blood transfusion

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Introduction

Emergencies

Indications

* post acute myocardial infarction, a transfusion threshold of hemoglobin < 8 g/dl was non-inferior to a transfusion threshold of hemoglobin < 10 g/dl in preventing major cardiovascular events within 30 days[37] (no statistical difference[38]

* cardiac-related death at 30 days occurs less often with threshold of < 10 g/dl (4% vs. 6%)[42]

* all-cause mortality at 6 months less common with threshold of < 10 g/dl (19% vs. 21%)[42]

* cncidences of acute heart failure & other adverse events are similar[2]

Contraindications

* discuss alternative strategies during informed consent

* Rh-negative females of child-bearing potential should never be given Rh-positive blood[2]

Benefit/risk

* largest trial used a blood hemoglobin of 10.0 g/dL for liberal & 7.0 g/dl for conservative transfusion threshold[19]

* other studies used varying hematocrit levels as the trigger, or followed a protocol of immediate post-operative transfusion vs transfusing at a blood hemoglobin below 9.0 g/dL[19]

* 30-day mortality is higher in transfused than in nontransfused post surgical patients (13% vs 10%)[20]

* 30-day incidence of postoperative complications is higher in transfused patients (43% vs 39%)[20]

* restrictive strategy (Hgb < 7.5 g/dL) equivalent to liberal strategy (Hgb < 9.5 g/dL if in ICU, 8.5 g/dL not in ICU) 6 months after cardiac surgery[31]

* myocardial infarction occurs less commonly in transfused post surgical patients cohort (4% vs 7%)[20]

* blood hemoglobin target in post myocardial infarction with anemia is 9 g/dL[40]

* no consensus on what defines conservative transfusion threshold

Laboratory

Procedure

large bore peripheral intravenous access if large volumes of blood & crystalloid are needed quickly[2]

use the minimum number of units needed to relieve symptoms

the goal in stable, non-cardiac patients is a hemoglobin of 7 to 8 g/dL[10]

normal saline (0.9%) is the only IV solution to be used with a blood transfusion

An RN must start the infusion

Another person must verify the patient's identity

  • an MD, an RN or an LPN

Vital signs must be checked

  • before the transfusion starts
  • 15 minutes after transfusion starts
  • hourly until the transfusion is complete
  • 15 minutes post completion of transfusion

Transfusion of blood must be initiated within 30 minutes of release from the blood bank

Transfusion of 1st 50 mL of blood over a period of 15 minutes, remainder should be tranfused in < 3-4 hours

Verification prior to starting transfusion:

  • patient's id
  • patient's ABO type
  • patient's RH type
  • transfusion number

Patients may be observed for transfusion reactions by

  • RN, LPN, nursing assistant

The development of fever during transfusion requires the tranfusion be stopped until a hemolytic reaction can be ruled out[2]

Prophylaxis

Complications

Notes

  • also see blood donation
  • blood products transfused to patients with stem cell transplantation should be irradiated to prevent graft vs host disease[2]
  • ICU patient survival unaffected by the age of transfused blood[17]
  • AABB recommends using standard-issue blood rather than limiting transfusions to fresher blood (<10 days' storage)[25]
  • organ dysfunction after cardiac surgery unaffected by the age of transfused packed RBC[18]
  • fresh packed red blood cells no better than those stored for longer period of time[26]
  • receipt of blood transfusion from an ever-pregnant female donor, compared with a male donor, associated with increased all-cause mortality among male recipients (RR=1.13) but not among female recipients (RR=0.99)[29]
  • receipt of bllod ransfusions from never-pregnant female donor is not associated with increased mortality among male or female recipients[29]
  • factors influencing blood hemoglobin increases after transfusion[36]
    • larger hemoglobin increments observed in recipients of male-donor units vs female-donor units
    • larger hemoglobin increases in recipients of whole-blood-derived units compared with apheresis-derived units
    • donor- or recipient-positive RhD status associated with increased hemoglobin increments
    • donor age > 70 years & RBC storage durations > 35 days associated with decreased hemoglobin increment 24 & 48 hours after transfusion
    • irradiation results in smaller hemoglobin increments after transfusion
    • characteristics additive: lowest increments observed in recipients of irradiated or apheresis-derived units from female donors[36]

