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Answer Key

Chapter 1 Chapter 5
Review Questions Case 5-1
1. c 6. c 11. b 16. a 1. No. Adding check cells to all tubes negative at the AHG
2. c 7. d 12. d 17. d phase provides a quality-control measure to the test. The
3. b 8. d 13. d 18. c expected result is positive agglutination. A negative result
4. c 9. a 14. c 19. c deems our test invalid.
5. d 10. a 15. c 20. a 2. The blood bank tech is required to repeat the test, starting
from step 1.
3. The most likely cause is failure to adequately wash cells
after the incubation phase.
Chapter 2 4. Failing to add AHG reagent is also common; AHG reagent
that has failed QC or is expired should never be used for
Review Questions patient testing.
1. b 5. d 9. c 13. a Case 5-2
2. b 6. d 10. a 14. a
3. c 7. b 11. b 15. c 1. Yes.
4. d 8. a 12. a 2. The initial antibody screen gel reaction is positive but
may be demonstrating a method-dependent antibody.
Some antibodies, both specific and nonspecific, have the
ability to demonstrate method dependency. The results
Chapter 3 show reactivity in one method but not others. The nega-
tive reactions in the LISS panel confirm the prediction of
Review Questions the method-dependent antibody.
3. The use of PCR technology to genotype the patient might
1. a 7. b 13. d 19. a
be useful in situations of method-dependent antibodies.
2. c 8. c 14. c 20. b
It should also be noted in the patient’s record that future
3. b 9. d 15. a 21. d
testing should be conducting using the LISS method.
4. d 10. c 16. b
5. d 11. a 17. c Review Questions
6. c 12. a 18. d
1. d 5. b 9. b 13. a
2. c 6. b 10. a 14. b
3. a 7. d 11. c 15. c
Chapter 4 4. a 8. a 12. c 16. b

Review Questions
1. a 5. d 9. c 13. c
2. c 6. a 10. b
3. c 7. d 11. b
4. b 8. d 12. d

