Recommendations

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.

3.

Do not transfuse more units of blood than necessary.

Every unit of blood transfused presents benefits and risks to the patients. Risks associated with transfusion include:

febrile reactions
allergic reactions and anaphylaxis
haemolytic reactions
transfusion- transmitted infections
transfusion-associated acute lung injury, transfusion-associated circulatory overload
alloimmunisation.

Each unit transfused must have a clear indication and unnecessary transfusions must be avoided.

A restrictive transfusion strategy (Haemoglobin (Hb) of 70-80g/L) should be used for the majority of hospitalised, stable (non-bleeding) adult patients. The decision to give a red blood cell transfusion should not be dictated by Hb alone and should also include an assessment of the patient’s underlying condition, any clinical signs and symptoms and response to previous transfusions.

A single unit of red cell transfusions is the standard of care for non-bleeding, hospitalised patients. Additional units should only be prescribed after clinical re-assessment of the patient and their haemoglobin value.

Supporting evidence

Carson et al 2016, ‘Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion’, Cochrane Database of Systematic Reviews Oct 16; 2016, Issue 10. DOI: 10.1002/14651858.CD002042.pub4.

Carson et al, ‘Liberal or restrictive transfusion in high-risk patients after hip surgery’, N Engl J Med 2011 365(26):2453–2462. DOI: 10.1056/NEJMoa1012452. Accessed 25/11/2020.

Gu et al 2018, ‘Restrictive versus liberal strategy for red blood-cell transfusion a systematic review and meta-analysis in orthopaedic patients’, J Bone and Joint Surgery 100-A(8):686-695. doi: 10.2106/JBJS.17.00375.

Kheiri et al 2019, ‘Restrictive versus liberal red blood cell transfusion for cardiac surgery: a systematic review and meta-analysis of randomised controlled trials. Journal of Thrombosis and Thrombolysis 47(2):179-185. doi.org/10.1007/s11239-018-1784-1. Accessed 25/11/2020.

LaCroix et al,’ Transfusion strategies for patients in pediatric intensive care units’, N Engl J Med. 2007 Apr 19;356(16):1609-19.

Mazer et al 2018, ‘Six-month outcomes after restrictive or liberal transfusion for cardiac surgery’, N Engl J Med 2018 379:1224-33. DOI: 10.1056/NEJMoa1808561.

Szczepiorkowski et al, ‘Transfusion guidelines: when to transfuse’, Hematology Am. Soc. Hematol. Educ. Program. 2013; 2013:638-644. doi.org/10.1182/asheducation-2013.1.638.

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.