More general terms

More specific terms

Additional terms

References

  1. ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 613-616
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2022
    Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  3. ↑ Veterans Administration
  4. ↑ [No authors listed] Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the american society of anesthesiologists task force on perioperative blood transfusion and adjuvant therapies. Anesthesiology. 2006 Jul;105(1):198-208. No abstract available. PMID: https://pubmed.ncbi.nlm.nih.gov/16810012 corresponding NGC guideline updated Feb 2016 http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-200607000-00030.htm
  5. ↑ 5.0 5.1 Carson JL et al Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB Annals of Internal Medicine, March 26, 2012 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/22454395 <Internet> http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-201206190-00429.full corresponding NGC guideline withdrawn June 2017
    Vincent JL Indications for Blood Transfusions: Too Complex to Base on a Single Number? Annals of Internal Medicine, March 26, 2012 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/22454394 <Internet> http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-201206190-00431
  6. ↑ Transfusion medicine. A series of papers. The Lancet. May 24, 2013 http://www.thelancet.com/themed/transfusion-medicine
  7. ↑ Goodell PP, Uhl L, Mohammed M, Powers AA. Risk of hemolytic transfusion reactions following emergency- release RBC transfusion. Am J Clin Pathol. 2010 Aug;134(2):202-6 PMID: https://pubmed.ncbi.nlm.nih.gov/20660321
  8. ↑ Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy. 2007 Oct;27(10):1394-411. PMID: https://pubmed.ncbi.nlm.nih.gov/17896895
  9. ↑ Hebert PC, Wells G, Blajchman MA et al A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999 Feb 11;340(6):409-17. PMID: https://pubmed.ncbi.nlm.nih.gov/9971864
  10. ↑ 10.0 10.1 Hicks LK et al. The ASH Choosing Wisely Campaign: Five hematologic tests and treatments to question. Blood 2013 Dec 5; 122:3879. <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/24319155 <Internet> http://bloodjournal.hematologylibrary.org/content/122/24/3879
  11. ↑ Carson JL, Grossman BJ, Kleinman S et al Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012 Jul 3;157(1):49-58 PMID: https://pubmed.ncbi.nlm.nih.gov/22751760 corresponding NGC guideline withdrawn June 2017
  12. ↑ Carson JL, Terrin ML, Magaziner J et al Transfusion trigger trial for functional outcomes in cardiovascular patients undergoing surgical hip fracture repair (FOCUS). Transfusion. 2006 Dec;46(12):2192-206. PMID: https://pubmed.ncbi.nlm.nih.gov/17176334
  13. ↑ Carson JL, Terrin ML, Noveck H et al Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011 Dec 29;365(26):2453-62 PMID: https://pubmed.ncbi.nlm.nih.gov/22168590
  14. ↑ 14.0 14.1 Brett AS Incidence of Transfusion Complications in Noncardiac Surgery Patients. NEJM Journal Watch. Jan 13, 2015 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
    Clifford L et al. Characterizing the epidemiology of perioperative transfusion- associated circulatory overload. Anesthesiology 2015 Jan; 122:21 PMID: https://pubmed.ncbi.nlm.nih.gov/25611653
  15. ↑ 15.0 15.1 Pinheiro de Almeida J et al. Transfusion requirements in surgical oncology patients: A prospective, randomized controlled trial. Anesthesiology 2015 Jan; 122:29. <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/25401417 <Internet> http://anesthesiology.pubs.asahq.org/Article.aspx?articleid=2043033
  16. ↑ 16.0 16.1 16.2 Murphy GJ et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 2015 Mar 12; 372:997. <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/25760354 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1403612
    Spertus J. "TITRe"ing the approach to transfusions after cardiac surgery. N Engl J Med 2015 Mar 12; 372:1069. <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/25760360 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1415394
  17. ↑ 17.0 17.1 Lacroix J et al. Age of transfused blood in critically ill adults. N Engl J Med 2015 Mar 17; <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/25776801 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1500704
