Transfusion Medicine, Apheresis, and Hemostasis: Review Questions and Case Studies

Transfusion Medicine, Apheresis, and Hemostasis

Review Questions and Case Studies

Edited by

Huy P. Pham

University of Alabama at Birmingham

Birmingham, AL, United States

Lance A. Williams, III

University of Alabama at Birmingham

Birmingham, AL, United States

Table of Contents

Cover

Title page

Copyright

Dedication

Contributors

About the Editors

Preface

Acknowledgment

Laboratory Reference Ranges

Chapter 1: Pretest

Abstract

Answers and Brief Explanations

Chapter 2: Statistics and General Principles of Laboratory Management

Abstract

Chapter 3: Quality Assurance and Regulatory Issues

Abstract

Chapter 4: Blood Donation and Collection

Abstract

Chapter 5: Blood Component Preparation and Storage

Abstract

Chapter 6: Blood Group Antigens and Antibodies

Abstract

Chapter 7: Pretransfusion Testing

Abstract

Chapter 8: Adult Transfusion—Principles and Practice

Abstract

Chapter 9: Patient Blood Management

Abstract

Chapter 10: Perinatal, Neonatal, and Pediatric Transfusion—Principles and Practice

Abstract

Acknowledgements

Chapter 11: Infectious Complications of Blood Transfusion

Abstract

Acknowledgments

Chapter 12: Noninfectious Risks of Transfusion

Abstract

Well-documented Indications

Recommended Indications

Nonindications

Chapter 13: Hemostasis and Thrombosis—Laboratory Diagnosis and Treatment

Abstract

Chapter 14: Therapeutic and Donor Apheresis

Abstract

Chapter 15: Special Clinical Scenarios in Transfusion Medicine and Hemostasis

Abstract

Chapter 16: Clinical Histocompatibility Testing

Abstract

Chapter 17: Cellular Therapy

Abstract

Chapter 18: Human Tissue Banking and Hospital-Based Surgical Tissue Management

Abstract

Chapter 19: Pathology Informatics

Abstract

Chapter 20: Practical and Advanced Calculations in Transfusion Medicine, Apheresis, and Hemostasis

Abstract

Chapter 21: Data Interpretation in Laboratory Medicine

Abstract

Chapter 22: Posttest

Abstract

Answers and Brief Explanations

Index

Copyright

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Notices

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Dedication

To

Our parents

Hay P. Pham and DanVan T. Hoang

and

Lawrence and Mary Williams

and

Our teachers and mentors throughout our lives

for their love and support in the undertaking of this work, for which we are deeply grateful.

Contributors

Jill Adamski,     Mayo Clinic Arizona, Phoenix, AZ, United States

Maksim Agaronov,     Kings County Hospital, Brooklyn, NY, United States

Beth M. Alden,     University of Iowa, Iowa City, IA, United States

Suzanne Arinsburg,     Icahn School of Medicine at Mount Sinai, New York, NY, United States

Evan M. Bloch,     Johns Hopkins University, School of Medicine, Baltimore, MD, United States

Michelle R. Brown,     University of Alabama at Birmingham, Birmingham, AL, United States

R. Pat Bucy,     University of Alabama at Birmingham, Birmingham, AL, United States

D. Joe Chaffin,     Blood Bank Guy Web Site (BBGuy.org), LifeStream Blood Bank, San Bernardino, CA, United States

Vishesh Chhibber,     Hofstra Northwell School of Medicine and Northwell Health, Manhasset, NY, United States

Jason E. Crane,     LifeSource Blood Center, Rosemont, IL, United States

Karen Dallas,     St. Paul’s Hospital, Vancouver, BC, Canada

Helene DePalma,     City University of New York, Jamaica, NY, United States

Emmanuel A. Fadeyi,     Wake Forest University School of Medicine, Winston Salem, NC, United States

Richard O. Francis,     New York-Presbyterian Hospital—Columbia University, New York, NY, United States

George A. Fritsma,     The Fritsma Factor, Your Interactive Hemostasis Resource, Birmingham, AL, United States

Michael D. Gautreaux,     Wake Forest University School of Medicine, Winston-Salem, NC, United States

Eric A. Gehrie,     The Johns Hopkins Hospital, Baltimore, MD, United States

Javi L. Hartenstine,     University of California, Irvine, CA, United States

Chelsea Hayes,     Cedars-Sinai Medical Center, Los Angeles, CA, United States

Jeanne E. Hendrickson,     Yale University, New Haven, CT, United States

Yen-Michael S. Hsu,     New York-Presbyterian Hospital, New York, NY, United States

Tina S. Ipe,     Houston Methodist Hospital, Houston, TX, United States

Cyril Jacquot,     Children’s National Health System and George Washington University, Washington, DC, United States

Jeffrey S. Jhang,     Icahn School of Medicine at Mount Sinai, New York, NY, United States

Susan T. Johnson,     Blood Center of Wisconsin, Marquette University, University of Wisconsin-Milwaukee, Milwaukee, WI, United States

Alesia Kaplan,     Institute for Transfusion Medicine, Pittsburgh, PA, United States

Theresa Kinard,     Mayo Clinic Arizona, Phoenix, AZ, United States

Robin G. Lorenz,     University of Alabama at Birmingham, Birmingham, AL, United States

Marisa B. Marques,     University of Alabama at Birmingham, Birmingham, AL, United States

Holli M. Mason,     Harbor-UCLA Medical Center, Torrance, CA, United States

Shanna Morgan

American Red Cross, Saint Paul

University of Minnesota, Minneapolis, MN, United States

Theresa A. Nester,     University of Washington Medical Center and Bloodworks Northwest, Seattle, WA, United States

Monica B. Pagano,     University of Washington Medical Center, Seattle, WA, United States

Mona Papari,     LifeSource Blood Center, Rosemont, IL, United States

Seung Park,     Indiana University Health, Indianapolis, IN, United States

Huy P. Pham,     University of Alabama at Birmingham, Birmingham, AL, United States

Patricia M. Raciti,     New York-Presbyterian Hospital—Columbia University, New York, NY, United States

Swati Ratkal,     Hofstra Northwell School of Medicine and Northwell Health, Manhasset, NY, United States

Ronit Reich-Slotky,     New York-Presbyterian Hospital, New York, NY, United States

Annette J. Schlueter,     University of Iowa, Iowa City, IA, United States

John Schmitz,     University of North Carolina School of Medicine, Chapel Hill, NC, United States

