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Answer Key

Chapter 1 Chapter 5
Review Questions Case 5-1
1. c 6. c 11. b 16. a 1. No. Adding check cells to all tubes negative at the AHG
2. c 7. d 12. d 17. d phase provides a quality-control measure to the test. The
3. b 8. d 13. d 18. c expected result is positive agglutination. A negative result
4. c 9. a 14. c 19. c deems our test invalid.
5. d 10. a 15. c 20. a 2. The blood bank tech is required to repeat the test, starting
from step 1.
3. The most likely cause is failure to adequately wash cells
after the incubation phase.
Chapter 2 4. Failing to add AHG reagent is also common; AHG reagent
that has failed QC or is expired should never be used for
Review Questions patient testing.
1. b 5. d 9. c 13. a Case 5-2
2. b 6. d 10. a 14. a
3. c 7. b 11. b 15. c 1. Yes.
4. d 8. a 12. a 2. The initial antibody screen gel reaction is positive but
may be demonstrating a method-dependent antibody.
Some antibodies, both specific and nonspecific, have the
ability to demonstrate method dependency. The results
Chapter 3 show reactivity in one method but not others. The nega-
tive reactions in the LISS panel confirm the prediction of
Review Questions the method-dependent antibody.
3. The use of PCR technology to genotype the patient might
1. a 7. b 13. d 19. a
be useful in situations of method-dependent antibodies.
2. c 8. c 14. c 20. b
It should also be noted in the patient’s record that future
3. b 9. d 15. a 21. d
testing should be conducting using the LISS method.
4. d 10. c 16. b
5. d 11. a 17. c Review Questions
6. c 12. a 18. d
1. d 5. b 9. b 13. a
2. c 6. b 10. a 14. b
3. a 7. d 11. c 15. c
Chapter 4 4. a 8. a 12. c 16. b

Review Questions
1. a 5. d 9. c 13. c
2. c 6. a 10. b
3. c 7. d 11. b
4. b 8. d 12. d

601
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602 Answer Key

Chapter 6 Case 7-2

1. The patient’s ABO, Rh type is O Rh-positive. The antibody
detection test (screen) is positive. NOTE: In this case
Case 6-1
study, antibodies are excluded only if the patient’s serum
1. The results indicate an ABO discrepancy in the reverse does not react with panel cells that possess a double-dose
grouping since there is only a 2+ reaction with the reagent expression of the antigen (from a donor with homozygous
A1 red cells. Normally, ABO forward and reverse testing expression).
show strong 3+ to 4+ reactions. 2. Anti-c, anti-E, and anti-K on a double-dose cell (K+k-).
2. Since the antibody screen was negative, the blood bank 3. Test the patient’s serum or plasma against selected cells
technologist proceeded to type the patient’s RBCs with that are c-E+K- and c-E-K+ and phenotype the patient’s
anti-A1 lectin, Dolichos biflorus. This was decided because, RBCs.
based on the negative antibody screen and patient history, 4. DCe/DCe (R1/R1), DCe/dCe (R1/r’)
an alloantibody was most likely not causing the ABO 5. k
discrepancy. 6. Confirm the patient has an anti-c and her red cells lack
3. The reaction with anti-A1 lectin indicates the patient’s the c antigen. Now that we know the patient is K+, we
cells are not type A1. The additional serum studies show do not need to run additional selected cells to rule
that the antibody is not directed toward a possible alloan- anti-K out.
tibody reacting at room temperature and that the antibody 7. Anti-E is difficult to rule out in the presence of anti-c
is not anti-A, in that only anti-A would react with A2 cells. because a D+C+c-E+e- (DCE/DCE or RzRz) individual
If a cold autoantibody or alloantibody was causing the occurs in less than 1% of the population
discrepancy, the patient’s serum would likely react with
the reagent O cells. Case 7-3
Results indicate the patient is a likely group A2 and
1. The patient’s ABO, Rh type is interpreted as A Rh-negative,
has formed an anti-A1.
and the antibody detection test (screen) is negative, indi-
4. During surgery, the OR ordered 2 units of packed RBCs.
cating no unexpected antibodies present in her plasma.
Two type O–positive packed RBCs were crossmatched
2. DCe/dce (R1r) or Dce/dCe (R0r’)
with the patient serum and found to be compatible. Only
3. DCe/dce (R1r) is most probable; however, if the patient
1 unit was transfused without episode. The patient was
has weakened expression of RhD due to C in Trans to
discharged 4 days later.
RHD, she could possess the Dce/dCe (R0r’).
In this case, there was an ABO discrepancy caused by
anti-A1 in the reverse grouping. Although anti-A1 is Review Questions
considered to be nonreactive at 37°C, it was decided to
transfuse type O–positive cells to this patient since there 1. a 4. a 7. d 10. c
was ample supply. 2. c 5. c 8. c 11. d
3. b 6. c 9. e 12. c
Review Questions
13.
1. d 4. b 7. a 10. b R1r DCe/dce Rh:1,2,-3,4,5
2. a. 5. c 8. a R2R0 DcE/Dce Rh:1,-2,3,4,5
3. d. 6. b 9. c RzR1 DCE/DCe Rh:1,2,3,-4,5
ryr dCE/dce RH:-1,2,3,4,5
(see Table 7–3)
Chapter 7 14.
15.
d
b
Case 7-1 16. d
1. The patient’s ABO, Rh type is O Rh-negative. 17. a
2. Both screening cells 1 and 2 show positive reactivity.
3. Given the patient is Rh-negative, elderly, and has six
children, it is very likely the positive antibody screen is
due to anti-D. In addition, both screening cells are D+. Chapter 8
4. An antibody identification panel should be performed.
Review Questions
5. Anti-D is present in the patient’s plasma. All D-positive
panel cells are reactive (2+), and all D-negative cells are 1. d 4. c 7. a 10. c
negative. In addition, all other common alloantibodies 2. b 5. a 8. d 11. a
are ruled out using at least one double-dose donor cell. 3. a 6. d 9. b 12. c
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Answer Key 603

