CHAPTER 49

Blood Transfusion

MULTIPLE CHOICE QUESTIONS

11. Which  of the following is beer 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 dened as: (PGI 95)
c. Transm
Transmission
ission 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 transmied 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 aer cause hemorrhage due to: (PGI 98)
massive blood transfusion? (AIIMS May 2009) a. Increas
Increased
ed t-PA
a. Hyperkalemia b. Citrate toxicity  b. Dilutional thrombocytopenia
c. Hypothermia d. Metabolic acidosis c. Vitamin K deciency
d. Decreased brinogen
4. Fresh hold blood transfusion is done with in how much time
of collection? (DNB 2006) 15. Arterial blood gas analysis in a bole
bole containing heparin
a. Immediately b. 1 hours causes a decrease in value of:
c. 4 hours d. 24 hours a. pCO2 b. HCO 3
c. pH d. All of the above
5. Which of the following investigations should be done
immediately to best conrm a non matched blood transfusion 16. Massive blood transfusion is dened as:
reaction? (All India 2010) a. Whole blood volume in 24 hours (Recent Questions 2013)
a. Indirect Coomb’
Coomb’ss test  b. Half blood volume in 24 hours
 b. Direct Coomb’s
Coomb’s test c. 40% blood volume in 24 hours
c. Antibody in patient’
patient’ss 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. Aer  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 aer 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
prior to infusion
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
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 ow is always
always maintained c. Mannitol d. Hemacele
e. No need for stopping transfusion 21. Mismatched blood transfusion in anesthetic patient presents
10. Tr
True
ue about blood transfusions:
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
antigens  b. Hypotension and bleeding from site of wound
wound
c. Anti-d is naturally occurring antibody c. Bradycardia and hypertension
d. Cryoprecipitate contains all coagulation factors d. Ta
Tachycardia
chycardia and hypertension
 1002 Surgery Essence

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 decient 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
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 – 40°C to – 50°C
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
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 aer 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. 20-24°C for 5 days b. 20-24°C for 8 days 33. Rosenthal’s syndrome is seen in deciency of factor:
c. 4-8°C for 5 days d. 4-8°C 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

  s
aer: (PGI 88, 81, AIIMS 86)
  r a. 24 hours b. 48 hours CRYOPRECIPITATE

  e c. 72 hours d. 96 hours

34. Cryoprecipitate contains: (MCI March 2009)
   h
   t a. Factor II b. Factor V
PLASMA c. Factor VIII d. Factor IX
   O 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

   0  b. Nutritional supplement c. Factor X d. Factor VII

   1 c. Coagulation factor deciency 36. Which one

one of the following
following blood fractions
fractions is stored at
at
d. Wa
Warfarin
rfarin toxicity -40°C? (UPSC 2006)

  n e. Hypoalbuminemia a. Cryoprecipitate b. Human albumin

  o 28. True about

about FFP (Fresh frozen plasma) is the following c. Platelet concentrate d. Packed red cells
   i
   t except: (MHPGMCET 2009) 37. Cryoprecipitate contains all except: (AIIMS Nov 2007)

  c a. Good source of all coagulation factors a. Factor VIII b. Factor IX

  e  b. Prepared from single unit of blood c. Fibrinogen d. VWF

   S
 Blood Transfusion 1003

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 CQ • RBC allosensitizationQ
reaction (FNHTR
(FNHTR):): MCQ • Hepatitis GQ • HLA allosensitizationQ
• Allergic • HIV-1 and -2Q • Graft-versus-host
Graft-versus-ho st disease
• Delayed hemolyticQ • HTLV-I and -II Q
• Transfusion-related acute lung • MalariaQ
(TRALI))Q
injury (TRALI • West Nile virusQ
• Acute hemolyticQ • Parvovirus B-19Q  S 
• Fatal hemolytic • HHV-8Q  e
• Anaphylactic • CMVQ  c
t  
i  
2. Ans. c. Dengue virus  o
3. Ans. d. Metabolic acidosis (Ref: Harrison 18/e p954-956) n
• Massive transfusion can lead to coagulopathy and metabolic complicationsQ. 1 
 0 
Metabolic Complications of Massive Transfusion
 : 
General Electrolyte
 O
• Fluid overloadQ
• Hyperkalemia Q t  
h 
• HypothermiaQ • HypocalcemiaQ
 e
• Impaired oxygen delivery capacity of Hb Q
(decreased 2, 3-DPG)
•
•
HypomagnesemiaQ
Metabolic alkalosisQ
r 
 s 
• Metabolic acidosis (rare)Q