Joseph Schwartz,     New York-Presbyterian Hospital—Columbia University, New York, NY, United States

Salima Shaikh,     Blood Centers of the Pacific, San Francisco, CA, United States

Beth H. Shaz,     New York Blood Center, New York, NY, United States

Rance C. Siniard,     The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States

Jayanna Kay Slayten,     Indiana Blood Center SBB Program, Indianapolis, IN, United States

Christopher A. Tormey,     Yale University, New Haven, CT, United States

Mrigender Virk,     MedStar Georgetown University Hospital, Washington, DC, United States

Lance A. Williams,, III,     University of Alabama at Birmingham, Birmingham, AL, United States

Edward C.C. Wong

Children’s National Medical Center, Center for Cancer and Blood Disorders

George Washington University School of Medicine and Health Sciences, Departments of Pediatrics and Pathology, Washington, DC, United States

YanYun Wu,     Bloodworks Northwest, Seattle, WA, United States

X. Long Zheng,     University of Alabama at Birmingham, Birmingham, AL, United States

About the Editors

Huy P. Pham, MD, MPH

Dr. Pham is currently an Assistant Professor in the Department of Pathology, Division of Laboratory Medicine, and serves as the Medical Director of Apheresis at the University of Alabama at Birmingham. He also regularly attends clinical service and provides resident/fellow teaching in the Transfusion Medicine, Apheresis, and Hemostasis. With research interests in statistics, mathematical modeling, and health economics in addition to the clinical aspects of the field, he has been the lead author or senior author for many original research and review articles as well as book chapters on different topics in Transfusion Medicine, Hemostasis, Apheresis, and Cellular Therapy. Nationally, he serves on multiple professional organization committees to provide guidance for clinical practice and research direction for advancing the field. Dr. Pham is board certified in both Clinical Pathology and Transfusion Medicine. Dr. Pham received his BS with high honors in bioengineering from the University of California, Berkeley, MD from the Chicago Medical School, and MPH in Biostatistics from Columbia University. He completed his Clinical Pathology residency at the New York-Presbyterian Hospital—Columbia University Medical Center and Transfusion Medicine fellowship training at the joint program between the New York Blood Center and Columbia University Medical Center.

Lance A. Williams, III, MD

Dr. Williams is currently an Assistant Professor in the Department of Pathology, Division of Laboratory Medicine, and serves as the Medical Director of Hemostasis Laboratory at the University of Alabama at Birmingham. He is also the Director of Transfusion Medicine for the Community Pathology Practice Program, which encompasses five hospitals throughout Alabama. Dr. Williams received his BS with high honors in Biology from Longwood University and his MD with honors from Ross University. He completed residency training at East Carolina University and two fellowships—Transfusion Medicine at Yale University and Hematopathology at Virginia Commonwealth University. Dr. Williams is an award-winning teacher, known for his innovative teaching methods and his dedication to elevating students of all levels. His publications include original research articles, review articles, and books, including Quick Guide to Transfusion Medicine, second edition. Nationally, he is known as an engaging and knowledgeable speaker and he serves on many committees committed to advancing the science of Transfusion Medicine, Apheresis, and Hemostasis.

Preface

With great excitement, we present this inaugural edition of Transfusion Medicine, Apheresis, and Hemostasis: Review Questions and Case Studies. This project is the collaborative effort that spanned a time period of 2 years and included more than 50 experts, many of whom are national leaders in their respected fields. It also represents the passion and privilege we feel to teach the next generation of physicians in Transfusion Medicine and Apheresis.

The main goal for this book is to help the readers build a solid foundation of both basic and advanced conceptual knowledge to prepare for the American Board of Pathology (ABP) certification exam in Transfusion Medicine. This book is not intended to be a substitute for textbooks, original research or review articles, and/or clinical training. Further, since the field of medicine, both from a scientific and regulatory perspective, rapidly changes, the readers are advised to continuously update their knowledge by attending national meetings and reading clinical journals.

To equip the readers with the basic knowledge in critical reading and data analysis, which is an essential skill in daily medical practice, a novel chapter titled Data Interpretation in Laboratory Medicine was included in this book. In this chapter, the readers are asked to make logical conclusions based on the given data and/or statistical results. Moreover, there is also a chapter on Practical Calculations in Transfusion Medicine, Apheresis, and Hemostasis to help consolidate all the necessary formulas commonly used in daily practice for easy reference. These chapters are unique to our book and will not be found in any other currently on the market.

All of the questions in this book were originally created by the authors of each chapter. Each question can either be standalone or part of a case scenario representing challenge cases in Transfusion Medicine, Apheresis, and Hemostasis. These questions often represent both rare and common clinical scenarios that the authors have seen during their clinical practice. Each question is then followed by five possible answers, with only one being correct (or the best answer). After the question, there is a conceptual explanation followed by a more factual explanation of the right and wrong answers. We gave the individual authors the freedom to choose how they explained the wrong answer choices. Some authors chose to be more direct (e.g., Answer A is incorrect because…), while other authors chose a more conversational style [e.g., Human resources (Answer A) includes staffing, selection, orientation, training, and competency assessment of employees]. This format is designed to help the student linking the conceptual and factual knowledge together to form a solid foundation for use in clinical practice. At the end of each chapter, there is a list of articles and textbooks that will prove useful to the motivated student who wishes to become an expert in the field. Another special feature to our textbook is the presence of a pretest and posttest, which are provided to help the readers with self-assessment.

As stated above, the main focus of this book is to help the readers preparing for the ABP certification exam in Transfusion Medicine. However, due to the interdisciplinary nature of the field of Transfusion Medicine, Apheresis, and Hemostasis, we believe that this book is also beneficial to and can be used by all clinicians involved in the management of complex transfusion, apheresis, and hemostasis issues, such as hematologists, anesthesiologists, surgeons, and critical care physicians. We further believe that it is a helpful guide for these specialists to prepare for their own specialty certification exam, when the topics are related to Transfusion Medicine, Apheresis, and Hemostasis.

Although the authors and editors have aimed for perfection in content, grammar, and syntax, we are realistic enough to know that there will be errors in our book. Therefore, we created an email for the readers to alert us such mistakes or criticisms and to discuss different viewpoints, as well as to provide suggestions for the next edition of the book. Please email us at: TMQuestionBook@gmail.com.

In conclusion, we are very grateful for the opportunity given to us by Elsevier. We are also deeply dedicated to the field of Transfusion Medicine, Apheresis, and Hemostasis and the education of trainee and future leaders in the field. We hope that this book will be used to help the readers to successfully pass the board certification exams, as a teaching tool for trainees, and to enhance knowledge for daily clinical practice.

