This document discusses guidelines for single unit red blood cell transfusions based on Patient Blood Management Guidelines. It provides 3 key reasons why excessive transfusion is problematic: 1) each transfusion increases the risk of nosocomial infection and other morbidities, 2) higher transfusion requirements are associated with more clinical complications, and 3) transfusion associated circulatory overload is a high risk adverse effect. The document emphasizes transfusing one unit at a time and reassessing the patient before additional units, in order to follow a more restrictive approach and reduce risks whenever possible based on the patient's clinical status rather than hemoglobin levels alone.

1. SINGLE UNIT TRANSFUSION
FOR
RED BLOOD CELL TRANSFUSION
Based on the Patient Blood Management Guidelines
Every ONE
matters

2. WHY GIVE 2 WHEN 1 WILL DO….
TOWARD A MORE RESTRICTIVE RED CELL
TRANSFUSION APPROACH

Objectives

Discuss Patient Blood Management Guidelines

Discuss the reasons for single unit blood
transfusions.

To provide resource material in the form of a
wikispace and hard copy for the doctor to refer to.

3. WHY GIVE 2 WHEN 1 WILL DO…
PATIENT BLOOD MANAGEMENT GUIDELINES
(PBM)

What are the Patient Blood Management guidelines?

Evidence-based blood management guidelines that are a
summary of recommendations and practice points
developed by the National Blood Authority and is based on
systematic reviews. The Medical model is the third in a
series of six modules
Why have a Patient Blood Management Guidelines?


The Patient Blood Management Guidelines were introduced
in 2012 to improve clinical outcomes by avoiding
unnecessary exposure to blood components.
Transfusion is a live tissue transplant and not without
associated risks

4. WHY GIVE 2 WHEN 1 WILL DO…
PATIENT BLOOD MANAGEMENT GUIDELINES
(PBM)

Why have a Patient Blood Management Guidelines?

Blood products are a scarce resource and will only
become more scarce with the ageing population.
Economic costs – about $1 Billion per year in plus the
added costs.
 http://www.blood.gov.au/pbm-module-3


5. PBM MODULE 3- SYSTEMATIC REVIEW
QUESTIONS









Box 2.1 Systematic review questions
Questions 1 – 5 are relevant to all six modules of these guidelines; Question 6 is specific to
medical transfusion (i.e. to this module).
• Question 1 – In medical patients, is anaemia an independent risk factor for
adverse outcomes? (Aetiological question)
• Question 2 – In medical patients, what is the effect of RBC transfusion on
patient outcomes? (Interventional question)
• Question 3 – In medical patients, what is the effect of non-transfusion
interventions to increase Hb concentration on morbidity, mortality and need for
RBC blood transfusion? (Interventional question)
• Question 4 – In medical patients, what is the effect of
FFP, cryoprecipitate, fibrinogen concentrate, and/or platelet transfusion on
patient outcomes? (Interventional question)
• Question 5 – In medical patients, at what INR (PT/APTT) for FFP, fibrinogen
level for cryoprecipitate and platelet count for platelets concentrates should
patients be transfused to avoid risks of significant adverse events?
(Interventional and Prognostic question)
• Question 6 – In specific regularly and chronically transfused patients, at what
Hb threshold should patients be transfused to avoid adverse outcomes?
(Interventional question)
APTT, activated partial thromboplastin time; FFP, fresh frozen plasma; Hb, haemoglobin;
INR, international

6. WHY GIVE 2 WHEN 1 WILL DO…PATIENT
BLOOD MANAGEMENT GUIDELINES
www.blood.gov.au
www.blood.gov.au/pbm-guidelines

7. WHY GIVE 2 WHEN 1 WILL DO…SINGLE
UNIT TRANSFUSION
WHO
The
stable, normovolaemic
adult inpatient who does
NOThave clinically significant
bleeding with symptoms of
anaemia
Haemoglobin as defined in the
Patient Blood Management
Guidelines www.blood.gov.au/patient-bloodmanagement

8. WHY GIVE 2 WHEN 1 WILL DO

This does not include the chronically
transfused such as patients with MDS.
According to the Patient Blood Management
Guidelines;
“…there is no evidence to guide clinicians on the
Hb threshold for transfusion in patients with
MDS and chronic anaemia. Further studies are
needed to assess the benefit of transfusion in this
population”
http://www.blood.gov.au/pbm-module-3