13. d 18. b 23. c 28. b 3. When working up any antibody identification, it is good
14. c 19. c 24. d 29. d practice to get the patient’s history of transfusions, trans-
15. c 20. d 25. c 30. c plantations, and, if female, pregnancies. A list of medica-
16. b 21. b 26. d tions and the patient’s diagnosis may prove helpful.
17. c 22. a 27. b Knowing the patient’s ethnicity may give clues as to the
identity of the antibody, as antigen frequencies vary
among races. One example of a high-prevalence antigen
associated with a specific ethnicity is the U antigen,
Chapter 9 which is present in virtually all whites and all but approx-
imately 1% of blacks. Anti-U is produced mainly in
Case 9-1 multiparous black females or those patients who have
1. There is inconsistent reactivity (1+ to 3+). The pattern of been repeatedly transfused.
reactivity appears to fit anti-Fyb; however, one homozy-
gous cell (cell 2) reacts 3+ while others (cells 8 and 9) Case 9-3
react only 2+. This inconsistency is seen in the cells with 1. A positive reaction was seen with cell 4 only, which is Jsa
heterozygous antigen expression as well. Cell 7 reacts 2+, positive. All other antibody specificities have been elim-
while cells 1, 6, and 11 react only 1+. inated except for anti-Lua (an antibody to another other
2. Anti-C, anti-Cw, anti-K, anti-Kpa, anti-Jsa, anti-Fyb, anti- low-prevalence antigen).
Jka, and anti-Lua have not been excluded. Fyb antigens 2. Testing with additional antigen-positive cells will be
would be destroyed or diminished after treatment with required to confirm the specificity. Panel cells that are
enzymes. C, Cw, Jka, and Lua would have enhanced antigen positive for these rare antigens are normally indicated on
expression. K, Kpa and Jsa would be unaffected by routine the panel profile sheet or listed on the extended typing
enzymes. form. Testing two other cells positive for the Jsa antigen
3. The specificity of the antibodies was unclear after the ini- to satisfy the 3 and 3 rule and phenotyping the patient
tial panel. After repeating the panel using ficin-treated for the Jsa antigen should be done to complete the antibody
cells, it appears that the antibodies present are anti-K and identification workup. If additional cells are not readily
anti-Fyb. The enzyme treatment removed the Fyb anti- available, consult a reference laboratory.
gens, thereby eliminating the anti-Fyb reactivity, which
allows the anti-K to present clearly. Anti-C and anti-Jka Case 9-4
were also not eliminated by the initial panel. However, 1. All cells (except the I-negative cord blood cells) are positive
one would expect these antibodies to demonstrate en- at the immediate spin phase of testing, and the autocontrol
hanced reactivity with the ficin-treated cells. Anti-Jka may is positive. The reactivity does not persist into the AHG
be excluded using cell 8 of the ficin panel. Whereas phase of testing.
anti-C cannot be excluded using a homozygous cell, the 2. The use of cord blood cells, which lack the I antigen, con-
pattern of reactivity and lack of response to enzyme treat- firms the presence of anti-I in this sample.
ment suggest it is not present in this sample. 3. Many laboratories avoid detection of cold autoantibodies
4. Testing a C+, c–, K–, Fyb– cell would be necessary for by omitting the immediate spin phase of the antibody
exclusion. screen (and panel) and by using monospecific anti-IgG
Coombs’ reagent.
Case 9-2 One of the least complex methods used to prevent cold
1. The positive reactions on this panel are all the same autoantibodies from interfering in antibody detection or
strength. Cell 10, the only cell that failed to react with identification tests is the prewarm technique. In this
the patient’s serum, has been identified as being Yta neg- procedure, the serum being tested and the screen or panel
ative. As Yta is a high-prevalence antigen, one may be sus- cells are heated to 37°C in separate test tubes. Once at
picious that this is the antibody present in this specimen. 37°C, a drop of warm RBCs is added to each of the tubes
2. For this case, the ideal solution is to test two additional containing serum, and the test proceeds with incubation,
Yta-negative cells, which would provide 95% confidence of washing, and AHG steps. The wash step uses saline that
correct antibody identification and allow for additional ex- has also been maintained at 37°C so that at no time is the
clusions. If antigen-negative cells are not readily available, test system allowed to drop below that temperature, thus
it may be necessary to consult a reference laboratory that avoiding the optimal temperature range of the autoanti-
maintains a stock of rare cells. Any other antibodies not body. Because this method does not usually have enhance-
excluded following this testing may require patient phe- ment media in the system, it is possible to fail to detect
notyping or absorption studies to confirm their presence some weak significant antibodies. Also, the warm saline
or absence. The services of a reference laboratory may be may result in the dissociation of some significant antibodies
required to antigen type the patient for the Yta antigen. from the cells.
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604 Answer Key

