Guideline:
Blood transfusion indications and administration
Bibliographic Source(s)
- Finnish Medical Society Duodecim. Blood transfusion: indications and administration. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2008 Jan 10 [Various].
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Finnish Medical Society Duodecim. Blood transfusion: indications and administration. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2006 Aug 8 [Various].
Guideline Category
Treatment
Intended Users
Clinical Laboratory Personnel
Health Care Providers
Nurses
Physicians
Guideline Objective(s)
Evidence-Based Medicine Guidelines collects summarizes and updates the core clinical knowledge essential in general practice. The guidelines also describe the scientific evidence underlying the given recommendations.
Target Population
Patients in primary care settings who have with symptomatic chronic anemia or acute bleeding
Interventions and Practices Considered
- Determining need for red blood cell (RBC) transfusion based on hemoglobin concentration and symptoms
- Treatment of acute bleeding
- Volume replacement with physiological saline
- Phenotyped RBC products
- Washed cell products (platelets and RBCs)
- Irradiated blood cell products
- Procedures for transfusion of blood products: RBCs platelets fresh frozen plasma
- Collection of blood for grouping and compatibility testing
- Checking procedures prior to transfusion (verifying patient identification ensuring suitability of the product for the patient ensuring integrity of the product)
- Administration of blood transfusion (timeliness temperature checks filters administration sets record-keeping)
Major Outcomes Considered
Transfusion reactions
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The evidence reviewed was collected from the Cochrane database of systematic reviews and the Database of Abstracts of Reviews of Effectiveness (DARE). In addition the Cochrane Library and medical journals were searched specifically for original publications.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Classification of the Quality of Evidence
| Code | Quality of Evidence | Definition |
|---|---|---|
| A | High | Further research is very unlikely to change our confidence in the estimate of effect.
|
| B | Moderate | Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
|
| C | Low | Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.
|
| D | Very Low | Any estimate of effect is very uncertain.
|
GRADE (Grading of Recommendations Assessment Development and Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial Team).
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
In General
- In primary care a blood transfusion is usually only administered in the treatment of symptomatic chronic anaemia where no specific treatment is available.
- It may also be necessary to use various blood products in cases of acute bleeding.
Indications for a Blood Transfusion
Red Blood Cell Transfusion in Chronic or Slowly Developing Anaemia
- It is not possible to give an exact haemoglobin (Hb) value below which a red blood cell infusion is indicated since the need for a transfusion is based on the patient's underlying illnesses and symptoms.
- Most patients will suffer uncomfortable symptoms if the concentration of Hb falls below 7 g/dL (70 g/L).
- Even a less significant fall in the Hb concentration may cause symptoms in patients with heart or pulmonary disease. An Hb concentration of 10 g/dL (100 g/L) is usually needed to safeguard an adequate oxygen transport.
- Transfusions of red blood cells are not routinely recommended for the correction of anaemia in patients with malignant disease or serious chronic disease unless the correction of Hb concentration is expected to significantly improve the patient's condition and independence.
Treatment of Acute Bleeding
- Volume replacement is the most important first aid measure in acute bleeding. This can be achieved for example with physiological saline (0.9% NaCl).
- The general condition of the patient and his/her underlying illnesses should be taken into account when assessing the need for red blood cell transfusion. The Hb concentration is only one of many criteria when assessing the extent of the bleed and the condition of the patient.
- In patients with ischaemic heart disease an acutely reduced oxygen-carrying capacity may increase the risk of myocardial infarction.
- In prolonged bleeding it may be necessary to administer platelets and clotting factors.
Choosing a Blood Product in Special Cases
- All blood products are now filtered; (i.e. they are leukocyte-depleted.)
- Phenotyped red blood cell products (i.e. products where all the blood-group antigens that may have significance for blood transfusions are extensively identified) are used in patients who have developed clinically significant red blood cell antibodies as a result of previous transfusions or pregnancies.
- Washed cell products (platelets and red blood cells) are used in patients with confirmed deficiency of immunoglobulin A (IgA) (serum IgA <0.05 l). regular frozen plasma or plasma products that contain iga should not be administered to these li>
- For patients with recurrent severe allergic-type adverse effects (e.g. fever generalized urticaria and/or dyspnoea) after red cell or platelet transfusions washed cell products should preferably be used for transfusion.
- Irradiated blood cell products are used to prevent graft-versus-host reactions in immunosuppressed patients (e.g. after stem cell or bone marrow transplantation and in small premature babies).
Transfusion of Blood Products (Red Blood Cells Platelets and Fresh Frozen Plasma)
The Collection of Blood for Grouping and Compatibility Testing (Cross Matching)
- Verify the identity of the patient.
- Ask the patient to state his/her own identification details.
- If necessary check them against the patient's identity wrist band and
- With the exception of an emergency transfusion the collection of a blood sample for blood grouping and red cell antibody screening and the collection of a second sample for blood group checking and compatibility testing should be taken at different times by two different people. This procedure will ensure that the patient's identity is correctly verified and that the samples are taken from the correct person.
