GC155 Is Blood Transfusion Absolutely Required In Patient Management Nowadays
Blood transfusion remains essential in specific clinical scenarios such as massive hemorrhage, severe anemia, and critical coagulopathies, though modern alternatives like cell salvage, erythropoietin, and restrictive transfusion strategies have significantly reduced its absolute necessity.
Is Blood Transfusion Absolutely Required in Patient Management Nowadays?
The Big Idea: Blood transfusion is a life-saving but imperfect therapy. It is not always necessary, carries real risks, and faces supply constraints. The modern paradigm—Patient Blood Management (PBM)—shifts the focus from reflexive transfusion to optimising the patient's own haematopoiesis, minimising blood loss, and tolerating physiological anaemia. The answer to the title question is: transfusion is absolutely required in some scenarios, but can and should be avoided or minimised in many others.
Learning Objectives (from the lecture slides) [1]:
- Why does one need blood transfusion during treatment?
- Is current blood transfusion safe enough?
- What can I do if I don't want blood transfusion?
- How and what can a doctor advise on blood transfusion?
How this fits into exams: This lecture is tested both directly (MCQ/SAQ on transfusion thresholds, risks, alternatives, PBM) and indirectly (Upper GI bleeding management, massive transfusion complications, trauma resuscitation, haematology data interpretation). The 2025 SAQ Q2 is a near-perfect match.
Core Concepts and Mechanisms
Typical indications: (a) anaemia to a degree with moderate to serious symptoms, (b) active blood loss in trauma or surgical operation, (c) leukaemia, thalassaemia major, other causes of bone marrow failure. [1]
From first principles:
- Red blood cells carry oxygen. When Hb drops acutely, oxygen delivery to tissues falls → tissue hypoxia → organ dysfunction → death.
- Platelets form the primary haemostatic plug. When platelet count is critically low (or function impaired), uncontrolled bleeding ensues.
- Coagulation factors (in plasma) amplify and stabilise the clot. Deficiency → coagulopathic bleeding.
- In bone marrow failure (e.g. leukaemia, aplastic anaemia, thalassaemia major), the body simply cannot make enough blood cells → transfusion is the only bridge until the marrow recovers or is replaced (transplant).
Why blood transfusion is often needed: [1]
- Surgical operation — blood loss can range from minimal to massive depending on site and patient condition
- Bone marrow failure, leukaemia, thalassaemia — haematopoiesis fails → transfusion alleviates anaemia symptoms and bleeding. Can be temporary or permanent.
- Anaemia in elderly with co-morbidities — less likelihood of self-recovery
Blood transfusion should not always be given! [1]
- Many patients undergo treatment not in life-threatening conditions. They may come in for elective operation.
- There are alternatives to enhance erythropoiesis or correct the underlying situation.
- Doctors can have drugs and skills to reduce, minimise, control or stop bleeding.
- Bedside tools (POCT) to monitor coagulopathy and guide specific treatment.
Wrong Decisions for Transfusion — High Yield
Wrong decision for transfusion: [1]
- "Good for weakness and malaise" — Transfusion is NOT a tonic. It does not treat fatigue unless it is caused by significant anaemia.
- "More are better" — Each unit exposes the patient to additional risk. The modern approach is single unit transfusion and reassess.
