NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
National Clinical Guideline Centre (UK). Blood Transfusion. London: National Institute for Health and Care Excellence (NICE); 2015 Nov. (NICE Guideline, No. 24.)
1.1. Key priorities for implementation
From the full set of recommendations, the GDG selected [10] key priorities for implementation. The criteria used for selecting these recommendations are listed in detail in the NICE guidelines manual(NICE2014).216 The reason that each of these recommendations was chosen are shown in the table linking the evidence to the recommendation in the relevant chapter.
Alternatives to blood transfusion for patients having surgery
Intravenous and oral iron
- Offer oral iron before and after surgery to patients with iron-deficiency anaemia.
Cell salvage and tranexamic acid
- 2.
Offer tranexamic acid to adults undergoing surgery who are expected to have at least moderate blood loss (greater than 500 ml).
- 3.
Consider intra-operative cell salvage with tranexamic acid for patients who are expected to lose a very high volume of blood (for example in cardiac and complex vascular surgery, major obstetric procedures, and pelvic reconstruction and scoliosis surgery).
Red Blood Cells
Thresholds and Targets
- 4.
When using a restrictive red blood cell transfusion threshold, consider a threshold of 70 g/litre and a haemoglobin concentration target of 70–90 g/litre after transfusion.
Doses
- 5.
Consider single-unit red blood cell transfusions for adults (or equivalent volumes calculated based on body weight for children or adults with low body weight) who do not have active bleeding.
Platelets
Thresholds and Targets
Patients who are not bleeding or having invasive procedures or surgery
- 6.
Offer prophylactic platelet transfusions to patients with a platelet count below 10×109 per litre who are not bleeding or having invasive procedures or surgery, and who do not have any of the following conditions:
- chronic bone marrow failure
- autoimmune thrombocytopenia
- heparin-induced thrombocytopenia
- thrombotic thrombocytopenic purpura.
Doses
- 7.
Do not routinely transfuse more than a single dose of platelets.
Fresh frozen plasma
- 8.
Do not offer fresh frozen plasma transfusions to correct abnormal coagulation in patients who:
- are not bleeding (unless they are having invasive procedures or surgery with a risk of clinically significant bleeding)
- need reversal of a vitamin K antagonist.
Prothrombin complex concentrate
- 9.
Offer immediate prothrombin complex concentrate transfusions for the emergency reversal of warfarin anticoagulation in patients with either:
- severe bleeding or
- head injury with suspected intracerebral haemorrhage.
Patient information
- 10.
Provide verbal and written information to patients who may have or who have had a transfusion, and their family members or carers (as appropriate), explaining:
- the reason for the transfusion
- the risks and benefits
- the transfusion process
- any transfusion needs specific to them
- any alternatives that are available, and how they might reduce their need for a transfusion
- that they are no longer eligible to donate blood
- that they are encouraged to ask questions.
1.2. Full list of recommendations
Alternatives to blood transfusion for patients having surgery: Oral iron, IV iron and erythropoietin
- Do not offer erythropoietin to reduce the need for blood transfusion in patients having surgery, unless:
- the patient has anaemia and meets the criteria for blood transfusion, but declines it because of religious beliefs or other reasons or
- the appropriate blood type is not available because of the patient's red cell antibodies.
- Offer oral iron before and after surgery to patients with iron-deficiency anaemia.
- Consider intravenous iron before or after surgery for patients who:
- have iron-deficiency anaemia and cannot tolerate or absorb oral iron, or are unable to adhere to oral iron treatment (see the NICE guideline on medicines adherence)
- are diagnosed with functional iron deficiency
- are diagnosed with iron-deficiency anaemia, and the interval between the diagnosis of anaemia and surgery is predicted to be too short for oral iron to be effective.
- For guidance on managing anaemia in patients with chronic kidney disease, see the NICE guideline on anaemia management in chronic kidney disease.
- For guidance on managing blood transfusions for people with acute upper gastrointestinal bleeding, see section 1.2 in the NICE guideline on acute upper gastrointestinal bleeding.
Alternatives to blood transfusion for patients having surgery: Cell salvage and tranexamic acid
- 6.
Offer tranexamic acid to adults undergoing surgery who are expected to have at least moderate blood loss (greater than 500 ml)
- 7.
Consider tranexamic acid for children undergoing surgery who are expected to have at least moderate blood loss (greater than 10% blood volume).
- 8.
Do not routinely use cell salvage without tranexamic acid.
- 9.
Consider intra-operative cell salvage with tranexamic acid for patients who are expected to lose a very high volume of blood (for example in cardiac and complex vascular surgery, major obstetric procedures, and pelvic reconstruction and scoliosis surgery).
Monitoring for acute reactions
- 10.
Monitor the patient's condition and vital signs before, during and after blood transfusions, to detect acute transfusion reactions that may need immediate investigation and treatment.
- 11.
Observe patients who are having or have had a blood transfusion in a suitable environment with staff who are able to monitor and manage acute reactions.
Electronic patient identification
- 12.
Consider using a system that electronically identifies patients to improve the safety and efficiency of the blood transfusion process.