601
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602 Answer Key

Chapter 6 Case 7-2

1. The patient’s ABO, Rh type is O Rh-positive. The antibody
detection test (screen) is positive. NOTE: In this case
Case 6-1
study, antibodies are excluded only if the patient’s serum
1. The results indicate an ABO discrepancy in the reverse does not react with panel cells that possess a double-dose
grouping since there is only a 2+ reaction with the reagent expression of the antigen (from a donor with homozygous
A1 red cells. Normally, ABO forward and reverse testing expression).
show strong 3+ to 4+ reactions. 2. Anti-c, anti-E, and anti-K on a double-dose cell (K+k-).
2. Since the antibody screen was negative, the blood bank 3. Test the patient’s serum or plasma against selected cells
technologist proceeded to type the patient’s RBCs with that are c-E+K- and c-E-K+ and phenotype the patient’s
anti-A1 lectin, Dolichos biflorus. This was decided because, RBCs.
based on the negative antibody screen and patient history, 4. DCe/DCe (R1/R1), DCe/dCe (R1/r’)
an alloantibody was most likely not causing the ABO 5. k
discrepancy. 6. Confirm the patient has an anti-c and her red cells lack
3. The reaction with anti-A1 lectin indicates the patient’s the c antigen. Now that we know the patient is K+, we
cells are not type A1. The additional serum studies show do not need to run additional selected cells to rule
that the antibody is not directed toward a possible alloan- anti-K out.
tibody reacting at room temperature and that the antibody 7. Anti-E is difficult to rule out in the presence of anti-c
is not anti-A, in that only anti-A would react with A2 cells. because a D+C+c-E+e- (DCE/DCE or RzRz) individual
If a cold autoantibody or alloantibody was causing the occurs in less than 1% of the population
discrepancy, the patient’s serum would likely react with
the reagent O cells. Case 7-3
Results indicate the patient is a likely group A2 and
1. The patient’s ABO, Rh type is interpreted as A Rh-negative,
has formed an anti-A1.
and the antibody detection test (screen) is negative, indi-
4. During surgery, the OR ordered 2 units of packed RBCs.
cating no unexpected antibodies present in her plasma.
Two type O–positive packed RBCs were crossmatched
2. DCe/dce (R1r) or Dce/dCe (R0r’)
with the patient serum and found to be compatible. Only
3. DCe/dce (R1r) is most probable; however, if the patient
1 unit was transfused without episode. The patient was
has weakened expression of RhD due to C in Trans to
discharged 4 days later.
RHD, she could possess the Dce/dCe (R0r’).
In this case, there was an ABO discrepancy caused by
anti-A1 in the reverse grouping. Although anti-A1 is Review Questions
considered to be nonreactive at 37°C, it was decided to
transfuse type O–positive cells to this patient since there 1. a 4. a 7. d 10. c
was ample supply. 2. c 5. c 8. c 11. d
3. b 6. c 9. e 12. c
Review Questions
13.
1. d 4. b 7. a 10. b R1r DCe/dce Rh:1,2,-3,4,5
2. a. 5. c 8. a R2R0 DcE/Dce Rh:1,-2,3,4,5
3. d. 6. b 9. c RzR1 DCE/DCe Rh:1,2,3,-4,5
ryr dCE/dce RH:-1,2,3,4,5
(see Table 7–3)
Chapter 7 14.
15.
d
b
Case 7-1 16. d
1. The patient’s ABO, Rh type is O Rh-negative. 17. a
2. Both screening cells 1 and 2 show positive reactivity.
3. Given the patient is Rh-negative, elderly, and has six
children, it is very likely the positive antibody screen is
due to anti-D. In addition, both screening cells are D+. Chapter 8
4. An antibody identification panel should be performed.
Review Questions
5. Anti-D is present in the patient’s plasma. All D-positive
panel cells are reactive (2+), and all D-negative cells are 1. d 4. c 7. a 10. c
negative. In addition, all other common alloantibodies 2. b 5. a 8. d 11. a
are ruled out using at least one double-dose donor cell. 3. a 6. d 9. b 12. c
2682_Answer Key_601-612 22/05/12 5:40 PM Page 603
13. d 18. b 23. c 28. b
14. c 19. c 24. d 29. d
15. c 20. d 25. c 30. c
16. b 21. b 26. d tions and the patient’s diagnosis may prove helpful.
17. c 22. a 27. b Knowing the patient’s ethnicity may give clues as to the
Chapter 9
Case 9-1
1. There is inconsistent reactivity (1+ to 3+). The pattern of
reactivity appears to fit anti-Fyb; however, one homozy-
gous cell (cell 2) reacts 3+ while others (cells 8 and 9)
react only 2+. This inconsistency is seen in the cells with
heterozygous antigen expression as well. Cell 7 reacts 2+,
while cells 1, 6, and 11 react only 1+.
2. Anti-C, anti-Cw, anti-K, anti-Kpa, anti-Jsa, anti-Fyb, anti-
Jka, and anti-Lua have not been excluded. Fyb antigens
would be destroyed or diminished after treatment with
enzymes. C, Cw, Jka, and Lua would have enhanced antigen
expression. K, Kpa and Jsa would be unaffected by routine
enzymes.
3. The specificity of the antibodies was unclear after the ini-
tial panel. After repeating the panel using ficin-treated
cells, it appears that the antibodies present are anti-K and
anti-Fyb. The enzyme treatment removed the Fyb anti-
gens, thereby eliminating the anti-Fyb reactivity, which
allows the anti-K to present clearly. Anti-C and anti-Jka
were also not eliminated by the initial panel. However,
one would expect these antibodies to demonstrate en-
hanced reactivity with the ficin-treated cells. Anti-Jka may
be excluded using cell 8 of the ficin panel. Whereas
anti-C cannot be excluded using a homozygous cell, the
pattern of reactivity and lack of response to enzyme treat-
ment suggest it is not present in this sample.
4. Testing a C+, c–, K–, Fyb– cell would be necessary for
exclusion.
Case 9-2
1. The positive reactions on this panel are all the same
strength. Cell 10, the only cell that failed to react with
the patient’s serum, has been identified as being Yta neg-
ative. As Yta is a high-prevalence antigen, one may be sus-
picious that this is the antibody present in this specimen.
2. For this case, the ideal solution is to test two additional
Yta-negative cells, which would provide 95% confidence of
correct antibody identification and allow for additional ex-
clusions. If antigen-negative cells are not readily available,
it may be necessary to consult a reference laboratory that
maintains a stock of rare cells. Any other antibodies not
excluded following this testing may require patient phe-
notyping or absorption studies to confirm their presence
or absence. The services of a reference laboratory may be
required to antigen type the patient for the Yta antigen.
Answer Key 603
3. When working up any antibody identification, it is good
practice to get the patient’s history of transfusions, trans-
plantations, and, if female, pregnancies. A list of medica-
identity of the antibody, as antigen frequencies vary
among races. One example of a high-prevalence antigen
associated with a specific ethnicity is the U antigen,
which is present in virtually all whites and all but approx-
imately 1% of blacks. Anti-U is produced mainly in
multiparous black females or those patients who have
been repeatedly transfused.
Case 9-3
1. A positive reaction was seen with cell 4 only, which is Jsa
positive. All other antibody specificities have been elim-
inated except for anti-Lua (an antibody to another other
low-prevalence antigen).
2. Testing with additional antigen-positive cells will be
required to confirm the specificity. Panel cells that are
positive for these rare antigens are normally indicated on
the panel profile sheet or listed on the extended typing