Huy P. Pham, MD, MPH

Lance A. Williams, III, MD

Acknowledgment

We, the editors, would like to acknowledge the excellent technical and professional support of Lisa Eppich, Jeffrey Rossetti, Joseph Poulouse, and many other team members at Elsevier. Each of these individuals played critical role in the creation of the first edition of this question book, and we sincerely thank them.

We would like to thank our expert contributors and the department leadership at our institution for their collaboration and support of this project. We are indebted to all our teachers and mentors for their encouragement and mentorships provided in our professional careers. We are grateful to all our students, residents, fellows, and colleagues for their questions, scientific curiosity and discussions, and intellectual stimuli. We would like to acknowledge with gratitude, the support, patient, and love of our family members, especially Dr. Pham’s parents (Hay P. Pham and Dan Van T. Hoang) and wife (Ning Jiang); and Dr. Williams’ parents (Lawrence and Mary Williams), sisters (Christy Gill and Dana McGuire), and girlfriend (Beth Lett); and both editors’ mentors (in alphabetical order: Jill Adamski, Jeffrey S. Jhang, Marisa B. Marques, Joseph (Yossi) Schwartz, Beth H. Shaz, John Smith, Edward Snyder, Steven L. Spitalnik, Christopher Tormey, YanYun Wu, and X. Long Zheng). Without their unconditional love, support, and mentorship, this project could not have come to fruition. There are also many others to thank and recognize, therefore, we offer those unnamed persons our most sincere Thank You!

Laboratory Reference Ranges

Chapter 1

Pretest

Huy P. Pham*

Helene DePalma**

Lance A. Williams, III*

*    University of Alabama at Birmingham, Birmingham, AL, United States

**    City University of New York, Jamaica, NY, United States

Abstract

This chapter provides a tool for you to evaluate your knowledge before reading the book. This will allow you to compare the knowledge you gain after completion. All topics covered in this pretest have been covered throughout the book. At the end of the book, there is a posttest to be used as a comparison of the pretest results.

Keywords

transfusion

hemostasis

cellular therapy

apheresis

This chapter provides a tool for you to evaluate your knowledge before reading the book. This will allow you to compare the knowledge you gain after completion. For the most accurate representation of your current knowledge, you should aim to complete this test within 80 min. All topics covered in this pretest have been covered throughout the book. At the end of the book, there is a posttest to be used as a comparison of the pretest results.

There are many ways to estimate the blood volume of a patient. For the purpose of this test, unless otherwise stated, please use 70 mL/kg (for adults) and 80 mL/kg (for neonates) when calculating the blood volume of a person.

Place your answers in the spaces provided. Check your answers at the end of the chapter and give yourself a final score.

Number Correct _____/Number Incorrect _____ × 100% = Final Score __________%

Please answer Questions 1–3 based on the following clinical scenario.

A 34-year-old female at 6 weeks-postpartum and without any other medical history is admitted to the emergency department (ED) with 2 days of fatigue, petechia, and dark urine. The following are laboratories drawn upon admissions: white blood count (WBC) 11,200/μL, hemoglobin (Hgb) 7.2 g/dL, platelet count 38,000/μL, unremarkable electrolytes except for Cr 2.6 mg/dL, and urinalysis showed the presence of Hgb without blood. Her LDH is 4 times the upper limit of the reference range. The blood film is shown in Fig. 1.1.

Figure 1.1   Blood film for patient in Question 1. Source: Image courtesy of Dr. Vishnu Reddy, University of Alabama at Birmingham, Birmingham, AL.

1. The ED physician would like to initiate emergent plasma exchange for the presumed diagnosis of thrombotic thrombocytopenic purpura (TTP). What laboratory test should be sent to confirm the diagnosis of TTP?

A. ADAMTS13 level drawn prior to plasma exchange

B. ADAMTS13 level drawn immediately after plasma exchange

C. ADAMTS13 level drawn 24 h after the first procedure but immediately prior to the second procedure

D. Complement levels drawn prior to plasma exchange

E. Complement levels drawn immediately after plasma exchange

2. Which of the following replacement fluid has the highest risk of citrate toxicity during a plasma exchange procedure?

A. 0.9% normal saline

B. 5% albumin

C. Lactated Ringer’s solution

D. Red blood cells (RBCs)

E. Plasma

3. After five plasma exchanges, the patient’s platelet count increased to 128,000/μL and her LDH is now within the reference range. However, her Cr continues to increase to 4.1 mg/dL. What is the best next step of management?

A. Continue with plasma exchange without any further modification

B. Continue with plasma exchange except exchanging 1.5 plasma volume instead of 1

C. Continue with plasma exchange except using cryo-depleted plasma instead of plasma

D. Stop plasma exchange and start eculizumab

E. Stop plasma exchange and start rituximab and vincristine

End of Case

Please answer Questions 4 and 5 based on the following clinical scenario.

A 23-year-old male with history of severe hemophilia A is admitted to the emergency department (ED) with joint bleeding. He weighs 90 kg. His complete blood count (CBC) shows WBC 7,200/μL, Hgb 12 g/dL, hematocrit (Hct) 37%, and platelet count 338,000/μL.

4. The ED physician requested recombinant factor VIII to treat the joint bleeding. Assuming that his initial factor VIII level is <1%, then what is the appropriate dosage to be administered?

A. 8,000 IU to achieve a goal of 100% factor VIII level

B. 8,000 IU to achieve a goal of 80% factor VIII level

C. 4,000 IU to achieve a goal of 100% factor VIII level

D. 4,000 IU to achieve a goal of 80% factor VIII level

E. 2,000 IU to achieve a goal of 80% factor VIII level

5. The patient received the appropriate dose to have his expected factor VIII level increase to ∼100%. However, the peak factor VIII level drawn approximately 30 min after administration is still <1%. What is the appropriate next step of laboratory management and treatment?

A. Perform a Bethesda assay to quantify the inhibitor and if detected, 180 μg/kg recombinant activated factor VII should be given

B. Perform a Bethesda assay to quantify the inhibitor and if detected, 90 μg/kg recombinant activated factor VII should be given

C. Perform a Bethesda assay to quantify the inhibitor and if detected, 45 μg/kg recombinant activated factor VII should be given

D. Perform a dilute Russel viper venom test to quantify the inhibitor and if detected, 90 μg/kg recombinant activated factor VII should be given

E. Perform a dilute Russel viper venom test to quantify the inhibitor and if detected, 45 μg/kg recombinant activated factor VII should be given

End of Case

Please answer Questions 6–8 based on the following clinical scenario.