A more complex method, discussed previously, is ad- ZZAP to enhance expression of certain antigens and facili-
sorption. The patient’s autologous cells may be incubated tate autoantibody removal. These treatment and adsorption
with the patient’s serum at 4°C to remove the autoanti- steps are time-consuming. There is an alternative method,
bodies before antibody detection steps are performed. in which PEG is used to enhance antibody removal, cutting
This method provides autoantibody-free serum for anti- the processing time approximately in half while still pro-
body detection and identification procedures and for viding for adequate autoantibody removal.50,51
compatibility testing. If the autoantibody is particularly 4. The pattern of reactivity in the “absorbed serum” column
strong or if the patient has been recently transfused, RESt of Figure 9–14 matches that of anti-K. Positive reactions
may be used to perform the adsorption instead of the in the autoabsorbed serum were found with cells 2, 6, and
patient’s RBCs. RESt-adsorbed serum is not suitable for 10, which were positive for the K antigen. All other
crossmatch, as anti-B may be removed. antibody specificities could be ruled out except for Cw,
Sulfhydryl compounds, such as DTT and 2-mercap- Kpa, Jsa, and Lua. These are low-prevalence antigens and
toethanol (2-ME), are known to break the disulfide bonds generally do not need to be excluded. Additional pheno-
in IgM. Treating the patient’s serum with such a reagent typing strategies should be employed to determine if the
before the antibody detection test will denature the cold patient is negative for the K antigen.
autoantibody. IgG antibodies are not affected by these 5. Transfusion requirements include RBC units negative for
reagents and will remain detectable. A control of saline the K antigen that appear to be less incompatible with the
and serum is tested in parallel with the treated serum to warm autoantibody than the patient’s own cells (least
ensure that the autoantibody was truly denatured, not incompatible) when tested with the antiglobulin cross-
merely diluted. match method using unabsorbed serum.

Case 9-5 Review Questions

1. Warm autoantibody with an underlying alloantibody. The 1. d 5. c 9. b 13. a
reactivity with all cells, including the autocontrol, at the 2. a 6. c 10. c
AHG phase of testing is typical for a warm autoantibody. 3. c 7. d 11. b
The increased reactivity on cells 2, 6, and 10 suggests that 4. b 8. a 12. d
an additional antibody is present. With the patient’s trans-
fusion history, one must consider the possible presence
of an alloantibody.
2. Typically with an antibody to a high-prevalence antigen,
the autocontrol will be negative. However, if the patient
Chapter 10
has been recently transfused with RBCs that possess the Case 10-1
high-prevalence antigen, the autocontrol may be positive, 1. Since she has had two previous deliveries at this facility,
as the antibody will react with the antigen-positive donor then our patient’s history should also include a previous
RBCs remaining in circulation. ABO/Rh and antibody screen determination, which ex-
3. Autoadsorption is the method of choice when the patient pands the crossmatch options. The first and most common
has not been recently transfused (transfusion in the past crossmatch option is an immediate spin crossmatch. Of
3 months) and when a sufficient quantity of autologous course, an AHG crossmatch option is also available but is
RBCs is available. The patient’s RBCs must first be not a very good STAT procedure, even though some facil-
stripped of autoantibody before they can be used to ad- ities still have this option as their standard protocol in all
sorb autoantibody from the serum. Partial elution using situations. The final option, which is the least common, is
gentle heat or chemical methods is used to produce an a computer crossmatch. Since there are two separate
antibody-free cell. ZZAP is one chemical that works par- determinations of the patient’s ABO and no unexpected
ticularly well for this. It is composed of DTT and papain, antibodies are present (both currently and previously),
resulting in the destruction of enzyme-sensitive antigens then this option is also available, if the facility’s computer
and denaturing Kell, LW, Dombrock, Knops, and Cromer system has been validated for computer crossmatching.
antigens. Once the autoantibody has been removed from 2. Playing the odds, the most likely crossmatch selected for
the cells, the treated cells can be incubated with the this situation is going to be the immediate spin cross-
patient’s serum at 37°C to absorb autoantibody from match, since it is the most widely accepted and used. It
the serum. Multiple steps are necessary to treat the is fast and effective in STAT situations. Transfusion service
cells and adsorb the autoantibody, which makes this technologists can rapidly perform an immediate spin
procedure very time-consuming. Once the autoantibody crossmatch and tag compatible units.
is removed, the adsorbed serum can be tested for under- The computer crossmatch is also quite efficient and
lying alloantibodies. may even be faster since no serologic testing is required.
When patient cells are limited or when the patient has Just let the computer select the packed cells and print up
been recently transfused, allogeneic cells are used for the tags. The reality is that only about 2% of transfusion
adsorption. The cells used for homologous or differential services in the United States have computer crossmatch-
adsorption are usually treated with enzymes or with ing capabilities.
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Answer Key 605