form. Testing two other cells positive for the Jsa antigen
to satisfy the 3 and 3 rule and phenotyping the patient
for the Jsa antigen should be done to complete the antibody
identification workup. If additional cells are not readily
available, consult a reference laboratory.
Case 9-4
1. All cells (except the I-negative cord blood cells) are positive
at the immediate spin phase of testing, and the autocontrol
is positive. The reactivity does not persist into the AHG
phase of testing.
2. The use of cord blood cells, which lack the I antigen, con-
firms the presence of anti-I in this sample.
3. Many laboratories avoid detection of cold autoantibodies
by omitting the immediate spin phase of the antibody
screen (and panel) and by using monospecific anti-IgG
Coombs’ reagent.
One of the least complex methods used to prevent cold
autoantibodies from interfering in antibody detection or
identification tests is the prewarm technique. In this
procedure, the serum being tested and the screen or panel
cells are heated to 37°C in separate test tubes. Once at
37°C, a drop of warm RBCs is added to each of the tubes
containing serum, and the test proceeds with incubation,
washing, and AHG steps. The wash step uses saline that
has also been maintained at 37°C so that at no time is the
test system allowed to drop below that temperature, thus
avoiding the optimal temperature range of the autoanti-
body. Because this method does not usually have enhance-
ment media in the system, it is possible to fail to detect
some weak significant antibodies. Also, the warm saline
may result in the dissociation of some significant antibodies
from the cells.
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604 Answer Key
A more complex method, discussed previously, is ad-
sorption. The patient’s autologous cells may be incubated
with the patient’s serum at 4°C to remove the autoanti-
bodies before antibody detection steps are performed.
This method provides autoantibody-free serum for anti-
body detection and identification procedures and for
compatibility testing. If the autoantibody is particularly
strong or if the patient has been recently transfused, RESt
may be used to perform the adsorption instead of the
patient’s RBCs. RESt-adsorbed serum is not suitable for
crossmatch, as anti-B may be removed.
Sulfhydryl compounds, such as DTT and 2-mercap-
toethanol (2-ME), are known to break the disulfide bonds
in IgM. Treating the patient’s serum with such a reagent
before the antibody detection test will denature the cold
autoantibody. IgG antibodies are not affected by these
reagents and will remain detectable. A control of saline
and serum is tested in parallel with the treated serum to
ensure that the autoantibody was truly denatured, not
merely diluted.
Case 9-5
1. Warm autoantibody with an underlying alloantibody. The
reactivity with all cells, including the autocontrol, at the
AHG phase of testing is typical for a warm autoantibody.
The increased reactivity on cells 2, 6, and 10 suggests that
an additional antibody is present. With the patient’s trans-
fusion history, one must consider the possible presence
of an alloantibody.
2. Typically with an antibody to a high-prevalence antigen,
the autocontrol will be negative. However, if the patient
has been recently transfused with RBCs that possess the
high-prevalence antigen, the autocontrol may be positive,
as the antibody will react with the antigen-positive donor
RBCs remaining in circulation.
3. Autoadsorption is the method of choice when the patient
has not been recently transfused (transfusion in the past
3 months) and when a sufficient quantity of autologous
RBCs is available. The patient’s RBCs must first be
stripped of autoantibody before they can be used to ad-
sorb autoantibody from the serum. Partial elution using
gentle heat or chemical methods is used to produce an
antibody-free cell. ZZAP is one chemical that works par-
ticularly well for this. It is composed of DTT and papain,
resulting in the destruction of enzyme-sensitive antigens
and denaturing Kell, LW, Dombrock, Knops, and Cromer
antigens. Once the autoantibody has been removed from
the cells, the treated cells can be incubated with the
patient’s serum at 37°C to absorb autoantibody from
the serum. Multiple steps are necessary to treat the
cells and adsorb the autoantibody, which makes this
procedure very time-consuming. Once the autoantibody
is removed, the adsorbed serum can be tested for under-
lying alloantibodies.
When patient cells are limited or when the patient has
been recently transfused, allogeneic cells are used for
adsorption. The cells used for homologous or differential
adsorption are usually treated with enzymes or with
ZZAP to enhance expression of certain antigens and facili-
tate autoantibody removal. These treatment and adsorption
steps are time-consuming. There is an alternative method,
in which PEG is used to enhance antibody removal, cutting
the processing time approximately in half while still pro-
viding for adequate autoantibody removal.50,51
4. The pattern of reactivity in the “absorbed serum” column
of Figure 9–14 matches that of anti-K. Positive reactions
in the autoabsorbed serum were found with cells 2, 6, and
10, which were positive for the K antigen. All other
antibody specificities could be ruled out except for Cw,
Kpa, Jsa, and Lua. These are low-prevalence antigens and
generally do not need to be excluded. Additional pheno-
typing strategies should be employed to determine if the
patient is negative for the K antigen.
5. Transfusion requirements include RBC units negative for
the K antigen that appear to be less incompatible with the
warm autoantibody than the patient’s own cells (least
incompatible) when tested with the antiglobulin cross-
match method using unabsorbed serum.
Review Questions
1. d 5. c 9. b 13. a
2. a 6. c 10. c
3. c 7. d 11. b
4. b 8. a 12. d
Chapter 10
Case 10-1
1. Since she has had two previous deliveries at this facility,
then our patient’s history should also include a previous
ABO/Rh and antibody screen determination, which ex-
pands the crossmatch options. The first and most common
crossmatch option is an immediate spin crossmatch. Of
course, an AHG crossmatch option is also available but is
not a very good STAT procedure, even though some facil-
ities still have this option as their standard protocol in all
situations. The final option, which is the least common, is
a computer crossmatch. Since there are two separate
determinations of the patient’s ABO and no unexpected
antibodies are present (both currently and previously),
then this option is also available, if the facility’s computer
system has been validated for computer crossmatching.
2. Playing the odds, the most likely crossmatch selected for
this situation is going to be the immediate spin cross-
match, since it is the most widely accepted and used. It
is fast and effective in STAT situations. Transfusion service
technologists can rapidly perform an immediate spin
crossmatch and tag compatible units.
The computer crossmatch is also quite efficient and
may even be faster since no serologic testing is required.
Just let the computer select the packed cells and print up
the tags. The reality is that only about 2% of transfusion
services in the United States have computer crossmatch-
ing capabilities.
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Answer Key 605