4 Dimensions to consider: Adequacy, Quality, Safety, Outcome [1]
| Dimension | Key Points |
|---|---|
| Adequacy | Refers to common blood products (red cells, platelets, plasma) of common blood groups. Supply ≠ turning on a tap. Short shelf-life products (e.g. platelets: 5 days at 20–24°C) are especially vulnerable to shortage. |
| Quality | Affected by donor medication/diet/health, processing procedures, storage and handling at hospital blood bank and wards. |
| Safety | Blood is a biological substance. Screening is comprehensive but NOT exhaustive (window periods, hidden information). Patients are relatively immunocompromised during transfusion. |
| Outcome | Must balance risks vs benefits. Aim: correct symptoms, prevent risk of excessive bleeding. Patient still needs functional bone marrow and liver to recover. |
For every 1,000 Hong Kong citizens, only 30 participate in blood donation — and this is SHRINKING. [1]
- Ageing population → increasing demand
- Fewer young donors → new young donors (< 25) have declined dramatically since 2010 [1]
- COVID-19 pandemic → disrupted donation drives
- Public health factors → low Hb and high prevalence of iron deficiency in the general (donor) population [1]
- Clinical control of blood usage lags behind Western countries [1]
- School blood drives have fallen from 406 drives/year (2005-06) to 129 (2021-22) [1]
BTS (Blood Transfusion Service) is responsible for collection, processing and testing. BTS supplies blood to hospital blood banks. Blood supply is driven by clinical demand. [1]
Shelf Life of Blood Products
| Product | Storage | Shelf Life | Notes |
|---|---|---|---|
| Packed red cells | 2–6°C | 35–42 days | CPDA-1/SAGM additive [2] |
| Whole blood | 2–6°C | 35 days | Rarely given in HK [2] |
| Platelet concentrates | 20–24°C | 5 days | Short life = frequent shortage [1][2] |
| FFP | < −30°C | 1 year (thawed: 24h) | Must thaw before use [2] |
| Cryoprecipitate | < −25°C | 1 year | Contains fibrinogen, vWF, FVIII, FXIII [2] |
Mandatory tests on every donated unit: [1]
- ABO grouping, Rh(D) typing, Antibody screening
- Serological: HBsAg, anti-HCV, anti-HTLV I & II, HIV Ag/Ab Combo, anti-syphilis Ab
- NAT (nucleic acid testing): HBV DNA, HCV RNA, HEV RNA, HIV RNA
- Bacterial culture: ALL platelet units
Supplementary tests for selected groups: Anti-CMV, Zika by NAT [1]
Why both serology AND NAT? Serology detects antibodies/antigens but misses the "window period" (time between infection and detectable markers). NAT detects viral nucleic acid directly, shortening the window period dramatically.
Transfusion Risks
Current residual risk of transfusion-transmitted infection in Hong Kong: [1]
Pathogen Residual Risk Window Period HIV > 1 in 10,000,000 5.9 days Hepatitis C > 1 in 10,000,000 2.6 days Hepatitis B 1 in 126,000 15.1 days
HBV Has the Highest Residual Risk
HBV is the most common residual infectious risk because: (1) HK has high HBV carrier prevalence, (2) HBV has a longer NAT window period (15.1 days) compared to HIV and HCV, and (3) occult HBV infection can have very low viral loads that evade detection.
Agents that cannot be routinely tested in blood donation: [1]
- Malaria (now possible), Dengue (now possible)
- vCJD (restriction for UK/Europe stay lifted)
- Other emerging infections: Zika, Japanese Encephalitis
The lecture specifically notes a transfusion-transmitted Japanese Encephalitis case on 21/07/2017 in Hong Kong [1].
Non-infectious transfusion risks: [1]
| Reaction | Frequency | Key Features |
|---|---|---|
| Febrile non-haemolytic transfusion reaction (FNHTR) | Fairly common | Fever, chills, rigors. Due to cytokines in stored blood or recipient antibodies against donor WBC. Exclude AHTR/sepsis first. Mx: paracetamol, slow infusion rate [2]. |
| Minor allergic reaction | Fairly common (1–3%) | Urticaria, pruritus. Due to antibodies against donor plasma proteins. Mx: antihistamines [2]. |
| Haemolytic transfusion reaction | Rare but can be fatal | ABO mismatch → acute intravascular haemolysis → DIC, renal failure. Most commonly due to clerical/identification error. [1][2] |
| Transfusion-associated circulatory overload (TACO) | Often under-recognised | SOB, APO. Risk in elderly, cardiac/renal impairment. Mx: diuretics, slow rate [1][2]. |
| Transfusion-related acute lung injury (TRALI) | Rare | Non-cardiogenic pulmonary oedema within 6h. Due to donor anti-leukocyte antibodies. Mx: ventilatory support [1][2]. |
| Transfusion-associated GvHD (TA-GvHD) | Very rare, usually fatal | Donor T-lymphocytes attack recipient tissues. Prevented by irradiation of blood products [1][2]. |
| Post-transfusion purpura | Not seen locally [1] | Thrombocytopenia 5–10 days post-transfusion due to anti-platelet antibodies. |
Patient Blood Management (PBM)
PBM: A multidisciplinary, evidence-based approach to optimizing the care of patients who might need a blood transfusion. Aims to improve patient outcomes. Quite often, better outcomes can be achieved with reduction or avoidance of exposure to allogeneic blood. [1]
Modifying the Risk Factors: [1]
- Optimise red cell mass — Treat anaemia and iron deficiency pre-operatively
- Minimise blood loss and bleeding — Surgical technique, haemostatic drugs, POCT-guided coagulation management
- Harness and optimise physiological reserve of anaemia — Optimise cardiopulmonary function so the patient can tolerate lower Hb
Western Australia Study (4 adult tertiary-care hospitals, 604,046 admissions, 2008–2014): [1]
Clinical Outcome Reduction In-hospital mortality ↓15% Hospital length of stay ↓28% Hospital-acquired infections ↓21% Heart attack or stroke ↓31%
Blood Product Reduction Red cells (units per 1000 admissions) 311 → 182 (↓41%) Plasma ↓47% Platelets ↓28% Product-related cost savings: AU $18.5M [1]
PBM Not Only Saves Lives But Has Significant Outcome Benefits
This is a key exam message: PBM reduces mortality, infections, length of stay, and cardiovascular events — not just blood usage. It is endorsed by the WHO [1].