9. “EVERY ONE MATTERS”
WHAT
Transfuse one unit, then reassess the
patient for clinical symptoms before
transfusing another
 Every unit is a new clinical
decision
 Base decision on patient
symptoms, not only on
haemoglobin

10. SINGLE UNIT TRANSFUSION
WHY
It is important to align practice with the
national Patient Blood Management
Guidelines
 Transfusion
may be an independent risk
factor for increased morbidity, mortality and
length of stay.
 Potential harm from transfusion is dose
dependent
 Transfusion is a live tissue transplant
The British Committee for Standards in Haematology (2012). Guidelines on the Administration of Blood Components. Addendum to

11. THREEREASONS WHY EXCESSIVE
TRANSFUSION IS A PROBLEM
Reason 1:
Each transfusion increases the risk of
nosocomial infection increases other morbidities
Analysis of 11,963 patients after CABG surgery
showed that perioperative RBC transfusion was
associated with a dose-dependent increased risk of
postoperative cardiac complications, serious
infection, renal failure, neurologic
complications, overall morbidity, prolonged
ventilator support, and in-hospital mortality.
Koch CG et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery
bypass grafting. Crit Care Med 2006, 34: 1608-1616.

12. THREEREASONS WHY EXCESSIVE
TRANSFUSION IS A PROBLEM
Reason 2:
Transfusion requirements after cardiac surgery
(TRACS) study prospectively demonstrated the
safety of a restrictive strategy of red blood cell
(RBC) transfusion in patients undergoing
cardiac surgery. Also reported: the higher the
number of transfused RBC, the higher was the
number of clinical complications.
Hajjar LA et al. Transfusion requirements after cardiac surgery: the TRACS randomised controlled trial.
JAMA, 304:1559-1567.

13. THREEREASONS WHY EXCESSIVE
TRANSFUSION IS A PROBLEM
Reason 3:
Transfusion associated circulatory overload
(TACO) is among the high risk adverse
effects of red cell transfusion (up to 1 in 100
per unit transfused).
National Blood Authority, 2012. Patient Blood Management Guidelines: Module 2 - Perioperative.
Appendix B, Table B.2.Transfusion Risks in perspective.

14. WHY GIVE 2 WHEN 1 WILL DO….
TOWARD A MORE RESTRICTIVE TRANSFUSION
APPROACH

How are these guidelines relevant to you?
 Practice
Points 4.4 (Red Cells and Cancer)
 RBC
transfusion should not be dictated by a Hb concentration
alone, but also base on the assessment of the clinical status of
the patient
 When
indicated, the transfusion of a single unit of red
cells, followed by clinical reassessment to determine the need
for further transfusion, is appropriate.
http://www.blood.gov.au/pbm-module-3

15. HOW IS THIS RELEVANT TO YOU IN THE
ONCOLOGY/HAEMOTOLOGY SETTING?

Refer to the Handouts from the Patient Blood
Management Guidelines;
1. Effect of anaemia on outcomes (3.1.4)
 2.Effect of RBC on outcomes (3.2.4)
 3. What is the effect of non-transfusion interventions
to increase Hb concentration. (3.3.1)
 Red cell Transfusion in the chronically transfused
(3.3.1)


Myleodysplastic syndrome (3.3.6)

Assessment of patient after red blood cell transfusion (p.68)

16. SINGLE UNIT TRANSFUSION GUIDELINE
Benefits: Safer, evidence based transfusion
PLUS:
 Reduced risk of non-infectious adverse events
 Reduced demand on limited blood supply
 Reduced risk from new infectious agents
Every ONE matters

17. RESEARCH QUESTIONS AND OTHER
THOUGHTS….

The NBA states that there is currently no strong
evidence –base underpinning treatment and
dosing with blood products.

The number 1 research priority area identified by the
NBA is to ensure the use of blood and blood products
is appropriate, eg in chronically transfused
patients, there is currently no evidence to guide
clinicians.

Patient Education….to educate and shift patient
thinking that they will automatically be transfused
with two units (or three or four…)

18. EVERY ONEMATTERS
Transfuse One Unit
Re-assess the patient
Don’t increase the
RISKS
if
NO BENEFIT