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SU3.1-3 | Blood and Blood Components — Graded Quiz
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Within 15 minutes of starting a red-cell transfusion, a patient develops sudden hypotension, widespread urticaria, wheeze and stridor, but no fever. Which is the most likely reaction and the immediate priority?
Correct. Urticaria, wheeze, stridor and hypotension without fever indicate an anaphylactic/severe allergic reaction. Stop the transfusion immediately and give intramuscular adrenaline, with airway support and fluids as needed.
Severe allergic/anaphylactic transfusion reactions present early with mucocutaneous and airway features and hypotension. Management mirrors any anaphylaxis: stop the trigger, IM adrenaline, oxygen, fluids, and airway protection.
The combination of urticaria, bronchospasm, stridor and hypotension is anaphylaxis. The transfusion must be stopped at once and intramuscular adrenaline given — antipyretics, diuretics or calcium do not address the airway and circulatory collapse.
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A patient with disseminated intravascular coagulation has a fibrinogen of 0.6 g/L and continues to bleed. Which blood component is the most appropriate to specifically replace fibrinogen?
Correct. Cryoprecipitate is concentrated in fibrinogen, factor VIII, von Willebrand factor and factor XIII, making it the component of choice for hypofibrinogenaemia such as in DIC.
Cryoprecipitate is the fibrinogen-rich fraction prepared from FFP; it is indicated for hypofibrinogenaemia (e.g. DIC, massive transfusion). FFP replaces all coagulation factors more broadly when multiple are deficient.
Fibrinogen replacement requires cryoprecipitate (rich in fibrinogen, factor VIII, vWF and factor XIII). Platelets, red cells, saline and albumin do not correct a low fibrinogen.
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Two hours into a unit of red cells, a patient develops an isolated temperature rise of 1.2 °C with mild chills but remains haemodynamically stable, with no pain, rash or breathlessness. What is the most likely reaction?
Correct. An isolated mild temperature rise with chills, in a stable patient without pain, hypotension or respiratory features, is a febrile non-haemolytic reaction, caused by recipient antibodies to donor leucocytes/cytokines. Slow or pause and treat with an antipyretic.
Febrile non-haemolytic reactions are common and benign, caused by anti-leucocyte antibodies/cytokines; leucodepletion reduces them. The key skill is distinguishing this benign fever from the early fever of a haemolytic or septic reaction.
A benign febrile non-haemolytic reaction is an isolated mild fever in a stable patient. The dangerous reactions (haemolysis, anaphylaxis, TRALI, sepsis) add loin pain, hypotension, airway compromise or breathlessness — none present here.
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Within 4 hours of a plasma-containing transfusion a previously well patient develops acute hypoxaemia, hypotension and bilateral pulmonary infiltrates, with a normal JVP and no signs of fluid overload. Which complication is most likely?
Correct. TRALI is non-cardiogenic pulmonary oedema occurring within 6 hours of transfusion, with hypoxaemia, hypotension and bilateral infiltrates but a normal JVP. It is treated with respiratory support; it is distinguished from TACO by the absence of fluid-overload signs.
TRALI occurs within 6 hours, presents as hypotensive non-cardiogenic pulmonary oedema, and is managed supportively. The TACO-versus-TRALI distinction (hypertension/raised JVP vs hypotension/normal JVP) governs whether to diurese or simply support oxygenation.
Hypoxaemia with bilateral infiltrates within 6 hours, hypotension and a normal JVP is TRALI (non-cardiogenic). TACO would show hypertension and raised JVP; haemolysis would show loin pain and haemoglobinuria.
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You are observing a transfusion. According to safe practice, when should the patient's baseline observations (temperature, pulse, blood pressure, respiratory rate) and the first set of observations after starting be recorded?
Correct. Baseline observations are taken before the unit is hung and repeated at about 15 minutes, because the most dangerous reactions declare themselves early. The patient is also watched closely during the first 15 minutes and observed periodically thereafter.
The first 15 minutes are everything: start the unit slowly, stay with the patient, and record baseline and ~15-minute observations. Early vital-sign change is the earliest warning of a life-threatening reaction.
Because acute haemolytic, anaphylactic and septic reactions appear early, observations are recorded as a baseline before starting and again around 15 minutes in, with close watching during that first window — not only at the end or only when symptomatic.
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A patient who is a Jehovah's Witness declines blood transfusion despite understanding that this may be fatal. What is the most appropriate response when counselling and obtaining consent?
Correct. A competent adult may refuse any treatment, including a life-saving transfusion. Valid-consent counselling means ensuring the refusal is informed, documenting it clearly, and exploring acceptable alternatives such as cell salvage, tranexamic acid and meticulous haemostasis.
Valid consent for transfusion requires capacity, information and voluntariness. A competent adult's informed refusal must be respected and documented; the clinician should still offer and plan acceptable blood-conservation alternatives.
Consent is grounded in respect for an informed, competent adult's decision. Transfusing against a competent refusal, overruling via family, abandoning the patient, or waiting for unconsciousness all violate valid consent and the law.
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