytic transfusion reaction is the most common complication associated with the transfusion of cellular blood
components.

Complications of Blood Transfusion

Reactions Infections Other Complications


Febrile non-hemolytic transfusion Hepatitis B and C Q
RBC allosensitizationQ
reaction (FNHTR): MCQ Hepatitis GQ HLA allosensitizationQ
Allergic HIV-1 and -2Q Graft-versus-host disease
Delayed hemolyticQ HTLV-I and -IIQ
Transfusion-related acute lung MalariaQ
injury (TRALI)Q West Nile virusQ
Acute hemolyticQ Parvovirus B-19Q
Fatal hemolytic

Section 10: Others


HHV-8Q
Anaphylactic CMVQ

2. Ans. c. Dengue virus


3. Ans. d. Metabolic acidosis (Ref: Harrison 18/e p954-956)

Massive transfusion can lead to coagulopathy and metabolic complicationsQ.

Metabolic Complications of Massive Transfusion

General Electrolyte
Fluid overload Q
Hyperkalemia Q

HypothermiaQ HypocalcemiaQ
Impaired oxygen delivery capacity of HbQ HypomagnesemiaQ
(decreased 2, 3-DPG) Metabolic alkalosisQ
Metabolic acidosis (rare)Q

4. Ans. d. 24 hours
5. Ans. b. Direct Coombs test (Ref: Harrison 18/e p954)

Direct Coombs test or direct antiglobulin test on post-transfusion blood sample from patient should be done to detect
antibodies directed against the transfused RBCsQ.

6. Ans. e. All of the above (Ref: Harrison 18/e p952-954)

Characteristics of Selected Blood Components


Component Volume (mL) Content Clinical Response
Whole Blood 450 ml 45 No elements removed Not for routine use
Contains RBCs, WBCs, plasma and Used for acute massive bleeding,
platelets (WBCs and platelets may be open heart surgery and neonatal total
non-functionalQ) exchange
Packed RBCs 180200 RBCs with variable leukocyte content Increase Hb 1 gm/dL and hematocrit
and small amount of plasma 3%Q
Platelets 5070 5.5 x 1010/RD unit Increase platelet count 500010,000/LQ
FFP 200250 Plasma proteins: Coagulation factors, Increases coagulation factors about
proteins C and S, antithrombinQ 2%
Cryoprecipitate 1015 Cold-insoluble plasma proteins, Topical fibrin glue, also 80 IU factor VIIIQ
fibrinogen, factor VIII, vWFQ

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7. Ans. a. O negative (Ref: Harrison 18/e p951; Bailey 26/e p21-22, 25/e p21-22)

Selection of Blood for Emergency Transfusion

Patients Blood group is known Patients Blood group cannot be determined

Unmatched blood group of the same group Group O RBCs are chosen
should be used Such unmatched blood should be Rh negative,
when used in women of child bearing age, in whom
sensitization to Rh antigen would be undesirable
Rh positive blood can be used if Rh negative blood is
not available in older females and males

8. Ans. b. 1 gm%
9. Ans. a. Complement mediated hemolysis is seen (Ref: Harrison 18/e p954)

Acute hemolytic transfusion reactions following blood transfusion are type II hypersensitivity reactions caused most often by
the complement mediated hemolysisQ.
These reactions are often life-threatening and complications include oliguria and acute renal failure (decreased renal blood flow)Q.
10. Ans. a. Antigen D determines Rh positivity; b. Febrile reaction is due to HLA antigens (Ref: Harrison 18/e p954)

Rh positive or negative status depends on the presence or absence of antigen D (Rh D) on RBCsQ.
Section 10: Others

Febrile (non-hemolytic) reactions are caused by antibodies directed against donor leucocytes and HLA antigen may mediate
these reactionsQ.
11. Ans. b. Hematocrit
12. Ans. d. Whole blood volume
13. Ans. c. 28 days (Ref: Sabiston 19/e p588)

Whole Blood
Anticoagulant used Maximum storage
ACD/CPD/CP2D 21 daysQ
CPDA-1 35 daysQ
(citrate phosphate dextrose adenine)
14. Ans. b. Dilutional thrombocytopenia
15. Ans. d. All of the above (Ref: Clinical Laboratory Medicine 6/e p396)

Heparin Excess in Blood gas Syringe

Effects due to Dilution of Sample Effects due to Acidic Nature of Heparin


Decreased PaCO2Q Decreased pHQ
Decreased HCO3Q

16. Ans. a. i.e., Whole blood volume in 24 hours


According to Sabiston - Massive Blood Transfusion is defined as -
Transfusion greater than patients total blood volume in 24 hours
Or as acute administration of more than 10 units of blood over a few hours.
According to Schwartz Massive transfusion is a single transfusion of 2500 ml or 5000 ml transfused over a period of 24 hours

BLOOD TRANSFUSION COMPLICATIONS


17. Ans. b. Antibodies against donor leukocytes and HLA Ag
18. Ans. b. Dextran
19. Ans. c. Dextran
20. Ans. b. Dextran (Ref: en.wikipedia.org/wiki/Dextran)

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Blood Transfusion 1005

Dextran
It is a polysaccharide polymer of varying molecular weight producing an osmotic pressure similar to the plasma
Disadvantages:
It induces rouleaux of RBCs and this interferes with blood grouping and cross matchingQ procedures, hence need for a blood
sample beforehand.
It interferes with platelet function, hence it is recommended that total volume of dextran should not exceed 1000 mL.

