1.

Which of the following is the best explanation for why the ABO system is
the most important blood group system in transfusion safety?
A- It is the only system in which antibodies are normally produced for the
antigens an individual lacks
B- ABO antibodies are capable of causing rapid, severe intravascular
hemolysis
C- Reactions with ABO antibodies are the most common cause of
transfusion-related death
D- ABO antibodies are often implicated in severe hemolytic disease of the
fetus and newborn
E- Routine ABO forward and reverse grouping is difficult to interpret and
fraught with error

B is the best answer because of the potential horrific, near-immediate

consequences of receiving ABO-mismatched blood. While ABO is
famous for the reciprocal antibodies, it is not the only blood group with
"naturally occurring" antibodies. Transfusion-related acute lung injury
(TRALI) is currently the most common cause of transfusion-related
death (though hemolytic transfusion reactions are second). Answer D is
incorrect because the HDFN caused by ABO antibodies (almost always
in group O moms) is generally mild (and some don't even refer to it as
"HDFN"; see [Link]/038). Answer E is a subjective statement; only
a minority of samples submitted for ABO typing would have
discrepancies that cause difficult in interpretation (and blood banks do a
darn good job even with those!). Question contributed by Monica
LaSarre and Joe Chaffin.

2. A 26 year old pregnant female is being tested prior to a scheduled

C-section tomorrow. Her cell grouping (forward typing) is
consistent with blood group O, while her serum grouping (reverse
grouping or "back-typing") appears to be group A. The most
common reason for this type of ABO discrepancy is:
A- She has the Bombay phenotype
B- She is a non-secretor, so her plasma lacks A
C- Clerical errors or a sample mix-up
D- Use of an uncalibrated centrifuge
E- She has undiagnosed acute leukemia (AML)

Issues with the integrity or identity of the sample are more likely than
any other choice to cause this ABO discrepancy. Bombay phenotype
 is extremely rare. Secretor status will not affect the ability to detect A
and B antigens on red cells. An uncalibrated centrifuge might make a
difference in testing, but ABO system antigens/antibodies are so
hearty that they are likely to not be effected by over- or under-
centrifugation. Finally, while group A patients with AML can have an
acquired weakening of their A antigen due to hematologic
malignancies, such an event would be less common than a sample
integrity issue. Question contributed by Monica LaSarre and Joe
Chaffin

3. An ABO discrepancy between forward and reverse grouping owing

to weak-reacting or missing antibodies could be BEST explained
by which of the following:
A- Patient has a subgroup of blood group A
B- Patient is very old or very young
C- Patient has acquired B phenotype
D- Patient has antibodies to low incidence antigens
E- Patient has antibodies against reagent preservatives

In the very old and very young, the natural expression

of isoagglutinins can either be depressed or delayed, respectively.
Group A subgroups often lead to missing red cell (forward) reactions,
and the acquired B phenotype results in extra red cell reactions;
neither typically leads to missing antibody reactions. Antibodies to low
incidence antigens or reagents would give extra antibody reactions
rather than missing reactions. Other causes of weak-reacting or
missing antibodies are: Patients with leukemias demonstrating
hypogammaglobulinemia (e.g., CLL), patients with lymphomas;
patients using immunosuppressive drugs, congenital
agammaglobulinemia, and immunodeficiency diseases. Question
contributed by Monica LaSarre and Joe Chaffin.

4. Approximately what percentage of group A individuals could be

further classified as subgroup A1?
A- 20%
B- 40%
C- 60%
D- 80%
E- 99%
CORRECT! The vast majority of group A patients are either subgroup
A1 (about 80%) or A2 (about 20%). A1 and A2 red cells have both quantitative
and qualitative differences in the A antigen present on their surfaces, and this
is discussed in another answer below.

