Safe Transfusion Practice Quiz OSCE 5

What is the first action you should take if a transfusion reaction is suspected?

• Slow the transfusion and observe closely.

• Stop the transfusion immediately.

• Administer IV hydrocortisone before anything else.

• Continue the transfusion but notify the blood bank.

Answer explanation

Correct Answer: Stop the transfusion immediately. 

Rationale: The very first step in any suspected transfusion reaction is to stop the transfusion at once to prevent more of the potentially harmful blood from entering the patient. The IV line should be kept open with normal saline, and the blood bank and medical team should be notified promptly after stopping the transfusion. This prioritises patient safety before any other interventions. 

A patient receiving a red cell transfusion develops fever, chills, flank pain, and dark red urine 20 minutes into the transfusion. Blood pressure is dropping. Which transfusion reaction is most likely?

• Febrile non-haemolytic transfusion reaction (FNHTR)

• Acute haemolytic transfusion reaction

• Transfusion-associated circulatory overload (TACO)

• Allergic transfusion reaction

Answer explanation

Correct Answer: Acute haemolytic transfusion reaction 

Rationale: Sudden fever, chills, flank/back pain, hypotension, and haemoglobinuria (red/dark urine) are classic signs of an acute haemolytic transfusion reaction. This is often caused by an ABO incompatibility (e.g. the patient receiving the wrong blood type), leading to intravascular haemolysis. It is a medical emergency: the transfusion must be stopped and intensive supportive care (IV fluids, etc.) initiated immediately. 

Which statement is TRUE regarding a febrile non-haemolytic transfusion reaction (FNHTR)?

• It is usually caused by ABO incompatibility.

• It typically presents with high fever >39°C and shock.

• It is often due to donor leukocyte cytokines accumulating in the blood unit.

• It is one of the most lethal immediate transfusion reactions.

Answer explanation

Correct Answer: It is often due to donor leukocyte cytokines accumulating in the blood unit. 

Rationale: FNHTR is generally caused by cytokines or other substances from donor leukocytes (white cells) in the blood product, especially in components that have not been leucocyte-reduced. It usually causes a mild fever (often a temperature rise of ≥1°C with possible chills, malaise) but is not usually life-threatening. Options A and B describe features of acute haemolytic or septic reactions, and D is incorrect as FNHTR is uncomfortable but not typically fatal. 

During a platelet transfusion, a patient suddenly develops wheezing, stridor, difficulty breathing, and hypotension, without fever. Which type of transfusion reaction is this most suggestive of?

• Acute allergic (anaphylactic) reaction

• Transfusion-related acute lung injury (TRALI)

• Febrile non-haemolytic reaction

• Transfusion-associated circulatory overload (TACO)

Answer explanation

Correct Answer: Acute allergic/anaphylactic reaction

Rationale: Respiratory distress with bronchospasm (wheezing/stridor) and hypotension occurring soon after start of transfusion, in the absence of fever, points to a severe allergic anaphylactic reaction. TRALI can also cause respiratory distress but typically with pulmonary edema on X-ray and without the upper airway edema/bronchospasm seen in anaphylaxis. Febrile non-haemolytic reactions cause fever/chills, not hypotensive allergic shock, and TACO presents with fluid overload signs (hypertension, not hypotension). 

A 60-year-old patient with no cardiac history is 2 hours into a red cell transfusion when they develop acute respiratory distress. O₂ saturation drops to 85%, blood pressure falls, and chest X-ray shows bilateral lung infiltrates. Jugular venous pressure (JVP) is normal. What is the most likely reaction?

• Transfusion-related acute lung injury (TRALI)

• Transfusion-associated circulatory overload (TACO)

• Acute haemolytic reaction

• Mild allergic reaction

Answer explanation

Correct Answer: TRALI

Rationale: TRALI presents with acute hypoxaemic respiratory failure (like ARDS) within 6 hours of transfusion, with bilateral pulmonary infiltrates on chest X-ray, hypotension, but no signs of fluid overload such as elevated JVP or hypertension. It is often caused by donor anti-leukocyte antibodies. TACO, in contrast, usually features hypertension and overt fluid overload signs. An acute haemolytic reaction would present with fever, hemoglobinuria, etc., and an allergic reaction would not typically cause bilateral infiltrates on X-ray. 

An elderly patient with congestive heart failure is receiving a blood transfusion. Mid-transfusion, they develop acute shortness of breath, elevated blood pressure, distended neck veins, and crackles on lung auscultation. What is the most likely transfusion complication?

