Excerpt

This guideline contains recommendations about general principles of blood transfusion, and applies to a range of conditions and different settings. It does not include recommendations relating to specific conditions and provides guidance on:

• the appropriate use of blood components
• alternatives to transfusion for surgical patients
• ensuring patient safety, including monitoring for transfusion reactions
• providing patients with information about transfusion.

This guideline focuses on the general principles of transfusion. To do this, it was necessary to limit the scope by excluding:

• patient groups with special transfusion needs, such as foetuses, neonates and children under 1 year old, pregnant women, and patients with haemoglobinopathies
• specialist areas already covered by NICE guidelines, for example, anaemia in chronic kidney disease, upper gastrointestinal bleeding and trauma and massive haemorrhage
• the use and administration of blood products, such as intravenous immunoglobulin, anti-D and recombinant activated factor VII
• near-patient testing for haemoglobin concentration and haemostasis
• laboratory procedures relating to the safety and quality of blood, including pre-transfusion compatibility testing.
• the diagnosis of anaemia
• the management of anaemia in medical patients is out of the scope of this guidance, but it is important to note that the correct approach for managing anaemia in medical patients is important for avoiding unnecessary use of blood.

Contents

• Guideline Development Group members
• NCGC technical team members
• Acknowledgements
• 1. Guideline summary
  • 1.1. Key priorities for implementation
  • 1.2. Full list of recommendations
  • 1.3. Key research recommendations
  • 1.4. Algorithm
• 2. Introduction
• 3. Development of the guideline
  • 3.1. What is a NICE clinical guideline?
  • 3.2. Remit
  • 3.3. Who developed this guideline?
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Searching for evidence
  • 4.3. Evidence of effectiveness
  • 4.4. Evidence of cost-effectiveness
  • 4.5. Developing recommendations
• 5. Alternatives to blood transfusion for patients having surgery: Oral iron, IV iron and erythropoietin
  • 5.1. Review question: What is the clinical- and cost-effectiveness of oral iron, IV iron and erythropoietin in reducing blood transfusion requirements in surgical patients?
  • 5.2. Clinical evidence
  • 5.3. Economic evidence
  • 5.4. Evidence statements
  • Recommendations and link to evidence
• 6. Alternatives to blood transfusion for patients having surgery: Cell salvage and tranexamic acid
  • 6.1. Review question: What is the clinical and cost-effectiveness of using alternatives to blood transfusion (cell salvage or tranexamic acid alone or in combination with one another) to reduce blood transfusion requirements?
  • 6.2. Methodology of clinical evidence review
  • 6.3. Clinical evidence
  • 6.4. Economic evidence
  • 6.5. Evidence statements
  • 6.6. Recommendations and link to evidence
• 7. Monitoring for acute blood transfusion reactions
  • 7.1. Review question: What is the clinical- and cost-effectiveness of monitoring for acute reactions at different times in relation to the transfusion?
  • 7.2. Clinical evidence
  • 7.3. Economic evidence
  • 7.4. Evidence statements
  • 7.5. Recommendations and link to evidence
• 8. Electronic decision support
  • 8.1. Review question: What is the clinical- and cost-effectiveness of electronic decision-support blood order systems to reduce inappropriate blood transfusions?
  • 8.2. Clinical evidence
  • 8.3. Economic evidence
  • 8.4. Evidence statements
  • 8.5. Recommendations and link to evidence
• 9. Electronic patient identification systems
  • 9.1. Review question: What are the clinical- and cost-effectiveness of electronic patient identification systems such as patient identification band, bar code or radiofrequency identification (RFID) to ensure patient safety during blood transfusions?
  • 9.2. Clinical evidence
  • 9.3. Economic evidence
  • 9.4. Evidence statements
  • 9.5. Recommendations and link to evidence
• 10. Red blood cell: thresholds and targets
  • 10.1. Review question: What is the clinical- and cost-effectiveness of red blood cell transfusion at different haemoglobin concentrations?
  • 10.2. Review question: What is the clinical- and cost-effectiveness of different target levels of post-transfusion haemoglobin concentrations for red blood cell transfusion?
  • 10.3. Methodology of clinical evidence review (threshold haemoglobin concentrations and target haemoglobin levels for blood transfusion)
  • 10.4. Clinical evidence
  • 10.5. Economic evidence
  • 10.6. Evidence statements
  • 10.7. Recommendations and link to evidence
  • 10.8. Research Recommendations
• 11. Red blood cell: doses
