Patient blood management and transfusion consent — Rapid

Synopsis

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 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.
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.

Key red flags

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.

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.

Investigation priorities

First-line: full blood count and indicesFirst stepFirst line

Detect preoperative anaemia and classify microcytic, normocytic or macrocytic patterns.

First-line: ferritin and iron studiesFirst line

Confirm absolute or functional iron restriction and guide oral versus intravenous replacement.

Management branches

Preoperative anaemiaFind and treat the cause early

Anaemia is identified before surgery with expected blood loss.

Classify anaemia with FBC, ferritin and directed B12, folate, renal, inflammatory, haemolysis and bleeding assessment.
Start oral iron first-line when tolerated and time permits; use intravenous iron for NICE-defined intolerance, malabsorption, adherence, functional or timing reasons.
Recheck response, investigate the source and coordinate whether surgery should proceed, be optimised or be rescheduled based on urgency.

Key medicines

Ferrous sulfate for iron-deficiency anaemiaGive 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.

Tranexamic acid for routine surgical blood conservationGive 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.

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