5. Which of the following statements is TRUE regarding the A 2 blood

group?
A- Dolichos biflorus lectin agglutinates A2 but not A1 RBCs
B- Ulex europaeus lectin will give stronger reactions with A1 than with
A2 RBCs
C- A2 RBCs have more H antigen than A1 RBCs
D- If anti-A1 is made by an A2 person, it is usually clinically significant
E- Most A2 individuals have a different form of anti-B than A1 individuals

Sorry, that's incorrect. The major difference between the A1 and

A2 subgroups is quantitative; A1 RBCs have about five times more A antigen
than A2 RBCs (and, as a result, much less H antigen). There are also,
however, some qualitative differences between these two subgroups, as
evidenced by the fact that A2 individuals can, on occasion, make anti-A1 (1-8%
of the time). This antibody, while we talk about it a lot and it can lead to ABO
discrepancies in serum typing, is usually (though not always)
clinically insignificant. Most A2 people have exactly the same antibody that
A1 people have: Anti-B. The lectin of Dolichos biflorus, in concentrations used
in laboratories, only agglutinates RBCs containing A1 specificity, while the
lectin of Ulex europaeus agglutinates RBCs with increased H antigen (like
A2 RBCs) more strongly than those with less H (like like most A1).

6. Which of the following statements is TRUE regarding Hemolytic

Disease of the Fetus/Newborn (HDFN) caused by ABO antibodies?
A- Fetal hemolysis is typically severe
B- It rarely occurs during the first pregnancy
C- It is most common with O mothers and A babies
D- A negative cord blood direct antiglobulin test excludes it
E- It occurs less commonly than Rh HDFN

Sorry, that's incorrect. HDFN caused by ABO incompatibility between

mother and child is, in fact, the most common form of HDFN (though it is so
mild that some don't even call it "HDFN"). In virtually all situations, ABO HDFN
is seen with a group O mother and a group A or B child. Group O individuals
carry IgG ABO antibodies that, unlike the primarily IgM antibodies in non-
group O people, are transported across the placenta and enter the fetal
circulation. These antibodies (either anti-A, anti-B, or anti-A,B) are "naturally
occurring," like all ABO antibodies, so the interaction may occur during the
first pregnancy (unlike the classic form of HDFN due to Rh antibodies, which
usually occurs in second pregnancies and beyond). However, the relatively
weak ABO antigen expression on the surface of fetal and neonatal red cells
means that the clinical and laboratory sequelae (including hemolysis) of ABO
HDFN are usually not severe. In fact, affected babies may have a negative
direct antiglobulin test (DAT).

7. If a patient had a positive direct antiglobulin test (DAT) with Anti-

IgG, what would happen if you performed a Weak D test on the
patient cells?
A- A false-positive result
B- A false-negative result
C- An indeterminate result
D- A valid test result
E- An invalid Rh control test
Sorry, that's incorrect. The Weak D test is nothing more than an indirect
antiglobulin test (IAT). Cells that are coated with IgG will agglutinate whenever
you add a reagent that contains Anti-IgG, as is done in the last step of an IAT.
Anti-IgG is added in both the direct and indirect antiglobulin tests (see the blog
post on DAT vs. IAT if you are confused). Cells that have a positive DAT (i.e.,
are already coated with antibody) will of course agglutinate in the antiglobulin
phase in an IAT. In this case, the patient has a positive DAT. The patient cells
will give false-positive agglutination during the Weak D test, since Anti-IgG is
added prior to reading the AHG phase of testing. To get an accurate Weak D
typing in this case, the antibody coating the cells must be removed. This can
be accomplished by adding a chemical such as Chloroquine diphosphate to
the cells. Chloroquine causes a gentle elution that removes the coating
antibody without destroying the antigen integrity of the cells. Once the DAT on
the patient cells is negative, an accurate Weak D typing can be obtained. This
question contributed by Bill Turcan, August 2013.

8. In which of the following groups is Weak D testing required if the

initial D typing results appear negative?
A- Routine testing of pregnant female blood recipients
B- Rh typing of allogeneic (volunteer) whole blood donors
C- Pretransfusion testing for sickle cell anemia patients
D- Pretransfusion testing for cardiac surgery patients
E- Confirmatory testing of D-negative RBC by a transfusion service
Sorry, that's incorrect. Weak D testing must be performed on all blood
donors who test initially D-negative on routine Rh typing by US standard. If D
antigen testing was stopped at the immediate spin phase on a blood product
that is actually from a donor with the Weak D phenotype, that product would
falsely be labeled as "D-negative" when it is actually D-positive. Since the
falsely labeled product would most likely be transfused to a D-negative
patient, the patient could make immune anti-D as a result. When performing
pre-transfusion testing on patients, however, the weak D test is not required.
A patient that is D-negative at the immediate spin phase will usually receive
D-negative blood products. Transfusing a D-negative blood product to a
patient that is really weak D positive will not cause the patient any adverse
effects of transfusion due to the D antigen. Finally, weak D testing is not
required when a transfusion service is confirming the Rh type of RBC units
labeled as D-negative. For more detail on weak D, see my 2012 video "Weak
in the D’s," the glossary entry on weak D, and finally, the BBGuy Essentials
Podcast, Episode 005. This question contributed by Bill Turcan, August 2013
and modified by Joe Chaffin, December 2017.

