JPAC Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee

8: Effective transfusion in medical patients

Essentials

  • Inappropriate blood transfusions in medical patients are common and may cause harm.
  • Blood transfusion should not be performed where there are appropriate alternatives such as haematinic replacement (in iron deficiency) or erythropoiesis stimulating agents (in chronic kidney disease).
  • There is no universal transfusion trigger – the decision to transfuse should be based on clinical assessment of the patient, supported by the results of laboratory tests and informed by evidence-based guidelines.
  • Haemodynamically stable haemato-oncology patients who are anaemic after intensive chemotherapy rarely need transfusion if the Hb is >80 g/L.
  • Treatment of patients dependent on long-term transfusion (e.g. myelodysplasia) should aim to minimise symptoms of anaemia and improve health-related quality of life rather than achieve an arbitrary Hb concentration.
  • Prophylactic platelet transfusions should be given to patients receiving intensive chemotherapy, with a transfusion trigger of 10×109/L.
  • Platelet prophylaxis is not required for bone marrow aspiration or trephine biopsy and a level of 50×109/L is safe for other invasive procedures.
  • Component selection errors for patients who have changed blood group after allogeneic haemopoietic stem cell transplantation are common and often stem from poor communication between clinical and laboratory teams.
  • Transfusion in patients with haemoglobinopathies (thalassaemia and sickle cell disease) is complex and changing. It should be directed by specialist teams in line with national guidelines and research evidence.
  • Transfusion reactions in patients with sickle cell disease may be misinterpreted as sickle cell crises and treated incorrectly.

 

More than 50% of red cells in the UK are transfused for non-surgical indications. The recipients are often elderly and have an increased risk of transfusion complications such as transfusion-associated circulatory overload (TACO). Although overall red cell demand has fallen in the UK in the last decade, largely because of a reduction in surgical transfusions, there has been a continuing rise in requests for platelets and fresh frozen plasma (FFP).

The decision to transfuse, and how much, should be based on clinical assessment and clearly defined objectives, such as reduction in fatigue, not on the Hb level alone. Evidence-based guidelines improve the balance between efficacy and safety as well as improving the economy of blood use. Alternatives to donor blood should be used where appropriate. The introduction of computerised ordering systems for blood components offers the opportunity to link requests to ‘real time’ laboratory data and provide on-screen decision support to the prescriber based on best evidence for the clinical indication. Inappropriate transfusions have been significantly reduced by the introduction of such systems in certain US hospitals (Murphy et al., 2013).

The biggest medical users of blood are haematology, oncology, gastrointestinal medicine (including liver disease) and renal medicine (National Comparative Audit of Blood Transfusion – 2011 Audit of Use of Blood in Adult Medical Patients – Part 1 http://hospital.blood.co.uk/library/pdf/Medical_Use_Audit_Part_1_Report.pdf). The median age of transfused patients in this audit was 73 years and nearly half were transfused outside current national guidelines. It was found that 20% of patients were transfused despite having a treatable cause for anaemia, such as iron deficiency; 29% were transfused at an Hb concentration above the predefined ‘trigger’; and patients were often transfused up to a higher than necessary Hb concentration (especially patients of low body weight).