6 TRANSFUSION REACTIONS Flashcards
(1) A patient had a transfusion reaction to packed RBCs. The MLS began the laboratory investigation of the transfusion reaction by assembling pre- and post-transfusion specimens and all paperwork and computer printouts. What should the MLS do next?
A. Perform a DAT on the post-transfusion sample
B. Check for clerical error(s)
C. Repeat ABO and Rh typing of patient and donor units
D. Perform an antibody screen on the post transfusion sample
B. Check for clerical error(s)
Over 90% of transfusion reactions are caused by some type of clerical error. The most time-saving approach would be to check all paperwork before performing any laboratory testing.
(2) What is the pathophysiological cause surrounding anaphylactic and anaphylactoid reactions?
A. Antibody in patient’s serum is detected 3 to 7 days after transfusion and is attached to donor RBCs
B. Donor plasma has reagins (IgE or IgA) that combine with allergens in patient’s plasma
C. Patient is deficient in IgE and develops IgE antibodies via sensitization as a result of transfusion or pregnancy
D. Patient is deficient in IgA and develops IgA antibodies via sensitization as a result of transfusion or pregnancy
D. Patient is deficient in IgA and develops IgA antibodies via sensitization as a result of transfusion or pregnancy.
Anaphylactic or anaphylactoid reactions are the most severe form of allergic transfusion reaction and are associated with deficient or absent IgA in the patients, allowing the formation of anti-IgA. These patients must be transfused with washed cellular products where the plasma has been removed.
(3) A patient has a hemolytic reaction to blood transfused 8 days ago. What is the most likely cause?
A. Immediate, nonimmunologic, probably as a result of volume overload
B. Delayed immunologic, probably as a result of an antibody such as anti-Jka
C. Delayed nonimmunologic, probably as a result of iron overload
D. Immediate, immunologic, probably as a result of clerical error, ABO incompatibility
B. Delayed immunologic, probably as a result of an antibody such as anti-Jka
A transfusion reaction that occurs several days after a transfusion of blood products is probably a delayed immunologic reaction as a result of an antibody formed against donor antigens. This is a classic example of a reaction caused by an antibody, such as anti-Jka
(4) What may be found in the serum of a person who is exhibiting signs of transfusion-related acute lung injury (TRALI)?
A. RBC alloantibody
B. IgA antibody
C. Antileukocyte antibody
D. Allergen
C. Antileukocyte antibody
TRALI is associated with antibodies to human leukocyte antigens or neutrophil antigens, which react with the patient’s granulocytes and cause acute respiratory insufficiency.
(5) Which type of transfusion reaction occurs in about 1% of all transfusions, results in a temperature rise of greater than 1°C above 37°C associated with blood component transfusion, and is not related to the patient’s medical condition?
A. Immediate hemolytic
B. Delayed hemolytic
C. Febrile nonhemolytic reaction
D. TRALI
C. Febrile nonhemolytic reaction
FNHTR is defined as a rise in temperature of greater than 1°C above 37°C, associated with transfusion and unexplained by other causes. The patient has formed antibodies to HLA, which reacted with donor cells and resulted in release of pyrogens.
(6) What would be the result of group A blood given to a group O patient?
A. Nonimmune transfusion reaction
B. Immediate hemolytic transfusion reaction
C. Delayed hemolytic transfusion reaction
D. Febrile nonhemolytic transfusion reaction (FNHTR)
B. Immediate hemolytic transfusion reaction
Group A blood given to a group O patient would cause an immediate hemolytic transfusion reaction because a group O patient has anti-A and anti-B antibodies and would destroy A cells.
(7) Patient DB received 2 units of group A-positive RBCs 2 days ago. Two days later, he developed a fever and appeared jaundiced. His blood type was A positive. A transfusion reaction workup was ordered. There were no clerical errors detected. A post-transfusion specimen was collected and a DAT performed. The DAT result was positive with monospecific anti-IgG. The plasma was also hemolyzed. An antibody screen and panel studies revealed the presence of anti-Jkb in the post transfusion specimen. The antibody screen on the pretransfusion specimen was negative. Which of the following explains the positive DAT?
A. The donor cells had a positive DAT
B. The donor cells were polyagglutinable
C. The donor cells were likely positive for the Jkb antigen
D. The recipient cells were likely positive for the Jkb antigen
C. The donor cells were likely positive for the Jkb antigen
This is an example of an anamnestic reaction, where the patient was most likely exposed to the Jkb antigen at some point in his life, and upon re exposure to the antigen, the antibody titer rose to detectable levels. This resulted in positive DAT and post-transfusion antibody screen results.
(8) All of the following are part of the preliminary evaluation of a transfusion reaction, except:
A. Check pre- and post-transfusion samples for color of serum
B. Perform ABO and Rh recheck
C. Perform DAT on the post-transfusion sample
D. Perform a panel on pre- and post-transfusion samples
D. Perform a panel on pre- and post-transfusion samples
The preliminary evaluation of a transfusion reaction includes checking the color of serum and performing ABO and Rh checks and DAT on the post-transfusion sample. A panel would not be part of the preliminary workup.
(9) A 68-year-old female diagnosed with neutropenia and inflammation of the left hand was typed as A positive and received 1 packed RBC unit. The antibody screen was negative, and crossmatch was compatible. During the transfusion, her pulse was 94, and blood pressure (BP) rose from 114/59 mm Hg to 132/64 mm Hg. Temperature rose from 37.1°C before transfusion to 37.8°C 60 minutes after starting transfusion and then to 38.3°C upon completion. A post-transfusion specimen yielded plasma that was neither hemolyzed nor icteric, and a negative DAT. Post-transfusion urinalysis showed 1+ blood and protein with 10 RBCs/high-power field (hpf) microscopically. The clerical check result was acceptable. What type of reaction most likely occurred as a result of transfusion?