9. A 35 year old O-negative male trauma patient receives a

transfusion of two units of O-positive red blood cells before his
blood type is known. After his typing is completed, he is switched
to O-negative and he receives 6 additional type-specific RBC units.
He survives and is transferred to the surgical ICU. Which of the
following is TRUE regarding his situation?
A- He has an 80% chance of forming anti-D
B- He is at high risk for an acute hemolytic transfusion reaction
C- Blood bank case review is needed to find the reason for this error
D- He should immediately be given 20 vials of Rh Immune Globulin
(RhIG)
E- He is unlikely to develop delayed hemolysis

Sorry, that's incorrect. This type of event is not uncommon in trauma

transfusion, and giving Rh positive RBCs to males in these settings is fairly
standard in the US. Historically, we would say that D-negative people
receiving D-positive RBC transfusions had a roughly 80% chance of forming
anti-D. That statistic was based on exposure in D-negative healthy people,
however, and most patients getting this type of exposure are far from healthy!
Current studies have shown the risk to about 22% in hospitalized patients,
which is still really high, but not close to 80%. It is very unlikely that this man
will develop an acute hemolytic reaction, unless he already has a pre-formed
anti-D (from a previous D-positive transfusion). Even a delayed hemolytic
reaction is unlikely in this situation, as the transfused cells will likely no longer
be around by the time any antibody could be formed. So, the final question is
whether prevention is indicated in the form of RhIG. I personally do not think
that such an intervention is the greatest idea, due to the facts that a) A large
amount of RhIG would be required (at least 20 vials, which could be given
intravenously), and b) If the RhIG works (coating and resulting in clearance of
the D-positive RBCs from the circulation), you might THEN be dealing with the
consequences of hemolysis. I don’t believe in it, but there are those who feel
strongly the other way.

10. A patient has a positive antibody screen and positive results

against cells in the antibody panel. The patient specimen is
retested with antibody panel cells that have been treated with the
enzyme "ficin." The antibody no longer reacts against cells in the
antibody panel. Which of the following antibodies is most
consistent with these results?
A- Anti-D
B- Anti-K
C- Anti-Jkb
D- Anti-Fya
E- Anti-Lea

Sorry, that's incorrect. Ficin is a "proteolytic enzyme" that destroys certain

common antigens found on red blood cells. The antigens are: Fya, Fyb, M, N,
S, s, Xga (see image below).

If a patient has an antibody against one of these antigens, the test result will
be negative after the reagent red cells are treated with the enzyme, since
there is no longer a target antigen for the antibody. Keep in mind that the
patient still has the antibody itself. The antibody is just not detected using
 antibody screening cells or antibody panel cells that have been treated with
ficin. One more time, to be clear (because beginners get this confused quite a
bit): Blood Bank enzymes affect antigens, not antibodies. Question
contributed by Bill Turcan, January 2013; modified by Joe Chaffin, January
2018.