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

• Direct Coomb’s test or direct antiglobulin test 

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

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 
plasma  and • Used for acute massive bleeding,
platelets (
platelets (WBCs
WBCs and platelets
platelets may
 may be open heart surgery 
surgery  and neonatal total
non-functionalQ) exchange
Packed RBCs 180–200 • RBCs with variable leukocyte content • Increase Hb 1 gm/dL 
gm/dL  and hematocrit
and small amount of plasma 3%Q
Platelets 50–70 • 5.5 x 1010/RD unit • Increase platelet count 5000–10,000/µLQ
F FP 200–250 • Plasma proteins:
proteins: Coagulation factors, • Increases coagulation factors about
proteins C and S, antithrombin Q
proteins C 2%
Cryoprecipitate 10–15 • Cold-insoluble plasma proteins, • Topical brin glue, also  80 IU factor VIII Q
also 80
brinogen, factor VIII, vWF Q
 1004 Surgery Essence

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

Patient’s Blood group is known Patient’s Blood group cannot be determined

• Unmatched blood group of the 

the  same group • Group ‘O’
Group  ‘O’ RBCs are chosen
should be used • Such unmatched
unmatched blood should be Rh negative,
negative,
when used in women of child bearing age,
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
Complement mediated
mediated hemolysis
hemolysis is seen (Ref: Harrison 18/e p954)

• Acute hemolytic transfusion reactions following

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

  s
• D  (Rh D) on RBCsQ.
Rh positive  or negative status depends on the presence or absence of antigen D (Rh

  r • Febrile (non-hemolytic) reactions are

reactions are caused by antibodies directed against donor leucocytes and
leucocytes and HLA antigen may mediate

  e these reactionsQ.

   h
   t
11. Ans. b. Hematocrit
12. Ans. d. Whole blood volume

   O 13. Ans. c. 28 days (Ref: Sabiston 19/e p588)

  : Whole Blood

   0 Anticoagulant used Maximum storage
   1 ACD/CPD/CP2D 21 daysQ

  n CPDA-1 35 daysQ

  o
   i
(citrate phosphate dextrose adenine)
   t 14. Ans. b. Dilutional thrombocytopenia
  c
  e
15. Ans. d. All of the above (Ref: Clinical Laboratory Medicine 6/e p396)

   S Heparin Excess in Blood gas Syringe

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

Q
• Decreased PaCO 2 • Decreased pH Q
• Decreased HCO 3Q

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

According to Sabiston - Massive Blood Transfusion is dened as -
• Transfusion greater than patient’s 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
single transfusion of 2500
2500 ml or 5000 ml transfused
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)
en.wikipedia.org/wiki/Dextran)
 Blood Transfusion 1005

DEXTRAN

• It is a polysaccharide polymer of
polymer of varying molecular weight producing an osmotic pressure similar
pressure similar to the plasma
• Disadvantages:
− It induces rouleaux of RBCs and grouping and cross matchingQ procedures, hence need for a blood
RBCs and this interferes with blood grouping and
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)

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

21. Ans. b. Hypotension and bleeding from site of wound

wound (Ref:
 (Ref: Schwartz 10/e p119,122,171
p119,122,171-172,
-172, 9/e p83)

• Schwartz says “In patients who are anesthetized 

anesthetized   and have an open wound , the two dominant signs (of mismatched blood
transfusion)) are diuse bleeding and hypotension
transfusion hypotension.”.”