A 69-year-old female admitted to the oncology unit for the treatment of acute myeloid leukemia. The patient received the standard induction chemotherapy. She is hemodynamically stable and is not currently bleeding. She also does not have any history of acute or chronic cardiac issues.

6. If the patient is medically stable, then what is the threshold for platelet transfusion?

A. Not yet determined

B. 5,000/μL

C. 10,000/μL

D. 20,000/μL

E. 50,000/μL

7. This patient’s blood type is O Rh negative. She is scheduled to receive an unrelated hematopoietic progenitor cell (HPC) transplant from an unrelated donor with a blood type of B Rh positive. Please classify the type of this HPC transplant as well as the ABO type of the blood products this patient needs to receive before the full RBC engraftment.

A. Major mismatched; O RBCs and B or AB plasma-contained products are required

B. Major mismatched; B RBCs and O plasma-contained products are required

C. Minor mismatched; O RBCs and B or AB plasma-contained products are required

D. Minor mismatched; B RBCs and O plasma-contained products are required

E. Bidirectional mismatched; O or B RBCs and B or AB plasma-contained products are required

8. For transfusion, what modification to the cellular product is required?

A. CMV negative

B. Irradiation

C. Washed

D. Negative for hemoglobin S

E. Less than 7 days old

End of Case

9. Which of the following is an advantage of using ISBT 128 labeling?

A. It allows each facility to develop its own labeling according to its preference

B. It can track donations for up to 500 years

C. It has a safety mechanism that no addition or deletion of information for autologous donor is allowed

D. It has a safety mechanism by having a built-in self-checking character

E. It has a safety mechanism that it allows only one code to be read at one time

10. What are Current Procedural Terminology (CPT) codes?

A. Used to code medical diagnoses

B. Used to code adverse events

C. Used to code the amount of time a physician spent in diagnosis and treatment

D. Used to code if a physician trainee is involved in a medical procedure

E. Used to code medical procedures

11. A 39-year-old female comes to the clinic for a preoperative assessment prior to her scheduled hysterectomy. Her CBC shows Hgb 7.2 g/dL, a mean corpuscular volume of 70 fL, and a platelet count of 167,000/μL. Her ferritin level is 6 ng/mL (reference range: 11–307 ng/mL). Which of the following statements is true regarding correcting this patient’s anemia?

A. A unit of RBC should be transfused prior to surgery to prevent intraoperative anemia

B. Blood salvage should be set up intraoperatively to prevent intraoperative anemia

C. Iron supplementation should be given to assist with RBC production

D. Vitamin B12 and folic acid should be given to assist with RBC production

E. No further management is necessary since the anemia is due to her underlying disease

12. Currently in the United States, which of the following antibodies is the most common cause of hemolytic disease of the fetus and newborn (HDFN)?

A. Anti-D

B. Anti-K

C. Anti-Jkb

D. Anti-P1

E. Anti-A,B

13. In pediatric patients with beta thalassemia major, in order to suppress ineffective erythropoiesis, what should be the Hgb goal for transfusion?

A. 15–16 g/dL

B. 13–14 g/dL

C. 11–12 g/dL

D. 9–10 g/dL

E. 7–8 g/dL

Please answer Questions 14 and 15 based on the following clinical scenario.

A 3.5-kg full term newborn with HDFN (due to anti-c) is required 2-volume whole blood exchange transfusion. The patient’s current Hct is 30%. The critical care team would like to have a reconstituted whole blood with an Hct of 50% using the freshest RBC unit possible that is lacking the c-antigen and extended crossmatched compatible with the mother’s plasma.

14. The transfusion service identifies two RBC units that may be used for whole blood reconstitution and they are CPDA-1 units (average Hct ∼70%). How much plasma should be used for this procedure of whole blood reconstitution? Please use 85 mL/kg as an estimate for a newborn’s blood volume.

A. 170 mL

B. 200 mL

C. 245 mL

D. 425 mL

E. 595 mL

15. Which of the following is a potential complication of whole blood exchange?

A. Vascular insufficiency of lower limbs

B. Seizure

C. Thrombocytosis

D. Bilirubin removal

E. Pancytopenia

End of Case

Please answer Questions 16–18 based on the following clinical scenario.

A 65-year-old woman G5P5005 admitted to the oncology unit for chemotherapy treatment of her relapsed acute myeloid leukemia (AML). For a platelet count of 7,500/μL, she was transfused with 1 unit of apheresis platelets. However, her 1-h posttransfusion platelet count was only 7,800/μL. Another unit of apheresis platelets was ordered. This time, an ABO-identical day 4 apheresis platelet unit was selected for the transfusion and 30-min posttransfusion, her platelet count went up to 8,600/μL.

16. The patient is currently stable without active signs of bleeding. In order to provide the platelets that may help her to achieve a reasonable increment as soon as possible, what is the next step of management?

A. ABO identical apheresis platelets

B. Day 1 apheresis platelets

C. Crossmatched compatible platelets

D. Apheresis platelets that are matched for the patient’s HLA-A, B, and C antigens

E. Irradiated day 7 apheresis platelets after tested negative with Pan Genera Detection (PGD) assay

17. For a platelet count of 9,700/μL, this patient is transfused with a unit of crossmatched compatible platelets. She was stable throughout the procedure without any signs or symptoms of transfusion reaction. However, about 2 h after the transfusion, she develops severe respiratory distress and was intubated. An echocardiogram was performed and did not show any left ventricular dysfunction. Her chest X-ray is shown in Fig. 1.2.

Figure 1.2   Chest X-ray.

(A) Before transfusion; (B) 2 h after transfusion. Source: Adapted from P.M. Kopko, P.V. Holland, Br. J. Haematol. 105 (1999) 322—329.

What is the most likely cause of this patient’s respiratory distress?

A. Allergic reaction

B. Anaphylactic reaction

C. Septic reaction

D. Transfusion associated circulatory overload (TACO)

E. Transfusion associated acute lung injury (TRALI)

18. Which of the following antibodies has been implicated as part of the pathogenesis of the reaction described in Question 17?

A. Anti-IgA

B. Anti-Jka

C. Anti-ADAMTS13

D. Anti-HNA (human neutrophil antigen)

E. Anti-C5

End of Case

Please answer Questions 19–21 based on the following clinical scenario.

