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SU3.1-3 | Blood and Blood Components — PBL Case
CLINICAL SETTING
A 62-year-old man with carcinoma of the stomach is on the surgical ward two days after a partial gastrectomy. His haemoglobin has fallen to 6.8 g/dL and he feels weak and breathless on exertion. The surgical team prescribes two units of packed red cells. The intern is asked to obtain consent and to observe the transfusion. The first unit is hung at 9:00 am. This case unfolds in three triggers; discuss each fully before revealing the next.
Trigger 1: Consent and the decision to transfuse
Before the first unit is started, the patient asks the intern, 'Is this blood safe? Could it give me an infection?' He is alert and oriented. The intern must obtain valid consent and decide that transfusion is genuinely indicated, weighing the haemoglobin, the symptoms and the alternatives.
DISCUSSION POINTS
- What are the components of valid consent for transfusion in a competent adult, and how should the intern answer the patient's question about safety and infection risk?
- What is the threshold and rationale for transfusing red cells in a stable, symptomatic patient, and what alternatives to transfusion should be considered?
- Why does positive patient identification matter at the moment the unit is hung, and how is it performed correctly?
Click to reveal Trigger 2: A reaction during the transfusion (discuss previous trigger first!)
Trigger 2: A reaction during the transfusion
Twelve minutes after the first unit is started, the patient develops a temperature rise to 38.6 °C with rigors, then complains of severe loin pain and becomes hypotensive (blood pressure 88/50 mmHg). The nurse notices his urine in the catheter bag has turned dark red.
DISCUSSION POINTS
- What transfusion reaction does this picture suggest, and what is its underlying mechanism?
- What are the immediate steps the team must take, in order, and which is the single most important?
- How would the team distinguish this dangerous reaction from a benign febrile non-haemolytic reaction, and what investigations should be sent?
Click to reveal Trigger 3: Root cause and prevention (discuss previous trigger first!)
Trigger 3: Root cause and prevention
Investigation reveals the patient received a unit intended for another patient with a similar name; the bedside identity check had been performed against the prescription chart only, not against the patient and the unit's compatibility label. The patient recovers with supportive care.
DISCUSSION POINTS
- Where in the chain from sampling to administration did the error occur, and how does a correct bedside check prevent it?
- What system and human-factors changes reduce the risk of wrong-patient transfusion?
- How should this serious adverse event be documented, reported and disclosed to the patient?
Group Task Assignments
- Produce a one-page bedside transfusion checklist covering consent, positive patient identification, observation schedule and the actions to take if a reaction occurs.
- Prepare a short teaching summary contrasting the five major acute transfusion reactions by timing, key features and immediate management.
- Draft a patient-friendly explanation of why blood is tested and why voluntary donation matters, suitable for counselling a patient or family member.
Learning Issues
Research these questions and bring your findings to the discussion.
- [SU3.1] What are the indications for each blood component and the mechanisms, features and management of the major transfusion complications?
- [SU3.2] What is the correct step-by-step procedure for observing a transfusion, including baseline and post-start observations and bedside identity verification?
- [SU3.3] How should a clinician counsel a patient for transfusion consent and counsel relatives about voluntary blood donation?