Red blood cells: thresholds and targets
- 13.
Use restrictive red blood cell transfusion thresholds for patients who need red blood cell transfusions and who do not:
- have major haemorrhage or
- have acute coronary syndrome or
- need regular blood transfusions for chronic anaemia.
- 14.
When using a restrictive red blood cell transfusion threshold, consider a threshold of 70 g/litre and a haemoglobin concentration target of 70–90 g/litre after transfusion.
- 15.
Consider a red blood cell transfusion threshold of 80 g/litre and a haemoglobin concentration target of 80–100 g/litre after transfusion for patients with acute coronary syndrome.
- 16.
Consider setting individual thresholds and haemoglobin concentration targets for each patient who needs regular blood transfusions for chronic anaemia.
Red blood cells: doses
- 17.
Consider single-unit red blood cell transfusions for adults (or equivalent volumes calculated based on body weight for children or adults with low body weight) who do not have active bleeding.
- 18.
After each single-unit red blood cell transfusion (or equivalent volumes calculated based on body weight for children or adults with low body weight), clinically reassess and check haemoglobin levels, and give further transfusions if needed.
Platelet: Thresholds and Targets
Patients with thrombocytopenia who are bleeding
- 19.
Offer platelet transfusions to patients with thrombocytopenia who have clinically significant bleeding (World Health Organization [WHO] grade 2) and a platelet count below 30×109 per litre.
- 20.
Use higher platelet thresholds (up to a maximum of 100×109 per litre) for patients with thrombocytopenia and either of the following:
- severe bleeding (WHO grades 3 and 4)
- bleeding in critical sites, such as the central nervous system (including eyes).
Patients who are not bleeding or having invasive procedures or surgery
- 21.
Offer prophylactic platelet transfusions to patients with a platelet count below 10×109 per litre who are not bleeding or having invasive procedures or surgery, and who do not have any of the following conditions:
- chronic bone marrow failure
- autoimmune thrombocytopenia
- heparin-induced thrombocytopenia
- thrombotic thrombocytopenic purpura.
Patients who are having invasive procedures or surgery
- 22.
Consider prophylactic platelet transfusions to raise the platelet count above 50×109 per litre in patients who are having invasive procedures or surgery.
- 23.
Consider a higher threshold (for example 50–75×109 per litre) for patients with a high risk of bleeding who are having invasive procedures or surgery, after taking into account:
- the specific procedure the patient is having
- the cause of the thrombocytopenia
- whether the patient's platelet count is falling
- any coexisting causes of abnormal haemostasis.
- 24.
Consider prophylactic platelet transfusions to raise the platelet count above 100×109 per litre in patients having surgery in critical sites, such as the central nervous system (including the posterior segment of the eyes).
When prophylactic platelet transfusions are not indicated
- 25.
Do not routinely offer prophylactic platelet transfusions to patients with any of the following:
- chronic bone marrow failure
- autoimmune thrombocytopenia
- heparin-induced thrombocytopenia
- thrombotic thrombocytopenic purpura.
- 26.
Do not offer prophylactic platelet transfusions to patients having procedures with a low risk of bleeding, such as adults having central venous cannulation or any patients having bone marrow aspiration and trephine biopsy.
Platelet: doses
- 27.
Do not routinely transfuse more than a single dose of platelets.
- 28.
Only consider giving more than a single dose of platelets in a transfusion for patients with severe thrombocytopenia and bleeding in a critical site, such as the central nervous system (including eyes).
- 29.
Reassess the patient's clinical condition and check their platelet count after each platelet transfusion, and give further doses if needed.
Fresh frozen plasma: thresholds and targets
- 30.
Only consider fresh frozen plasma transfusion for patients with clinically significant bleeding but without major haemorrhage if they have abnormal coagulation test results (for example, prothrombin time ratio or activated partial thromboplastin time ratio above 1.5).
- 31.
Do not offer fresh frozen plasma transfusions to correct abnormal coagulation in patients who:
- are not bleeding (unless they are having invasive procedures or surgery with a risk of clinically significant bleeding)
- need reversal of a vitamin K antagonist.
- 32.
Consider prophylactic fresh frozen plasma transfusions for patients with abnormal coagulation who are having invasive procedures or surgery with a risk of clinically significant bleeding.
Fresh frozen plasma: doses
- 33.
Reassess the patient's clinical condition and repeat the coagulation tests after fresh frozen plasma transfusion to ensure that they are getting an adequate dose, and give further doses if needed.
Cryoprecipitate: thresholds and targets
- 34.
Consider cryoprecipitate transfusions for patients without major haemorrhage who have:
- clinically significant bleeding and
- a fibrinogen level below 1.5 g/litre.
- 35.
Do not offer cryoprecipitate transfusions to correct the fibrinogen level in patients who:
- are not bleeding and
- are not having invasive procedures or surgery with a risk of clinically significant bleeding.
- 36.
Consider prophylactic cryoprecipitate transfusions for patients with a fibrinogen level below 1.0 g/litre who are having invasive procedures or surgery with a risk of clinically significant bleeding.
