Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Patient blood management and transfusion consent
Haematology and transfusion · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
!
Immediate transfusion without prior discussion
Life-saving treatment can proceed when delay to obtain consent would endanger a patient who lacks capacity, but emergency necessity does not erase documentation or later communication duties.
Action: Confirm and document the immediate indication, capacity assessment, why delay is unsafe and any known valid advance decision, treatment refusal or patient-specific limitation. Use the least blood necessary in the patient's best interests and involve a senior clinician. As soon as the patient regains capacity, provide a face-to-face retrospective discussion covering what was given, why, material risks or reactions and implications including future donation; document the conversation and inform the GP or continuing team.
Role and principles
Optimise the patient's own blood, minimise avoidable loss, use evidence-based transfusion and obtain valid documented consent or refusal across elective and emergency care.
Patient blood management is a strategy, not a blood-bank restriction. It asks whether the patient's own red-cell mass can be improved, whether bleeding and iatrogenic loss can be reduced and whether physiological tolerance allows safer time for cause-directed care. The outcome is not zero transfusion; it is the right component, dose and time for an informed patient. Apply the approach across primary care, preassessment, theatre, critical care, maternity, oncology and discharge so that anaemia is not rediscovered at each boundary.
Begin early with risk stratification. Identify procedures with expected blood loss and patients with anaemia, low body weight, anticoagulation, bleeding disorders, antibodies or refusal. Obtain a full blood count far enough in advance to investigate. Microcytosis and low ferritin suggest iron deficiency, but inflammation can make ferritin misleading; consider transferrin saturation, CRP, renal function, B12, folate, reticulocytes and the clinical source. New iron-deficiency anaemia in an adult requires appropriate gastrointestinal and menstrual evaluation rather than replacement alone.
Practice
Two practice questions
Your practice draft is saved in this browser.
Question 1 of 2
0 correct
Haematology and transfusionOriginal SBA
Reducing blood loss in surgery
An adult is having elective surgery in an operating theatre that breaches skin and carries some bleeding risk. There is no contraindication to antifibrinolytic treatment. What does current NICE guidance recommend?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Treat iron deficiency according to urgency and mechanism. Oral ferrous salt is first-line when absorption, adherence and time are adequate; once-daily dosing is often effective and better tolerated than divided dosing. Check haemoglobin response within the planned interval and continue replacement after normalisation to restore stores. Use intravenous iron when oral iron is not tolerated or absorbed, adherence is unlikely, functional deficiency limits response or surgery is too close. Intravenous preparations have non-equivalent maximum single doses and infusion instructions, so calculate deficit and follow the exact product protocol.
NICE advises against routine erythropoietin to reduce surgical transfusion. Consider it only when the anaemic patient meets criteria because transfusion is declined or compatible blood is unavailable due to red-cell antibodies, with specialist assessment of thrombosis, hypertension, iron availability and tumour context. Correct B12 and folate deficiency when present. Do not give folate alone before excluding B12 deficiency when neurological B12 injury is possible, because haematological improvement can mask progression.
Reduce operative blood loss through meticulous technique, minimally invasive or staged approaches where appropriate, normothermia, anticoagulant planning and antifibrinolysis. NICE's updated 2026 recommendation is to offer tranexamic acid to adults undergoing surgery in an operating theatre with any risk of bleeding when skin or mucosa is breached; 1 g slowly intravenously just before surgery is a typical adult dose. Outside an operating theatre, offer it when expected blood loss exceeds 500 mL. Consider cell salvage plus tranexamic acid when very high blood loss is expected. Use speciality protocols for obstetrics, cardiac surgery, trauma and paediatrics and never administer tranexamic acid intrathecally.
Consent is a continuing shared decision, not a signature. SaBTO's 2025 guidance applies when a patient may, is likely to or will receive a blood transfusion. Explain the clinical reason in plain language, likely benefit, material and patient-specific risks, reasonable alternatives and what may happen without blood. Invite questions and make clear that the patient can refuse or change their mind. Discuss component-specific concerns, previous reactions, antibodies, infection risk, TACO, alternatives and personal values to the degree relevant to the decision.