How Can Blood Transfusion Be Minimised?
| Factor | Details |
|---|---|
| Surgical factors | Operating site, procedure type, local haemostatic control, proximity to major vessels |
| Doctor's factors | Technical skill, confidence level, willingness to seek help |
| Patient's factors | Age, underlying medical illnesses (heart/lung disease), coagulation disorders, rare blood groups, presence of red cell antibodies |
| Others | Pre-surgical optimisation (very important!!) — diagnose and manage anaemia esp. iron deficiency; optimise cardiopulmonary reserve; pre-surgical autologous deposits; perioperative cell salvage; postoperative salvage |
Pre-surgical autologous deposits, perioperative deposits and salvage, postoperative salvage — still very uncommonly practised in Hong Kong. [1]
KWH O&G study: 114 menorrhagic women given 2 doses of IV Iron (Venofer 200mg) and oral iron supplement: [1]
Parameter Pre-treatment Post-treatment Hb (g/dL) 7.1 ± 0.7 10.5 ± 1.2 Ferritin (ng/dL) 6.8 ± 9.4 41.2 ± 28.1
This demonstrates that IV iron can significantly raise Hb before elective surgery, often eliminating the need for transfusion.
Nowadays, most experts recommend blood transfusion only in haemodynamically unstable patients. One unit and reassess — i.e. Single Unit Transfusion. [1]
| Clinical Setting | Transfuse When | Target | Source |
|---|---|---|---|
| General stable patient | Hb < 7 g/dL | 7–9 g/dL | [1][2][3] |
| Acute variceal bleeding (cirrhosis) | Hb < 7 g/dL | 7–9 g/dL (restrictive) | [4][5] |
| Underlying CVD / ACS | Hb < 8–9 g/dL | ≥ 8–9 g/dL | [5][6] |
| Haemodynamically unstable / massive bleeding | Transfuse immediately | Stabilise vital signs | [1][7] |
| Hb 7–10 | Consider if: elderly, symptomatic, ongoing Hb drop, CVD/respiratory disease | Clinical judgement | [2] |
| Hb > 10 | Generally NOT required | — | [2] |
Restrictive vs Liberal Transfusion — Exam Discriminator
Restrictive transfusion (Hb < 7) has been shown to be non-inferior to liberal transfusion (Hb < 10) in mortality, with fewer transfusion-related complications. In variceal bleeding specifically, liberal transfusion increases portal pressure → more rebleeding → worse survival [4][5]. But exceptions exist: haemodynamically unstable patients and those with underlying CVD should be transfused more liberally [5].
Massive Transfusion
For trauma with massive haemorrhage:
Ratio of RBCs : FFP : Platelets = 1:1:1 [7]
When BSS (balanced salt solution) infusion > 30 mL/kg, blood transfusion is indicated. No steroids or vasopressors to treat hypovolaemic shock in trauma — surgical intervention to STOP THE BLEEDING. [7]
Complications of massive transfusion (high yield for SAQ):
- Hypothermia — stored blood is cold (2–6°C)
- Hyperkalaemia — K+ leaks out of stored RBCs
- Hypocalcaemia — citrate anticoagulant chelates calcium
- Coagulopathy — dilutional (dilution of clotting factors and platelets) + consumption
- Metabolic alkalosis — citrate is metabolised to bicarbonate
- TACO — volume overload
- Transfusion reactions — increased exposure = increased risk
What If the Patient Refuses Transfusion?
Patients may request no blood transfusion for religious, cultural or personal reasons (perceived infectious risk). [1]
Patients may request autologous blood or directed donation. [1]
- Always balance risk vs benefit
- Understand risk of homologous vs autologous vs directed donation
- Explore alternatives — any potential delay in treatment?
