Guidelines for Red Blood Cell Transfusion

British Columbia Transfusion Medicine Advisory Group, November 2003

Purpose

The purpose of these guidelines is to support physicians in their clinical decisions related to the appropriate use of red blood cells (RBCs). They are not intended to provide a rigid prescription for care and do not replace the need to consult with an expert in transfusion medicine. The decision to transfuse RBCs should be based on the judgment of the attending physician after careful review of the patient’s condition and clinical situation. The goal is to optimize patient outcomes and to ensure appropriate use of the allogeneic (donor) blood supply.

The guidelines apply to RBC transfusion in adults and children over 4 months of age.

General Considerations

1. Informed consent is required for the transfusion of RBCs.

2. A patient’s hemoglobin value, although important, should not be the sole deciding factor when considering whether to transfuse RBCs. The decision to transfuse should be supported by the need to prevent or alleviate clinical symptoms, signs or morbidity due to inadequate tissue oxygen delivery. RBC transfusion should not be used to expand vascular volume when oxygen-carrying capacity is adequate.

3. RBC transfusion should be given only after the risks associated with transfusion have been considered and only when the benefits outweigh the risks, taking into account the expected life span of the patient. It is particularly important to avoid the long-term complications of transfusion in a young patient.

4. Strategies should be undertaken to minimize the need to transfuse RBCs, for example:

investigate, diagnose and treat previously recognized anemia;
implement available alternatives, when appropriate, to reduce the risk of allogenic transfusion, i.e. iron supplement (oral or IV), erythropoietin, autologous blood donation, cell saver, etc.;
preoperatively assess for anemia (within 28-35 days) prior to surgical intervention with anticipated risk of transfusion (significant blood loss);
discontinue anti-coagulants and antiplatelet drugs before planned surgery;
minimize the frequency and volume of blood sampling for laboratory testing;
utilize a simple protocol to guide when hemoglobin should be assessed and when RBCs should be transfused;
utilize a surgical technique that minimizes blood loss;
utilize appropriate pharmacologic interventions to minimize blood loss (e.g., antifibrinolytics)

5. A patient with acute blood loss should receive effective resuscitation (appropriate volume replacement with crystalloid solutions or colloids, i.e. Pentastarch), while the need for transfusion is assessed.

6. In non-urgent settings, RBCs should be administered one unit at a time and the patient should be assessed prior to transfusing additional units (clinical exam and hemoglobin level).

7. In situations where RBCs are transfused, the reasons for the transfusion should be clearly and accurately recorded in the patient’s chart and in any documentation used in ordering or administering RBCs

8. Hospital transfusion committees should function at the local level to promote, guide and direct prudent transfusion practice and assist in the dissemination of information pertaining to safe transfusion practice.

9. In all situations where RBCs are transfused, a process for clinical review should be in place and utilized to monitor the appropriateness of RBC use and to develop systems for the implementation of these guidelines.

Threshold and target hemoglobin levels for RBC transfusion

As a general guide, in normal healthy individuals, a transfusion threshold of 70 g/L is appropriate and leaves some margin of safety over the critical level of 40-50 g/L. In patients with indications of cardiac disease, the available evidence suggests that, as a general guide, it may be safer to maintain the hemoglobin above 90 g/L. Transfusion at hemoglobin above 100 g/L is unlikely to be appropriate unless there are specific indications.

For patients undergoing planned surgery

Where the patient is stable, is not bleeding and further major bleeding is not anticipated:

For patients without cardiovascular disease, and especially younger patients, transfusion is likely to be appropriate to maintain hemoglobin levels in the range of 70-90 g/L. Lower thresholds may be acceptable in younger patients without signs or symptoms of impaired oxygen transport. Transfusion is unlikely to be appropriate at hemoglobin levels above 90 g/L.

· For patients known to have or likely to have cardiovascular disease, transfusion is likely to be appropriate to maintain hemoglobin in the range of 90-100 g/L.

Specific factors to consider include:

Patient’s cardiopulmonary reserve – if pulmonary function is not normal, it may be necessary to consider transfusing at a higher hemoglobin threshold.
Volume of blood loss – clinical assessment should attempt to quantify the volume of blood loss before, during and after surgery, to ensure maintenance of normal blood volume.
Oxygen consumption – this may be affected by a number of factors, including fever, anesthesia and shivering; if increased, then the patient’s need for RBC transfusion could be higher.
Atherosclerotic disease – critical arterial stenosis to major organs, particularly the heart, may modify indications for the use of RBCs.

This general guidance also applies to prescribing a postoperative transfusion. Postoperative blood loss must be accurately monitored and documented and there should be a clear protocol or individual management plan, including the criteria for the administration of a transfusion, and for surgical re-exploration if blood loss is excessive.

For patients with acute blood loss

Maintaining adequate intravascular volume (including crystalloid and colloid infusion) is critical to ensuring adequate tissue oxygenation. Transfusion is likely to be appropriate to maintain hemoglobin above 70 g/L during active bleeding. Consider the rate of bleeding, assess hemodynamic factors, observe for evidence of tissue ischemia, and take into account the institutional challenges of providing appropriate blood products and laboratory testing in the decision to transfuse.

Consider maintaining a higher hemoglobin level for patients with:

Impaired pulmonary function
Increased oxygen consumption (fever, chills)
Coronary artery disease
Unstable coronary syndromes
Uncontrolled/unpredictable bleeding.

Patients with hemoglobin above 100 g/L are unlikely to benefit from transfusion.

For critically ill patients with anemia

Patients with critical illness frequently develop anemia. Transfusion may be appropriate to control anemia-related symptoms if the hemoglobin falls below 70 g/L, with the aim of maintaining the hemoglobin concentration in the range of 70-90 g/L. A possible exception to this guideline is patients with known ischemic heart disease, where it may be preferable to maintain the hemoglobin in the range of 90-100 g/L. The aim is not to achieve a predetermined oxygen delivery but to assess whether the oxygen delivery is adequate by examining urine output, skin temperature, and the severity of lactic acidosis.

For patients with chronic anemia

Determine the cause of anemia so that, where appropriate, treatment other than RBC transfusion may be used. Administer RBCs at intervals to relieve symptoms of anemia and to maintain the hemoglobin at a reasonable and safe level to compensate for unexpected blood loss. Maintaining the hemoglobin greater than 80 g/L may be appropriate in a patient on a chronic transfusion regime or during bone marrow suppressive therapy. Assess patients that are expected to have long-term transfusion-dependent survival for iron overload and treat if appropriate.

Source

These guidelines have been developed through the consensus of the British Columbia Transfusion Medicine Advisory Group (TMAG), which consists of transfusion medicine physicians, technologists and nurses from hospitals across BC. The guidelines are based on existing guidelines for transfusion medicine practice, in particular the UK Blood Transfusion and Tissue Transplantation Guidelines (UK Handbook of Transfusion Medicine, Third Edition 2001) and the Australian National Health and Medical Research Council/Australasian Society of Blood Transfusion Clinical Practice Guidelines for the Appropriate Use of Red Blood Cells (2001), and the best available published research regarding the clinical indications for transfusion.

For More Information

For more information, consult the following:

UK Handbook of Transfusion Medicine, Third Edition. UK Blood Transfusion Services, 2001.

National Health and Medical Research Council. Clinical practice guidelines on the use of blood components

Appropriate use of red blood cells. Canberra, Australia 2001 (pdf)

Guidelines for red blood cell and plasma transfusion for adults and children, Report of the Expert Working Group. Can Med Assoc J 1997;156 (11 suppl):S1-S24.

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