11. A 65 year old female with gram-negative sepsis secondary to a

ruptured colon is receiving a red cell transfusion. Her temperature has
been fluctuating wildly between 37C up to a maximum of 39.6C for the
past 8 hours. Prior to the start of the transfusion, her temperature is
38C. Thirty minutes into the transfusion, however, her temperature is
39.5C. She does not appear agitated, and her other vital signs are
unchanged. What is the FIRST thing that the person responsible for
infusing the blood should do?
 Order a gram stain of the unit, as it was likely contaminated
 Request a transfusion reaction workup from the blood bank
 Stop the transfusion
 Consult with infectious disease for an antibiotic change
 Request that the attending physician evaluate the patient STAT
Sorry, that’s incorrect. While all of the other choices are things that might (or
probably will, with some choices) be done, the most important (and FIRST)
step that the person administering the transfusion should take is to STOP
THE TRANSFUSION! This is a difficult and complicated scenario, one that will
most likely take a while to evaluate. The history of a fever before the
transfusion does not eliminate the possibility that the patient may be febrile
now for a different reason! If that reason is that the unit was mismatched in
the blood bank or at the bedside, or if there is any other undetected
incompatibility or contamination of the unit, the WORST thing the
transfusionist can do is continue running the blood into the patient. First stop
the transfusion, keep the line open with saline, and THEN call in the guard to
figure out the whole situation. I always recommend to blood bank staff to ask if
the transfusion has been stopped before embarking on a workup. NOTE: I
recognize that in urgent situations, the need to infuse blood in a complex
patient with fluctuating temperatures such as this may trump the evaluation of
every fever. I just don't believe that you can ignore the first spike. In these
situations, blood banks can work with clinical teams to rule out significant
issues quickly so that the transfusion can continue.
 12. An anesthesiologist wants to return a unit of red blood cells which
was not used during surgery. Which of the following is a TRUE
statement regarding the transfusion service's ability to accept and later
reissue the unit?
 Reissue of products is not possible under any circumstances
 If the product temperature has not exceeded 24C, it may be reissued
 At least one integral segment must remain attached to the unit
 The unit must not have been out of the transfusion service for > 4 hours
 If the product was "spiked" in a sterile manner, it may be reissued

n order for a product to be accepted by the transfusion service and reissued,

four things must be true, according to AABB Standard 5.26 (33rd ed, 2022):
1. The container closure has not been disturbed (i.e., the unit has not been
"spiked")
2. The appropriate temperature has been maintained
3. For RBCs, at least one integral "segment" must remain attached to the unit
4. The unit passes a documented visual inspection
Appropriate storage temperature for RBCs is 1-6C, with 1-10C allowed for
shipping from one facility to another; either way, choice B is incorrect. Choice
D is tricky, as the question gives no information on how the unit was issued
(handed directly to someone from the OR? sent in a validated "cooler?" Sent
via pneumatic tube?), so there is no way to tell if a 4 hour limit would apply (to
be clear, if the unit was not sent in a validated device that extends the RBC
storage temperature of 1-6C for a specific period of time, the unit would in fact
have to be transfused before 4 hours after it was issued). Choice E is
incorrect, as "spiking" the unit violates requirement 1 from AABB Standards
listed above.

13. A unit of red blood cells is signed out of the transfusion service at
9:00 am, to be given to an oncology patient who has come in to the
facility for an outpatient transfusion. At 9:45 am, the nurse responsible
for the transfusion calls to report that before she could spike the unit,
the patient's initial IV failed, and that the staff are having a very hard
time re-establishing access. The nurse, who happens to be a regular
 blood donor, does not want the unit to go to waste, so she asks your
help. She states that the unit still feels cool to the touch. Which of the
following is your advice about this unit?
 Don't bring it back; finish the transfusion within 4 hours if possible
 Don't bring it back; finish the transfusion within 6 hours if possible
 Throw it in the trash and come get a new one as it is compromised
 Return it and it will be accepted into inventory
 Return it for a temperature check and subsequent reissue decision
Sorry, that’s incorrect. There is no specific standard from either the AABB or
the FDA regarding how long a unit of blood can be out of monitored storage
until it can no longer be accepted back into inventory. The regulation that does
apply here is that units of red cells must stay at a temperature less than 10C
when they are shipped. Each facility is required to set up its own time limit,
based on that maximum temperature value, and validate that limit by testing
what actually happens (i.e., how long does it take a unit to exceed 10C in that
specific facility). By far, the most common limit that transfusion services arrive
at is around 30 minutes (this has been called the "30 minute rule"). There's
nothing magical about 30 minutes; it's just a number that people have used
since a study was published showing that units of RBCs set on a counter at
room temperature take about that long to exceed 10C. So, most facilities set
up a 30 minute limit beyond which the unit will be discarded if returned.
Remember, though, the time limit to transfuse the unit is 4 hours from when it
leaves the transfusion service! As a result, if the unit came back to the
transfusion service, it would likely be discarded, but if it is transfused, it's all
good as long as it is infused within 4 hours! That leads to choice A as the
most likely advice you would give to our conscientious nurse. IMPORTANT
NOTE: Remember, the "30 minute rule" is not actually a rule at all! Each
facility must validate their own time limit. Inspectors will cite facilities that say,
"Oh, we just use the '30 minute rule'" without any additional thought.