Agree and record how long consent remains valid. One discussion may cover a defined course of repeated transfusions when the indication and risks remain stable, but the team still checks before every episode that the patient agrees and circumstances have not materially changed. Renew the discussion when diagnosis, component, risk, capacity or patient preference changes. A generic admission consent or a form signed without dialogue is insufficient. Provide accessible written or interpreted information as support, not replacement for conversation.
Capacity is decision and time specific. Support communication and assess whether the adult can understand, retain, weigh and communicate the relevant information. A capacitous refusal must be respected. When capacity is absent, search for a valid and applicable advance decision, health and welfare attorney or court order and make a documented best-interests decision with those close to the patient where appropriate. In children, seek parental responsibility and the child's assent or competence, and obtain urgent legal advice when refusal threatens life and time permits.
Some patients decline whole blood but accept selected fractions, medicines, cell salvage or procedures; never infer the details from a label or faith. Record what is and is not acceptable, whether conditions apply and how the plan changes in life-threatening circumstances. Early anaesthetic, surgical, haematology and legal planning enables iron, erythropoietin where commissioned, haemostasis, cell salvage and senior technique. Keep the plan immediately visible while protecting confidentiality.
Emergency treatment may proceed in the best interests of an incapacitated patient when delay threatens life and no valid applicable refusal is known. Document capacity, necessity, alternatives considered and senior decision. When the patient recovers, SaBTO requires a retrospective face-to-face discussion: tell them the component, indication, outcome, material adverse event and any continuing special requirement. Ensure discharge information and the GP record the transfusion, and explain the UK restriction on subsequent blood donation.
Key points
Patient blood management combines three goals: optimise red-cell mass, minimise blood loss and harness physiological tolerance of anaemia while transfusing only when benefit exceeds risk.
Screen for anaemia early before surgery with expected blood loss, classify the cause and allow time for oral or intravenous iron and other targeted treatment.
First-line for iron-deficiency anaemia is oral iron when tolerated and time permits; use intravenous iron for intolerance, malabsorption, functional deficiency, non-adherence or insufficient time for oral response.
NICE restricts perioperative erythropoietin to anaemic patients who decline transfusion or when compatible blood is unavailable because of red-cell antibodies.
For adults having surgery in an operating theatre with any expected bleeding risk and a breach of skin or mucosa, NICE 2026 recommends tranexamic acid; a typical adult dose is 1 g slowly intravenously just before surgery.
Consider cell salvage with tranexamic acid when very high blood loss is expected and use a local quality-controlled pathway, including obstetric and cancer-specific practice.
Minimise iatrogenic loss through appropriate tests, small-volume tubes, closed sampling systems where available and avoidance of repeated uninformative phlebotomy.
Use restrictive thresholds and one-unit red-cell prescribing with reassessment in stable non-bleeding adults; avoid prophylactic haemostatic components without an evidence-based indication.
Assessment and patient selection
Correctable preoperative anaemia
Low haemoglobin before foreseeable blood loss triggers cause classification and iron or vitamin treatment rather than automatic perioperative red cells.
High blood-loss procedure
Surgery with bleeding risk supports tranexamic acid and, when loss may be very high, quality-controlled cell salvage planning.
Iatrogenic blood loss
Frequent routine phlebotomy, large tubes and duplicated testing can become a material anaemia source in critical or prolonged care.
Valid prospective consent
The patient understands indication, benefit, material risks, alternatives and refusal and voluntarily communicates a decision that is documented.
Decision-specific incapacity
Inability to understand, retain, weigh or communicate relevant transfusion information despite support triggers the legal best-interests pathway.
Informed refusal
A capacitous patient declines all or defined components after discussion, requiring respect, explicit limits and a proactive blood-conservation plan.
Red flags requiring action
Proceeding with elective transfusion after an informed capacitous refusal is unlawful even when clinicians strongly recommend treatment; escalate alternatives and document clearly.
Anaemia discovered shortly before high-blood-loss surgery can signal occult malignancy, gastrointestinal bleeding, renal disease or haemolysis and should not be normalised with donor cells without investigation.