A 29-year-old female is admitted to the hospital for an elective cholecystectomy. However, upon interviewing, she revealed that she has a history of excessive bleeding. Specifically, she usually has heavy menstruation. One time, she had prolonged bleeding after a dental surgery. She has no history of hemarthroses. She also stated that her mother and sister also tend to have heavy menstruation with easy bruising. Her current Hgb is 13.9 g/dL and her platelet count is 127,000/μL. There is no abnormality detected on the blood film. Her basic coagulation test results [prothrombin time (PT), and activated partial thromboplastin time (aPTT)] are within the reference range.

19. Based on her bleeding history and basic laboratory values, what is the most likely diagnosis?

A. Hemophilia A

B. Hemophilia C

C. Antithrombin III deficiency

D. Bernard-Soulier syndrome

E. von Willebrand disease

20. The physician ordered a von Willebrand panel. The results are as following: von Willebrand factor (vWF): 120%, Ristocetin Cofactor: 40%, and the von Willebrand multimer study shows a loss of high molecular multimer. A ristocetin-induced platelet aggregation demonstrates aggregation with both high and low dose ristocetin. What is the most likely diagnosis?

A. Type 1 von Willebrand disease

B. Type 2A von Willebrand disease

C. Type 2B von Willebrand disease

D. Type 2N von Willebrand disease

E. Type 3 von Willebrand disease

21. If the patient has bleeding during the operation, which of the following options is the best treatment modality?

A. Desmopressin

B. Recombinant vWF

C. Recombinant activated factor VII

D. Recombinant factor VIII

E. Cryoprecipitated AHF

End of Case

22. A company just developed a new medication for the treatment of TTP. They tested this medication in a clinical trial. The following are information and results from this clinical trial.

• Study question: Is the new medication better than TPE in the treatment of TTP?

• Study design: Clinical trial with subjects with TTP divided into two groups: Group 1: New medication and TPE; Group 2: TPE only

• Results: 40 subjects enrolled total, 20 in each group. The baseline characteristics were similar between the two groups. Please see Table. 1.1 for more detailed results.

Table 1.1

Detailed Results

Which of the following statements is correct regarding the clinical trial and its results?

A. The new medication should be used instead of TPE in the treatment of TTP

B. The new medication is safer than TPE

C. The new medication and TPE is safer than TPE alone

D. The new medication and TPE resulted in more exacerbation and relapse than TPE alone

E. If TPE is not available immediately, then the new medication should be used as a bridging therapy instead of plasma infusion

23. Which of the following storage temperature and length for the corresponding type of tissue used for transplant is correct?

A. Sclera at room temperature for 10 years

B. Frozen skin at room temperature for 5 years

C. Freeze dried bone at 4oC for 10 years

D. Corneas for keratoplasty at 2–8°C for 14 days

E. Cornea for procedures other than keratoplasty at room temperature for 5 years

24. A 36-year-old male received multiple fluid and blood products during resuscitation. Which of the following conditions make him suitable for a cell and tissue donation assuming that there is no preinfusion sample for infectious testing?

A. Infusion of 2 RBC units in the last 24 h

B. Infusion of 6 RBC units, 6 plasma units, and 1 apheresis platelet unit in the last 24 h

C. Infusion of 6 RBC units, 6 plasma units, and 1 apheresis platelet unit in the last 36 h

D. Infusion of 2 L normal saline in the last 30 min

E. Infusion of 1 L normal saline, 6 RBCs unit, and 4 plasma units in the last 8 h

25. Which of the following choices represent correctly the type of infectious test and its associated window period and residual risk of transfusion?

HCV, Hepatitis C virus; HIV, human immunodeficiency virus; HTLV, human T-lymphotropic virus.

26. You are providing medical support for a blood drive at a large urban college campus. There are many first-time donors from the faculty, staff, and students on campus. Which of the following blood donors would be acceptable for whole blood donation today?

A. A 17-year-old female, weight 108 lbs, Hgb 12.0 g/dL, received an HPV (human papilloma virus) vaccine 4 weeks ago

B. A 17-year-old male, weight 140 lbs, Hgb 13.5 g/dL, temperature 37.2°C, discontinued Accutane 3 months ago

C. An 18-year-old male, weight 135 lbs, Hgb 12.5 g/dL, temperature 37.7°C, received the flu vaccine 2 weeks ago, tattoo 6 months ago in an unregulated facility

D. A 48-year-old male, weight 160 lbs, Hgb 14.5 g/dL, temperature 37.1°C currently taking Finasteride

E. A 64-year-old female, weight 145 lbs, Hgb 12.5 g/dL, received shingles vaccine 6 weeks ago, spent 6 months on sabbatical in London in 1995

27. What are the most common side effects of plerixafor and G-CSF when using for HPC mobilization?

A. Diarrhea for plerixafor and bone pain for G-CSF

B. Bone pain for plerixafor and diarrhea for G-CSF

C. Nausea for plerixafor and anorexia for G-CSF

D. Anorexia for plerixafor and nausea for G-CSF

E. Fever for both plerixafor and G-CSF

28. Assuming everything else except for the conditions described in the following statements is the same, which one is correct?

A. HPC derived from bone marrow has higher risk for graft versus host disease than HPC derived from peripheral blood

B. HPC derived from peripheral blood usually has less CD34+ cells than HPC derived from umbilical cord

C. The engraftment time for HPC derived from peripheral blood is longer than from bone marrow

D. HPC derived from bone marrow tends to have the largest volume when comparing to HPC derived from peripheral blood or from umbilical cord

E. HPC derived from peripheral blood tends to have higher hematocrit when comparing to HPC derived from bone marrow

29. A 47-year-old female blood donor presents at the donor center to donate apheresis platelets. Her last apheresis platelet donation was 7 days ago. Her predonation platelet count is 177,000/μL. She reports taking aspirin yesterday for joint pain. She received a hepatitis A vaccine (HAV) 3 days ago to prepare for an upcoming trip to Thailand. Which statement is true regarding her eligibility today?

A. She is eligible to donate apheresis platelets today

B. She is eligible to donate platelets again 14 days after her last donation

C. She is temporarily deferred from platelet donation until 48 h after the aspirin dose

D. She is temporarily deferred from platelet donation until 2 weeks after the HAV vaccine

E. She is deferred from apheresis platelet donation due to her platelet count

30. In the absence of prior transfusion or pregnancy, the plasma of an individual with the Bombay phenotype will have which antibody?

