These represent guidelines for transfusion. Not all patients who meet the criteria set forth in these guidelines will require transfusion. In certain clinical circumstances the provider may consider transfusion to be appropriate outside these guidelines. The decision to transfuse is a clinical decision based on real-time clinical assessment of the patient by the provider responsible for that patient’s care. In all circumstances, the indication for transfusion, and the clinical decision and supporting data, should be documented in the medical record. Accumen recommends that all cellular blood products be leukoreduced.
RED BLOOD CELLS (RBCs, pRBCs)
- One unit is the usual adult dose. Two units or more can be considered for hemodynamically unstable patients with large volume blood loss and ongoing hemorrhage.
- One unit of packed red cells transfused to an adult; will increase hemoglobin by approximately 1 g/dL or hematocrit by approximately 3%.
Guideline by hemoglobin threshold and clinical indication:
Active bleeding independent of hemoglobin
- Active bleeding with greater than 1500 mL blood loss and hemodynamic instability1
- Massive hemorrhage or massive transfusion protocol initiated1
Hemoglobin less than 7 g/dL (or hematocrit less than 21%)*
- Hemoglobin less than 7 g/dL and signs or symptoms of anemia unresponsive to management without transfusion2,3
- Hemoglobin less than 7 g/dL in a patient with STABLE ischemic heart disease and signs or symptoms of anemia unresponsive to management without transfusion4,5,6
- Hemoglobin less than 7 g/dL in a patient with acute upper gastrointestinal hemorrhage7
- Hemoglobin less than 7 g/dL in a patient with sepsis5
- Hemoglobin less than 7 g/dL in patient with marrow suppression due to chemotherapy and/or radiotherapy8,9,10,11
Hemoglobin less than 8 g/dL (or hematocrit less than 24%)*
- Hemoglobin less than 8 g/dL in patients with acute coronary syndrome or evidence to support the need for increased O2 delivery indicated by any of the following12,13:
- Tachycardia and/or hypotension unresponsive to pharmacologic therapy
- New EKG changes
- Recurrent chest pain
- Mixed venous hemoglobin O2 saturation less than 60% after optimization of oxygenation
- Acute respiratory failure, inadequate cardiac output, or inadequate oxygenation
- Hemoglobin less than 8 g/dL in a patient with bone marrow suppression or bone marrow failure (e.g. thalassemia, myelodysplasia, marrow aplasia) AND long-term transfusion dependency whose anemia cannot be managed with erythropoietic stimulating agents and/or intravenous iron14,15
Hemoglobin less than 9 g/dL (or hematocrit less than 27%)*
- Hemoglobin less than 9-10 g/dL in a sickle cell anemia patient undergoing surgery to bring the hemoglobin to 10 g/dl16,17, 18
- Sihler KC, Napolitano LM. Massive transfusion: new insights. Chest. 2009 Dec;136(6):1654-67
- Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340:409-17.
- Carson, J.L. et al., 2016. Clinical Practice Guidelines From the AABB Red blood cell transfusion thresholds an storage. Jama, 8901(19), pp.1–11.
- Hébert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001; 29:227–234
- Holst LB, Haase N, Wetterslev J, et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. N Engl J Med 371;15 2014
- Qaseem A, Humphrey LL, Fitterman N, et al. Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2013;159(11):770-779.
- Villanueva C, Colomo A, Bosch A, et al. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2013;368:11-21.
- Hicks LK, Bering H, Carson KR, et al. The ASH Choosing Wisely® campaign: five hematologic tests and treatments to question. Blood 2013. 122: 3879-3883
- Chinese Society of Clinical Oncology (CSCO). Clinical practice guidelines on cancer-related anemia (2012-2013 Edition). Chin Clin Oncol 2012;1(2):18
- Berger MD, Gerber B, Arn K, Senn O, Schanz U, Stussi G. Significant reduction of red blood cell transfusion requirements by changing from a double-unit to a single-unit transfusion policy in patients receiving intensive chemotherapy or stem cell transplantation. Haematologica 2012;97(1):116–22.
- Gross I, Trentino KM, Andreescu A, Pierson R, Maietta RA, Farmer S. Impact of a Patient Blood Management Program and an Outpatient Anemia Management Protocol on Red Cell Transfusions in Oncology Inpatients and Outpatients. Oncologist. 2016 Mar;21(3):327-32.
- Bassand J-P, Hamm CW, Ardissino D, Boersma E, Budaj A, Fernández-Avilés F, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. European heart journal. 2007;28(13):1598–660.
- Chatterjee S, Wetterslev J, Sharma A, Lichstein E, Mukherjee, D. Association of blood transfusion with increased mortality in myocardial infarction. JAMA internal medicine, 2013 173(2),132-139.
- Webert KE, Cook RJ, Couban S, Carruthers J, Lee K-ai, Blajchman MA, et al. A multicenter pilot-randomized controlled trial of the feasibility of an augmented red blood cell transfusion strategy for patients treated with induction chemotherapy for acute leukemia or stem cell transplantation. Transfusion 2008;48(1):81–91.
- Watkins T, Surowiecka MK, McCullough J. Transfusion Indications for Patients With Cancer. Cancer Control. 2015; 22, 1.
- Debaun MR, Gordon M, McKinstry RC, et al. Controlled trial of transfusions for silent cerebral infarcts in sickle cell anemia. New England Journal of Medicine, 2014; 371:699-710.
- Yawn BP, Buchanan GR, Afenyi-Annan AN, Ballas SK, Hassell KL, James AH, et al. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA. 2014 Sep 10;312(10):1033-48.
- Fusaro, M. V. et al., 2016. Restrictive versus liberal red blood cell transfusion strategy after hip surgery: a decision model analysis of healthcare costs. Transfusion, 0, pp.1–10.
*Note: Hemoglobin is preferred over hematocrit as a more accurate measure of the severity of anemia, though some providers continue to use hematocrit. Hemoglobin is used by the World Health Organization to define anemia.
Disclaimer: Accumen has no authority, responsibility or liability with respect to any clinical decisions made by—or in connection with—a provider’s laboratory, patient blood management, or other operations. Nothing herein and no aspect of any services provided by Accumen is intended—or shall be deemed—to subordinate, usurp or otherwise diminish any providers’ sole authority and discretion with respect to all clinical decision—making for its patients.