Baseline assessment
01First-line: full blood count and indicesFirst stepFirst line
Why
Detect preoperative anaemia and classify microcytic, normocytic or macrocytic patterns.
Interpretation and limitations
Trend with baseline and planned surgery; associated leucopenia or thrombocytopenia suggests broader marrow or systemic disease.
02First-line: ferritin and iron studiesFirst line
Why
Confirm absolute or functional iron restriction and guide oral versus intravenous replacement.
Interpretation and limitations
Low ferritin is specific for deficiency, while normal or high ferritin during inflammation requires transferrin saturation and context.
03B12, folate, reticulocytes, renal profile and CRP
Why
Identify nutritional, marrow-response, renal and inflammatory contributors.
Interpretation and limitations
Combine results rather than attributing all anaemia to one borderline value; investigate haemolysis or bleeding when the response is inappropriate.
04Cause-directed bleeding investigation
Why
Find gastrointestinal, gynaecological, urinary or operative blood loss.
Interpretation and limitations
Use age, sex, symptoms, examination and cancer-risk pathways; iron response does not remove the need to identify an important source.
Interventions
01Preoperative anaemiaFind and treat the cause earlyFirst stepAnaemia is identified before surgery with expected blood loss.+
1Classify anaemia with FBC, ferritin and directed B12, folate, renal, inflammatory, haemolysis and bleeding assessment.
2First lineStart oral iron first-line when tolerated and time permits; use intravenous iron for NICE-defined intolerance, malabsorption, adherence, functional or timing reasons.
3Recheck response, investigate the source and coordinate whether surgery should proceed, be optimised or be rescheduled based on urgency.
02Operative blood conservationPrevent avoidable lossAn adult in an operating theatre is undergoing surgery that breaches skin or mucosa and carries any bleeding risk.+
1Give tranexamic acid, typically 1 g slowly intravenously just before surgery, unless contraindicated
Medicines and treatment safety
First-line replacement for stable iron-deficiency anaemia when oral absorption, adherence and available treatment time are adequate.
Ferrous sulfate for iron-deficiency anaemia
Give one 200 mg ferrous sulfate tablet orally once daily, providing about 65 mg elemental iron; if not tolerated, use one tablet on alternate days, a different oral preparation or intravenous iron. Check response within about 4 weeks and continue for around 3 months after haemoglobin normalises to replenish stores.
Explain nausea, abdominal discomfort, constipation or diarrhoea and dark stools. Absorption falls with food, tea, calcium, antacids and interacting medicines, but taking with food can improve adherence. Investigate the bleeding source, separate from levothyroxine and selected antibiotics, and keep away from children because overdose is dangerous.
NICE-recommended antifibrinolytic prevention that reduces operative bleeding and allogeneic transfusion exposure.
Tranexamic acid for routine surgical blood conservation
Give 1 g intravenously slowly just before surgery in a typical adult when the procedure breaches skin or mucosa and has any risk of bleeding; use the relevant specialty and local regimen when repeated or weight-based dosing is required.
Review active thrombosis, seizure history and urinary-tract clot obstruction and adjust repeated exposure in renal impairment. Use a clearly segregated intravenous preparation and never administer intrathecally; intrathecal tranexamic acid is usually fatal. Pregnancy and postpartum use follow obstetric-specific regimens rather than this routine surgical dose.
Targets, monitoring and follow-up
Recheck haemoglobin after a defined oral or intravenous iron interval and confirm that the rise matches adherence, absorption and ongoing blood loss.
Monitor ferritin or iron status after recovery when ongoing loss or repeated replacement is likely; avoid unnecessary long-term iron once stores are replete.
Audit perioperative tranexamic acid administration, cell-salvage use, blood loss, transfusion exposure and adverse events against the surgical pathway.
Before each component, verify that consent remains valid, the indication and risks have not changed and any refusal or special requirement is visible.
After transfusion, record component, outcome and reaction, provide patient information and ensure discharge and GP communication is complete.
Review institutional metrics including preoperative anaemia screening, single-unit practice, TACO, wastage and missed consent to identify system improvement.
Special situations
PBM is not transfusion denial
Optimising red cells and reducing loss makes necessary transfusion safer and more available rather than imposing a universal no-blood target.
