Transfusion Medicine — Viva Defence

Opening statement (SASPOP, delivered aloud)

"Mr Reid is a 74-year-old retired engineer with transfusion-dependent myelodysplastic syndrome, presenting with shortening transfusion intervals. His main problems are: progressive marrow failure with transfusion-dependent anaemia; cumulative iron exposure from over 60 lifetime units; alloimmunisation risk; and the question of whether his disease is progressing. I would like to assess his transfusion program, screen for iron overload, and revisit disease-modifying options with him." [1]

Structured problem list

1. Transfusion-dependent anaemia (MDS) — currently 2 units every 3 weeks; interval shortening may signal progression, bleeding, haemolysis, or hypersplenism.
2. Iron exposure — each unit carries about 200–250 mg of iron with no physiological exit route; at his cumulative dose, formal assessment is due [1].
3. Alloimmunisation risk — chronic transfusion raises antibody formation; future crossmatches get harder.
4. Disease trajectory and goals of care — MDS is not static; the conversation belongs in the management plan.

Integrated management plan

• Investigate the shortening interval: repeat FBC and film, reticulocytes, DAT and haemolysis screen, ferritin/iron studies, renal and liver function, and review the antibody screen history; consider marrow reassessment for progression.
• Individualise the threshold to symptoms rather than a fixed number — restrictive thresholds are the default, but a symptomatic transfusion-dependent patient is managed against function and comorbidity [1].
• Screen for iron overload: ferritin trend plus liver or cardiac MRI; start chelation (deferasirox, desferrioxamine or deferiprone) when overload is demonstrated and prognosis justifies it.
• Prevent reactions: single-unit policy where feasible, slow rates — TACO prevention matters in a 74-year-old [2].
• Revisit disease-modifying therapy (e.g., hypomethylating agents, erythropoiesis-stimulating agents if erythropoietin level is low) and document goals of care.

Probing questions with model answers

"What is your transfusion threshold for this man?" — "For a stable transfusion-dependent outpatient I individualise to symptoms: the trial thresholds (70–80 g/L) guide me, but I transfuse to keep him functional, one unit at a time where possible, and I reassess rather than prescribing by calendar" [1].

"When do you start chelation?" — "When there is evidence of clinically significant iron loading — a sustained ferritin elevation with a transfusion burden around 20 units, or MRI-demonstrated organ loading — in a patient whose prognosis makes organ protection meaningful. I would get a liver or cardiac MRI before committing him to daily chelation." [1]

"He develops dyspnoea two hours into a unit. Walk me through it." — "Stop the unit, keep the line open with saline, check his identity against the bag, assess ABC. Then discriminate TACO from TRALI: blood pressure, JVP, fever, BNP, fluid balance, and later diuretic response. He is 74 with a transfusion burden — TACO is statistically likely, and both diagnoses are reportable to the blood bank" [2].

"What if he were a Jehovah's Witness?" — "A competent adult can refuse blood products even if refusal risks death. I would clarify exactly which products and fractions he personally accepts, document it, treat reversible causes aggressively with iron, B12 and erythropoietin where appropriate, minimise blood tests, and plan any procedures with bloodless techniques." [4]

Communication points

• Open disclosure if any transfusion reaction occurs — explain what happened, what it means, and what changes.
• Shared decision-making on chelation: daily drug burden versus long-term organ protection [3].
• Goals of care in a progressive marrow disease — raised early, not in crisis.