Australian and New Zealand Society of Blood Transfusion

The Australian and New Zealand Society of Blood Transfusion comprises over 400 members from diverse scientific, medical and nursing backgrounds working within the area of blood transfusion and related fields. NB. These recommendations do not apply to emergency situations, severe acute bleeding and acute phase of major trauma resuscitation.


Do not transfuse red blood cells for iron deficiency where there is no haemodynamic instability.

Blood transfusion has become a routine medical response despite cheaper and safer alternatives in some settings. Pre-operative patients with iron deficiency and patients with chronic iron deficiency without hemodynamic instability (even with low haemoglobin levels) should be given oral and/or intravenous iron. Possible exceptions are where reliable ingestion of iron may not occur or gastrointestinal issues exist.

Supporting evidence

Aapro et al, ‘Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines’, Annals of Oncology. 2018; 29(Supplement 4); iv96-iv110.

Friedman et al, ‘Iron deficiency anemia in women across the life span’, J Women’s Health (Larchmt). 2012 Dec; 21(12):1282–9.

Lin et al, ‘Efficacy and safety of erythropoietin and intravenous iron in perioperative blood management: a systematic review’, Transfus Med Rev. 2013 Oct;27(4):221–34.

Litton et al, ‘Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials’, BMJ. 2013 Aug 15;347:f4822. doi: 10.1136/bmj.f4822.

Lopez et al, ‘Red blood cell transfusion after a global strategy for early detection and treatment of iron deficiency anaemia: three-year results of a prospective observational study’, Transfusion 2018; 58; 1399-1407.

Mueller, et al ‘Patient Blood Management: Recommendations from the 2018 Frankfurt Consensus Conference’, JAMA. 2019; 321(10); 983-997.

Ng et al ‘Iron therapy for preoperative anaemia’, Cochrane Database of Systematic Reviews. 2019; volume (12)

Richards et al ‘Preoperative intravenous iron to treat anaemia before major abdominal surgery (RPEVENTT): a randomised, double-blind, controlled trial’. 2020. 396; 1353-1361

Spahn et al ‘Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial’, The Lancet. 2019; 393 (10187); 2201-2212.

Zhang et al ‘Efficacy and safety of iron supplementation in patients with heart failure and iron deficiency: a meta-analysis’, British Journal of Nutrition. 2019. 212; 841-848.

How this list was made How this list was made

As part of the Evolve program, the RACP Policy and Advocacy team has worked with the Australian and New Zealand Society of Blood Transfusion (ANZSBT) to develop and finalise this Evolve Top-5 list of low-value care that pertains to the specialty.

Per usual processes, the list of low value practices was first identified by the ANZSBT Council and condensed to the top-5 recommendations, through a membership survey, extensive research and rounds of redrafting under the guidance of the ANZSBT Council. The list was subjected to an extensive review and consultation process that involved RACP-affiliated specialty societies and other key colleges via the Choosing Wisely program. Feedback from the consultation has been integrated into the top-5 recommendations by the ANZSBT and approved by its Council in December 2021.

Version 1 published January 2022.