Theoretically safer, but: [1]
- Not every patient eligible/suitable
- Risk of bacteraemia
- Risk of mix-up (clerical error still possible)
- Risk of wastage (if not needed, it is discarded — cannot be given to others)
Not every potential donor is eligible/suitable. [1]
- Donor may hide important information or be under pressure to donate
- Risk of positive infectious disease markers → wastage
- Risk of TA-GvHD — because a family member is more likely to share HLA haplotypes → donor lymphocytes are not rejected and attack recipient. Prevented by irradiation. [1]
Directed Donation TA-GvHD Risk
This is a classic exam trap. Students assume directed (family) donation is safer, but a first-degree relative sharing an HLA haplotype can cause fatal TA-GvHD. Always irradiate directed donations.
Type and Screen (T/S) is the current practice in HK (not traditional cross-match): [8]
- Type: ABO and RhD grouping
- Screen: Test for clinically significant antibodies using indirect antiglobulin test (IAT) against panel of screening RBCs
- Cross-match: Only if screen is positive or history of anti-RBC antibodies
| Key Fact | Detail |
|---|---|
| T/S validity | 72 hours (short because new antibodies can form, especially in pregnant women) [8] |
| Thalassaemia patients | T/S can be extended to 1 week [8] |
| Operative patients (no transfusion in interval) | Can be extended to 1 month [8] |
| Platelet transfusion | No T/S necessary (ABO compatibility not required for platelets, except in children < 1 year) [8] |
| FFP transfusion | T/S required — plasma is full of antibodies, must be ABO compatible [8] |
| Product | Indication | Dose/Increment | Emergency Group |
|---|---|---|---|
| Packed red cells | Hb < 7 (stable); symptomatic anaemia; active bleeding | 1 unit ↑ Hb ~1 g/dL (70 kg adult) | O negative (or O positive in males) |
| Platelets | < 10 (stable); < 20 (fever/sepsis); < 50 (invasive procedures); < 100 (CNS/eye surgery) | RDP: 4 units; SDP: 1 unit (=6 RDP) | Any group |
| FFP | Coagulopathy with bleeding; reversal of anticoagulation; massive transfusion; DIC | 2–4 units | AB |
| Cryoprecipitate | Fibrinogen < 100 mg/dL; vWD; DIC | 10 units/dose | Any group |
(Table synthesised from lecture + senior notes for completeness) [1][2]
Clinical Case from the Lecture
A 47-year-old woman with severe menorrhagia, Hb 4.0, multiple fibroids, advised for hysterectomy, refused transfusion. [1]
Management in acute stage: [1]
- Transfusion of ONE unit (or at most two) for symptom control — she has chronic anaemia so no need to aggressively correct
- IV Iron replacement (preferred over oral — fewer side effects, better compliance)
- Haemostatic drugs (e.g. tranexamic acid) to control excessive bleeding
After stabilisation with iron, menorrhagia persisted. Electively admitted for surgery with Hb ~12. [1]
- Does she need transfusion? → No. Hb 12 is adequate. Hysterectomy is curative and normally does not cause excessive bleeding. Once complete, no more source of bleeding. [1]
- If she asks for directed donation? → Not recommended. Risk of TA-GvHD, pressure on donor, potential wastage, positive markers. [1]
Summary points from the lecture: [1]
- Blood transfusion carries benefits but also risks and adverse events
- Blood supply can be limited and has shelf life; many reasons prevent immediate availability
- Nowadays, most experts recommend transfusion only in haemodynamically unstable patients. Single Unit Transfusion — one unit and reassess
- Alternative measures available — e.g. IV iron can replace transfusion and optimise patients' reserve (including cardiopulmonary status) for better tolerance to surgery
- Think twice or even more times before initiating a blood transfusion
Integration with Related GC Lectures
This lecture complements GC 155 by covering the acute and chronic complications in detail:
- Acute reactions: FNHTR, allergic, AHTR, septic, TRALI, TACO, anaphylaxis
- Chronic complications: iron overload, delayed haemolytic reaction, infection transmission
- Step 1 of any transfusion reaction: STOP the transfusion, keep IV patent with NS, recheck identity, send blood bag for investigation
- In trauma: early blood transfusion for transient or non-responders
- RBC:FFP:Plt = 1:1:1 ratio in massive transfusion
- No vasopressors/steroids for hypovolaemic shock — surgical intervention to stop the bleeding
- Restrictive transfusion strategy (Hb < 7, aim 7–9)
- Exception: haemodynamically unstable or underlying CVD → transfuse more liberally
