Transfusion Questions

Antibody panels should be familiar to you from part 1 of the exam - and the revision transfusion course run by NHSBT should give you a good refresher on these. As with HPLC interpretation, it would be good to time yourself on identifying the antibody, as a possible viva question could involve data interpretation within a short space of time. Please see the files below for practice questions to become familiar with antibody panels again, and otherwise here are some other questions to answer for the short answer paper:

Question 1.

A 18 week pregnant woman has had her booking blood tests and stated that she is a Jehovah's Witness. Her booking bloods show the following:

Hb 102g/L, MCV 67fl, MCH 21, WCC 9.2x10^9/L, Plt 170x10^9/L

a) Outline briefly further investigations you may request for this lady.

b) Come up with a management plan given the results above, and a peri-delivery plan.

Question 2.

Give recommendations for the blood products you would require for a patient with the following history (choose the single best option):

a) Hodgkin's disease patient with diagnosed HIV undergoing chemotherapy (red cells)

b) Pregnant woman at 30 weeks' gestation with a history of sickle cell disease having exchange transfusions prior to delivery (red cells)

c) Pregnant woman with a planned intrauterine transfusion, previous history of being CMV negative (red cells)

d) Multiply transfused thalassaemia patient with anti-Jkb antibodies (red cells)

e) Allogeneic stem cell transplant patient prior to engraftment (donor A RhD+, recipient O RhD-) - (FFP and platelets)

f) Neonatal transfusion in a septic baby who has not previously had an intrauterine transfusion (red cells)

g) Autologous stem cell transplant patient (mini-BEAM) with lymphoma with previous R-bendamustine and ESHAP therapy (red cells)

h) Myeloablative allogeneic stem cell transplant patient for leukaemia five days prior to the start of conditioning. Donor group A RhD+, recipient B RhD+. (red cells)

Question 3.

A 33 year old patient with sickle cell disease (HbSS) on hydroxycarbamide attends hospital with a vaso-occlusive crisis and has saturations of 88% on air. The decision is made to perform a manual exchange transfusion on the patient. He has a historic red cell phenotype of O C-c+D+E+e- K-k+.

Baseline Hb from historical results: 72g/L, bilirubin 20umol/L

Pre-exchange: Hb 60g/L, WCC 9.2x10^9/L, Plt 460x10^9/L

Post-exchange: Hb 90g/L, WCC 7.4x10^9/L, Plt 380x10^9/L

a) Comment on the results above.

b) Outline two possibilities of his Fisher-Race notation.

c) 12 hours later he is breathless, and a chest radiograph was unremarkable with no evidence of consolidation or lung infiltrates. Repeat blood tests were taken:

Hb 52g/L, WCC 12.3*10^9/L, Plt 400X10^9/L, DAT negative, bilirubin 86umol/L, LDH elevated (512)

Comment on the results, suggest differentials and recommend a management plan.

Question 4.

A 72 year old man with low risk MDS has attended the day unit for five years and is transfusion dependent, and has two units of red cells every four weeks, with minimal symptoms related to his disease. Notably on his annual review his ferritin was 2846 and transferrin saturations >90%. You decide to offer him a chelation agent to control the iron overload.

a) State how much iron is contained in an average unit of red cells transfused.

b) Identify the main types of chelation agents available with their advantages and disadvantages; mode of administration; and state the side effects and monitoring required.

Question 5.

A two month old baby is brought into the Emergency Department with anaemia, He was previously treated on neonatal ITU for jaundice, diagnosed as ABO haemolytic disease of the newborn and was discharged with a slightly low FBC, but was otherwise well and the parents had no concerns with him until the presentation back in hospital today. The baby's mother volunteers that she has been unwell and has a past medical history of type I diabetes and a splenectomy. You request an urgent blood film today.

Blood film: numerous spherocytes present, mild lymphocytosis

Hb 33g/L, reticulocytes 0.6%, WCC 15.2x10^9/L, lymphs 10.5x10^9/L, platelets 256x10^9/L, bilirubin 88umol/L

a) Suggest possible diagnoses.

b) Why is it medically safe to transfuse on a historic group (assuming all the identifiers - name, date of birth and hospital number) are correct?

c) Results of DAT show that the reaction is IgG negative, C3d negative. Suggest any further investigations you may wish to request, the likely diagnosis and management plan.

Question 6.

A 54 year old patient with a gastrointestinal bleed after a hemicolectomy is rushed back to theatre. Post-operative bloods shortly after the hemicolectomy about two hours ago showed the following, with repeat bloods just prior to returning to theatre awaited.

a) Outline four components that cryoprecipitate might be used to replace.

b) His blood results showed the following:

Hb 65g/L, MCV 90fl, WCC 12.8x10^9/L, Platelets 85x10^9/L

PT 18s (NR 9-13s), APTT 39s (NR 25-35s), fibrinogen 0.7g/L

Suggest what would be appropriate blood products to offer this patient, and in what doses.

c) Unfortunately, in spite of appropriate blood product ratios offered, the patient continues to bleed. Outline possible alternatives, with potential risks.

Question 7.

Regarding apheresis:

a) state the appropriate exchange replacement fluid for patients with symptomatic hyperviscosity secondary to lymphoplasmacytic lymphoma.

b) list three indications for the use of emergency red cell exchange.

c) in sickle cell disease, list three reasons for elective red cell exchange

d) state the target HbS% for patients undergoing elective red cell exchanges for primary or secondary stroke prevention.

e) What are some of the symptoms of citrate toxicity and its management?

Question 8.

A 31 year old Japanese woman in her second pregnancy attends your clinic at the end of her first trimester having been referred from the midwife, with concerns of 'low platelets' in her first child at birth. She describes that her baby had a rash which settled after a few weeks and was monitored by the paediatricians, but she said she was fine throughout the pregnancy. She denies any previous history of transfusions, and otherwise her previous pregnancy was unremarkable.

Mum's FBC was noted to be normal. Hb 110g/L, MCV 80fl, WCC 5.7x10^9/L, Plt 240x10^9/L, as was her coagulation screen.

a) You suspect NAIT. Outline the methodology in PIFT and MAIPA testing.

b) Outline a management plan for this lady leading up to delivery.

Question 9.

Outline in brief the functions of the following bodies:

a) Hospital transfusion committee

b) SHOT

c) MHRA

d) NBTC

e) SABRE

f) A 'never' event of an ABO incompatible transfusion has occurred in your hospital. State the transfusion bodies that need to be involved in the reporting of the incident.

Question 10.

A patient with leukaemia was transfused with a pool of platelets prior to a Hickman line insertion in preparation for the second cycle of chemotherapy. They were well and did not have any fevers, and was well throughout and after the transfusion.

Group O R1r, K-

Hb 94g/L, WCC 2.5x10^9/L, neuts 1.6x10^9/L, Plt 35x10^9/L (pre transfusion), Plt 56x10^9/L post transfusion

a) State the Rh antigens in full that this patient will have.

b) What ABO and Rh group platelets would be suitable for this patient? Blood bank have reported that they do not have O RhD+ platelets available for this lady.

c) A repeat FBC on admission to hospital a week later showed Hb 92g/L, WCC 3.4x10^9/L, neuts 1.6x10^9/L, Plt 5x10^9/L. She describes a rash on her calves and some blood blisters in her mouth. State the possible diagnoses.

d) Briefly describe the pathophysiology of PTP.

When you have finished with the questions, please see the answers on this page (Transfusion answers). The answers for the antibody panels are in a separate file as marked below.