Case 10-2 2. Symptoms include malaise, fever, fatigue, anorexia, vom-

1. Scenario 1: Patient could have an antibody to a low- iting, and abdominal pain.
incidence antigen that wasn’t present on the screening 3. Yes, the donor with the high titer should be permanently
cells of the antibody screening test that was present on deferred.
the donor red blood cells. 4. No, the donor who was not tested should be indefinitely
Scenario 2: Another explanation is that the technologist deferred until he or she can be tested.
performing the antibody screening test did not add patient
serum to the screen cells but did to the crossmatch test. Case 13-2
2. Scenario 1: Perform an antibody identification using 1. After transfusion of 1 unit of leukoreduced RBCs, the hgb
selected panel cells with low-incidence antigens present. should increase approximately 1 g/dl or 11.6; hematocrit
Determine specificity of antibody, then antigen-type both should have increased 3% or approximately 35%.
the patient and donor cells (all 3 units) for the correspon- 2. One unit of apheresis platelets will usually increase the
ding antigen. Transfuse antigen-negative, crossmatch platelet count of a 70 kg adult by 30,000 to 60,000/uL.
(AHG crossmatch) compatible units. Make sure units are This is consistent with the patient platelet count results
labeled with antigen typing results. from 5-23 to 5-24, which increased from 72,000 to
Scenario 2: Repeat all testing, including the antibody 103,000.
screen, this time adding patient serum to all screening 3. FFP is frozen within 8 hours of collection and PF24 is
cells. If antibody screen is positive, then identify antibody frozen within 24 hours of collection. FFP contains all
and antigen-type both the patient and donor red cells coagulation factors, and PF24 contains all factors con-
(all 3 units) for the corresponding antigen. Transfuse tained in FFP with reduced amounts of factors V and VIII.
antigen-negative, crossmatch (AHG crossmatch) compat- Since this patient had liver abnormalities and not a
ible units. Make sure units are labeled with antigen typing specific factor deficiency and was taken off Coumadin,
results. standard of practice dictates that FFP and PF24 can be
used interchangeably except in hemophilic cases where
Review Questions there is a specific deficiency of factor VIII.
1. c 5. b 9. d 13. b
Review Questions
2. d 6. d 10. c 14. a
3. d 7. b 11. b 15. d 1. c 6. e 11. a 16. d
4. c 8. b 12. d 2. d 7. a 12. e 17. c
3. e 8. b 13. b 18. a
4. a 9. c 14. b 19. c

Chapter 11 5. a 10. e 15. a 20. c

Review Questions
1. d 3. d 5. a 7. c Chapter 14
2. a 4. c 6. d 8. d
Case 14-1
1. Top five possible diagnoses for this case:

Chapter 12 • Hemolytic uremic syndrome

• Thrombotic thrombocytopenic purpura (TTP)
• Disseminated intravascular coagulation (DIC)
Review Questions • Malignant hypertension
1. a 4. b 7. c 10. c • Sepsis
2. d 5. c 8. b 2. Thrombotic thrombocytopenic purpura (TTP). Why? See
3. d 6. a 9. c below + normal coagulation studies and the ADAMTS13
will be significantly decreased.
3. In classic cases, patients present with a pentad of clinical

Chapter 13 and laboratory findings:

• Microangiopathic hemolytic anemia (MAHA);
• Thrombocytopenia
Case 13-1 • Neurological symptoms and signs
1. Yes, the incubation period for Babesia microti is 2 to • Renal function abnormalities
8 weeks. The component transfused is red blood cells, • Fever
which the organism is able to penetrate. 4. Plasma exchange with fresh frozen plasma (FFP).
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606 Answer Key

