Blood transfusion
Best Practice Guidance
Summary
A blood transfusion may be indicated if a patient has a shortage of red blood cells (RBC) causing haemodynamic instability or impeding oxygen delivery to tissues and organs. This can be for a variety of reasons including severe bleeding, cancer or a blood disorder. However, blood transfusion carries risks and only the minimum number of units should be transfused to avoid harm.
It is recommended to use restrictive thresholds for transfusion, and to give only a single unit at a time, except where the patient has active bleeding.
This guidance applies to adults (or equivalent based on body weight for children or adults with low body weight) only.
Recommendation
This guidance focuses on RBC transfusions for adults (or equivalent based on body weight for children or adults with low body weight) only.
Do not give RBC transfusions to patients with B12, folate or iron deficiency anaemia unless there is haemodynamic instability. If haemodynamic instability is present, treat this with transfusion of appropriate blood components (do not delay emergency transfusions).
Where, however, severe acute anaemia (Hb <70g/litre) exists that is symptomatic and prevents rehabilitation or mobilisation, those patients may benefit from a single unit of blood.
For adult patients (or equivalent based on body weight for children or adults with low body weight) needing RBC transfusion, suggest restrictive thresholds and giving a single unit at a time except in case of exceptions below.
Restrictive RBC transfusion thresholds are for patients who need RBC transfusions and who do not:
- Have major haemorrhage or
- Have acute coronary syndrome or
- Need regular blood transfusions for chronic anaemia.
While transfusions are given to replace deficient red blood cells, they will not correct the underlying cause of the anaemia. RBC transfusions will only provide temporary improvement. It is important to investigate why patients are anaemic and treat the cause as well as the symptoms.
Note: Consider whether a dramatic fall in haemoglobin could be due to a severe haemolytic episode and not associated with any of the 3 exceptions. This would also be a possible indication to transfuse more than one unit at a time.
When using a restrictive RBC transfusion threshold, consider a threshold of 70 g/litre and a haemoglobin concentration target of 70–90 g/litre after transfusion. For patients with acute coronary syndrome, a RBC transfusion threshold of 80 g/litre should be considered and a haemoglobin concentration target of 80–100 g/litre after transfusion. For patients requiring regular transfusion for chronic anaemia, NICE advise defining thresholds and haemoglobin concentration targets for each individual.
Rationale for recommendation
NICE guidelines recommend single-unit RBC transfusion for adults (or equivalent based on body weight for children or adults with low body weight) who are not actively bleeding, do not have acute coronary syndrome or need regular blood transfusions for chronic anaemia. This decision should be based on a clinical assessment of each individual patient including their underlying cause of anaemia. They also recommend that after each single‑unit RBC transfusion the patient should be reassessed clinically, and have their haemoglobin levels checked and be given further transfusions if required.
Several randomised control trials (RCTs) have proven that it is safe to give single-unit RBC transfusions with a restrictive transfusion trigger (pretransfusion haemoglobin level or symptoms of anaemia). After receiving a single-unit RBC transfusion, symptoms may be alleviated enough to make it possible to give alternative anaemia treatment and postpone the need for further blood transfusions.
There is high quality evidence that demonstrates a lack of benefit and, in some cases, harm to patients transfused to achieve an arbitrary transfusion level. If necessary, transfuse only the minimum number of units required instead of a liberal transfusion strategy. Potential risks and harms associated with RBC transfusions include:
- Pulmonary complications: transfusion of two or more RBC units in succession is associated with an increase in pulmonary oedema or transfusion-associated circulatory overload
- Volume overload
- Haemolysis, in particular for those with sickle cell disease
- Acute transfusion reaction due to allergy
- Transmission of infection
To monitor for transfusion reactions, observe and monitor the patient’s condition and vital signs before, during and after blood transfusions.
This guidance is in line with the work of the Serious Hazards of Transfusion organisation
Patient information
There is no specific EBI patient guidance for this intervention.
However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
Coding
Code Script
Inpatient
WHEN LEFT(der.Spell_Dominant_Procedure,4) in ('X331','X332','X338','X339’)
AND (apcs.der_diagnosis_all like '%D5[02][0189]%’
OR apcs.der_diagnosis_all like '%D51[012389]%’)
AND not (apcs.der_diagnosis_all like '%D5[38][01289]%’
OR apcs.der_diagnosis_all like '%D55[012389]%’
OR apcs.der_diagnosis_all like '%D56[0123489]%’
OR apcs.der_diagnosis_all like '%D57[01238]%’
OR apcs.der_diagnosis_all like '%D59[012345689]%’
OR apcs.der_diagnosis_all like '%D60[0189]%’
OR apcs.der_diagnosis_all like '%D61[012389]%’
OR apcs.der_diagnosis_all like '%D62%’
OR apcs.der_diagnosis_all like '%D63[08]%’
OR apcs.der_diagnosis_all like '%D64[0123489]%’)
THEN ‘EE_blood_transfusion'
Outpatient