A group and save starts a conversation
If clinicians foresee enough risk to request compatibility testing, the patient should usually receive proportionate information before the procedure.
Refusal is granular
Patients may distinguish red cells, plasma, fractions, salvage and medicines, so a religious or personal label never substitutes for direct questions.
Retrospective discussion is personal
SaBTO expects face-to-face explanation after emergency transfusion; a leaflet in discharge paperwork does not close the autonomy gap.
Common pitfalls
01
Do not use donor red cells to bypass investigation and treatment of stable iron-deficiency anaemia.
02
Do not wait until the day of high-blood-loss surgery to begin anaemia optimisation.
03
Do not prescribe intravenous iron without using the selected product's dose, maximum single infusion and monitoring instructions.
04
Do not use perioperative erythropoietin routinely outside the NICE restricted indications.
05
Do not assume consent lasts indefinitely across a changed diagnosis, risk or treatment course.
06
Do not override a capacitous refusal or infer which blood fractions a patient accepts.
07
Do not omit retrospective face-to-face discussion after emergency best-interests transfusion.
08
Do not forget to tell a transfused patient about the UK restriction on donating blood.
JurisdictionUnited Kingdom
Valid consent covers the indication, expected benefit, material risks, alternatives including no transfusion, opportunity for questions and the patient's right to refuse.
Consent discussions apply when the patient may, is likely to or will receive blood; group-and-save before a procedure should trigger proportionate pre-emptive information.
If emergency transfusion occurred without prior consent, give a retrospective face-to-face explanation when capacity returns and document it; written information alone is insufficient.
After transfusion tell the patient what was given, document reactions and special requirements and explain that recipients must not donate blood in the UK.
A consent form signed without a patient-specific discussion of indication, benefit, material risks, alternatives and refusal does not demonstrate valid consent.
Failure to ask about advance decisions, beliefs, previous reactions and acceptable fractions before predictable bleeding can create an avoidable ethical and clinical crisis.
A group-and-save request means transfusion may be foreseeable; SaBTO expects information and consent planning before the patient reaches an emergency where possible.
05Transfusion-risk and compatibility assessment
Why
Anticipate antibodies, special components, TACO and difficult supply before the procedure.
Interpretation and limitations
A group-and-save signals possible transfusion and should trigger patient information and early laboratory warning for antibodies.
06Capacity and preference assessment
Why
Establish who can authorise treatment and which components or alternatives are acceptable.
Interpretation and limitations
Document supported decision-making, advance decisions, attorney authority, patient-specific refusals and any agreed duration of consent.
or a specialty regimen applies.
2Use meticulous haemostasis, normothermia and an anticoagulant plan and consider cell salvage with tranexamic acid when very high loss is expected.
3After surgery, minimise diagnostic phlebotomy, treat anaemia's cause and use restrictive single-unit transfusion when stable.
03Prospective transfusion consentMake one patient-specific decisionA patient may, is likely to or will receive a component.+
1Explain indication, benefit, material risks, alternatives including no transfusion and the right to refuse in an accessible format.
2Explore values, prior reactions and component-specific preferences, answer questions and agree the duration or treatment course covered.
3Document the discussion and decision and check before each transfusion that consent and circumstances remain valid.
04Refusal or absent capacityRespect autonomy and apply the legal frameworkThe patient refuses or cannot make the transfusion decision.+
1For a capacitous refusal, clarify exact limits, document and implement feasible conservation alternatives without coercion.
2For incapacity, seek a valid advance decision or authorised representative and make a documented best-interests decision with senior and legal input where needed.
3Create an immediately accessible emergency plan specifying accepted components, fractions, salvage and haemostatic treatments.
05Emergency without prior consentTreat necessity and close the consent loopImmediate blood was required while the patient lacked capacity and discussion would have caused dangerous delay.+
1Document the emergency indication, capacity, known wishes, best-interests reasoning, components and senior authorisation.
2When capacity returns, provide a face-to-face retrospective explanation of what was given, why, benefit, risks and any reaction.
3Record the discussion, provide written information, notify continuing care and explain future special requirements and non-donation status.