  18. ↑ 18.0 18.1 18.2 Steiner ME et al. Effects of red-cell storage duration on patients undergoing cardiac surgery. N Engl J Med 2015 Apr 9; 372:1419. <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/25853746 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1414219
  19. ↑ 19.0 19.1 19.2 19.3 The NNT: Using Liberal Hemoglobin Levels As Indication for Blood Transfusion
    http://www.thennt.com/nnt/liberal-hemoglobin-levels-for-blood-transfusions/
    Carless PA, Henry DA, Carson JL, Hebert PP, McClelland B, Ker K. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD002042 PMID: https://pubmed.ncbi.nlm.nih.gov/20927728
  20. ↑ 20.0 20.1 20.2 20.3 Abdelsattar ZM et al. Variation in transfusion practices and the effect on outcomes after noncardiac surgery. Ann Surg 2015 Jul; 262:1. PMID: https://pubmed.ncbi.nlm.nih.gov/26020111
  21. ↑ 21.0 21.1 Murphy EL, Kwaan N, Looney MR et al Risk factors and outcomes in transfusion-associated circulatory overload. Am J Med. 2013 Apr;126(4):357.e29-38 PMID: https://pubmed.ncbi.nlm.nih.gov/23357450
  22. ↑ Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014 Feb;127(2):124-131.e3. Review. PMID: https://pubmed.ncbi.nlm.nih.gov/24331453
  23. ↑ Ortega R, Canelli RJ, Quillen K et al (video) Transfusion of Red Cells. N Engl J Med 2016; 374:e12. March 17, 2016 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/26981950 (video) <Internet> http://www.nejm.org/doi/full/10.1056/NEJMvcm1504413
  24. ↑ Hogshire LC, Patel MS, Rivera E, Carson JL. Evidence review: periprocedural use of blood products. J Hosp Med. 2013 Nov;8(11):647-52. Review. PMID: https://pubmed.ncbi.nlm.nih.gov/24124069
  25. ↑ 25.0 25.1 25.2 25.3 25.4 25.5 Carson JL, Guyatt G, Heddle NM et al Clinical Practice Guidelines From the AABB. Red Blood Cell Transfusion Thresholds and Storage. JAMA. Published online October 12, 2016 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/27732721 <Internet> http://jamanetwork.com/journals/jama/article-abstract/2569055
    Yazer MH, Triulzi DJ AABB Red Blood Cell Transfusion Guidelines. Something for Almost Everyone. JAMA. Published online October 12, 2016 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/27732707 <Internet> http://jamanetwork.com/journals/jama/fullarticle/2569053
  26. ↑ 26.0 26.1 Heddle NM, Cook RJ, Arnold DM et al Effect of Short-Term vs. Long-Term Blood Storage on Mortality after Transfusion. N Engl J Med. October 24, 2016 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/27775503 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1609014?query=pfw&jwd=000000793830&jspc=FPG
    Tobian AA, Ness PM Red Cells - Aging Gracefully in the Blood Bank. N Engl J Med. October 24, 2016 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/27775504 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1612444
  27. ↑ 27.0 27.1 Bergamin FS et al. Liberal versus restrictive transfusion strategy in critically ill oncologic patients: The Transfusion Requirements in Critically Ill Oncologic Patients randomized controlled trial. Crit Care Med 2017 May; 45:766. <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/28240687 <Internet> http://insights.ovid.com/crossref?an=00003246-201705000-00003
  28. ↑ Rothaus C Red-Cell Transfusion. Resident 360. Sept. 27, 2017 https://resident360.nejm.org/content_items/red-cell-transfusion
  29. ↑ 29.0 29.1 29.2 Caram-Deelder C, Kreuger AL, Evers D et al Association of Blood Transfusion From Female Donors With and Without a History of Pregnancy With Mortality Among Male and Female Transfusion Recipients. JAMA. 2017;318(15):1471-1478 PMID: https://pubmed.ncbi.nlm.nih.gov/29049654 https://jamanetwork.com/journals/jama/article-abstract/2657377
    Cable RG, Edgren G Blood Transfusions From Previously Pregnant Women and Mortality. Interpreting the Evidence. JAMA. 2017;318(15):1445-1447. PMID: https://pubmed.ncbi.nlm.nih.gov/29049638 https://jamanetwork.com/journals/jama/article-abstract/2657356
  30. ↑ 30.0 30.1 Mazer CD, Whitlock RP, Fergusson DA et al Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med. Nov 12, 2017 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/29130845 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1711818
