Clinical Practice Guidelines for Blood Transfusions Purpose: To provide practice guidelines regarding the transfusion of blood and blood components and to advance the safety and quality of care for the patients receiving blood transfusions. Hospitals and other organizations that transfuse blood or blood components are required under the Joint Commission (JC), the AABB (American Association of Blood Banks), and the College of American Pathologists (CAP) to evaluate and improve the use of these products. Criteria are established here to guide physician practice, against which performance will be measured. The review process and all transfusion guidelines are under the direction of the Hospital Service Organization s (HSO) Transfusion Committee, which consists of a cross-functional group of physicians, management, and staff. General Principles: 1. In many scenarios, restrictive strategies are at least as beneficial to patients, if not superior to more liberal approaches. 2. When applying these guidelines, practitioners must use their training, experience, judgment, and the patient s specific clinical information to make optimal decisions on the patient s behalf. In this context, transfusion orders must document the clinical necessity and justification for the transfusion. 3. Informed consent is required and will include discussion regarding the risks, benefits, and alternatives to allogeneic blood transfusions. Transfusion in certain situations can be inappropriate and can pose unnecessary risks, while offering little or no benefit to patients. Risks include but are not limited to: host immune response to transfusion, transmission of infectious agents, volume overload, and transfusion-related acute lung injury (TRALI). 4. One packed cell unit should be transfused at a time with re-evaluation of the patient s condition and hemoglobin level before further transfusion, unless dictated otherwise by patient s clinical condition. 5. Adverse events related to transfusion will be identified, evaluated, and reported. 6. Blood and blood product transfusions will be documented and monitored; prospective or retrospective reviews will be performed when warranted. A. Guidance for RBC Transfusions in the Adult Inpatient Setting The following guidelines should be considered in any decision to transfuse an adult patient with red blood cells. Guidelines are based upon expert opinion and synthesis of current literature, and are grouped by specific clinical situations. These guidelines should not be construed as requirements to transfuse, only as situations in which transfusion may be beneficial, depending on individual patient needs. Individual patient needs within each clinical situation should be carefully considered when using these guidelines. In general, one unit PRBCs should be transfused at a time, with re-evaluation of the patient s 1
condition and hemoglobin level, unless otherwise dictated by the patient s clinical condition (e.g. severe hemorrhagic shock or severe symptoms of inadequate blood oxygen carrying capacity). Providers MUST document reasons for transfusion very clearly in the patient s medical record. This is especially important when a transfusion is administered in exception to the recommended guidelines. When feasible, clinicians are encouraged to consult with their transfusion service when a situation falls outside of standard guidelines. Clinical Indications for Adult Transfusion of Red Blood Cells: Active Bleeding (AB) 1. Hemorrhagic shock with life threatening bleeding, where explicit transfusion protocols are activated, such as Massive Transfusion Protocol 2. Active, non-life threatening bleeding and Hgb <8 g/dl 3. Life threatening bleeding - no Hgb threshold. This criterion will be applied most often in the intra-operative setting Bleeding Risk (BR) 1. Preoperative assessment of surgical bleeding risk a. Hgb <9 g/dl if intraoperative bleeding is b. Hgb <8 g/dl if intraoperative bleeding is not expected to be lifethreatening Anemia (AN) 1. Asymptomatic a. Hgb < 7 g/dl for healthy, asymptomatic, hemodynamically stable inpatients b. Cardiovascular Disease: Hgb < 8 g/dl for asymptomatic inpatients with evidence of preexisting cardiovascular disease or complications 2. Symptomatic a. No Hgb threshold in the setting of acute blood loss or symptomatic, otherwise unexplained anemia, manifested by one or more of below: i. tachycardia or hypotension (e.g., diastolic pressures <60 mm Hg, systolic pressures reduced by 30 mm Hg, especially if unresponsive to fluids) ii. oliguria or anuria iii. other evidence of inadequate oxygen delivery, increased oxygen extraction, reduced central venous or tissue oxygen saturations, elevated lactate, or elevated laboratory indicators of organ failure iv. Otherwise-clinically manifested cardiovascular failure related to anemia or chest pain that is cardiac in nature" 2