• MC symptom of hemolytic transfusion reactions

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

22. Ans. a. Hypokalemia

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

Hypothermia; d. Thrombocytopenia
 S 
 e
RED BLOOD CELLS
 c
24. Ans. d. 50 days (Ref: Schwartz 10/e p1914-1915, 9/e p78; Bailey 26/e p21, 25/e p21) t  
i  
 o
RED BLOOD CELLS n
• RBCs are stored at 1-60CQ; Mean life of
RBCs are RBCs is 35 daysQ.
life of transfused RBCs is 1 
 0 
 : 
Anticoagulant used Maximum storage

 O
ACD/CPD/CP2D 21 daysQ
CPDA-1 35 daysQ
t  
h 
 e
PLATELETS r 
 s 
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 mlQ
Volume:
• products which are stored at room temperature, 20-24 0 CQ (survival is 4-5 days )Q.
Platelets are the only blood products which
• platelet  increases the count by 5000-10000Q.
1 unit of platelet increases

• transfusion is 10,000/ µLQ.
The threshold for prophylactic platelet transfusion is
• For invasive procedures , 50,000/ µL platelets is the usual target level.
• Platelet count should be 1,00,000/ µL before accepting the patient for surgery.
surgery.
• Transfused platelets generally
platelets generally survive for 2-7 days following transfusion.
• ABO compatibility is
compatibility is desirable but not necessary.
necessary.

• blood are non-functional aer 24 hoursQ.

Blood platelets in stored blood are

26. Ans. a. 24 hours

PLASMA

Warfarin toxicity (Ref: Harrison 18/e p953; Sabiston 19/e p588)

27. Ans. c. Coagulation factor deciency; d. Warfarin
 1006 Surgery Essence

FRESH-FROZEN  PLASMA (FFP)

• FFP is produced from the separation

the separation of plasma from  donated bloodQ.
from donated
0 Q
• Stored at  -18 C and has a shelf
at -18 a shelf life of 1 year .
• Each unit contains 400 mg of brinogen and 1 unit activity of each of the cloing factors Q.

• Most labile cloing factors (V and be diminishedQ proportional to shelf life.

 VIII)) may be diminished
and VIII
• FFP contains stable coagulation factors and proteins: brinogen, antithrombin, albumin, proteins C and S Q.
factors and plasma proteins:

Indications for FFP

• Correction of coagulopathies: • Treatment of thrombotic thrombocytopenic
₋ Rapid reversal of warfarin Q purpuraQ
₋ Supplying decient plasma proteinsQ
• Patients who are IgA-decient and require plasma support should
support should receive FFP from IgA-decient donors to prevent anaphylaxis.

• FFP should not be routinely used to expand blood volume Q.

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

28. Ans. a. Good source of all coagulation

coagulation factors
29. Ans. c. Factors
Factors 5 and 8
30. Ans. a. It is used as volume expander
31. Ans. a. Just before operation
  s
  r The question is incomplete. It should be “A cirrhotic patient with abnormal coagulation needs cholecystectomy
cholecystectomy,, FFP should be given:”
  e
   h
   t
FRESH FROZEN PLASMA

• Transfusions with FFP

Transfusions  are given to replenish cloing factors Q.
FFP are
   O • The eectiveness of the transfusion
transfusion in
 in maintaining hemostasis is dependent on 
on  the quantity of each factor delivered and its

  :
half-life..
half-life

   0
   1
• The half-life on the most stable cloing factor , factor VII , is 4 to 6 hoursQ.
half-life on
• A reasonable transfusion scheme would be to give FFP on call  to the operating room.room.
  n • This way the transfusion is is   complete prior to the 
the  incision , with circulating factors to cover  the operative  and immediate

  o
   i
postoperative periodQ.

   t
  c 32. Ans. b. 8 hours

  e • The half life of factor VIII is 8-12 hours

hours..
   S 33. Ans. d. XI (Ref: htp://en.wikipedi
htp://en.wikipedia.org/wiki/Haemophi
a.org/wiki/Haemophilia_C)
lia_C)

• Hemophilia C (Rosenthal syndrome): Due to factor XI deciencyQ

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 brinogenQ, factor VIIIQ and von Willebrand factor (vWF) Q.

Cryoprecipitate is
• It is ideal for supplying brinogen  to the volume-sensitive patient.
• Stored at ≤-180C

• 1 unit of VIII and 250 mg of brinogenQ.

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

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

37. Ans. b. Factor IX