Review Questions 3. If it is anticipated that the patient will experience bone

marrow recovery soon (after the chemotherapy), no RBC
1. d 4. a 7. b 10. d transfusion is indicated. If, however, the bone marrow
2. a 5. c 8. a will be suppressed for several weeks, one or two units are
3. b 6. d 9. c indicated, with a recheck in a couple weeks for another
possible transfusion. Each unit of RBCs is expected to
increase the hemoglobin level about 1 g/dL.
Chapter 15 Case 15-4
Case 15-1 1. The blood group for RBC transfusions is O, which is the
1. It is necessary to know the patient’s hemoglobin and universal blood group.
hematocrit levels, the surgeon’s usual blood usage, 2. Group AB should be selected for plasma and platelet
whether this is the first surgical procedure on this hip transfusion. If AB platelets are not available, any other
(redo surgery uses more blood), and whether the patient blood group can be selected.
has any pretransfusion compatibility problems. 3. RBCs, plasma, and platelets in the amount specified by
2. Considerations should be the patient’s general health, he- your massive transfusion protocol.
moglobin and hematocrit levels, amount of time between 4. RBCS, plasma, and platelets should be B. The Rh can be
request for donation and the time of surgery, and whether positive because the patient is male. If group B RBCs are
the patient has infectious diseases that might interfere in short supply, group O can continue to be used.
(e.g., bacterial infections). 5. Workup of the positive antibody screen should start as soon
3. Tests should include PT, PTT, and platelet count. If these as possible, but without delay of providing products for the
tests are normal and von Willebrand’s disease is sus- massive transfusion. Transfusing RBCs in massive hemor-
pected, vWF workup should be considered. rhage is more important than obtaining “compatible” units.
4. If the patient has moderate to severe von Willebrand’s dis- With massive transfusion, the patient’s antibody will be
ease, the patient may need factor VIII concentrate known removed and diluted by the hemorrhage and the replace-
to contain vWF. ment of blood components. The “incompatible” RBCs will
be removed more slowly because the mechanism is extravas-
Case 15-2 cular hemolysis. When the serologic problem is solved,
1. Both answers can be justified. If the answer is yes, her compatible RBC units can be obtained and transfused.
hemoglobin is close to 6 g/dL, which is the criterion for
Review Questions
RBC transfusion. She will be less tired and weak if she re-
ceives a transfusion. If the answer is no, she is not in any 1. d 4. c 7. a 10. a
acute distress. She is iron-deficient (from chronic blood 2. c 5. a 8. b
loss) and should be treated with iron replacement rather 3. c 6. a 9. d
than with transfusion, which has higher risk of compli-
cations. The safest, least-expensive, and the most effective
long-term strategy is to prescribe iron and not transfuse.
2. For adults, each unit of blood should increase the hemo- Chapter 16
globin 1 g/dL and the hematocrit 3 percentage points. For
accuracy, this is based on a hypothetical 70-kg man. For Case 16-1
smaller men and women, the increase is greater; for larger 1. A reaction in which signs and symptoms occur during or
ones, less. within 24 hours of transfusion.
2. Hemolysis.
Case 15-3 3. Volume of incompatible blood transfused.
1. The platelet count is 5,000/µL; therefore, a platelet trans- 4. Look for matching or discrepant information between the
fusion is indicated. Without the platelet transfusion, she information on the labels on the pre- and post-transfusion
would be at increased risk of bleeding from the site of the samples, transfused units, patient transfusion service
bone marrow biopsy. Although the hemoglobin and records.
hematocrit levels are lower than normal for a woman of
this age, an RBC transfusion is not indicated (hemoglobin Case 16-2
greater than 6 g/dL in an otherwise healthy young adult). 1. Communication with other health professionals served
2. For an adult, each unit (bag) of platelet concentrate as the key to resolving this incident.
should increase the patient’s platelet count by 5,000 to 2. Chemical or mechanical damage such as improper ship-
10,000/µL. The platelet count should be at about ping, storage temperatures, incomplete deglycerolization
20,000/µL because a bone marrow biopsy is an invasive of frozen red blood cells, inappropriate needle bore size
procedure. Thus, one unit of platelets (plateletpheresis or for transfusion rapid infusion, improper use of blood
pool) would be indicated. warmers, unapproved fluid infusion.
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Answer Key 607

Case 16-3
1. Laboratory workup for the diagnosis of TAS must rule Chapter 18
out hemolysis and perform a gram stain and culture
Review Questions
of the implicated component and patient. The culture
must be obtained from the container and not the seg- 1. a 8. b 15. a 22. c
ments attached to the product. Blood cultures from the 2. b 9. d 16. c 23. a
patient should be drawn from a site other than the site of 3. d 10. c 17. a 24. d
transfusion. 4. a 11. c 18. d 25. b
2. Symptoms implicated with TAS include a fever with 5. c 12. d 19. c
greater than 2°C increase in body temperature, rigors, and 6. b 13. a 20. d
hypotension. 7. c 14. d 21. b