A. Anti-Rh 29

B. Anti-Ku

C. Anti-Jk3

D. Anti-H

E. None of the above, no antibody would be expected

Please answer Questions 31 and 32 based on the following clinical scenario.

31. The following results are obtained with a patient’s plasma test against an antibody identification panel. Evaluate the panel results and choose the correct association with the antibody you identify and the next steps in your investigation.

CC, check cells; NT, not tested.

A. IgM alloantibody directed against an enzyme sensitive antigen/Test against an enzyme pretreated panel

B. Multiple alloantibodies/obtain an RBC phenotype and test additional selected red cells

C. IgG alloantibody associated with an antigen sensitive to DTT treatment/test against a DTT-treated panel

D. IgG alloantibody associated with a ficin sensitive antigen/test against a ficin pretreated panel

E. IgM alloantibody/proceed with neutralization using blood group substance

32. What is the purpose of adding check cells to all negative AHG tubes?

A. To ensure proper scoring of agglutination reactions

B. To ensure adequate cell washing and addition of AHG reagent

C. To check for hemolysis or reaction of complement

D. To check for attachment of an IgM antibody

E. To ensure there was no interruption during the washing steps

End of Case

33. Which of the following combinations correctly represents the antibody specificity with the expected reactivity?

34. A 67-year-old female with multiple myeloma received a unit of RBC 2 weeks ago. At that time, her antibody screen was negative. She is now presenting in the oncology clinic for follow-up. She is clinically stable and there is no evidence of hemolysis. However, her direct antiglobulin test (DAT) is positive (with anti-IgG but not with anti-C3d). Her autocontrol is also positive. Elution was performed and the eluate shows anti-E. Which of the following choices is correct?

35. Which of the following combinations represents correctly the interference of daratumumab with immunohematology tests and possible solution?

36. An adult patient’s red cells phenotype as Le(a−b+). Based on these results, which statement is correct?

A. The patient’s possible genotype is Lele Hh sese

B. The patient’s possible genotype is lele Hh Sese

C. The patient is a nonsecretor

D. The patient is not at risk to make a Lewis antibody

E. The patient is at risk to make anti-Lea, a clinically significant antibody

37. A type and screen specimen on a 37-year-old female is submitted to the blood bank. The patient’s red cells type O Rh negative. Due to suspected anemia, the clinician orders a DAT and the red cells are positive with both polyspecific and anti-IgG antiglobulin reagents. Which of the following results should the technologist always expect?

A. The ABO front and back type will not agree

B. All crossmatches will be incompatible

C. The antibody screen will always be positive by PEG IAT

D. The antibody screen will always be positive by column agglutination method

E. The weak D test and Rh control will be positive

38. What is the general recommended dose for plasma administration?

A. 1–5 mL/kg

B. 5–10 mL/kg

C. 10–20 mL/kg

D. 20–40 mL/kg

E. 40–50 mL/kg

39. What is the minimum interval between double RBC donation?

A. 2 weeks

B. 4 weeks

C. 8 weeks

D. 12 weeks

E. 16 weeks

40. You have been asked to justify the expense associated with upgrading the methodology used for type and screen testing from semiautomated gel technology to an automated platform. Which of the following is considered an indirect expense?

A. Technologist salary

B. Service contract for the automated analyzer

C. Internet service for remote troubleshooting by the vendor

D. Reagents and disposables for the automated analyzer

E. Barcode scanner for specimen input

41. A Kleihauer-Betke stain shows a result of 2% for a 28-year-old female who recently delivered at 39 weeks of gestation. Her weight is 60 kg and her recent Hct is 33%. The patient is Rh negative and the baby is also Rh negative. She received one vial of RhIG at 28 weeks of pregnancy and another vial of RhIG at 35 weeks when she was involved in a minor car accident. Which of the following combinations is correct regarding RhIG dosage and time frame for administration?

42. Transfusion-transmitted infection is an important concern in transfusion practice. Which of the following combinations is correct regarding the type of blood products associated with the highest rate of bacterial contamination and the associated fatality?

43. Which of the following situations correctly describes when a blood product can be transfused if the infectious disease markers are positive?

A. Anti-HBc repeat reactive; HBV minipool NAT negative

B. Anti-HBsAg repeat reactive; HBV minipool NAT negative

C. Anti-HBc initial reactive, duplicate testing demonstrates one nonreactive and one reactive, HBV minipool NAT negative

D. Anti-HBc initial reactive, repeat testing nonreactive on two samples; HBV minipool NAT negative

E. Anti-HCV initial reactive, duplicate testing demonstrates one nonreactive and one reactive, HCV minipool NAT negative

44. Additive solutions (AS) for blood products offer many advantages for product storage and cell viability. Which of the following statements regarding these solutions is correct?

A. AS red cells have a final hematocrit (Hct) of 55%–65%

B. Red cell additive solutions consist mainly of electrolytes and glucose

C. Platelet additive solution (PAS) is approved for both whole blood derived and apheresis platelets

D. PAS platelets have higher isohemagglutinin titers (anti-A and anti-B)

E. Mannitol is a key component of PAS

45. Blood product quality control has been submitted for your review. Based on the results provided, which product is considered a quality control failure?

A. Whole blood derived platelet with pH 6.8 and platelet count 5.7 × 10¹⁰

B. Cryoprecipitated AHF with 250 mg fibrinogen and 85 IU Factor VIII

C. Apheresis platelets with pH 6.4 and platelet count 3.3 × 10¹¹

D. Apheresis red blood cells with 70 g of hemoglobin

E. Red blood cells, leukoreduced with 5.5 × 10⁶ residual leukocytes

46. The following are HLA typing results for a family:

Father: HLA A1, –; B57, 62; DR4, 7

Mother: HLA A7, 8; B3, 7; DR15, 17

Child 1: HLA A1, 7; B3, 57; DR 7, 15

Child 2: HLA A1, 8; B7, 62; DR 4, 17

Assuming there is no crossover and child 3 is the true child of this couple, then which of the following is a potential HLA typing for child 3?

A. HLA A1, 7; B3, 62; DR 7, 15

B. HLA A1, 8; B7, 57; DR 7, 17

C. HLA A1, 8; B3, 57; DR 7, 17

D. HLA A1, 7; B3, 57; DR 4, 15

E. HLA A1, 7; B7, 57; DR 7, 15

47. Which of the following interpretations of lymphocyte crossmatch is correct?

48. The evening shift supervisor in the transfusion service of a busy tertiary care facility is retiring after 20 years of service. This a bench supervisor position with responsibility for equipment quality control, workflow coordination and review of the testing/products required for the following day’s surgical and outpatient schedules. The job description requires a minimum of 6 years’ experience with SBB certification preferred. The human resources department has identified a candidate for you to interview. Which of the following questions are you allowed to ask the candidate?