Case 10-2 2. Symptoms include malaise, fever, fatigue, anorexia, vom-

1. Scenario 1: Patient could have an antibody to a low- iting, and abdominal pain.
incidence antigen that wasn’t present on the screening 3. Yes, the donor with the high titer should be permanently
cells of the antibody screening test that was present on deferred.
the donor red blood cells. 4. No, the donor who was not tested should be indefinitely
Scenario 2: Another explanation is that the technologist deferred until he or she can be tested.
performing the antibody screening test did not add patient
serum to the screen cells but did to the crossmatch test. Case 13-2
2. Scenario 1: Perform an antibody identification using 1. After transfusion of 1 unit of leukoreduced RBCs, the hgb
selected panel cells with low-incidence antigens present. should increase approximately 1 g/dl or 11.6; hematocrit
Determine specificity of antibody, then antigen-type both should have increased 3% or approximately 35%.
the patient and donor cells (all 3 units) for the correspon- 2. One unit of apheresis platelets will usually increase the
ding antigen. Transfuse antigen-negative, crossmatch platelet count of a 70 kg adult by 30,000 to 60,000/uL.
(AHG crossmatch) compatible units. Make sure units are This is consistent with the patient platelet count results
labeled with antigen typing results. from 5-23 to 5-24, which increased from 72,000 to
Scenario 2: Repeat all testing, including the antibody 103,000.
screen, this time adding patient serum to all screening 3. FFP is frozen within 8 hours of collection and PF24 is
cells. If antibody screen is positive, then identify antibody frozen within 24 hours of collection. FFP contains all
and antigen-type both the patient and donor red cells coagulation factors, and PF24 contains all factors con-
(all 3 units) for the corresponding antigen. Transfuse tained in FFP with reduced amounts of factors V and VIII.
antigen-negative, crossmatch (AHG crossmatch) compat- Since this patient had liver abnormalities and not a
ible units. Make sure units are labeled with antigen typing specific factor deficiency and was taken off Coumadin,
results. standard of practice dictates that FFP and PF24 can be
used interchangeably except in hemophilic cases where
Review Questions there is a specific deficiency of factor VIII.
1. c 5. b 9. d 13. b
Review Questions
2. d 6. d 10. c 14. a
3. d 7. b 11. b 15. d 1. c 6. e 11. a 16. d
4. c 8. b 12. d 2. d 7. a 12. e 17. c
3. e 8. b 13. b 18. a
4. a 9. c 14. b 19. c

Chapter 11 5. a 10. e 15. a 20. c

Review Questions
1. d 3. d 5. a 7. c Chapter 14
2. a 4. c 6. d 8. d
Case 14-1
1. Top five possible diagnoses for this case:

Chapter 12 • Hemolytic uremic syndrome

• Thrombotic thrombocytopenic purpura (TTP)
• Disseminated intravascular coagulation (DIC)
Review Questions • Malignant hypertension
1. a 4. b 7. c 10. c • Sepsis
2. d 5. c 8. b 2. Thrombotic thrombocytopenic purpura (TTP). Why? See
3. d 6. a 9. c below + normal coagulation studies and the ADAMTS13
will be significantly decreased.
3. In classic cases, patients present with a pentad of clinical

Chapter 13 and laboratory findings:

