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Red blood cell transfusion

What's new

Added 2023 AABB, 2023 BSH, 2021 ESICM, and 2019 ICC PBM guidelines on red blood cell transfusion.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of red blood cell transfusion are prepared by our editorial team based on guidelines from the American College of Chest Physicians (ACCP 2024), the British Society for Haematology (BSH 2024,2023,2022,2020,2018), the Neonatal Transfusion Network (NTN 2024), the American Association of Blood Banks (AABB 2023), the European Consensus Group on Respiratory Distress ...
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Diagnostic investigations

Pre-transfusion assessment: as per BSH 2018 guidelines, obtain a thorough pre-transfusion clinical assessment, including age, body weight, symptoms and concomitant medical conditions.
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  • Pre-transfusion blood sampling

  • Coagulation and viscoelastic testing

Inpatient care

Clinical monitoring
As per BSH 2018 guidelines:
Monitor and document HR, BP, temperature, and respiratory rate for every unit transfused, at least at following time points:
pre-transfusion ≤ 60 minutes before the start of the component transfusion
15 minutes after the start of each unit
post-transfusion ≤ 60 minutes after the end of the component transfusion
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Obtain regular visual monitoring of the patient throughout the transfusion episode,
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and document observations in the patient's clinical record distinguishable from other routine observations. Inform patients and/or parents/carers about the possibility of acute and delayed hemolytic transfusion reactions.
B
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Therapeutic procedures

Transfusion thresholds, non-bleeding: as per ACCP 2024 guidelines, use a restrictive (7-8 g/dL) RBC transfusion strategy over a permissive (9-10 g/dL) RBC transfusion strategy in critically ill patients.
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  • Transfusion thresholds (non-massive bleeding)

  • Transfusion thresholds (massive bleeding)

  • Transfusion thresholds (pediatric patients)

  • Transfusion thresholds (neonatal patients)

  • Transfusion strategies (general principles)

  • Transfusion strategies (non-bleeding)

  • Transfusion strategies (massive bleeding)

  • Technical considerations for administration

  • Use of irradiated blood components (emergency settings)

  • Use of irradiated blood components (immunodeficiencies)

  • Use of irradiated blood components (hematologic disorders)

  • Use of irradiated blood components (HSCT)

  • Use of irradiated blood components (solid organ transplantation)

  • Use of irradiated blood components (intrauterine transfusion and neonatal exchange transfusion)

  • Use of irradiated blood components (technical considerations)

  • Use of predeposit autologous blood

Specific circumstances

Preterm infants: as per NTN 2024 guidelines, use a restrictive RBC transfusion strategy in preterm infants born < 30 weeks of gestation, using the following hemoglobin- and hematocrit-based thresholds:
Situation
Guidance
Postnatal week 1
11 g/dL or 33% with respiratory support
10 g/dL or 30% with no or minimal respiratory support
Postnatal week 2
10 g/dL or 30% with respiratory support
8.5 g/dL or 25% with no or minimal respiratory support
Postnatal week ≥ 3
9 g/dL or 27% with respiratory support
7 g/dL or 21% with no or minimal respiratory support
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  • Patients with acute transfusion reactions (evaluation)

  • Patients with acute transfusion reactions (discontinuation of transfusion)

  • Patients with acute transfusion reactions (pharmacotherapy)

  • Patients with acute transfusion reactions (management of IgA deficiency)

  • Patients with acute transfusion reactions (secondary prevention)

Preventative measures

Blood sampling and conservation: as per ESICM 2020 guidelines, consider using small-volume blood collection tubes
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and blood conservation devices versus conventional blood sampling systems to prevent RBC transfusion in non-bleeding critically ill adult patients.
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  • Prophylactic iron and EPO therapy

  • Correction of preoperative anemia (assessment and timing of surgery)

  • Correction of preoperative anemia (thresholds)

  • Correction of preoperative anemia (iron supplements and EPO-stimulating agents)

  • Correction of preoperative anemia (RBC transfusion)

Quality improvement

Patient identification methods: as per BSH 2018 guidelines, ensure a patient identification band (or risk-assessed equivalent), including the core identifiers (first name, last name, date of birth, and unique patient identification number) is worn by all patients receiving a blood transfusion.
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  • Hospital requirements