Patient blood management and transfusion — structured SAQ (15 marks)

(a) Pre-operative anaemia optimisation plan (5 marks)

One mark per element, maximum five. ^[3][4]

• Confirm iron deficiency: ferritin under 30 µg/L and TSAT 10% confirm iron deficiency with no confounding inflammation (CRP normal). Document the cause (menorrhagia) and the severity (Hb 88 g/L). ^[4]
• IV iron now: ferric carboxymaltose 1000 mg IV over 15-30 minutes (or iron isomaltoside/iron derisomaltose), single-dose regimen based on calculated deficit; oral iron is too slow for surgery in 4 weeks; counsel on risk of hypersensitivity (rare with newer preparations). ^[4]
• Erythropoietin: add EPO 300-600 U/kg SC weekly if Hb remains under 100 g/L after iron, or as adjunct in this Jehovah's Witness patient; iron must be co-administered. ^[3]
• Treat the cause: consider medical management of fibroids (tranexamic acid 1 g PO q6h, mefenamic acid 500 mg PO q8h, or ulipristal acetate) until surgery to reduce ongoing menstrual loss; counsel on hormonal options including the levonorgestrel IUD if appropriate. ^[6]
• Schedule for recheck: Hb at 2-4 weeks post-infusion to confirm response; deferral decision if Hb under 80 g/L in elective setting (case-by-case).

Bands: name the iron preparation, dose, route; name the EPO and dose if applicable; treat the underlying cause; specify the recheck.

(b) Intra-operative blood management strategy and consent (4 marks)

One mark per aspect, marked for specificity. ^[5]

• Cell salvage set-up: arrange intra-operative cell salvage before skin incision; leucocyte depletion filter for re-infusion; documented as 'salvaged blood' in the anaesthetic record; set up specifically for this case as part of the preop planning. ^[5]
• Tranexamic acid: 1 g IV over 10 minutes within 30 minutes of skin incision (WOMAN trial principle applied to surgical blood loss). ^[6]
• Anaesthetic technique: controlled hypotension where appropriate, normothermia (warming), meticulous haemostasis; avoid blood pressure cuff on a leg that will be in stirrup; minimise phlebotomy. ^[3]
• The consent detail: explicit consent for cell salvage (autologous) and intra-operative cell salvage obtained at the booking visit; separate documentation of refusal of allogeneic blood and fractions (FFP, platelets, cryoprecipitate); the consent must specify each fraction separately, not a generic refusal.

(c) Transfusion threshold and post-operative management (4 marks)

One mark per aspect. ^[1][2]

• Restrictive threshold: restrictive threshold of Hb under 70 g/L in stable euvolaemic patient (TRICC trial); higher threshold (Hb under 80 g/L) in active bleeding, sepsis, or acute coronary syndrome (Docherty 2016 meta-analysis). ^[1][2]
• Post-operative anaemia management: continue IV iron or oral iron for 3 months to replenish stores; check ferritin at 4-6 weeks; consider re-dosing IV iron if ferritin remains low; consider EPO if Hb remains under 100 g/L and the patient consents. ^[3]
• VTE prophylaxis review: haemorrhage and tranexamic acid do not grant VTE immunity; resume VTE prophylaxis once bleeding is secure. ^[3]
• Discharge safety-netting: written, named contact; criteria for re-presentation (fatigue, breathlessness, dark urine, fever); planned follow-up in 4-6 weeks.

(d) Consent documentation (2 marks)

One mark per item, marked for completeness. ^[3]

• The consent must specify each component separately: allogeneic red cells, platelets, FFP, cryoprecipitate, fibrinogen concentrate, and autologous cell salvage. A generic refusal is not a refusal of the indicated therapy.
• Documentation includes: date and time of consent, the patient signature, the clinician signature, the witness, the rationale, and the escalation plan for 'permissive anaemia' (lowest acceptable Hb, decision point for ICU, decision point for hospice care if transfusion declined at end of life).