• Microangiopathic hemolytic anemia (MAHA);
• Thrombocytopenia
Case 13-1 • Neurological symptoms and signs
1. Yes, the incubation period for Babesia microti is 2 to • Renal function abnormalities
8 weeks. The component transfused is red blood cells, • Fever
which the organism is able to penetrate. 4. Plasma exchange with fresh frozen plasma (FFP).
2682_Answer Key_601-612 22/05/12 5:40 PM Page 606
606 Answer Key
Review Questions
1. d 4. a 7. b 10. d
2. a 5. c 8. a
3. b 6. d 9. c
Chapter 15
Case 15-1
1. It is necessary to know the patient’s hemoglobin and
hematocrit levels, the surgeon’s usual blood usage,
whether this is the first surgical procedure on this hip
(redo surgery uses more blood), and whether the patient
has any pretransfusion compatibility problems.
2. Considerations should be the patient’s general health, he-
moglobin and hematocrit levels, amount of time between
request for donation and the time of surgery, and whether
the patient has infectious diseases that might interfere
(e.g., bacterial infections).
3. Tests should include PT, PTT, and platelet count. If these
tests are normal and von Willebrand’s disease is sus-
pected, vWF workup should be considered.
4. If the patient has moderate to severe von Willebrand’s dis-
ease, the patient may need factor VIII concentrate known
to contain vWF.
Case 15-2
1. Both answers can be justified. If the answer is yes, her
hemoglobin is close to 6 g/dL, which is the criterion for
RBC transfusion. She will be less tired and weak if she re-
ceives a transfusion. If the answer is no, she is not in any
acute distress. She is iron-deficient (from chronic blood
loss) and should be treated with iron replacement rather
than with transfusion, which has higher risk of compli-
cations. The safest, least-expensive, and the most effective
long-term strategy is to prescribe iron and not transfuse.
2. For adults, each unit of blood should increase the hemo-
globin 1 g/dL and the hematocrit 3 percentage points. For
accuracy, this is based on a hypothetical 70-kg man. For
smaller men and women, the increase is greater; for larger
ones, less.
Case 15-3
1. The platelet count is 5,000/µL; therefore, a platelet trans-
fusion is indicated. Without the platelet transfusion, she
would be at increased risk of bleeding from the site of the
bone marrow biopsy. Although the hemoglobin and
hematocrit levels are lower than normal for a woman of
this age, an RBC transfusion is not indicated (hemoglobin
greater than 6 g/dL in an otherwise healthy young adult).
2. For an adult, each unit (bag) of platelet concentrate
should increase the patient’s platelet count by 5,000 to
10,000/µL. The platelet count should be at about
20,000/µL because a bone marrow biopsy is an invasive
procedure. Thus, one unit of platelets (plateletpheresis or
pool) would be indicated.
3. If it is anticipated that the patient will experience bone
marrow recovery soon (after the chemotherapy), no RBC
transfusion is indicated. If, however, the bone marrow
will be suppressed for several weeks, one or two units are
indicated, with a recheck in a couple weeks for another
possible transfusion. Each unit of RBCs is expected to
increase the hemoglobin level about 1 g/dL.
Case 15-4
1. The blood group for RBC transfusions is O, which is the
universal blood group.
2. Group AB should be selected for plasma and platelet
transfusion. If AB platelets are not available, any other
blood group can be selected.
3. RBCs, plasma, and platelets in the amount specified by
your massive transfusion protocol.
4. RBCS, plasma, and platelets should be B. The Rh can be
positive because the patient is male. If group B RBCs are
in short supply, group O can continue to be used.
5. Workup of the positive antibody screen should start as soon
as possible, but without delay of providing products for the
massive transfusion. Transfusing RBCs in massive hemor-
rhage is more important than obtaining “compatible” units.
With massive transfusion, the patient’s antibody will be
removed and diluted by the hemorrhage and the replace-
ment of blood components. The “incompatible” RBCs will
be removed more slowly because the mechanism is extravas-
cular hemolysis. When the serologic problem is solved,
compatible RBC units can be obtained and transfused.
Review Questions
1. d 4. c 7. a 10. a
2. c 5. a 8. b
3. c 6. a 9. d
Chapter 16
Case 16-1
1. A reaction in which signs and symptoms occur during or
within 24 hours of transfusion.
2. Hemolysis.
3. Volume of incompatible blood transfused.
4. Look for matching or discrepant information between the
information on the labels on the pre- and post-transfusion
samples, transfused units, patient transfusion service
records.
Case 16-2
1. Communication with other health professionals served
as the key to resolving this incident.
2. Chemical or mechanical damage such as improper ship-
ping, storage temperatures, incomplete deglycerolization
of frozen red blood cells, inappropriate needle bore size
for transfusion rapid infusion, improper use of blood
warmers, unapproved fluid infusion.
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Answer Key 607

Case 16-3
1. Laboratory workup for the diagnosis of TAS must rule Chapter 18
out hemolysis and perform a gram stain and culture
Review Questions
of the implicated component and patient. The culture
must be obtained from the container and not the seg- 1. a 8. b 15. a 22. c
ments attached to the product. Blood cultures from the 2. b 9. d 16. c 23. a
patient should be drawn from a site other than the site of 3. d 10. c 17. a 24. d
transfusion. 4. a 11. c 18. d 25. b
2. Symptoms implicated with TAS include a fever with 5. c 12. d 19. c
greater than 2°C increase in body temperature, rigors, and 6. b 13. a 20. d
hypotension. 7. c 14. d 21. b

