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130 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
C. 50%
D. 70%
E. 92%
B. Many studies and most experts believe a target S hemoglobin of 30% or less is an
effective prophylaxis against stroke. In the first STOP trial, patients receiving regular
transfusions to keep their hemoglobin S below 30% experienced a 92% lower rate
of developing an initial stroke compared to those with standard therapy. Given the
risks associated with chronic transfusion, alternatives to transfusion have been con-
sidered. A trial of using hydroxyurea (SWiTCH Trial) attempted to address the issue
of excessive iron overload in these patients, but was stopped early after failing to
show any significant benefit of hydroxyurea over standard therapy.
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Question 17: What diagnostic modality is currently believed to be the most sensi-
tive in predicting stroke risk in sickle cell patients?
A. Transcranial Doppler ultrasound.
B. Magnetic resonance imaging.
C. Magnetic resonance angiography.
D. Chest x-ray.
E. Family history.
A. Transcranial Doppler ultrasound is a very sensitive predictor of stroke risk, often
demonstrating abnormal results before such results are evident with magnetic reso-
nance angiography. The most effective use of transcranial Doppler seems to be as a
screening tool for abnormalities, followed by magnetic resonance angiography.
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Question 18: Prophylactic transfusion of sickle cell patients is generally agreed to
be effective in which of the following situations?
A. Prevention of early first trimester pre-term labor.
B. Prevention of intrauterine growth retardation.
C. Prevention of pulmonary infarction in elective surgery patients.
D. Prevention of complications in vitreoretinal surgery.
E. Prevention of complications in pediatric surgery.
D. There is much controversy over the effectiveness of prophylactic transfusion in
preventing complications in pregnancy and surgery. Most experts agree, however,
that transfusion to minimize hemoglobin S is beneficial in preventing complications
that may arise with vitreoretinal surgery. There is some consensus that although
aggressive minimization of hemoglobin S levels may or may not be beneficial, it is
SPECIAL TRANSFUSION SITUATIONS 131
useful to ensure adequate hydration and normalization of anemia in sickle cell
patients following surgery.
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夝
Question 19: Which of the following statements regarding massive transfusion is
true?
A. Defined as a full blood volume replacement within 48 hours.
B. Extremely rare incidence of coagulopathy.
C. Despite replacement of entire calculated red cell volume up to 1/3 of original
blood volume remains.
D. No role for Cryoprecipitated AHF.
E. Measuring platelet counts 15 minutes after transfusion is not recommended for
monitoring.
C. Models of blood loss predict that over one-third of the original blood volume
probably remains despite replacement of the entire red cell volume. Massive trans-
fusion can be defined in a number of ways, the most common being the replace-
ment of at least the full blood volume within 24 hours. Due to a complex
mechanism beyond just the loss of factors due to hemorrhage, there is often a coag-
ulopathy associated with massive transfusion. Monitoring of coagulation indices
including PT, PTT, and fibrinogen levels in addition to platelet levels is essential for
patient management. Cryoprecipitated AHF has a definite role in massive transfu-
sion if the fibrinogen levels decrease to 80 to 100 mg/dL.
________________________________ ________________________________
夝
Question 20: Which of the following scenarios is NOT an appropriate indication for
a platelet transfusion?
A. A patient undergoing a general surgery or invasive procedure with a platelet
count of less than 50,000/L.
B. A patient undergoing ophthalmic or neurosurgery with a platelet count of less
than 100,000/L.
C. A bleeding patient who has a congenital or acquired platelet function defect.
D. A patient who underwent cardiothoracic surgery and continues to have signifi-
cant chest tube drainage despite a relatively normal platelet count on CBC.
E. A patient who demonstrates platelet refractoriness.
E. Generally, therapeutic platelet transfusion for patients who may be undergoing an
invasive procedure is more liberal than prophylactic platelet transfusion for non-
bleeding, stable patients. Transfusion goals (platelet counts) differ depending on the
potential site for bleeding. A site such as the eye, brain, or lung would experience
devastating results from an acute hemorrhage. As a result, platelet counts greater
132 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
than 100,000/L are often encouraged. Refractoriness alone is not a sufficient rea-
son for platelet transfusion.