  • 11.1. Review question: What is the clinical- and cost-effectiveness of different doses of red blood cell transfusion?
  • 11.2. Clinical evidence
  • 11.3. Economic evidence
  • 11.4. Evidence statements
  • 11.5. Recommendations and link to evidence
• 12. Platelet: thresholds and targets
  • 12.1. Review question: What is the clinical- and cost-effectiveness of different target levels of post-transfusion platelet counts?
  • 12.2. Review question: What is the clinical- and cost-effectiveness of platelet transfusion at different platelet count thresholds?
  • 12.3. Clinical evidence
  • 12.4. Economic evidence
  • 12.5. Evidence statements
  • 12.6. Recommendations and link to evidence
• 13. Platelet: doses
  • 13.1. Review question: What is the clinical- and cost-effectiveness of different doses of platelet transfusion?
  • 13.2. Clinical evidence
  • 13.3. Economic evidence
  • 13.4. Evidence statements
  • 13.5. Recommendations and link to evidence
• 14. Fresh Frozen Plasma: thresholds and targets
  • 14.1. Review question: What is the clinical- and cost-effectiveness of transfusions of fresh frozen plasma (FFP) to treat and prevent bleeding?
  • 14.2. Review question: What is the clinical- and cost-effectiveness of different target levels of post-transfusion haemostasis tests with the use of fresh frozen plasma (FFP) for prophylactic transfusions?
  • 14.3. Clinical evidence
  • 14.4. Economic evidence
  • 14.5. Evidence statements
  • 14.6. Recommendations and link to evidence
• 15. Fresh Frozen Plasma: doses
  • 15.1. Review question: What is the clinical- and cost-effectiveness of different doses of FFP?
  • 15.2. Clinical evidence
  • 15.3. Economic evidence
  • 15.4. Evidence statements
  • 15.5. Recommendations and link to evidence
• 16. Cryoprecipitate: thresholds and targets
  • 16.1. Review question: What is the clinical- and cost-effectiveness of transfusions of cryoprecipitate to treat and prevent bleeding?
  • 16.2. Review question: What is the clinical- and cost-effectiveness of different target levels of post-transfusion haemostasis tests with the use of cryoprecipitate for prophylactic transfusions?
  • 16.3. Clinical evidence
  • 16.4. Economic evidence
  • 16.5. Evidence statements
  • 16.6. Recommendations and link to evidence
• 17. Cryoprecipitate: doses
  • 17.1. Review question: What is the clinical- and cost-effectiveness of different doses of cryoprecipitate for transfusion?
  • 17.2. Clinical evidence
  • 17.3. Economic evidence
  • 17.4. Evidence statements
  • 17.5. Recommendations and link to evidence
• 18. Prothrombin Complex Concentrates: thresholds and targets
  • 18.1. Review question: What is the clinical- and cost-effectiveness of transfusions of prothrombin complex concentrates (PCC) to treat and prevent bleeding?
  • 18.2. Review question: What is the clinical- and cost-effectiveness of different target levels of post-transfusion haemostasis tests with the use of prothrombin complex concentrates (PCC) for prophylactic transfusions?
  • 18.3. Clinical evidence
  • 18.4. Economic evidence
  • 18.5. Evidence statements
  • 18.6. Recommendations and link to evidence
• 19. Prothrombin Complex Concentrates: doses
  • 19.1. Review question: What is the clinical- and cost-effectiveness of different doses of prothrombin complex concentrates (PCC) for transfusion?
  • 19.2. Clinical evidence
  • 19.1. Economic evidence
  • 19.2. Evidence statements
  • 19.3. Recommendations and link to evidence
• 20. Patient information
  • 20.1. Review question: What is the information and support patients under consideration for a blood transfusion and their family members or carers would value and how would they prefer to receive it?
  • 20.2. Clinical evidence
  • 20.3. Economic evidence
  • 20.4. Narrative summary
  • 20.5. Recommendations and link to evidence
• 21. Acronyms and abbreviations
• 22. Glossary
• 23. Reference list
• Appendices A – G
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Clinical review protocols
  • Appendix D. Economic review protocol
  • Appendix E. Clinical article selection
  • Appendix F. Economic article selection
  • Appendix G. Literature search strategies
  • References
• Appendices H-I
  • Appendix H. Clinical evidence tables
  • Appendix I. Economic evidence tables
  • References
• Appendices J–L
  • Appendix J. GRADE tables
  • Appendix K. Forest plots
  • Appendix L. Network meta-analysis of alternatives to blood transfusion in surgical patients
  • References
• Appendices M-N
  • Appendix M. Cost-effectiveness analysis: tranexamic acid and cell salvage
  • Appendix N. Unit costs
  • References
• Appendices O-R
  • Appendix O. Research recommendations
  • Appendix P. Excluded clinical studies
  • Appendix Q. Excluded economic studies
  • Appendix R. NICE technical team
  • References

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and, where appropriate, their guardian or carer.