Review Questions
1.
2.
c
c
5.
6.
c
b
9.
10.
d
d
13. b
14. d
Chapter 19
3. b 7. c 11. d 15. d Case 19-1
4. b 8. b 12. a 1. The most probable cause is that the mother received
prophylactic Rh immune globulin at 28 weeks gestation.
The antibody screen was negative at 28 weeks gestation
Chapter 17 prior to the administration of Rh immune globulin. The
antibody titer of anti-D due to Rh immune globulin is
Case 17-1 typically less than 1:4.4
2. Yes, unless the newborn infant is Rh(D)-negative.
1. The blood group for RBC transfusion is O, which is the
only blood group compatible with both the donor and Case 19-2
recipient. If A is chosen, the cells will be hemolyzed
1. The maternal history, the same father, and the father
or have a shortened life span because of the preexisting
homozygous for the D antigen suggest that the infant is
anti-A in the patient. If B is chosen, engraftment will be
Rh(D)-positive.
difficult to determine.
2. The titer should be repeated in 6 weeks (16 weeks’
2. Group AB should be selected for FFP and platelet trans-
gestation).
fusion. If group A is selected, the anti-B in the plasma
3. The infant is only 8 weeks gestational age, so it is too
is incompatible with the recipient’s RBC and tissue
early in the pregnancy to perform any intervention
antigens (B). The anti-A in group B products is incom-
(MCA-PSV, cordocentesis, intrauterine transfusion). The
patible with the donor RBCs and, if selected, may contribute
earliest an intervention can take place is 16 weeks.
to delayed engraftment of RBC precursors.
4. The patient should be scheduled for MCA-PSV at 16 to
3. On day 117, the interpretation is B, as B cells and anti-A
18 weeks gestation to determine if the test is positive.
are present.
4. On day 200, the interpretation is group A, because A cells Case 19-3
are present, and B cells and anti-A are absent. On day 156,
1. The most probable cause is ABO HDFN. Group O mothers
the forward type is group O (remember that the patient
produce IgG anti-A, which can cross the placenta.
is receiving group O RBC transfusions), but the reverse
2. No. Anti-Lea does not cause HDFN because Lewis anti-
type still has anti-A; thus, the interpretation is indetermi-
gens are poorly developed at birth.
nate. The source of the anti-A may be small amount of
plasma in RBC transfusions or anti-A in ABO-incompatible Case 19-4
platelet transfusions.
1. The blood types of the cord blood and heel-stick speci-
Review Questions mens are different—A-negative versus O-negative. The
severely anemic infant could have HDFN, although the
1. a 4. b 7. c 10. a cord blood results do not indicate severe disease (DAT +/–).
2. e 5. c 8. c 11. b On the other hand, a large fetomaternal hemorrhage
3. d 6. d 9. c 12. c could have occurred.
2682_Answer Key_601-612 22/05/12 5:40 PM Page 608
608 Answer Key
2. Cord blood should be collected by needle and syringe
from the umbilical cord vein. Collecting the specimen by
allowing blood from the placenta or cord to drip into the
tube can contaminate the specimen with maternal blood.
In this case, the tube marked “cord blood” could be a
mislabeled maternal sample. The heel-stick is nearly all
adult blood because of the recent intrauterine transfusion.
Group O blood is usually used. As discussed in this chap-
ter, transfusion may cause suppression of erythropoiesis
and therefore the production of few fetal RBCs. The cells
produced are being hemolyzed by the high-titered mater-
nal antibody. This leads to anemia, in this case quite
severe, with elevated bilirubin levels indicating that
hemolysis is occurring. The eluate of the heel-stick spec-
imen confirms HDFN caused by anti-D.
Review Questions
1. c 4. d 7. d 10. b
2. a 5. d 8. d 11. a
3. b 6. a 9. b 12. c
Chapter 20
Case 20-1
1. There is an ABO serologic discrepancy and a positive
albumin control, so ABO/Rh results are invalid.
2. The antibody screen shows a strongly reactive immediate
spin (room temperature) reading and weak reactivity at
LISS 37°C phase. These preliminary results suggest a cold
agglutinin. Because the patient’s RBCs are also reactive
with his own serum, this appears to be a cold autoanti-
body, which would also affect the ABO serum typing
(tested at room temperature).
3. The patient’s RBCs are complement coated.
4. The most likely cause of these atypical results is a cold
autoantibody. To obtain valid ABO/Rh typing results, the
patient’s RBCs should be warmed to 37°C and washed
with warm saline. His serum and plasma should be cold
autoadsorbed and used for repeating the ABO serum typ-
ing and antibody screen.
5. The patient’s warm-washed RBCs type group A Rh-positive.
The cold autoadsorbed serum confirms that anti-B is
present, but not anti-A. This resolves the ABO serologic
discrepancy. The antibody screening performed with the
cold autoadsorbed serum also confirms that group O
RBCs are nonreactive and that there is no alloantibody
present.
6. The cold autoadsorbed serum is suitable for cross-
matching group A RBCs for transfusion (if still deemed
necessary).
7. A cold agglutinin titer and thermal amplitude would be
very useful to investigate whether the patient has cold
hemagglutinin disease (CHD), as suggested by the pre-
liminary testing and by his symptoms. If a diagnosis of
CHD were made, such testing might save him having to
endure the bone marrow biopsy.
Case 20-2
1. The patient is group O Rh-positive.
2. Her antibody screening is positive with all three screening
cells and with the autologous control at the indirect
antiglobulin phase. None of the four units crossmatched
are compatible. There is some variability in the strength
of the IAT reactivity. Because the patient has no history
of recent transfusion (within the last 3 months), the
positive auto control by IAT suggests a warm autoanti-
body is present. The variability of reactivity suggests
alloantibody may also be present.
3. A direct antiglobulin test should be done. Warm autoad-
sorption of the patient’s serum should also be done, and
an antibody identification panel tested with the adsorbed
serum.
4. The DAT shows that the patient’s cells are coated with
both IgG and complement. The predictive value of the
positive DAT in a patient with clinical indications of
hemolytic anemia (e.g., decreased hemoglobin and hema-
tocrit, increased reticulocyte count) is high; combined
with evidence of a warm autoantibody in the serum, these
results support a diagnosis of warm autoimmune he-
molytic anemia.
5. Anti-Jka is evident in the autoadsorbed serum. Further
testing could include typing the patient’s RBC for the Jka
antigen, which might be done using monoclonal anti-Jka
or using an IgG removal technique to treat her RBCs be-
fore typing her RBCs with a conventional anti-Jka reagent.
Although the patient has a history of prior transfusion
when she might have been exposed to Jk(a+) RBCs, it is
somewhat unusual to find anti-Jka strongly detectable so
many years after last exposure.
6. The patient’s autoadsorbed serum may be used to cross-
match group O Jk(a–) red blood cells for transfusion.
7. Transfusion to remedy the current anemia is a temporary
solution and may stimulate additional alloantibody and
increase autoantibody production. Her physician is likely
to recommend steroid therapy (e.g., prednisone) to sup-
press her immune system to try to control the autoim-
mune hemolytic process.
Case 20-3
1. The patient’s RBCs are group B Rh-positive. There is
nothing unusual about the blood grouping.
2. The antibody screening is negative, indicating no alloan-
tibodies to RBC antigens are present.
3. Because the antibody screening is negative, crossmatches
of the patient’s serum with three units of group B
Rh-positive units of red cells would be expected to be
compatible. The positive autocontrol and the color of the
patient’s serum are unexpected. Although there is no
history of recent transfusion, a DAT could be helpful if
the patient is anemic due to an autoimmune process. If
the DAT is positive, preparing and testing an eluate of the
patient’s RBCs could be informative.
4. The DAT shows that the patient’s RBCs are coated with
IgG and complement. These results could be seen in a
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Answer Key 609