- In variceal bleeding: liberal transfusion increases portal pressure → rebleeding
Exam Intelligence
| Trap | Correct Answer |
|---|---|
| "Transfuse to normal Hb" | No. Restrictive strategy: transfuse only if Hb < 7 in stable patients. Aim 7–9. |
| "O negative blood is always given in emergency" | Prefer group-specific blood. O negative is reserved for true emergencies when no time for T/S. O positive can be given to males but carries Rh sensitisation risk in females of childbearing age. |
| "Directed donation from family is safer" | No. Risk of TA-GvHD (shared HLA haplotype), donor hiding information, positive markers. Must irradiate. |
| "Autologous blood has no risk" | Wrong. Risk of bacteraemia, mix-up, wastage. |
| "Platelet transfusion needs cross-match" | No. No T/S required for platelets (except children < 1 year). |
| "FFP doesn't need compatibility testing" | Wrong. FFP is full of antibodies → ABO compatible. AB FFP is the universal donor plasma. |
| "Transfuse more blood in variceal bleeding" | No. Liberal transfusion increases portal pressure → rebleeding → worse survival. Use restrictive strategy. |
| "HCV is the main residual infectious risk" | No. HBV has the highest residual risk (1 in 126,000) due to longer window period. |
| "More units = better outcome" | Wrong. Each unit adds risk. Single unit policy: transfuse one, reassess. |
- Restrictive transfusion strategy is the answer when the patient is haemodynamically stable with Hb ~7 and underlying CVD — BUT the question must specify stable. If unstable, transfuse.
- If the question asks about a patient with IHD + upper GI bleed + stable vitals + Hb 7.5: answer is restrictive blood transfusion (not packed cell transfusion, not platelet transfusion, not continuing aspirin without nuance).
- The question may try to trick you with "continue aspirin" — generally aspirin is continued for secondary prevention unless severe bleeding, but the most appropriate pre-endoscopy step is restrictive transfusion, not aspirin management.
Past Paper Questions
Stem: "A 55-year-old male patient with a history of alcoholic cirrhosis presented with massive haematemesis. He developed hypotension and oliguria. 11 packs of packed cells were transfused during resuscitation. (a) Name two differential diagnoses for the patient's hypotension and oliguria. (2 marks) (b) Name one aim for blood transfusion. (2 marks) (c) What are the three risks of blood transfusion? (3 marks) (d) What are the three potential complications that he may develop from massive transfusion? (3 marks)"
Answer/Rationale:
(a) Hypovolaemic shock (from massive haematemesis) AND hepatorenal syndrome (pre-renal AKI from cirrhosis/bleeding). Other acceptable: sepsis, cardiogenic shock from TACO.
(b) To restore oxygen-carrying capacity / correct symptomatic anaemia / maintain haemodynamic stability / prevent tissue hypoxia. Key point from lecture: "Blood transfusion aims to correct the symptoms and prevents the risk of excessive bleeding" [1].
(c) Three risks of blood transfusion (pick from):
- Infectious — HBV, HCV, HIV, bacterial contamination
- Non-infectious — haemolytic reaction, FNHTR, allergic reaction, TACO, TRALI, TA-GvHD
- Immunological — alloimmunisation, TA-GvHD
(d) Three complications of massive transfusion:
- Hypothermia (cold blood)
- Hypocalcaemia (citrate chelation)
- Hyperkalaemia (leakage from stored RBCs)
- Dilutional coagulopathy (acceptable alternative)
- Metabolic alkalosis (citrate → bicarbonate)
Stem: "A 72-year-old man with underlying coronary artery disease on aspirin was admitted for fresh melena. BP 120/86, pulse 80. Hb 7.4 g/dL, platelets 90 × 10⁹/L. Which of the following management is correct? A. Histamine 2 receptor antagonists B. Packed cell transfusion C. Platelet transfusion D. Restrictive blood transfusion strategy"
Correct answer: D — Restrictive blood transfusion strategy
Rationale: Patient is haemodynamically stable (BP 120/86, pulse 80). Hb 7.4 is above 7 g/dL. He has CAD, so the threshold is slightly higher (Hb < 8–9), but since BP is stable and Hb is 7.4, the strategy is still restrictive — you monitor and transfuse if Hb drops further or he becomes symptomatic/unstable. Option B (packed cell transfusion) implies immediate liberal transfusion, which is not the right approach in a stable patient. Platelet transfusion is not indicated at 90 × 10⁹/L (threshold is < 50 for procedures). H2RA is not the priority management step.