Cryoprecipitate: doses
- 37.
Use an adult dose of 2 pools when giving cryoprecipitate transfusions (for children, use 5–10 ml/kg up to a maximum of 2 pools).
- 38.
Reassess the patient's clinical condition, repeat the fibrinogen level measurement and give further doses if needed.
Prothrombin complex concentrate: thresholds and targets
- 39.
Offer immediate prothrombin complex concentrate transfusions for the emergency reversal of warfarin anticoagulation in patients with either:
- severe bleeding or
- head injury with suspected intracerebral haemorrhage.
- 40.
For guidance on reversing anticoagulation treatment in people who have a stroke and a primary intracerebral haemorrhage, see recommendation 1.4.2.8 in the NICE guideline on the initial diagnosis and management of stroke.
- 41.
Consider immediate prothrombin complex concentrate transfusions to reverse warfarin anticoagulation in patients having emergency surgery, depending on the level of anticoagulation and the bleeding risk.
- 42.
Monitor the international normalised ratio (INR) to confirm that warfarin anticoagulation has been adequately reversed, and consider further prothrombin complex concentrate.
Patient information
- 43.
Provide verbal and written information to patients who may have or who have had a transfusion, and their family members or carers (as appropriate), explaining:
- the reason for the transfusion
- the risks and benefits
- the transfusion process
- any transfusion needs specific to them
- any alternatives that are available, and how they might reduce their need for a transfusion
- that they are no longer eligible to donate blood
- that they are encouraged to ask questions.
- 44.
Document discussions in the patient's notes.
- 45.
Provide the patient and their GP with copies of the discharge summary or other written communication that explains:
- the details of any transfusions they had
- the reasons for the transfusion
- any adverse events
- that they are no longer eligible to donate blood.
- 46.
For guidance on communication and patient-centred care for adults, see the NICE guideline on patient experience in adult NHS services.
1.3. Key research recommendations
- Post-operative cell salvage: For patients having cardiac surgery with a significant risk of post-operative blood loss, is post-operative cell salvage and reinfusion clinically and cost effective in reducing red blood cell use and improving clinical outcomes, compared with existing practice?
- Why this is important: There was some evidence for benefit from postoperative cell salvage, but the quality was low. Reducing blood loss during cardiac surgery may reduce the risk of complications. However, post-operative cell salvage carries additional cost. Studies are needed to determine whether post-operative cell salvage is more clinically and cost effective than existing practice for patients having cardiac surgery with a significant risk of post-operative blood loss. Important outcomes should include the use of red blood cells and other blood components, clinical outcomes and quality of life.
- Electronic Decision Support: What is the clinical and cost effectiveness of an electronic decision support system compared with current practice in reducing inappropriate blood transfusions, overall rates of blood transfusion and mortality?
- Why this is important: The clinical evidence evaluating electronic decision support systems is of low quality. There is also no evidence on their cost effectiveness within the NHS, and this is particularly important because of the potentially high setup and running costs of these systems. An evaluation of the clinical and cost effectiveness of electronic decision support systems for blood transfusion is needed. Important outcomes are rates of inappropriate transfusion, overall rates of transfusion, and patient safety outcomes including mortality and transfusion errors. Secondary outcomes should include length of hospital stay and quality of life; and pre-transfusion haemoglobin levels, platelet count and coagulation results.
- Red Blood Cell Transfusion: What is the clinical and cost effectiveness of restrictive compared with liberal red blood cell thresholds and targets for patients with chronic cardiovascular disease?
- Why this is important: The literature suggests that there may be some evidence of harm with the use of restrictive red blood cell thresholds in populations with coronary ischaemia at baseline. In this guideline a level of 80–100 g/litre was used for patients with acute coronary syndrome, but further studies are needed to determine the optimal transfusion threshold for patients with chronic cardiovascular disease.
- Fresh frozen plasma for patients with abnormal haemostasis who are having invasive procedures or surgery: What dose of fresh frozen plasma is most clinically effective at preventing bleeding in patients with abnormal haemostasis who are having invasive procedures or surgery?
- Why this is important: Audits have shown that fresh frozen plasma is widely used for non-bleeding patients in the intensive care unit (ICU) and many other clinical settings. There is a large variation in dose and no real evidence base to guide practice. Fresh frozen plasma transfusions may cause adverse outcomes in people who are critically ill, including transfusion-related acute lung injury, transfusion-related circulatory overload, multi-organ failure and an increased risk of infections.
- A multicentre study of ICUs in the UK showed that 12.7% of patients admitted to the ICU received fresh frozen plasma. The median dose was 10.8 ml/kg, but doses varied widely (range 2.4 – 41.1 ml/kg). This study showed that a high proportion of fresh frozen plasma transfusions had unproven clinical benefit.
- Better evidence from clinical trials could significantly alter how fresh frozen plasma is used, and in particular ensure that clinically effective doses are given to patients.
1.4. Algorithm
Flowchart (PDF, 322K)
- Guideline summary - Blood TransfusionGuideline summary - Blood Transfusion
Your browsing activity is empty.
Activity recording is turned off.
See more...