A. What childcare arrangements do you have in place to allow working an evening shift schedule?

B. What year did you graduate from high school?

C. Are you willing to provide weekend coverage?

D. What religious holidays do you celebrate?

E. Did you request any family and medical leave at your last job?

49. For which of the following issues should a blood product deviation report (BPDR) be submitted to the FDA?

A. A unit of RBCs is irradiated prior to shipment to a children’s hospital. The irradiation indicator on the product shows a successful irradiation cycle; however, the red cell expiration date was not changed prior to shipping

B. An antigen negative red cell unit is ordered by St John’s Hospital and is erroneously shipped to St Joseph’s Hospital, resulting in a service delay

C. A hospital received its shipment from their blood supplier. The packing slip states that 8 units of O Rh negative red cells were shipped; however, there are only 7 units in the box

D. A reagent quality control failure was overlooked by the novice night shift technologist. The supervisor noted the failure on the next morning and the test run is repeated before the blood products were shipped

E. Quality control is due for the refrigerated centrifuge by December 31. Due to an oversight, the QC is not performed until January 2. The blood center initiates a deviation report. No whole blood units were processed between December 31 and January 2

50. A physician from the adult hematology/oncology service contacts the transfusion service director because one of his patients was transfused a unit of RBCs that was not irradiated. He insists that the request for irradiated products was submitted when the patient was admitted; however, the transfusion service had no record of the request. The best way to investigate the nonconformance is the use of which tool?

A. Ishikawa (fishbone) diagram

B. Develop a control chart for the process

C. Prepare a run chart

D. Design a Pareto chart

E. Prepare a histogram

Answers and Brief Explanations

1. Answer: A—ADAMTS13 level should be drawn prior to plasma exchange. Refer to Chapter 14 Question 18 for more information.

2. Answer: E—Plasma, as a replacement fluid, has the highest risk of citrate toxicity in an apheresis procedure. Refer to Chapter 14 Question 4 for more information.

3. Answer: D—The patient may have atypical hemolytic-uremic syndrome (aHUS) and thus, eculizumab should be attempted. Refer to Chapter 14 Question 20 for more information.

4. Answer: C—Approximately, 4,000 IU of recombinant factor VIII will bring the patient’s factor VIII level to ∼100%. Refer to Chapter 20 Question 3 for more information.

5. Answer: B—The inappropriate response to a factor VIII administration should raise the suspicion of the presence of an inhibitor. Thus, a Bethesda assay should be performed to quantify the inhibitor level. If the inhibitor level is >5 BU, then recombinant activated factor VII should be considered (90 μg/kg). Additionally, Factor Eight Inhibitor Bypassing Agent (FEIBA) can be an alternative. Refer to Chapter 13 Questions 5 and 23 for more information.

6. Answer: C—In medically stable patients without active bleeding and acute or chronic cardiac issues, the threshold for platelet transfusion is 10,000/μL based on the AABB recommendations. Refer to Chapter 8 Question 25 and 26 for more information.

7. Answer: A—This case is an example of major mismatched HPC transplant. The patient should receive O RBCs and B or AB plasma-contained products before the full RBC engraftment. Refer to Chapter 17 Questions 9 and 11 for more information.

8. Answer: B—Irradiation should be performed for all cellular blood products (except HPC products) used for transfusions in order to prevent transfusion associated graft versus host disease (TA-GVHD). Refer to Chapter 8 Question 4 for more information.

9. Answer: D—ISBT 128 labeling has a built-in mechanism for self-checking errors through a check character intended to confirm the accurate entry of the DIN (donor identification number) when a manual keyboard entry is performed. Refer to Chapter 19 Question 9 for more information.

10. Answer: E—CPT codes are used to code medical procedures. Refer to Chapter 19 Question 19 for more information.

11. Answer: C—This patient has laboratory evidence of iron deficiency. Iron supplementation should be given to avoid the need of transfusion if the patient develops perioperative anemia. Refer to Chapter 9 Question 3 for more information.

12. Answer: E—With the routine use of Rh immunoglobulin (RhIG), HDFN due to ABO incompatibility is now the most common cause of HDFN in the United States. Refer to Chapter 10 Question 2 for more information.

13. Answer: B—Only transfusion of RBC to an Hgb goal of 13–14 g/dL can suppress ineffective erythropoiesis in pediatric patients with beta thalassemia major. Refer to Chapter 10 Question 16 for more information.

14. Answer: A—The total blood volume of this newborn is 85 (mL/kg) × 3.5 = 297.5 mL; thus, the total volume of the reconstituted unit is 297.5 × 2 = 595 mL. Since this unit must have an Hct of 50%, the volume of CPDA-1 unit must be used is 595 mL × 50%/70% = 425 mL. Therefore, the plasma volume is 595−425 mL = 170 mL. Refer to Chapter 20 Question 20 for more information.

15. Answer: A—Vascular insufficiency of the lower limbs can be a complication of whole blood exchange. Other complications are akin to the ones observed with massive transfusion. Refer to Chapter 10 Question 6 for more information.

16. Answer: C—This patient has evidence of immune-mediated platelet refractoriness. Therefore, providing crossmatched compatible platelets may be the quickest method to help her achieve a reasonable platelet count increment with transfusions. Refer to Chapter 15 Question 3 for more information.

17. Answer: E—The signs and symptoms that this patient experienced are consistent with the diagnosis of TRALI. Refer to Chapter 12 Question 19 for more information.

18. Answer: D—Anti-HNA and anti-HLA antibodies are implicated in the pathogenesis of TRALI. Refer to Chapter 12 Questions 19 and 21 for more information.

19. Answer: E—This patient’s clinical history and laboratory results suggest that she may have von Willebrand disease (vWD). Refer to Chapter 13 Questions 22 and 24 for more information.

20. Answer: C—This patient has low ristocetin cofactor comparing to the vWF antigen level. Furthermore, an abnormality in the von Willebrand multimer as well as platelet aggregation to both high and low dose of ristocetin in the ristocetin-induced platelet aggregation test are consistent with the diagnosis of a type 2B vWD. Of note, this patient also has mild thrombocytopenia, which is another feature of this diagnosis. Refer to Chapter 13 Question 24 for more information.