- The transfusion of fresh frozen plasma or platelets does not require compatibility testing but the blood group of the patient should be confirmed.
- The blood samples should be stored in a refrigerator; the samples will remain suitable for compatibility testing for up to five days from the time of collection. Also the transfusion itself should be performed within this time frame.
Checking Procedure Prior to Transfusion
- Verify the identity of the patient (see above).
- Ensure that the product is suitable and intended for the patient.
- The patient's identification details must match with the identification details of the laboratory form.
- The blood group of the product to be transfused must correspond with the patient's blood group.
- Before a transfusion of red blood cells check the result of the compatibility testing and verify that the correct product and patient was used for the test (i.e. the numbers on the red blood cell unit and its compatibility test tubing correspond to the numbers on the compatibility form issued by the laboratory.
- If the patient has red cell antibodies ensure that the label on the red blood cell unit states the absence of the antigens corresponding to the antibodies detected in the patient.
- Examine the blood product carefully.
- The integrity and cleanliness of the container.
- The presence of clots aggregates or gas or a black-red colour of a red blood cell product are suggestive of bacterial contamination.
- In a platelet product that is in proper condition the platelets swirl when inspected against light ("angel curls").
- Confirm that the checks have been carried out by signing the transfusion form.
Administration of a Blood Transfusion
- A transfusion of red blood cells should commence within six hours of removal of the unit from a refrigerator. The transfusion of a unit of red blood cells should be completed within six hours from the start.
- If a red blood cell product has been at room temperature for two hours it must not be returned to a refrigerator for storage but it must either be transfused (see above) or discarded and returned to the blood bank for writeoff (according to the local practice).
- Before starting a transfusion check the patient's vital signs (i.e. blood pressure pulse and temperature).
- Transfusion of red blood cells may usually be commenced immediately after the product has been taken out of refrigerator.
- If the patient has significant cold agglutinins red blood cell products should be warmed during transfusion with an approved commercial blood warmer. The temperature must not exceed +37 degrees C due to the risk of haemolysis.
- A blood administration set with a 200 micrometer filter (the drip chamber containing a large filter) should be used to transfuse all blood products (red blood cells platelets fresh frozen plasma).
- A biological pre-check is recommended at the beginning of a red blood cell transfusion; the red cells are transfused slowly (10 to 15 drops/min) during the first 10 minutes whilst carefully observing the patient. Procedure in suspected adverse reaction to the transfusion see the Finnish Medical Society Duodecim guideline "Adverse Effects of a Blood Transfusion and Administration of a Wrong Blood Product". The patient must be monitored throughout the entire transfusion.
- The same administration set may be used to transfuse several units of red blood cells without interruption (according to the capacity of the administration set filter) but it is recommended that the administration set is changed after six hours in order to reduce the risk of bacterial contamination.
- It is recommended that platelets are administered via a special platelet administration set.
- Record the start and end time of the blood product transfusion in the patient's notes and confirm the completion of transfusion with your signature. This will ensure the blood product may be traced back from the patient to the donor and vice versa.
Related Resources
Refer to the original guideline document for related evidence including Cochrane reviews and other evidence summaries.
Definitions:
Classification of the Quality of Evidence
| Code | Quality of Evidence | Definition |
|---|---|---|
| A | High | Further research is very unlikely to change our confidence in the estimate of effect.
|
| B | Moderate | Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
|
| C | Low | Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.
|
| D | Very Low | Any estimate of effect is very uncertain.
|
GRADE (Grading of Recommendations Assessment Development and Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial Team).
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
Concise summaries of scientific evidence attached to the individual guidelines are the unique feature of the Evidence-Based Medicine Guidelines. The evidence summaries allow the clinician to judge how well-founded the treatment recommendations are.
Potential Benefits
Appropriate selection and administration of blood and blood products to patients with symptomatic chronic anemia or acute bleeding
Potential Harms
- Bacterial contamination of blood or blood products
- Transfusion reactions
- Graft-versus-host reaction
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Safety
Bibliographic Source(s)
- Finnish Medical Society Duodecim. Blood transfusion: indications and administration. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2008 Jan 10 [Various].
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Finnish Medical Society Duodecim
Guideline Committee
Editorial Team of EBM Guidelines
Composition of Group that Authored the Guideline
Primary Author: Sinikka Koskinen
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Finnish Medical Society Duodecim. Blood transfusion: indications and administration. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2006 Aug 8 [Various].
Guideline Availability
This guideline is included in "EBM Guidelines. Evidence-Based Medicine" available from Duodecim Medical Publications Ltd PO Box 713 00101 Helsinki Finland; e-mail: info@ebm-guidelines.com; Web site: www.ebm-guidelines.com.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on December 17 2002. The information was verified by the guideline developer as of February 7 2003. This summary was updated by ECRI on July 15 2004 and on December 21 2006. This summary was updated by ECRI Institute on September 30 2008.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.
Tools
No Quick Reference tools have been developed.