normal individual. (Approximately 1 in 1,000 healthy Review Questions

blood donors have positive DATs.8) But since this patient
has severe anemia that developed in 1 week and frank 1. b
hemolysis noted in the sample, there is likely to be more 2. a
clinical significance to these DAT results. 3. b
5. The eluate is nonreactive with the three antibody detec- 4. a
tion cells but reacts with the patient’s own RBCs even
after they have been EGA-treated to remove in vivo IgG.
The results are consistent with a drug-induced antibody
that reacts with the patient’s drug-coated RBCs. Typical
Chapter 23
results seen in cases like this, called the “penicillin-type” Review Questions
drug-induced immune hemolytic anemia, are a negative
antibody screen and negative eluate in a patient with a 1. b 4. b 7. c 10. c
positive DAT and clinical signs of acute hemolysis. In 2. d 5. c 8. a
these cases, adsorption of the drug by the patient’s RBCs 3. d 6. d 9. a
causes them to react selectively with the drug antibody
in the patient’s serum or eluate.
6. Determining what drug the patient has been receiving is
key to knowing what drug antibody to suspect. In this Chapter 24
case, the patient was unaware of taking any drugs or
antibiotics during or following her hospitalization for Case 24-1
labor and delivery by C-section. A careful review of 1. A blood utilization management program is intended to
the surgical record revealed that she was given a single ensure blood components are administered appropriately,
dose of Cefotetan during surgery, presumably to prevent in accordance with hospital guidelines and evidence-
postoperative infection. based criteria. Its primary focus is to improve patient
safety by ensuring patients are not unnecessarily exposed
Review Questions to the risks of transfusion. If there is a large deviation
1. d 6. d 11. d 16. b from standard practice in a facility, reduction in inappro-
2. b 7. b 12. b 17. c priate ordering may be reflected in reduced expenditure
3. a 8. b 13. d 18. d for blood components. However, if this is not the case, a
4. a 9. c 14. a utilization management program may still reduce cost in
5. a 10. a 15. c terms of expenditures for treating transfusion-associated
adverse events, impact on length of stay and clinical
course, and improved blood component availability.
2. First steps include recruiting a multidisciplinary cross-
Chapter 21 functional team. This team should define the program’s
overall goal, then assess the current state and perform
Review Questions a gap analysis. This process will involve using evidence-
1. c 3. b 5. d 7. d based criteria and guidelines. Once improvement oppor-
2. c 4. a 6. b 8. a tunities are identified, the team may prioritize interventions
to promote evidence-based practice.
3. The blood utilization management team should include
the blood bank medical director and the blood bank su-
Chapter 22 pervisor. Additional members will depend upon the in-
dividual facility, but representation from nursing, clinical
Case 22-1 staff (especially from areas with greater blood use), and
1. b quality should be considered. Participation by an infor-
2. a mation technology associate may be particularly useful
in developing tools for queries and to track the metrics
Case 22-2 the team agrees upon. Administrative support, if not
1. c active participation, is critical.
2. d 4. Appropriate utilization criteria should be gleaned from
3. c evidence-based literature and the recommendations of
In DNA polymorphisms, the mutation rate can be as high consensus panels from various subspecialties. Active dis-
as 2 per 1,000; thus, a single mismatch, when all other sys- cussion of proposed guidelines with clinical staff is nec-
tems are consistent with paternity, may represent a mutation. essary to gain approval and promote compliance. Where
A minimum of two mismatches is necessary before an inter- necessary, exceptions for specific clinical populations or
pretation of exclusion is rendered. diagnoses should be included. The literature upon which
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610 Answer Key