Review Questions
1.
2.
c
c
5.
6.
c
b
9.
10.
d
d
13. b
14. d
Chapter 19
3. b 7. c 11. d 15. d Case 19-1
4. b 8. b 12. a 1. The most probable cause is that the mother received
prophylactic Rh immune globulin at 28 weeks gestation.
The antibody screen was negative at 28 weeks gestation
Chapter 17 prior to the administration of Rh immune globulin. The
antibody titer of anti-D due to Rh immune globulin is
Case 17-1 typically less than 1:4.4
2. Yes, unless the newborn infant is Rh(D)-negative.
1. The blood group for RBC transfusion is O, which is the
only blood group compatible with both the donor and Case 19-2
recipient. If A is chosen, the cells will be hemolyzed
1. The maternal history, the same father, and the father
or have a shortened life span because of the preexisting
homozygous for the D antigen suggest that the infant is
anti-A in the patient. If B is chosen, engraftment will be
Rh(D)-positive.
difficult to determine.
2. The titer should be repeated in 6 weeks (16 weeks’
2. Group AB should be selected for FFP and platelet trans-
gestation).
fusion. If group A is selected, the anti-B in the plasma
3. The infant is only 8 weeks gestational age, so it is too
is incompatible with the recipient’s RBC and tissue
early in the pregnancy to perform any intervention
antigens (B). The anti-A in group B products is incom-
(MCA-PSV, cordocentesis, intrauterine transfusion). The
patible with the donor RBCs and, if selected, may contribute
earliest an intervention can take place is 16 weeks.
to delayed engraftment of RBC precursors.
4. The patient should be scheduled for MCA-PSV at 16 to
3. On day 117, the interpretation is B, as B cells and anti-A
18 weeks gestation to determine if the test is positive.
are present.
4. On day 200, the interpretation is group A, because A cells Case 19-3
are present, and B cells and anti-A are absent. On day 156,
1. The most probable cause is ABO HDFN. Group O mothers
the forward type is group O (remember that the patient
produce IgG anti-A, which can cross the placenta.
is receiving group O RBC transfusions), but the reverse
2. No. Anti-Lea does not cause HDFN because Lewis anti-
type still has anti-A; thus, the interpretation is indetermi-
gens are poorly developed at birth.
nate. The source of the anti-A may be small amount of
plasma in RBC transfusions or anti-A in ABO-incompatible Case 19-4
platelet transfusions.
1. The blood types of the cord blood and heel-stick speci-
Review Questions mens are different—A-negative versus O-negative. The
severely anemic infant could have HDFN, although the
1. a 4. b 7. c 10. a cord blood results do not indicate severe disease (DAT +/–).
2. e 5. c 8. c 11. b On the other hand, a large fetomaternal hemorrhage
3. d 6. d 9. c 12. c could have occurred.
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608 Answer Key

2. Cord blood should be collected by needle and syringe Case 20-2

from the umbilical cord vein. Collecting the specimen by 1. The patient is group O Rh-positive.
allowing blood from the placenta or cord to drip into the 2. Her antibody screening is positive with all three screening
tube can contaminate the specimen with maternal blood. cells and with the autologous control at the indirect
In this case, the tube marked “cord blood” could be a antiglobulin phase. None of the four units crossmatched
mislabeled maternal sample. The heel-stick is nearly all are compatible. There is some variability in the strength
adult blood because of the recent intrauterine transfusion. of the IAT reactivity. Because the patient has no history
Group O blood is usually used. As discussed in this chap- of recent transfusion (within the last 3 months), the
ter, transfusion may cause suppression of erythropoiesis positive auto control by IAT suggests a warm autoanti-
and therefore the production of few fetal RBCs. The cells body is present. The variability of reactivity suggests
produced are being hemolyzed by the high-titered mater- alloantibody may also be present.
nal antibody. This leads to anemia, in this case quite 3. A direct antiglobulin test should be done. Warm autoad-
severe, with elevated bilirubin levels indicating that sorption of the patient’s serum should also be done, and
hemolysis is occurring. The eluate of the heel-stick spec- an antibody identification panel tested with the adsorbed
imen confirms HDFN caused by anti-D. serum.
4. The DAT shows that the patient’s cells are coated with
Review Questions
both IgG and complement. The predictive value of the
1. c 4. d 7. d 10. b positive DAT in a patient with clinical indications of
2. a 5. d 8. d 11. a hemolytic anemia (e.g., decreased hemoglobin and hema-
3. b 6. a 9. b 12. c tocrit, increased reticulocyte count) is high; combined
with evidence of a warm autoantibody in the serum, these
results support a diagnosis of warm autoimmune he-
Chapter 20 molytic anemia.
5. Anti-Jka is evident in the autoadsorbed serum. Further
Case 20-1 testing could include typing the patient’s RBC for the Jka
1. There is an ABO serologic discrepancy and a positive antigen, which might be done using monoclonal anti-Jka
albumin control, so ABO/Rh results are invalid. or using an IgG removal technique to treat her RBCs be-
2. The antibody screen shows a strongly reactive immediate fore typing her RBCs with a conventional anti-Jka reagent.
spin (room temperature) reading and weak reactivity at Although the patient has a history of prior transfusion
LISS 37°C phase. These preliminary results suggest a cold when she might have been exposed to Jk(a+) RBCs, it is
agglutinin. Because the patient’s RBCs are also reactive somewhat unusual to find anti-Jka strongly detectable so
with his own serum, this appears to be a cold autoanti- many years after last exposure.
body, which would also affect the ABO serum typing 6. The patient’s autoadsorbed serum may be used to cross-
(tested at room temperature). match group O Jk(a–) red blood cells for transfusion.
3. The patient’s RBCs are complement coated. 7. Transfusion to remedy the current anemia is a temporary
4. The most likely cause of these atypical results is a cold solution and may stimulate additional alloantibody and
autoantibody. To obtain valid ABO/Rh typing results, the increase autoantibody production. Her physician is likely
patient’s RBCs should be warmed to 37°C and washed to recommend steroid therapy (e.g., prednisone) to sup-
with warm saline. His serum and plasma should be cold press her immune system to try to control the autoim-
autoadsorbed and used for repeating the ABO serum typ- mune hemolytic process.
ing and antibody screen.
5. The patient’s warm-washed RBCs type group A Rh-positive. Case 20-3
The cold autoadsorbed serum confirms that anti-B is 1. The patient’s RBCs are group B Rh-positive. There is
present, but not anti-A. This resolves the ABO serologic nothing unusual about the blood grouping.
discrepancy. The antibody screening performed with the 2. The antibody screening is negative, indicating no alloan-
cold autoadsorbed serum also confirms that group O tibodies to RBC antigens are present.
RBCs are nonreactive and that there is no alloantibody 3. Because the antibody screening is negative, crossmatches
present. of the patient’s serum with three units of group B
6. The cold autoadsorbed serum is suitable for cross- Rh-positive units of red cells would be expected to be
matching group A RBCs for transfusion (if still deemed compatible. The positive autocontrol and the color of the
necessary). patient’s serum are unexpected. Although there is no
7. A cold agglutinin titer and thermal amplitude would be history of recent transfusion, a DAT could be helpful if
very useful to investigate whether the patient has cold the patient is anemic due to an autoimmune process. If
hemagglutinin disease (CHD), as suggested by the pre- the DAT is positive, preparing and testing an eluate of the
liminary testing and by his symptoms. If a diagnosis of patient’s RBCs could be informative.
CHD were made, such testing might save him having to 4. The DAT shows that the patient’s RBCs are coated with
endure the bone marrow biopsy. IgG and complement. These results could be seen in a
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Answer Key 609