14. The transfusion service lab scientist puts 2 units of red blood cells
directly in the hands of a "runner" from the Cardiac ICU (no "cooler" is
used). The units are intended for transfusion to a 66-year-old male who
had an acute myocardial infarction two days ago and now has a
hemoglobin of 7.5 g/dl. He has mild congestive heart failure, so the
cardiologist has requested that the units be infused slowly. How long
does the transfusionist have to transfuse the two units to this patient?
 2 hours total
 3 hours total
 3 hours for each unit (6 hours total)
 4 hours total
 4 hours for each unit (8 hours total)
Sorry, that’s incorrect. This scenario illustrates why transfusion services
may be reluctant to issue more than one unit at a time for use by a single
patient. The rule of transfusion time limits is simple: From the time the unit
leaves monitored storage, it must be transfused within 4 hours! This is true
whether there is one or ten other units issued at the same time (i.e., you don't
get extra time if you take more units!). In most patients, transfusing two RBC
units within 4 hours is possible, but probably not in this patient, given his
volume overload potential. One little clue to how some try to get creative with
this: It is NOT COOL for clinical staff to try to game the system by putting units
in unmonitored refrigerators or non-blood bank supplied coolers! PLEASE
don't allow anyone to put blood in a regular refrigerator! One more thing: If
these units had been issued in a "cooler" validated for storage by the
transfusion service, the 4 hour limit would not apply, and the time available to
transfuse would depend on the time limit for which the cooler was validated
(typically more than 4 hours).

15. A nurse who is transfusing a patient with two units of red blood
cells, one unit of apheresis platelets, and two units of fresh frozen
plasma (FFP) calls you. She says that the hospital materials department
is running short on blood infusion sets, and wants to know if there is any
way to minimize the number of sets she uses while transfusing these
products. Which of the following is the best advice?
 She can use the same set for up to 4 hours, for any product combination
 She must change the set after each product is infused
 She may use the same infusion set for all 5 of the products
 She can use a regular IV set for the platelets and plasma
 She must use 3 different sets (1 for each product type)
Sorry, that’s incorrect. OK, so the easy part is this: All blood components
(even platelets and plasma) must be infused through some sort of a
filter, and regular IV sets do not come with a filter. So, choice D is not
acceptable. The "standard" blood filter typically has a 170 micron filter, though
some may have up to 260 micron filters. Every manufacturer of standard
blood filters has their own set of rules in their package insert, but with most
types, you can use the same set for up to four products or for a maximum of 4
hours. Most manufacturers do not require the user to change the infusion set
after each product, and most allow multiple different products to be infused
through the same set.

16. What is the type of Antibody detected in this panel?

Answer: Anti-D

17. What are the suspected antibodies can be identify from this panel?

Answer: Anti-D & Anti-C

 18. What are the type of antibodies can be identify in this panel?

Answer: Fyb & Lea

19.

Answer: Fya
 20. What are the type of antibody?

Answer: Anti-Jkb

21. What is the type of blood group? Answer: A sub

25-year-old woman, she just came in for a prenatal type and screen. She doesn't have any
significant history, but she was in a motor vehicle accident 10 years ago, she did get transfused.
And so, she probably got some A1 red cells
22. classic history of an older person that had colon cancer, some kind of colon issue, they end of
gram negative bacteremia or gram negative sepsis. woman got a stem cell transplant.
What is the blood group of the patient? A and received stem cell from B.
What is the reason for this discrepancy? stem cell transplant

23. What is the reason for this discrepancy?

 a 74-year-old man who had multiple myeloma. He had also recently gotten some steroids. And
when we looked at his protein electrophoresis, it showed us right there that his IgM level was
below the detectable limits.

Answer: suppressing his IgM. And probably his recent steroid treatment was also suppressing his
antibodies. Also, sometimes we lose antibody reactivity when we get older

24. Case