Special Conditions (SC) - Exempt from Thresholds The presence of certain clinical conditions warrants maintaining a hemoglobin level higher than normally acceptable for an otherwise healthy, asymptomatic anemic patient; therefore patients in the following scenarios may fall outside of the stated guidelines. 1. Hematology/Oncology patients, including any of the following populations: a. Hematology/Bone Marrow Failure or Bone Marrow Transplant (BMT) patients b. Thalassemia or other congenital anemia patients c. Sickle cell syndrome patients d. Patients on protocols for various blood exchange procedures e. Oncology patients 2. Patients on chronic transfusion protocols Research (RE) 1. Patients on clinical research protocols Other (OT) 1. Extracorporeal device priming B. Guidance for RBC Transfusions in the Pediatric Inpatient Setting The following guidelines should be considered while making a decision to transfuse a pediatric patient with red blood cells. These guidelines do not represent requirements to transfuse, but rather characterize suggested thresholds in which transfusion may be beneficial, grouped by specific clinical situations and based upon expert opinion and synthesis of current literature. Individual patient needs within each clinical situation should be carefully considered when using these guidelines. In general, for Pediatric patients, 10 ml/kg or one unit prbcs should be transfused at a time, with reevaluation of the patient s condition and hemoglobin level, unless otherwise dictated by the patient s clinical condition (e.g. severe hemorrhagic shock or severe symptoms of inadequate blood oxygen carrying capacity). Providers MUST document reasons for transfusion very clearly in the patient s medical record. This is especially important when a transfusion is administered in exception to the recommended guidelines. When feasible, clinicians are encouraged to consult with their transfusion service when a situation falls outside of standard guidelines. Clinical Indications for Pediatric Transfusion of Red Blood Cells: Active Bleeding (AB) 1. Hemorrhagic shock with life-threatening bleeding, where explicit transfusion protocols are activated (e.g. Massive Transfusion Protocol at SLCH) 2. Active, non-life threatening bleeding and Hgb <8 g/dl 3
Bleeding Risk (BR) 1. Preoperative assessment of surgical bleeding risk a. Hgb <9 g/dl if intraoperative bleeding is b. Hgb <8 g/dl if intraoperative bleeding is not Anemia (AN) 1. Asymptomatic: Hgb <7 g/dl for hemodynamically stable inpatients (including critically ill) who lack symptoms of anemia 2. Symptomatic: Inpatients with symptomatic anemia evidenced by tachycardia, hypotension, and/or specific symptoms/signs of inadequate oxygen delivery Special Conditions (SC) - Exempt from Thresholds The presence of certain clinical conditions warrants maintaining a hemoglobin level higher than normally acceptable for an otherwise healthy, asymptomatic anemic patient; therefore patients in the following scenarios may fall outside of the stated guidelines. 1. Hematology/Oncology patients, including congenital and acquired anemia, cancer, radiation therapy, and bone marrow transplantation populations. 2. RBC exchange transfusion (either manual or apheresis) 3. Premature Neonates (e.g. gestational age < 34 weeks) a. Hgb <10 g/dl for acutely ill neonates b. Hgb <8 g/dl for apnea c. No Threshold for whole blood exchange transfusion 4. In-patients with cyanotic heart disease- Hgb threshold may vary from 10-14 g/dl, depending upon circumstances Research (RE) 1. Patients on clinical research protocols Other (OT) 1. Extracorporeal device priming 4
Guidance for RBC Transfusions in the Adult Inpatient setting AB-1 Hemorrhagic shock with life threatening bleeding, where explicit transfusion protocols are activated, such as Massive Transfusion Protocol Active Bleeding (AB) Guidance for RBC Transfusions in the Pediatric Inpatient setting AB-1 Hemorrhagic shock with life-threatening bleeding, where explicit transfusion protocols are activated (e.g. Massive Transfusion Protocol at SLCH) AB-2 Active, non-life threatening bleeding and Hgb <8 g/dl AB-2 Active, non-life threatening bleeding and Hgb <8 g/dl AB-3 Life threatening bleeding - no Hgb threshold. This criterion will be applied most often in the intraoperative setting Preoperative Assessment of Surgical Bleeding Risk (BR) BR-1a Hgb <9 g/dl if intraoperative bleeding is BR-1a Hgb <9 g/dl if intraoperative bleeding is BR-1b Hgb <8 g/dl if intraoperative bleeding is not BR-1b Hgb <8 g/dl if intraoperative bleeding is not Anemia (AN) AN-1a Asymptomatic: Hgb < 7 g/dl for healthy, asymptomatic, hemodynamically stable inpatients AN-1b Asymptomatic: Cardiovascular Disease - Hgb < 8 g/dl with evidence of preexisting cardiovascular disease or complications AN-2a Symptomatic: No Hgb threshold in the setting of acute blood loss or symptomatic, otherwise unexplained anemia, manifested by one or more of below: AN-2a i tachycardia or hypotension (e.g., diastolic pressures <60 mm Hg, systolic pressures reduced by 30 mm Hg, especially if unresponsive to fluids) AN-2a ii AN-2a iii AN-2a iv oliguria or anuria other evidence of inadequate oxygen delivery, increased oxygen extraction, reduced central venous or tissue oxygen saturations, elevated lactate, or elevated laboratory indicators of organ failure "Otherwise-clinically manifested cardiovascular failure related to anemia or chest pain that is cardiac in nature" AN-1 Asymptomatic: Hgb < 7 g/dl for hemodynamically stable inpatients (including critically ill) who lack symptoms of anemia AN-2 Symptomatic: In-patients with symptomatic anemia- evidenced by tachycardia, hypotension, and/or specific symptoms/signs of inadequate oxygen delivery 5