WHEN LEFT(OPA.Der_Procedure_All,4) in ('X331','X332','X338','X339')
AND (not (OPA.der_diagnosis_all LIKE '%D5[38][01289]%'
OR OPA.der_diagnosis_all LIKE '%D55[012389]%'
OR OPA.der_diagnosis_all LIKE '%D56[0123489]%'
OR OPA.der_diagnosis_all LIKE '%D57[01238]%'
OR OPA.der_diagnosis_all LIKE '%D59[012345689]%'
OR OPA.der_diagnosis_all LIKE '%D60[0189]%'
OR OPA.der_diagnosis_all LIKE '%D61[012389]%'
OR OPA.der_diagnosis_all LIKE '%D62%'
OR OPA.der_diagnosis_all LIKE '%D63[08]%'
OR OPA.der_diagnosis_all LIKE '%D64[0123489]%')
OR OPA.der_diagnosis_all IS NULL)
THEN 'proc_32_blood_transfusion'
Code Definitions
Procedure codes (OPCS)
X331 Intra-arterial blood transfusion
X332 Intravenous blood transfusion of packed cells
X338 Other specified other blood transfusion
X339 Unspecified other blood transfusion
Diagnosis codes (ICD):
Inclusion
D500 Iron deficiency anaemia secondary to blood loss (chronic)
D501 Sideropenic dysphagia
D508 Other iron deficiency anaemias
D509 Iron deficiency anaemia, unspecified
D510 Vitamin B₁₂ deficiency anaemia due to intrinsic factor deficiency
D511 Vitamin B₁₂ deficiency anaemia due to selective vitamin B₁₂ malabsorption with proteinuria
D512 Transcobalamin II deficiency
D513 Other dietary vitamin B₁₂ deficiency anaemia
D518 Other vitamin B₁₂ deficiency anaemias
D519 Vitamin B₁₂ deficiency anaemia, unspecified
D520 Dietary folate deficiency anaemia
D521 Drug-induced folate deficiency anaemia
D528 Other folate deficiency anaemias
D529 Folate deficiency anaemia, unspecified
Diagnosis codes (ICD)
Exclusion
D530 Protein deficiency anaemia
D531 Other megaloblastic anaemias, not elsewhere classified
D532 Scorbutic anaemia
D538 Other specified nutritional anaemias
D539 Nutritional anaemia, unspecified
D550 Anaemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency
D551 Anaemia due to other disorders of glutathione metabolism
D552 Anaemia due to disorders of glycolytic enzymes
D553 Anaemia due to disorders of nucleotide metabolism
D558 Other anaemias due to enzyme disorders
D559 Anaemia due to enzyme disorder, unspecified
D560 Alpha thalassaemia
D561 Beta thalassaemia
D562 Delta-beta thalassaemia
D563 Thalassaemia trait
D564 Hereditary persistence of fetal haemoglobin [HPFH]
D568 Other thalassaemias
D569 Thalassaemia, unspecified
D570 Sickle-cell anaemia with crisis
D571 Sickle-cell anaemia without crisis
D572 Double heterozygous sickling disorders
D573 Sickle-cell trait
D578 Other sickle-cell disorders
D580 Hereditary spherocytosis
D581 Hereditary elliptocytosis
D582 Other haemoglobinopathies
D588 Other specified hereditary haemolytic anaemias
D589 Hereditary haemolytic anaemia, unspecified
D590 Drug-induced autoimmune haemolytic anaemia
D591 Other autoimmune haemolytic anaemias
D592 Drug-induced nonautoimmune haemolytic anaemia
D593 Haemolytic-uraemic syndrome
D594 Other nonautoimmune haemolytic anaemias
D595 Paroxysmal nocturnal haemoglobinuria [Marchiafava-Micheli]
D596 Haemoglobinuria due to haemolysis from other external causes
D598 Other acquired haemolytic anaemias
D599 Acquired haemolytic anaemia, unspecified
D600 Chronic acquired pure red cell aplasia
D601 Transient acquired pure red cell aplasia
D608 Other acquired pure red cell aplasias
D609 Acquired pure red cell aplasia, unspecified
D610 Constitutional aplastic anaemia
D611 Drug-induced aplastic anaemia
D612 Aplastic anaemia due to other external agents
D613 Idiopathic aplastic anaemia
D618 Other specified aplastic anaemias
D619 Aplastic anaemia, unspecified
D62X Acute posthaemorrhagic anaemia
D630 Anaemia in neoplastic disease
D638 Anaemia in other chronic diseases classified elsewhere
D640 Hereditary sideroblastic anaemia
D641 Secondary sideroblastic anaemia due to disease
D642 Secondary sideroblastic anaemia due to drugs and toxins
D643 Other sideroblastic anaemias
D644 Congenital dyserythropoietic anaemia
D648 Other specified anaemias
D649 Anaemia, unspecified
Additional Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3[789]%' and apcs.der_diagnosis_all not like '%D4[012345678]%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
–Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’
References
- NICE guidance: Blood transfusion (NG24)
- NICE 2016 Blood transfusion Quality Standard (QS138.)
- Cochrane Review: Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion.
- NHS Advice on blood transfusion (NHS.uk)
- Choosing Wisely UK – Recommendations for blood transfusion.
- British Blood Transfusion Society https://www.bbts.org.uk/
- Choosing Wisely Canada Toolkit: Why give two when one will do: A toolkit for reducing unnecessary red blood cell transfusions in hospitals.
- JPAC (2013) Handbook of Transfusion Medicine. 7.1. Transfusion in surgery
- International Society of Blood Transfusion. Critical Transfusion. Single unit transfusion
- NHS Blood and Transplant – Single unit blood transfusions
- Markus M Mueller, MS; Hans Van Remoortel, PhD; Patrick Meybhn, MS, PhD; et al. Recommendations from the 2018 Frankfurt Consensus Conference. https://jamanetwork.com/journals/jama/article-abstract/2727453.
- Jeffrey L Carson; Simon J Stanworth; John H Alexander; Nareg Roubinian; Dean A Fergusson; Darrell J Triulzi; Shaun G Goodman; Sunil V. Rao; Carolyn Doree; Paul C Hebert. Clinical trials evaluating red blood cell transfusion thresholds: An updated systematic review and with additional focus on patients with cardiovascular disease. 2018. Am Heart J. doi: doi.org/10.1016/j.ahj.2018.04.007
- https://www.shotuk.org.
How up to date is this information?
Last revised December 2023
Changes
December 2023 - coding updated.