• Acute haemolytic reaction

• Transfusion-related acute lung injury (TRALI)

• Transfusion-associated circulatory overload (TACO)

• Anaphylactic reaction

Answer explanation

Correct Answer: Transfusion-associated circulatory overload

Rationale: TACO is likely in a patient with cardiac risk factors who develops acute pulmonary oedema (dyspnoea, crackles) with hypertension and jugular venous distension during or soon after a transfusion. It is essentially an acute heart failure exacerbation from too rapid/large volume transfusion. TRALI can also cause respiratory distress but usually with normal or low blood pressure and no fluid overload signs. Acute haemolytic reactions and anaphylaxis would present with different systemic signs (fever, shock, etc. rather than purely fluid overload). 

Thirty minutes into a unit of blood, a patient spikes a temperature of 40°C with shaking chills (rigors) and becomes hypotensive. The transfusion is stopped. The blood bag is noted to have a purple discolouration. Which reaction should be suspected?

• Septic transfusion reaction (bacterial contamination)

• Delayed haemolytic reaction

• Febrile non-haemolytic reaction

• Acute haemolytic reaction due to ABO incompatibility

Answer explanation

Correct Answer: Septic transfusion reaction due to bacterial contamination

Rationale: High fever (often >39°C) with rigors and hypotension very shortly into the transfusion strongly suggests a bacterial sepsis from contaminated blood. Discolouration of the unit can be a clue if bacteria have proliferated. Acute haemolytic reactions can also cause fever and hypotension early, but are often accompanied by back pain or red urine; in this scenario, contamination is more likely (especially with the bag appearance). Febrile non-haemolytic reactions cause milder fever without severe hypotension, and delayed haemolytic reactions occur days later. Bacterial sepsis from a transfusion is life-threatening and requires immediate broad-spectrum antibiotics and supportive care. 

Which of the following is a required step in the management and reporting of a severe transfusion reaction?

• Immediately discard the blood unit and tubing in the clinical waste bin.

• Continue the transfusion with a new unit of blood to finish quickly, then investigate.

• Return the remaining blood unit and IV giving set to the blood bank/laboratory for investigation.

• Keep the reaction unreported to avoid paperwork unless the patient deteriorates.

Answer explanation

Correct Answer: Return the remaining blood unit and IV giving set to the blood bank/laboratory for investigation. 

Rationale: After stabilising the patient (stop transfusion, support ABCs), the transfused unit and infusion set should be sent to the hospital transfusion laboratory for investigation. The incident must be documented and reported according to hospital policy (and to national haemovigilance systems if severe). This helps determine the reaction cause (e.g. perform culture, haemolysis tests, clerical check for misidentification) and prevents future errors. Options A, B, and D are inappropriate – the unit should not be simply discarded, one should never continue transfusing in a suspected reaction, and under-reporting compromises patient safety. 

What is the most important measure to prevent an acute haemolytic transfusion reaction due to ABO incompatibility?

• Premedication with paracetamol before every transfusion.

• Using only O-negative blood for all patients.

• Careful patient identification and matching of the blood unit before transfusion.

• Leucocyte depletion of blood components.

Answer explanation

Correct Answer: Careful patient identification and matching of the blood unit before transfusion. 

Rationale: The majority of serious hemolytic reactions are due to clerical errors – giving the wrong blood to the wrong patient. Rigorous patient identification, bedside checks, and proper cross-matching are therefore the most critical preventive measures. While O-negative is the universal donor for red cells, it’s not feasible or necessary for all patients and does not prevent all incompatibilities (and using the correct specific unit is preferred). Leucodepletion helps prevent febrile reactions, not ABO mismatch, and premedication with paracetamol prevents fever symptoms but does not prevent an ABO incompatibility reaction. 

An 80-year-old woman with chronic anaemia and heart failure requires a transfusion. Which approach below best reduces her risk of transfusion-associated circulatory overload (TACO)?

• Transfuse one unit at a time slowly, instead of two units back-to-back, and consider a diuretic between units.

• Transfuse two units as fast as possible to minimise time on IV fluids.

• Give only plasma, not red cells, to avoid overload.

• No special precautions – TACO is not a concern unless the patient is actively bleeding.

Answer explanation

Correct Answer: Transfuse one unit at a time slowly, instead of two units back-to-back, and consider a diuretic between units.

Rationale: In patients at risk for TACO (elderly, heart failure, etc.), guidelines recommend slow, careful transfusion of minimal necessary volume – for example, transfusing one unit and then reassessing, rather than multiple units consecutively. Also using diuretics prophylactically and adhering to appropriate infusion rates can help prevent fluid overload. Options B and D would increase TACO risk. Option C is incorrect because plasma transfusion can also cause fluid overload; the key is judicious volume management, not the type of component alone.