The presence of certain clinical conditions warrants maintaining a hemoglobin level higher than normally acceptable for an otherwise healthy, asymptomatic anemic patient; therefore patients in the following scenarios may fall outside of the stated guidelines. SC-1 Hematology/Oncology patients, including any of the following populations: SC-1a Hematology/Bone Marrow Failure or Bone Marrow Transplant (BMT) patients SC-1b Thalassemia or other congenital anemia patients SC-1c Sickle cell syndrome patients SC-1d Patients on protocols for various blood exchange procedures SC-1e Oncology patients SC-2 Patients on chronic transfusion protocols RE-1 Patients on clinical research protocols OT-1 Extracorporeal device priming Special Conditions (SC)- Exempt from Thresholds The presence of certain clinical conditions warrants maintaining a hemoglobin level higher than normally acceptable for an otherwise healthy, asymptomatic anemic patient; therefore patients in the following scenarios may fall outside of the stated guidelines. SC-1 Hematology/Oncology patients, including congenital and acquired anemia, cancer, radiation therapy, and bone marrow transplantation populations SC-2 RBC exchange transfusion (either manual or apheresis) SC-3a Premature Neonates (e.g. gestational age < 34 weeks)- Hgb < 10 g/dl if acutely ill SC-3b Premature Neonates (e.g. gestational age < 34 weeks)- Hgb < 8 g/dl for apnea SC-3c Premature Neonates (e.g. gestational age < 34 weeks)- No threshold for whole blood exchange transfusion SC-4 In-patients with cyanotic heart disease- Hgb threshold may vary from 10 14 g/dl, depending upon circumstances Research (RE) RE-1 Patients on clinical research protocols Other (OT) OT-1 Extracorporeal device priming ***Disclaimer*** This document will be updated periodically as new evidence becomes available and with the expertise of the Lab & Transfusion CEC Members. Additional guidance for transfusion practices with other blood products and components will be addressed with upcoming PBM phases. Center for Clinical Excellence Outcomes Team will be responsible for versioning and repository management via a BJC Patient Blood Management (PBM) SharePoint site. 6
References: 1. Macpherson J, Mahoney CB, Katz L, Haarmann J, Bianco C. Contribution of blood to hospital revenue in the United States. Transfusion. Aug 2007;47(2 Suppl):114S-116S; discussion 117S- 119S. 2. Leach Bennett J, Blajchman MA, Delage G, Fearon M, Devine D. Proceedings of a consensus conference: Risk-Based Decision Making for Blood Safety. Transfusion medicine reviews. Oct 2011;25(4):267-292. 3. Frank SM, Savage WJ, Rothschild JA, et al. Variability in blood and blood component utilization as assessed by an anesthesia information management system. Anesthesiology. Jul 2012;117(1):99-106. 4. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. The New England journal of medicine. Feb 11 1999;340(6):409-417. 5. Blajchman MA. Landmark studies that have changed the practice of transfusion medicine. Transfusion. Sep 2005;45(9):1523-1530. 6. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. The New England journal of medicine. Dec 29 2011;365(26):2453-2462. 7. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. The New England journal of medicine. Jan 3 2013;368(1):11-21. 8. Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. The New England journal of medicine. Oct 9 2014;371(15):1381-1391. 9. Hebert PC, Carson JL. Transfusion threshold of 7 g per deciliter--the new normal. The New England journal of medicine. Oct 9 2014;371(15):1459-1461. 10. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Critical care medicine. Sep 2008;36(9):2667-2674. 11. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. Jama. Oct 13 2010;304(14):1559-1567. 12. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Annals of internal medicine. Jul 3 2012;157(1):49-58. 13. Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy. Oct 2007;27(10):1394-1411. 14. Reason J. Human Error. Cambridge, UK: Cambridge University Press; 1990. Additional Resources: AABB Technical Manual, Current Edition American Society of Anesthesiologists CAP Guidelines Transfusion Medicine, TRM.40875 Standards for Blood Banks and Transfusion Services, Current Edition Society for the Advancement of Blood Management Society of Critical Care Medicine Society of Thoracic Surgeons 7