normal individual. (Approximately 1 in 1,000 healthy Review Questions

blood donors have positive DATs.8) But since this patient
has severe anemia that developed in 1 week and frank 1. b
hemolysis noted in the sample, there is likely to be more 2. a
clinical significance to these DAT results. 3. b
5. The eluate is nonreactive with the three antibody detec- 4. a
tion cells but reacts with the patient’s own RBCs even
after they have been EGA-treated to remove in vivo IgG.
The results are consistent with a drug-induced antibody
that reacts with the patient’s drug-coated RBCs. Typical
Chapter 23
results seen in cases like this, called the “penicillin-type” Review Questions
drug-induced immune hemolytic anemia, are a negative
antibody screen and negative eluate in a patient with a 1. b 4. b 7. c 10. c
positive DAT and clinical signs of acute hemolysis. In 2. d 5. c 8. a
these cases, adsorption of the drug by the patient’s RBCs 3. d 6. d 9. a
causes them to react selectively with the drug antibody
in the patient’s serum or eluate.
6. Determining what drug the patient has been receiving is
key to knowing what drug antibody to suspect. In this Chapter 24
case, the patient was unaware of taking any drugs or
antibiotics during or following her hospitalization for Case 24-1
labor and delivery by C-section. A careful review of 1. A blood utilization management program is intended to
the surgical record revealed that she was given a single ensure blood components are administered appropriately,
dose of Cefotetan during surgery, presumably to prevent in accordance with hospital guidelines and evidence-
postoperative infection. based criteria. Its primary focus is to improve patient
safety by ensuring patients are not unnecessarily exposed
Review Questions to the risks of transfusion. If there is a large deviation
1. d 6. d 11. d 16. b from standard practice in a facility, reduction in inappro-
2. b 7. b 12. b 17. c priate ordering may be reflected in reduced expenditure
3. a 8. b 13. d 18. d for blood components. However, if this is not the case, a
4. a 9. c 14. a utilization management program may still reduce cost in
5. a 10. a 15. c terms of expenditures for treating transfusion-associated
adverse events, impact on length of stay and clinical
course, and improved blood component availability.
2. First steps include recruiting a multidisciplinary cross-
Chapter 21 functional team. This team should define the program’s
overall goal, then assess the current state and perform
Review Questions a gap analysis. This process will involve using evidence-
1. c 3. b 5. d 7. d based criteria and guidelines. Once improvement oppor-
2. c 4. a 6. b 8. a tunities are identified, the team may prioritize interventions
to promote evidence-based practice.
3. The blood utilization management team should include
the blood bank medical director and the blood bank su-
Chapter 22 pervisor. Additional members will depend upon the in-
dividual facility, but representation from nursing, clinical
Case 22-1 staff (especially from areas with greater blood use), and
1. b quality should be considered. Participation by an infor-
2. a mation technology associate may be particularly useful
in developing tools for queries and to track the metrics
Case 22-2 the team agrees upon. Administrative support, if not
1. c active participation, is critical.
2. d 4. Appropriate utilization criteria should be gleaned from
3. c evidence-based literature and the recommendations of
In DNA polymorphisms, the mutation rate can be as high consensus panels from various subspecialties. Active dis-
as 2 per 1,000; thus, a single mismatch, when all other sys- cussion of proposed guidelines with clinical staff is nec-
tems are consistent with paternity, may represent a mutation. essary to gain approval and promote compliance. Where
A minimum of two mismatches is necessary before an inter- necessary, exceptions for specific clinical populations or
pretation of exclusion is rendered. diagnoses should be included. The literature upon which
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610 Answer Key

