What are the essential steps and considerations for consenting a patient for blood transfusion, including discussion of risks and mitigation strategies?

Blood Transfusion Consent: Risks, Benefits, and Mitigation Strategies

Blood transfusion consent requires a thorough discussion of risks, benefits, and alternatives with patients, with documentation of their understanding and agreement before proceeding with the transfusion.

Essential Components of Blood Transfusion Consent

Patient Identification and Preparation

• Positive patient identification is paramount prior to any blood transfusion episode to minimize wrong-blood-in-tube events and risks of ABO incompatibility 1
• All patients receiving a blood transfusion must wear a patient identification band with minimum identifiers including surname, forename, date of birth, and hospital unique identification number 1
• For patients with unknown identity, follow local guidelines using at least one unique identifier (e.g., randomly generated number with prefix) 1

Pre-transfusion Assessment

• Review previous medical records and interview the patient or family to identify:
  • Previous blood transfusion history 1
  • History of drug-induced coagulopathy (e.g., warfarin, clopidogrel, aspirin) 1
  • Presence of congenital coagulopathy 1
  • History of thrombotic events (e.g., deep vein thrombosis, pulmonary embolism) 1
  • Risk factors for organ ischemia (e.g., cardiorespiratory disease) which may influence transfusion triggers 1

Risk Discussion

• Discuss specific transfusion risks with patients, including: 2, 3
  • Infectious risks: bacterial contamination (most common), viral infections (HIV, hepatitis B, hepatitis C) 4
  • Immunologic risks: transfusion reactions (febrile, allergic, hypotensive), transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI) 1, 4
  • Alloimmunization and potential future transfusion complications 5
  • Immunomodulatory effects potentially leading to increased infection risk 4

Benefit Discussion

• Explain the specific benefits of transfusion for the patient's condition 2
• Clarify that the intended use of blood products is to reduce red blood cell transfusion requirements 1
• Discuss expected outcomes based on the patient's clinical situation 2

Alternatives Discussion

• Present available alternatives to allogeneic blood transfusion where applicable 2
• Discuss options such as cell salvage for surgical patients 1
• Consider erythropoietin with or without iron for selected patient populations (e.g., renal insufficiency, anemia of chronic disease) 1

Documentation Requirements

• Document the consent process clearly, including: 2
  • Patient's agreement to the transfusion
  • Discussions that led to that agreement
  • Patient's questions and the responses given
• Documentation can be completed on a standard consent form, anesthetic record, or in patient notes 2
• Record that the patient has received blood components after transfusion, as they will otherwise be unaware 1
• Inform the patient's general practitioner that the patient has received blood components 1

Risk Mitigation Strategies

Patient Monitoring

• Monitor vital signs throughout transfusion to identify and manage adverse reactions 1
• Observe respiratory rate, as dyspnea and tachypnea are typical early symptoms of serious transfusion reactions 1
• Record observations at minimum: before transfusion start (within 60 min), 15 min after start of each unit, and within 60 min of transfusion end 1

TACO Prevention

• TACO is now the most common cause of transfusion-related mortality and major morbidity 1
• Risk factors include: older non-bleeding patients (age >70 years), comorbidities (heart failure, renal failure, hypoalbuminemia), low body weight, and rapid transfusion 1
• Mitigation strategies include:
  • Assessing the need for transfusion
  • Body weight dosing of RBCs
  • Slow transfusion rates
  • Close monitoring of vital signs and fluid balance
  • Prophylactic diuretic administration in high-risk patients 1

Reaction Management

• For febrile reactions, intravenous paracetamol may be sufficient 1
• For allergic reactions, antihistamines are appropriate 1
• For severe reactions or suspected anaphylaxis, follow local anaphylaxis protocols 1
• Avoid indiscriminate use of steroids and/or antihistamines 1

Special Considerations

Emergency Situations

• All hospitals should have clear policies for transfusion when patient identity is unknown or in emergency situations 2
• Follow local emergency transfusion protocols 2

Verification Process

• Blood samples must be collected and labeled at the patient's side by appropriately trained personnel 1
• Immediately before transfusion, check the component next to the patient against the prescription 1
• Verify the four core identifiers on the compatibility label with the patient's identification 1
• Visually inspect the blood component for any leakage, discoloration, or abnormalities 1

Common Pitfalls in Transfusion Consent

• Inadequate discussion of risks: Studies show that important risks like TRALI are infrequently discussed with patients 3
• Overemphasis on benefits: Some discussed benefits (such as wound healing) may not be true benefits for all patients 3
• Poor patient understanding: Patients often have variable and incomplete recall of information from informed consent discussions 6
• Lack of standardized information: Many patients are unaware of available transfusion health guides that provide standardized information 3
• Insufficient documentation: Failure to properly document the consent process and patient understanding 2