NICE Guideline on Blood transfusion.

This guideline was developed by the National Clinical Guideline Centre (NCGC) on behalf of the National Institute for Health and Care Excellence (NICE). These are relating to Blood transfusion

Some people have religious beliefs that do not allow the transfusion of blood. Specific issues relating to these people have been addressed when reviewing the evidence and writing the recommendations.

The major recommendation of the guidelines are summarised as follows

Alternatives to Blood Transfusion for Patients Having Surgery

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

Intravenous and Oral Iron

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.


• 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

Cell Salvage and Tranexamic Acid

Offer tranexamic acid to adults undergoing surgery who are expected to have at least moderate blood loss (greater than 500 ml).

Consider tranexamic acid for children undergoing surgery who are expected to have at least moderate blood loss (greater than 10% blood volume).

Do not routinely use cell salvage without tranexamic acid.

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

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

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.

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.

Consider setting individual thresholds and haemoglobin concentration targets for each patient who needs regular blood transfusions for chronic anaemia.

Doses

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.

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.

Platelets

Thresholds and Targets

Patients with Thrombocytopenia Who Are Bleeding

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.

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 below)


• Bleeding in critical sites, such as the central nervous system (including eyes)

Patients Who Are Not Bleeding or Having Invasive Procedures or Surgery

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

Consider prophylactic platelet transfusions to raise the platelet count above 50×10⁹ per litre in patients who are having invasive procedures or surgery.

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

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

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

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.

Doses

Do not routinely transfuse more than a single dose of platelets.

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).

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

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).

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

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.

Doses

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

Consider cryoprecipitate transfusions for patients without major haemorrhage who have:

• Clinically significant bleeding and


• A fibrinogen level below 1.5 g/litre

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

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.

Doses

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).

Reassess the patient's clinical condition, repeat the fibrinogen level measurement and give further doses if needed.

Prothrombin Complex Concentrate

Thresholds and Targets

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

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.

Monitor the international normalised ratio (INR) to confirm that warfarin anticoagulation has been adequately reversed, and consider further prothrombin complex concentrate.

Patient Safety

Monitoring for Acute Blood Transfusion Reactions

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.

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 Systems

Consider using a system that electronically identifies patients to improve the safety and efficiency of the blood transfusion process.

Patient Information

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

Document discussions in the patient's notes.

Provide the patient and their general practitioner (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

Blood Transfusions for Patients with Acute Upper Gastrointestinal Bleeding





For full guidelines click on the following link:

NICE Guideline on Blood transfusion.