RED BLOOD CELL TRANSFUSION

• To revise the principles of transfusion, see Principles of transfusion and Consent for transfusion guidelines
• Packed red blood cells (RBC) in SAG-M additive solution, 280 ± 60 mL, Hct 0.5-0.7
• Collected from UK volunteer whole blood donors i.e. allogeneic
• Stored in controlled temperature at 2–6°C for <35 days
• Only store red cells in designated blood fridges
• Allocated RBC routinely derequisitioned (i.e. returned to stock) at 24 hr
• Areas without a satellite fridge collect 1 unit of blood at a time
• except renal dialysis patients and MHP activation

• Use red cells to restore oxygen carrying capacity in patients with anaemia or blood loss, where alternative treatments are ineffective or inappropriate
• Base decision to transfuse on the whole clinical picture:
• cause of anaemia
• symptom severity, underlying co-morbidities, chronicity
• current and historic laboratory parameters

Acute blood loss with haemodynamic instability/uncontrolled haemorrhage

• Benefit: Save life
• Target Hb: 70–90 g/L (once haemodynamically stable)
• Blood loss of >20–30% (where average circulating blood volume is 70 mL/kg) with on-going bleeding will likely require urgent transfusion
• Use cell salvage where possible to minimise allogeneic transfusion requirements
• See specific guidelines, including Acute upper gastrointestinal haemorrhage guideline and Major haemorrhage pathway

Recoverable anaemia in a haemodynamically stable patient e.g. post op, IDA

• Do not transfuse stable patients with iron deficiency anaemia. Give iron. See Iron deficiency
• See Chronic anaemia guideline, B₁₂ deficiency and folate deficiency guidelines where appropriate

No cardiovascular disease

• Benefit: Improve short term outcome
• Target Hb: 70–90 g/L (once haemodynamically stable)
• Threshold Hb for transfusion: <70 g/L

Cardiovascular disease

• Benefit: Improve short term outcome
• Target Hb: 80–100 g/L (once haemodynamically stable)
• Threshold Hb for transfusion: <80 g/L

Chronic transfusion dependence e.g. bone marrow failure (MDS, thalassaemia)

• Benefit: Improve quality of life
• Target Hb: Individual to patient (depending on cause and response)
• Threshold Hb for transfusion: Start at 80 g/L and adjust as required

Radiotherapy (weak evidence)

• Benefit: Improved response to therapy
• Target Hb: Individual to patient
• Threshold Hb for transfusion: Consider if <110 g/L in cervical cancer 

Exchange transfusion e.g. sickle cell disease, HDFN

• Benefit: Replace red cells and treat/prevent symptoms
• Target Hb: Individual to patient
• Threshold Hb for transfusion: n/a

• Regard each unit of red blood cells transfused as a treatment decision
• Blood transfusion is associated with significant risk
• use alternatives to transfusion wherever possible and appropriate
• Use the minimum number of units required to achieve target Hb/relieve moderate-severe symptoms i.e. single unit transfusion policy
• Patients with cardiovascular disease, especially acute MI, cardiac surgery (75 g/L), orthopaedic surgery, haemato-oncology patients and acute coronary syndrome may require higher targets
• Except in circumstances where patient’s condition is life threatening, the patient must be given time to ask questions and to make a decision to proceed with transfusion
• Always document indication for transfusion and consent in the medical notes

Alternatives to transfusion

• Use alternatives to allogeneic transfusion wherever possible and appropriate
• e.g. oral or intravenous iron, B₁₂/folate supplementation
• consider erythropoietin stimulating agents, although issues regarding funding
• Optimise oxygenation and management of underlying medical conditions to improve tolerance of anaemia and maximise erythropoiesis

Before every transfusion

• Assess all patients for risk of Transfusion Associated Circulatory Overload (TACO)
• manage appropriately e.g. slow infusion rate, diuretic use, increase frequency of observations
• Prescribe red blood cells (RBC) on fluid prescription of the drug chart
• dose in units (or mL in low weight patients e.g. <50 kg, who are at high risk of TACO)
• indicate special blood requirements (SBR) e.g. irradiated, HbS neg, Rh/Kell matched on prescription or No SBR (just as important)

Single unit transfusion policy

• Each single unit RBC transfused is a treatment decision (except in active bleeding)
• Full clinical and laboratory evaluation after each unit

Target Hb

• In the absence of active bleeding, use the minimum number of units required to achieve a target Hb taking into account patient size
• 1 unit RBC expected to raise Hb by 10 g/L in 70kg patient (but note 1 unit = 220–340 mL)
• 4 mL/kg RBC expected to raise Hb by 10 g/L (use in adult patients <50 kg)

• Transfuse RBC as soon as possible after removal from designated temperature-controlled storage using a standard blood giving set with a 170–200 micron filter
• Complete transfusion within 4 hr of red cells leaving cold storage
• Specify the transfusion rate depending on the clinical features
• do not give a range on the prescription chart
• if low risk of TACO, 90–120 min per unit
• if high risk of TACO, 3 hr per unit ± diuretics
• if MHP, ‘STAT’ through blood warmer (i.e. over 5–10 min)

Unavoidable delay

• Return to designated controlled temperature storage as soon as possible (within 30 min)

Monitor

• Monitor patients closely for fluid overload (TACO)

Document

• Any blood component connected to the patient’s IV access is regarded as ‘transfused’ for traceability purposes, even if the unit was subsequently (partially) wasted
• Trace administration of components on availability and location system 

• Assess every patient clinically after each unit transfused
• have the symptoms/signs of anaemia resolved? – document severity grade
• is there evidence of fluid overload (TACO)? – document any symptoms/signs
• Check Hb increment after each unit transfused (except in active bleeding, chronically transfused outpatients or where target threshold cannot realistically be achieved)
• repeat Hb can be performed from 15 min post transfusion as FBC or blood gas (latter for response assessment only)
• Patients transfused to >20 g/L above target threshold are deemed ‘over transfused’

Document

• Fully document transfusion and any complications in medical and nursing notes (plus discharge letter)
• Ensure definitive treatment also prescribed where appropriate e.g. iron therapy

• Group O RhD negative blood cells are a finite resource
• use only where clinically indicated i.e. Group O RhD negative patients and emergency situations whilst awaiting group specific blood
• Where a valid G&S is available in the lab, crossmatched blood (or group specific if inappropriate for electronic issue) can be available almost immediately
• Where no sample is available, group specific blood available within 15 min of sample receipt 

Administration

• Take crossmatch sample before group O red cell administration
• 2-sample rule does not apply in emergency setting
• Switch to group specific red cells as soon as available

Access

• Only staff who have undergone appropriate fridge training can access O RhD negative units (barcode required)
• Hospital specific method of access