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夝
Question 21: What would be the expected incremental increase in platelet count
after transfusion of a single apheresis platelet unit to an otherwise healthy adult?
A. 1,000 to 5,000.
B. 10,000 to 20,000.
C. 30,000 to 50,000.
D. At least 100,000.
E. 100,000 to 300,000.
C. The most accurate way to determine if a platelet transfusion produces an ade-
quate response is through the calculation of the corrected count increment (CCI).
Calculation of the CCI involves multiplying the ratio of the change in platelet counts
to the number of platelets transfused by the patient’s body surface area. Calculating
the CCI at 10 minutes to 1 hour after transfusion will provide an insight into whether
the patient achieved an adequate response (CCI greater than 5,000) or not.
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Question 22: What is the primary cause of immunologic platelet refractoriness?
A. Recipient D antibodies.
B. Recipient ABO antibodies.
C. Recipient HPA-5b antibodies.
D. Recipient HPA-1a antibodies.
E. Recipient Class I HLA antibodies.
E. Although not exclusive, the vast majority of platelet refractoriness is thought to be
due to recipient Class I HLA antibodies. A significant reduction in the development
of platelet alloimmunization and immune-mediated refractoriness has been demon-
strated in universally leukocyte-reduced platelets, highlighting a potential benefit of
universal prestorage leukocyte reduction.
________________________________ _______________________________
夝
Question 23: Which disorder shares many characteristics with posttransfusion pur-
pura?
A. Sickle cell anemia.
B. Neonatal alloimmunine thrombocytopenia.
SPECIAL TRANSFUSION SITUATIONS 133
C. Hermansky-Pudlak syndrome.
D. Heparin-induced thrombocytopenia.
E. Idiopathic thrombocytopenic purpura.
B. NAIT and PTP are similarly caused by immunization to the HPA-1a antigen on
platelets. In the case of NAIT, it is an alloimmunization that acts as an alloantibody
and results in destruction of neonatal platelets. In PTP, it is an alloimmunization to
infused platelets that results in destruction of both the transfused platelets as well as
the patient’s own “bystander” platelets.
________________________________ ________________________________
夝
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In: Leonard G, Licata M.
Practical Self-Assessment for Transfusion Medicine Professionals
Bethesda, MD: AABB Press, 2012
12
Transfusion Emergencies
QUESTIONS
Question 1: Acute blood loss is classified according to percentage of total blood
loss. Which of the following is a symptom of >40% total blood loss?
A. Tachycardia >100 bpm.
B. Tachypnea.
C. Markedly decreased (or absent) urinary output.
D. Cool/clammy skin.
E. Mild anxiety.
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Question 2: In acute hemorrhage, which has the highest priority?
A. Transfusion of red cells.
B. Transfusion of fresh whole blood.
C. Volume replacement with crystalloids.
D. Volume replacement with plasma.
E. Coagulation factor replacement.
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Question 3: What is a good rule of thumb for volume of crystalloid needed to
restore intravascular volume?
A. 1 volume crystalloid to 1 volume blood loss.
B. 1 volume crystalloid to 3 volumes blood loss.
C. 3 volumes crystalloid to 1 volume blood loss.
D. 10 volumes crystalloid to 1 volume blood loss.
E. 1/2 volume crystalloid to 1 volume blood loss.
140 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
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Question 4: What component of lactated Ringer’s solution makes it incompatible to
run in the same line as blood components?
A. Lactate.
B. Potassium.
C. Calcium.
D. Ammonia.
E. Citrate.
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夝
Question 5: If uncrossmatched blood is issued for emergency release what is the
most important reason that the incomplete portions of the compatibility testing be
performed?
A. Antibody determination.
B. Antigen determination.
C. Rh determination.
D. ABO determination.
E. Accurate record keeping for inspection purposes.
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Question 6: What antibody is of most concern when giving non-matched O-nega-
tive RBC units?
A. Anti-c.
B. Anti-A.
C. Anti-D.
D. Anti-E.
E. Anti-M.
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Question 7: Approximately what percentage of Rh-negative recipients will generate
an anti-D after receiving more than 200 mL of Rh-positive RBCs?
A. 5%
B. 25%
C. 50%
D. 85%
E. 100%