Stem: "A 60-year-old man on aspirin and carvedilol for IHD and CHF was admitted for fresh haematemesis. BP 100/60, pulse 110. Hb 7.5 g/dL, platelets 100 × 10⁹/L. Which management strategy before upper endoscopy is MOST APPROPRIATE? A. Continue aspirin B. Restrictive blood transfusion C. Stop carvedilol D. Terlipressin"
Correct answer: B — Restrictive blood transfusion
Rationale: Despite having IHD/CHF, the most appropriate pre-endoscopy strategy is restrictive transfusion (Hb < 7 threshold in general; in CVD patients, threshold may be slightly higher at ~8, and his Hb is 7.5 — still within range for restrictive approach with close monitoring). Terlipressin is for variceal bleeding (no cirrhosis mentioned). Aspirin continuation is debatable but not the "most appropriate." Stopping carvedilol is not the priority.
Stem: "A 50-year-old man on aspirin and bisoprolol for IHD and CHF was admitted for vomiting 800 mL of fresh blood. BP 120/80, pulse 80. Hb 7.5 g/dL, platelets 120 × 10⁹/L. Which management strategy is MOST APPROPRIATE? A. Continue aspirin B. Intravenous metoclopramide C. Platelet transfusion D. Restrictive transfusion strategy"
Correct answer: D — Restrictive transfusion strategy
Rationale: Nearly identical to 2023 Q43 and 2025 Q33. Patient is stable (BP 120/80). Hb 7.5, platelets 120 (above threshold). Restrictive strategy is the answer for a haemodynamically stable patient with upper GI bleed.
High Yield Summary
- Blood transfusion is NOT always needed — alternatives exist (IV iron, haemostatic drugs, pre-surgical optimisation, PBM).
- 4 Dimensions: Adequacy (supply is limited), Quality, Safety (blood is never 100% safe), Outcome (balance risks vs benefits).
- Restrictive transfusion strategy: Transfuse at Hb < 7 g/dL in stable patients; aim 7–9 g/dL. Exception: CVD patients (Hb < 8–9) and haemodynamically unstable (transfuse immediately).
- Single Unit Transfusion: Give one unit, reassess. "More is NOT better."
- HBV has the highest residual infectious risk in HK (1 in 126,000) due to long NAT window period.
- Non-infectious risks are far more common: FNHTR, allergic reactions, TACO (often under-recognised), TRALI, haemolytic reaction.
- Patient Blood Management reduces mortality, infections, LOS, MI/stroke, and blood product usage (Western Australia evidence).
- Directed donation carries risk of TA-GvHD — must irradiate. Autologous blood has risks of bacteraemia, mix-up, wastage.
- Massive transfusion complications: hypothermia, hyperkalaemia, hypocalcaemia, dilutional coagulopathy, metabolic alkalosis.
- T/S validity: 72 hours. Platelets don't need T/S. FFP needs ABO compatibility.
- IV iron is the key alternative to transfusion for iron-deficiency anaemia — lecture data shows Hb can rise from 7.1 to 10.5 g/dL with 2 doses of IV Venofer.
Active Recall - Blood Transfusion in Patient Management
[1] Lecture slides: GC 155. Is blood transfusion absolutely required in patient management nowadays.pdf [2] Senior notes: Maksim Medicine Notes.pdf (Haematology section, pp. 181–184) [3] Senior notes: Ryan Ho Haemtology.pdf (Section 5.1 Transfusion Medicine) [4] Senior notes: Block A - Abdominal distension_ ascites and cirrhosis.pdf (Restrictive transfusion in variceal bleeding) [5] Senior notes: Block A - Coffee ground vomitus tarry stool upper GI bleeding.pdf (Restrictive transfusion exceptions) [6] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (Transfusion thresholds in UGI bleeding) [7] Lecture slides: GC 188. Hit by a van, in shock with internal bleeding Abdominal injury.pdf (pp. 25, 31) [8] Senior notes: Block A - Introduction to Haematological investigations (CBP, Clotting).pdf (Part 3: Transfusion) [9] Lecture slides: GC 049. Fever after a blood transfusion.pdf [10] Past papers: 2025 Fourth Summative SAQ.pdf (Question 2) [11] Past papers: 2025 Fourth Summative MCQ.pdf (Question 33) [12] Past papers: 2023 Fourth Summative MCQ.pdf (Question 43) [13] Past papers: 2021 Fourth Summative Assessment MCQ.pdf (Question 37)
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