the guidelines are based should be widely disseminated were unwilling to change their practice patterns. Following
and readily available to clinical staff. review by the transfusion committee, the antiquated order
5. Any of the types of review (retrospective, concurrent, sets were removed and a discontinuous prospective review
targeted, or discontinuous prospective) may be utilized was adopted, focusing on plasma orders for coronary
depending on the facility. However, for a medium- or care patients. In addition, educational measures were
small-sized facility, retrospective review is most likely to employed, in the form of several short lectures on current
be the primary method, due to resource limitations. Large plasma guidelines presented to the coronary unit’s physi-
facilities such as academic institutions are more likely to cians and nursing staff.
have the available personnel to conduct concurrent and 4. Over the following three quarters, the transfusion safety
prospective review actions. Targeted or discontinuous officer continued the discontinuous prospective review
prospective review may be appropriate for smaller facilities, of the coronary care patients in addition to the monthly
since the benefits of “real-time” intervention are balanced retrospective reporting. At the end of the third quarter,
by the limited scope. blood utilization appeared to be at the desired state and
the labor-intensive discontinuous prospective review
Case Study 24-2 strategy was retired. It is important to always reassess and
1. The first step is to determine the gap between the current revaluate the blood utilization management process to
and desired state. This gap defines the scope of the prob- determine the effectiveness of corrective strategies and to
lem and should be qualified and quantified as succinctly identify new areas of waste.
as possible. Review of the value stream will help identify
the source of the problem. In this case, review of the nurs- Review Questions
ing units and physician services show that the plasma 1. d 4. c 7. b 10. b
trend appears to be related to a recent expansion in the 2. a 5. d 8. d
hospital’s coronary care unit. This is further supported by 3. b 6. b 9. a
the observation that the increased usage and waste trends
vanish when the data from the coronary unit are excluded
from the utilization report. Review of the timing of the
blood orders showed that the majority of the increased
utilization appeared just prior to the performance of Chapter 25
cardiac procedures and surgeries. Review Questions
2. Further auditing revealed multiple types of waste with
plasma usage among patients awaiting cardiac surgery 1. b 4. d 7. d 10. b
and procedures. In nearly every case, there was an excess 2. c 5. c 8. a
of plasma ordered in advance of the procedure that was 3. d 6. a 9. b
thawed by the blood bank but was either never dispensed
or never transfused. Regarding the dispensed plasma,
most of these patients had an average of 2 units of unused
thawed plasma. In a few cases, the product was improp-
erly returned and had to be discarded. This overproduc-
Chapter 26
tion type of waste increased the number of expired Review Questions
plasma components, resulting in increased inventory
waste. Further waste was identified through a detailed 1. c 4. b 7. d 10. c
medical chart audit, which demonstrated that nearly 2. a 5. a 8. a
half of the plasma transfused was likely inappropriately 3. d 6. b 9. b
administered when compared to the institution’s transfu- 11. Phase SCI SCII Interpretation
sion guidelines. IS 0 0 Negative
3. Solutions and improvements arise from the collaborative 37ºC 0 0
input of multiple sources such as the medical director AHG 0 0
of the blood bank, the blood bank supervisor, members CC + +
of the transfusion committee, and appropriate members
from administration. If a specific unit or specialty is 12. b
identifiable, as in this case, input should also be requested 13. A. Control functions
from clinical staff in that area. In this case, after investi- B. Acceptance Criteria
gation by the medical director, the new coronary unit was C. Test Cases
employing antiquated order sets copied from another D. Data entry methods
institution. These order sets included template standing E. Documentation methods
plasma orders that were not appropriate for a large insti- F. Result review
tution with readily available thawed plasma. Unfortunately, G. Corrective action
in spite of discussion with the involved practitioners, many H. Acceptance
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Answer Key 611

Chapter 27
2. The supplier’s facility and all intermediaries must be
registered with the FDA and hold state licenses, if appli-
cable by state.
Cases 27-1 through 27-6
Editor’s Note: Because of the nature of these cases, an- Case 28-2
swers are not provided. Answers to these questions would 1. See Box 28–2.
be decided by a judge or jury. 2. The hospital tissue bank must register with the FDA as a
tissue distributer.
Review Questions 3. A decision should be made as to whether the tissue should
1. d be cultured and if so, with which method. The storage con-
2. b tainer and appropriate temperature for storage should also
3. d be decided. (Any of the AORN recommendations for harvest
4. c of autologous tissue are correct answers to this question.)
5. a
Review Questions
1. d 4. b 7. d 10. d

Chapter 28 2. b
3. c
5. b
6. c
8. b
9. d
Case 28-1
1. This tissue manufacturer must be qualified by the medical
director of the tissue bank prior to ordering any tissue.
The surgeon may consider postponing surgeries until
the vendor has been qualified or use tissue from a vendor
currently qualified.