Patient blood management and transfusion consent

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.

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.