LMW dextran (short acting) prevents sludging of RBCs in vessels and renal shut down in severe
hypotension and it is less likely to induce rouleaux formation than HMW dextran (long acting).

21. Ans. b. Hypotension and bleeding from site of wound (Ref: Schwartz 10/e p119,122,171-172, 9/e p83)

Schwartz says In patients who are anesthetized and have an open wound, the two dominant signs (of mismatched blood
transfusion) are diffuse bleeding and hypotension.

MC symptom of hemolytic transfusion reactions in a conscious patient: Sensation of heat and pain along the vein into which
the blood is being transfusedQ.
MC sign of hemolytic transfusion reactions in a conscious patient: OliguriaQ >hemoglobinuria.

22. Ans. a. Hypokalemia

23. Ans. a. DIC; b. Hypothermia; d. Thrombocytopenia

Section 10: Others


RED BLOOD CELLS
24. Ans. d. 50 days (Ref: Schwartz 10/e p1914-1915, 9/e p78; Bailey 26/e p21, 25/e p21)

Red Blood Cells

RBCs are stored at 1-60CQ; Mean life of transfused RBCs is 35 daysQ.

Anticoagulant used Maximum storage


ACD/CPD/CP2D 21 daysQ
CPDA-1 35 daysQ

PLATELETS
25. Ans. a. 20-240 C for 5 days
(Ref: Harrison 18/e p953; Sabiston 19/e p588; Schwartz 10/e p85, 9/e p79; Bailey 26/e p21, 25/e p21)

Platelet Concentrates
Volume: 50 ml Q

Platelets are the only blood products which are stored at room temperature, 20-240 CQ (survival is 4-5 days)Q.
1 unit of platelet increases the count by 5000-10000Q.

The threshold for prophylactic platelet transfusion is 10,000/LQ.


For invasive procedures, 50,000/L platelets is the usual target level.
Platelet count should be 1,00,000/L before accepting the patient for surgery.
Transfused platelets generally survive for 2-7 days following transfusion.
ABO compatibility is desirable but not necessary.

Blood platelets in stored blood are non-functional after 24 hoursQ.

26. Ans. a. 24 hours

PLASMA
27. Ans. c. Coagulation factor deficiency; d. Warfarin toxicity (Ref: Harrison 18/e p953; Sabiston 19/e p588)

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Fresh-frozen Plasma (FFP)


FFP is produced from the separation of plasma from donated bloodQ.
Stored at -180C and has a shelf life of 1 yearQ.
Each unit contains 400 mg of fibrinogen and 1 unit activity of each of the clotting factorsQ.

Most labile clotting factors (V and VIII) may be diminishedQ proportional to shelf life.
FFP contains stable coagulation factors and plasma proteins: fibrinogen, antithrombin, albumin, proteins C and SQ.

Indications for FFP


Correction of coagulopathies: Treatment of thrombotic thrombocytopenic
Rapid reversal of warfarinQ purpuraQ
Supplying deficient plasma proteinsQ
Patients who are IgA-deficient and require plasma support should receive FFP from IgA-deficient donors to prevent anaphylaxis.

FFP should not be routinely used to expand blood volumeQ.


FFP: An acellular component and does not transmit intracellular infections, e.g., CMV.

28. Ans. a. Good source of all coagulation factors


29. Ans. c. Factors 5 and 8
30. Ans. a. It is used as volume expander
31. Ans. a. Just before operation
Section 10: Others

The question is incomplete. It should be A cirrhotic patient with abnormalcoagulation needs cholecystectomy, FFP should be given:

Fresh Frozen Plasma


Transfusions with FFP are given to replenish clotting factorsQ.
The effectiveness of the transfusion in maintaining hemostasis is dependent on the quantity of each factor delivered and its
half-life.

The half-life on the most stable clotting factor, factor VII, is 4 to 6 hoursQ.
A reasonable transfusion scheme would be to give FFP on call to the operating room.
This way the transfusion is complete prior to the incision, with circulating factors to cover the operative and immediate
postoperative periodQ.

32. Ans. b. 8 hours

Thehalf life of factor VIII is 8-12hours.

33. Ans. d. XI (Ref: http://en.wikipedia.org/wiki/Haemophilia_C)

Hemophilia C (Rosenthal syndrome): Due to factor XI deficiencyQ

CRYOPRECIPITATE
34. Ans. c. Factor VIII (Ref: Harrison 18/e p953; Sabiston 19/e p588; Schwartz 10/e p73-75,1599, 9/e p82; Bailey 26/e p21, 25/e p21)

Cryoprecipitate
Cryoprecipitate is a source of fibrinogenQ, factor VIIIQ and von Willebrand factor (vWF)Q.
It is ideal for supplying fibrinogen to the volume-sensitive patient.
Stored at -180C

1 unit of cryoprecipitate contains 80-145 units of Factor VIII and 250 mg of fibrinogenQ.
Cryoprecipitate is pooled from many donors, so there are maximum chances of disease transmission among all
blood productsQ.
Cryoprecipitate may also supply vWF to patients with dysfunctional (type II) or absent (type III) von Willebrand disease.

35. Ans. b. Factor VIII 36. Ans. a. Cryoprecipitate


37. Ans. b. Factor IX

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