  31. ↑ 31.0 31.1 31.2 Mazer CD, Whitlock RP, Fergusson DA et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Engl J Med 2018 Aug 26; PMID: https://pubmed.ncbi.nlm.nih.gov/30146969 Free Article https://www.nejm.org/doi/10.1056/NEJMoa1808561
  32. ↑ Choosing Wisely. July 23, 2018 Society for the Advancement of Blood Management. http://www.choosingwisely.org/societies/society-for-the-advancement-of-blood-management/
  33. ↑ 33.0 33.1 Goel R et al. Association of perioperative red blood cell transfusions with venous thromboembolism in a North American registry. JAMA Surg 2018 Sep 1; 153:826 PMID: https://pubmed.ncbi.nlm.nih.gov/29898202
  34. ↑ Roubinian NH, Murphy EL, Mark DG et al. Long-term outcomes among patients discharged from the hospital with moderate anemia: A retrospective cohort study. Ann Intern Med 2018 Dec 18; <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/30557414 <Internet> http://annals.org/aim/article-abstract/2719218/long-term-outcomes-among-patients-discharged-from-hospital-moderate-anemia
    Shander A, Goodnough LT. From tolerating anemia to treating anemia. Ann Intern Med 2018 Dec 18; <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/30557445 <Internet> http://annals.org/aim/article-abstract/2719220/from-tolerating-anemia-treating-anemia
  35. ↑ 35.0 35.1 Kherad O, Restellini S, Martel M et al. Outcomes following restrictive or liberal red blood cell transfusion in patients with lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2019 Apr;49(7):919-925: ePub Feb 25 PMID: https://pubmed.ncbi.nlm.nih.gov/30805962 https://onlinelibrary.wiley.com/doi/full/10.1111/apt.15158
  36. ↑ 36.0 36.1 36.2 Roubinian NH, Plimier C, Woo JP et al. Effect of donor, component, and recipient characteristics on hemoglobin increments following red blood cell transfusion. Blood 2019 Sep 26; 134:1003. PMID: https://pubmed.ncbi.nlm.nih.gov/31350268 https://ashpublications.org/blood/article-abstract/134/13/1003/374918/Effect-of-donor-component-and-recipient?redirectedFrom=fulltext
  37. ↑ 37.0 37.1 Ducrocq G, Gonzalez-Juanatey JR, Puymirat E et al Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia. The REALITY Randomized Clinical Trial. JAMA. 2021;325(6):552-560 PMID: https://pubmed.ncbi.nlm.nih.gov/33560322 https://jamanetwork.com/journals/jama/fullarticle/2776201
  38. ↑ 38.0 38.1 Carson JL et al. Restrictive or liberal transfusion strategy in myocardial infarction and anemia. N Engl J Med 2023 Nov 11; [e-pub]. PMID: https://pubmed.ncbi.nlm.nih.gov/37952133 https://www.nejm.org/doi/10.1056/NEJMoa2307983
  39. ↑ Raasveld SJ, de Bruin S, Reuland MC et al Red Blood Cell Transfusion in the Intensive Care Unit JAMA. 2023;330(19):1852-1861. https://jamanetwork.com/journals/jama/fullarticle/2810759
  40. ↑ 40.0 40.1 Portela GT, Carson JL, Swanson SA et al for the MINT Investigators Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia: A Target Trial Emulation Using MINT Trial Data. Ann Intern Med. 2024 Oct 1. PMID: https://pubmed.ncbi.nlm.nih.gov/39348705
    Bloch EM, Tobian AAR. Relaxing Transfusion Thresholds for Patients With Myocardial Infarction: Findings From the MINT Trial. Ann Intern Med. 2024 Oct 1. PMID: https://pubmed.ncbi.nlm.nih.gov/39348694 No abstract available.
  41. ↑ 41.0 41.1 Taccone FS, Rynkowski Bittencourt C et al. Restrictive vs liberal transfusion strategy in patients with acute brain injury: The TRAIN randomized clinical trial. JAMA 2024 Oct 9; [e-pub]. PMID: https://pubmed.ncbi.nlm.nih.gov/39382241 https://jamanetwork.com/journals/jama/fullarticle/2824930
    Turgeon AF, Lauzier F. Shifting balance of the risk-benefit of restrictive transfusion strategies in neurocritically ill patients - Is less still more? JAMA 2024 Oct 9; [e-pub]. PMID: https://pubmed.ncbi.nlm.nih.gov/39382236 https://jamanetwork.com/journals/jama/fullarticle/2824932
  42. ↑ 42.0 42.1 42.2 Carson JL et al. Restrictive versus liberal transfusion in myocardial infarction - A patient-level meta-analysis. NEJM Evid 2025 Feb; 4:EVIDoa2400223 PMID: https://pubmed.ncbi.nlm.nih.gov/39714935 https://evidence.nejm.org/doi/10.1056/EVIDoa2400223
  43. ↑ Abuzeid AM, O'Keeffe T. Review of massive transfusion protocols in the injured, bleeding patient. Curr Opin Crit Care. 2019;25:661-667. PMID: https://pubmed.ncbi.nlm.nih.gov/31574016
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