the guidelines are based should be widely disseminated were unwilling to change their practice patterns. Following
and readily available to clinical staff. review by the transfusion committee, the antiquated order
5. Any of the types of review (retrospective, concurrent, sets were removed and a discontinuous prospective review
targeted, or discontinuous prospective) may be utilized was adopted, focusing on plasma orders for coronary
depending on the facility. However, for a medium- or care patients. In addition, educational measures were
small-sized facility, retrospective review is most likely to employed, in the form of several short lectures on current
be the primary method, due to resource limitations. Large plasma guidelines presented to the coronary unit’s physi-
facilities such as academic institutions are more likely to cians and nursing staff.
have the available personnel to conduct concurrent and 4. Over the following three quarters, the transfusion safety
prospective review actions. Targeted or discontinuous officer continued the discontinuous prospective review
prospective review may be appropriate for smaller facilities, of the coronary care patients in addition to the monthly
since the benefits of “real-time” intervention are balanced retrospective reporting. At the end of the third quarter,
by the limited scope. blood utilization appeared to be at the desired state and
the labor-intensive discontinuous prospective review
Case Study 24-2 strategy was retired. It is important to always reassess and
1. The first step is to determine the gap between the current revaluate the blood utilization management process to
and desired state. This gap defines the scope of the prob- determine the effectiveness of corrective strategies and to
lem and should be qualified and quantified as succinctly identify new areas of waste.
as possible. Review of the value stream will help identify
the source of the problem. In this case, review of the nurs- Review Questions
ing units and physician services show that the plasma 1. d 4. c 7. b 10. b
trend appears to be related to a recent expansion in the 2. a 5. d 8. d
hospital’s coronary care unit. This is further supported by 3. b 6. b 9. a
the observation that the increased usage and waste trends
vanish when the data from the coronary unit are excluded
from the utilization report. Review of the timing of the
blood orders showed that the majority of the increased
utilization appeared just prior to the performance of Chapter 25
cardiac procedures and surgeries. Review Questions
2. Further auditing revealed multiple types of waste with
plasma usage among patients awaiting cardiac surgery 1. b 4. d 7. d 10. b
and procedures. In nearly every case, there was an excess 2. c 5. c 8. a
of plasma ordered in advance of the procedure that was 3. d 6. a 9. b
thawed by the blood bank but was either never dispensed
or never transfused. Regarding the dispensed plasma,
most of these patients had an average of 2 units of unused
thawed plasma. In a few cases, the product was improp-
erly returned and had to be discarded. This overproduc-
Chapter 26
tion type of waste increased the number of expired Review Questions
plasma components, resulting in increased inventory
waste. Further waste was identified through a detailed 1. c 4. b 7. d 10. c
medical chart audit, which demonstrated that nearly 2. a 5. a 8. a
half of the plasma transfused was likely inappropriately 3. d 6. b 9. b
administered when compared to the institution’s transfu- 11. Phase SCI SCII Interpretation
sion guidelines. IS 0 0 Negative
3. Solutions and improvements arise from the collaborative 37ºC 0 0
input of multiple sources such as the medical director AHG 0 0
of the blood bank, the blood bank supervisor, members CC + +
of the transfusion committee, and appropriate members
from administration. If a specific unit or specialty is 12. b
identifiable, as in this case, input should also be requested 13. A. Control functions
from clinical staff in that area. In this case, after investi- B. Acceptance Criteria
gation by the medical director, the new coronary unit was C. Test Cases
employing antiquated order sets copied from another D. Data entry methods
institution. These order sets included template standing E. Documentation methods
plasma orders that were not appropriate for a large insti- F. Result review
tution with readily available thawed plasma. Unfortunately, G. Corrective action
in spite of discussion with the involved practitioners, many H. Acceptance
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Answer Key 611

Chapter 27
2. The supplier’s facility and all intermediaries must be
registered with the FDA and hold state licenses, if appli-
cable by state.
Cases 27-1 through 27-6
Editor’s Note: Because of the nature of these cases, an- Case 28-2
swers are not provided. Answers to these questions would 1. See Box 28–2.
be decided by a judge or jury. 2. The hospital tissue bank must register with the FDA as a
tissue distributer.
Review Questions 3. A decision should be made as to whether the tissue should
1. d be cultured and if so, with which method. The storage con-
2. b tainer and appropriate temperature for storage should also
3. d be decided. (Any of the AORN recommendations for harvest
4. c of autologous tissue are correct answers to this question.)
5. a
Review Questions
1. d 4. b 7. d 10. d

Chapter 28 2. b
3. c
5. b
6. c
8. b
9. d
Case 28-1
1. This tissue manufacturer must be qualified by the medical
director of the tissue bank prior to ordering any tissue.
The surgeon may consider postponing surgeries until
the vendor has been qualified or use tissue from a vendor
currently qualified.