21. Answer: B—This patient has vWD, and thus, should be treated with recombinant vWF. Humate P, which is a factor VIII/vWF complex derived from human plasma, can also be used. Refer to Chapter 13 Questions 22–24 for more information.

22. Answer: D—The new medication and TPE (group 1) resulted in more exacerbation and relapse than TPE alone (group 2; 60% vs. 25%, respectively). This is trending toward statistical significant (P-value = 0.054). Refer to Chapter 21 for more information.

23. Answer: D—Corneas for keratoplasty should be stored at 2–8°C for 14 days. Refer to Chapter 18 Question 6 for more information.

24. Answer: A—Transfusions of blood products or infusions of colloidal or crystalloid solutions may cause a plasma dilution effect significant enough to alter the results of communicable disease testing. Postinfusion sample can be used for infectious testing if the patient (>12 year-old) receives <2,000 mL of whole blood, red blood cells, and/or colloids within 48 h or <2,000 mL of crystalloid within 1 h, or any combination. Refer to Chapter 18 Question 36 for more information.

25. Answer: B—Choice B represents the correct window period and residual risk of transfusion-transmitted infection for HIV minipool nucleic acid test (NAT). Refer to Chapter 11 Questions 32–35 for more information.

26. Answer: B—The donor meets weight and hemoglobin requirements. Accutane deferral is 1 month, therefore, sufficient time has elapsed. Refer to Chapter 4 Questions 1, 4, 13, and 14 for more information.

27. Answer: A—The most common side effects for plerixafor and G-CSF when using for HPC mobilization are diarrhea and bone pain, respectively. Refer to Chapter 17 Question 19 for more information.

28. Answer: D—HPC derived from bone marrow tends to have the largest volume when comparing to HPC derived from peripheral blood or from umbilical cord. Other choices are in reverse. Refer to Chapter 17 Question 12 for more information.

29. Answer: C—The donor is not a candidate for apheresis platelet donation today due to aspirin (defer for 48 h). Refer to Chapter 4 Questions 18 and 35 for more information.

30. Answer: D—The red cells of an individual with the Bombay phenotype (Oh) lacks the H antigen and anti-H will be detected in their plasma. Refer to Chapter 7 Question 6 for more information.

31. Answer: D—The pattern of reactivity fits anti-Fyb, an IgG antibody directed against a ficin sensitive antigen. Refer to Chapter 7 Questions 21 and 24 for more information.

32. Answer: B—Check cells ensure sufficient washing and that the AHG reagent is still active and has not been neutralized by unbound globulins. Refer to Chapter 7 Question 10 for more information.

33. Answer: E—Kell system antigens are denatured by sulfhydryl compounds, such as dithiothreitol (DTT), therefore, anti-K would not react with DTT-treated RBCs. Refer to Chapter 6 Questions 9 and 34 for more information.

34. Answer: E—This clinical scenario represents a delayed serologic transfusion reaction. A close observation (without any treatment) is all that is necessary at this time. If transfusion is clinically indicated, then the patient should receive extended crossmatched E-negative RBC units. Refer to Chapter 12 Question 10 for more information.

35. Answer: B—Daratumumab can cause panreactivity in antibody testing due to the presence of CD38 on RBC surface. DTT denatures CD38, and thus, removes the interference. Refer to Chapter 15 Question 20 for more information.

36. Answer: D—Individuals whose red cells are Le(a-b+) are not expected to make Lewis antibodies. Refer to Chapter 6 Questions 9 and 19 for more information.

37. Answer: E—Many serological complications can result when RBCs have a positive DAT; however, the only finding that will always be encountered is the weak D and Rh control, since the RBCs were coated with IgG molecules prior to the testing. Refer to Chapter 7 Question 25 for more information.

38. Answer: C—Based on the transfusion guidelines, most experts recommend the dose between 10 and 20 mL/kg for plasma transfusion. This dose of plasma would be expected to increase coagulation factors by ∼10%–20% immediately after infusion. Refer to Chapter 8 Question 15 for more information.

39. Answer: E—Sixteen weeks is the minimum interval between double RBC donation. An allogeneic donor is deferred from all types of blood donation for 8 weeks after whole blood donation. See Chapter 4 Question 6 for more information.

40. Answer: C—Internet service, utilized for multiple purposes in the laboratory, is considered overhead or an indirect expense. Refer to Chapter 2 Question 6 for more information.

41. Answer: E—Both the baby and the mother are Rh negative; thus, RhIG is not indicated in this clinical scenario. Refer to Chapter 20 Question 18 for more information.

42. Answer: C—Platelets are the blood products that have the highest rate of bacterial contamination. Most often, Gram positive bacteria are the cause. However, the fatality rate is higher when the platelet unit is contaminated with Gram negative bacteria. Refer to Chapter 11 Question 1 and Chapter 12 Question 40 for more information.

43. Answer: D—The unit collected from a donor with anti-HBc initial reactive, repeat testing nonreactive on two samples, and HBV minipool NAT negative may be used for transfusion. Refer to Chapter 11 Question 24 for more information.

44. Answer: A—AS red cells have a lower final Hct, approximately around 55%–65%. Refer to Chapter 5 Questions 6, 13, and 14 for more information.

45. Answer: E—Leukoreduced RBC units must have <5 × 10⁶ residual leukocytes. Refer to Chapter 5 Table 5.4 for more information.

46. Answer: B—From the family’s HLA typing, the father’s genotype is HLA A1, B57, DR7; HLA A1, B62, DR4. The mother’s genotype is HLA A7, B3, DR15; HLA A8, B7, DR17. HLA is inherited as haplotype; thus, HLA A1, 8; B7, 57; DR 7, 17 is a potential HLA for the next child. Refer to Chapter 16 Question 15 for more information.

47. Answer: A—Since B cells express both class I and class II HLA antigens while T cells only express Class I HLA antigen, a positive leukocyte crossmatch with both T and B cells means that there is a Class I ± Class II antibody presence in the serum. Refer to Chapter 16 Question 2 for more information.

48. Answer: C—Interview questions that could potentially discriminate against age, sex, religion, or other factors are not allowed. Refer to Chapter 2 Questions 7 for more information.

49. Answer: A—Incorrect labeling, such as an expiration date, on a product that is shipped out of the facility is an example of an error that would require filing a BPDR with the FDA. Refer to Chapter 3 Question 24 for more