A. Allergic
B. Circulatory overload
C. Febrile nonhemolytic
D. Delayed hemolytic
C. Febrile nonhemolytic
The temperature rose from 37.1°C to 38.3°C. The DAT result was negative, and although blood was found on the urinalysis, microscopic RBCs were also found. Because intact RBCs are not caused by a transfusion reaction, the cause of hematuria was not likely transfusion related. A febrile nonhemolytic reaction is highly consistent with both symptoms and post-transfusion test results.
(10) . A 92-year-old male diagnosed with anemia and episodes of frequent falling was typed as B negative and transfused with 1 unit of packed RBCs, also B negative. He had not been recently transfused, and the antibody screen was negative. During the transfusion, his temperature rose from 36.2°C to 36.4°C, his pulse from 96 to 124, respirations from 18 to 20, and BP from 127/81 mm Hg to 174/83 mm Hg. He was transfused with 205 mL before a reaction was called by the transfusionist. The post-transfusion specimen DAT result was negative, and the clerical check result was acceptable. Urinalysis showed 1+ blood with 5 RBCs microscopically. Other symptoms included tachycardia and flushing. What reaction had most likely taken place?
A. Febrile nonhemolytic
B. Acute hemolytic
C. Anaphylactic
D. Volume overload
D. Volume overload
The tachycardia, increased pulse, and volume transfused before a reaction was called are consistent with volume overload. The temperature change did not meet criteria for a febrile reaction, and evidence for a hemolytic reaction is lacking.
(11) A 76-year-old female diagnosed with urosepsis was transfused with 2 units of packed RBCs. Her type was AB positive and she had a negative result on antibody screen. The units transfused were AB positive. Upon receiving the second unit, the patient became hypoxic with tachypnea. The clerical check result was acceptable, and the DAT was negative. She received 269 mL from the second unit before a reaction was called. Her temperature fell from 38°C to 36.4°C, her pulse increased from 72 to 90, and respirations rose from 35 to 41. Her BP was 110/70 mm Hg. The patient die approximately 12 hours after the reaction was called. What type of reaction was most likely present?
A. Febrile
B. Symptoms not related to transfusion
C. Allergic
D. TRALI
B. Symptoms not related to transfusion
This case emphasizes the statistic that not all causes of death are related to transfusion. The temperature dropped ruling out a febrile reaction; there was no evidence of pulmonary edema or hypotension seen with TRALI (and plasma products are more associated with TRALI compared with RBCs); and there was no sign of hives or itching, which are often associated with an allergic reaction.
(12) A 52-year-old male received 2 units of packed RBCs as an outpatient in the intravenous (IV) therapy unit. He had had a head trauma 20 years ago and was quadriplegic. He had recurrent pneumonia and hematuria as a result of removal of a Foley catheter. His blood type was A positive, with previously identified anti-Fya. There was an ABO discrepancy, in that reverse typing with reagent A1 cells was positive. The MLS attributed this reaction to Fya antigen being present on the reagent A1 cells. The patient also had a cold autoantibody. Two units of A-positive packed cells were crossmatched that were Fya negative and were compatible. One unit was transfused at 11:30 a.m. without incident. The second unit was transfused at 2:16 p.m. and stopped at 3:55 p.m. because of reddish brown–tinged urine found in his collection bag. A post-transfusion specimen yielded a positive DAT and plasma that was grossly hemolyzed. A prewarm crossmatch was incompatible in both the pre- and post-transfusion specimens. Anti-E and anti-c were present in the post-transfusion specimen. What reaction was most likely present?
A. Acute hemolytic
B. Febrile
C. Allergic
D. TRALI
A. Acute hemolytic
This case represents an acute hemolytic reaction where the patient had previous sensitization to E and c antigens. Given the history of anti-Fya, an assumption was made that anti-Fya was the cause of the positive reverse type with A1 cells, even though this antibody does not react at the IS phase. This brings to light the importance of running a panel whenever the patient has a positive antibody screen, regardless of previous results. Hemoglobinuria, a positive DAT, and the hemolyzed post-transfusion specimen all are consistent with an acute hemolytic reaction.
(13) An 82-year-old male was admitted for renal failure. His type was B positive, and his antibody screen was negative. Two units of RBCs were ordered. The first unit was transfused at 1:00 p.m. without incident. The second was started at 4:15 p.m. and stopped at 5:12 p.m. after the nurse observed that the patient had died. Vital signs had been taken at 4:30 p.m with no abnormalities. A transfusion reaction was called and the blood unit, tubing, and paperwork sent to the blood bank. There were no clinical manifestations noted on the paperwork, and no post-transfusion specimen was sent to the blood bank. What type of reaction most likely occurred?
A. Cause not related to transfusion
B. Acute hemolytic reaction
C. Anaphylactic reaction
D. Volume overload
A. Cause not related to transfusion
This example represents a situation where the pathologist was not provided with all information needed to interpret the reaction. There was no information on patient symptoms, the patient had received another unit of RBCs hours previously with no problems, and a postreaction specimen was not collected. Therefore, any serological abnormalities could not be identified. The U.S. Food and Drug Administration (FDA) recommends collecting a postmortem specimen if a reaction is called so that the investigation of transfusion reaction can be completed. In this case, the pathologist interpreted the reaction as not related to transfusion because no symptoms were documented.
