Videos: Choosing Wisely Canada transfusion recommendations

Led by project director Dr. Clinton Campbell and developed with funding from Canadian Blood Services' BloodTechNet program, a series of short, entertaining and informative animated videos present Choosing Wisely Canada transfusion recommendations.

Choosing Wisely Canada transfusion recommendation #1: 

Don’t transfuse blood if other non-transfusion therapies or observation would be just as effective. Blood transfusion should not be given if other safer non-transfusion alternatives are available. For example, patients with iron deficiency without hemodynamic instability should be given iron therapy.

Sources:

  1. Carson JL, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012 Jul 3;157(1):49-58. PMID: 22751760.
  2. Retter A, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol. 2013 Feb;160(4):445-64. PMID: 23278459.
  3. Szczepiorkowski ZM, et al. Transfusion guidelines: when to transfuse. Hematology Am Soc Hematol Educ Program. 2013;2013:638-44. PMID: 24319244.

Choosing Wisely Canada transfusion recommendation #2 

Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients. Indications for red blood transfusion depend on clinical assessment and the cause of the anemia. In a stable, non-bleeding patient, often a single unit of blood is adequate to relieve patient symptoms or to raise the hemoglobin to an acceptable level. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients. Transfusion decisions should be influenced by symptoms and hemoglobin concentration. Single unit red cell transfusions should be the standard for non-bleeding, hospitalized patients. Additional units should only be prescribed after re-assessment of the patient and their hemoglobin value.

Sources:

  1. Bracey AW, et al. Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome. Transfusion. 1999 Oct;39(10):1070-7. PMID: 10532600.
  2. Carson JL, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD002042. PMID: 22513904.
  3. Carson JL, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012 Jul 3;157(1):49-58. PMID: 22751760.
  4. Hebert PC, 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: 9971864.
  5. Marik PE, et al. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit. Care Med. Sep 2008;36(9):2667-2674. PMID: 18679112.
  6. Retter A, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol. 2013 Feb;160(4):445-64. PMID: 23278459.
  7. Szczepiorkowski ZM, et al. Transfusion guidelines: when to transfuse. Hematology Am Soc Hematol Educ Program. 2013;2013:638-44. PMID: 24319244.
  8. Villanueva C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21. PMID: 23281973.
  9. Related Resources:Toolkit: Why Give Two When One Will Do – A toolkit for reducing unnecessary red blood cell transfusions in hospitals.

Choosing Wisely Canada transfusion recommendation #3 

Don’t transfuse plasma to correct a mildly elevated (<1.8) international normalized ratio (INR) or activated partial thromboplastin time (aPTT) before a procedure. A mildly elevated INR is not predictive of an increased risk of bleeding. Furthermore, transfusion of plasma has not been demonstrated to significantly change the INR value when the INR was only minimally elevated (<1.8).

Sources:

  1. Abdel-Wahab OI, et al. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion. 2006 Aug;46(8):1279-85. PMID: 16934060.
  2. Estcourt L, et al. Prophylactic platelet transfusion for prevention of bleeding in patients with haematological disorders after chemotherapy and stem cell transplantation. Cochrane Database Syst Rev. 2012 May 16;(5):CD004269. PMID: 22592695.
  3. Szczepiorkowski ZM, et al. Transfusion guidelines: when to transfuse. Hematology Am Soc Hematol Educ Program. 2013;2013:638-44. PMID: 24319244.

Choosing Wisely Canada transfusion recommendation #5 

Don’t routinely use plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists. Patients requiring non-emergent reversal of warfarin can often be treated with vitamin K or by discontinuing the warfarin therapy. Prothrombin complex concentrates should only be used for patients with serious bleeding or for those who need urgent surgery.  Plasma should only be used in this setting if prothrombin complex concentrates are not available or are contraindicated.

Sources:

  1. Holbrook A, et al. Evidence-Based Management of Anticoagulant Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e152S-84S. PMID: 22315259.
  2. Keeling D, et al. Guidelines on oral anticoagulation with warfarin – fourth edition. Br J Haematol. 2011 Aug;154(3):311-24. PMID: 21671894.
  3. National Advisory Committee on Blood and Blood Products (NAC). Prothrombin Complex Concentrates [Internet]. 2014 May [cited 2017 May 5].
  4. Scottish Intercollegiate Guidelines Network (SIGN). Sign 129: Antithrombotics: Indications and Management [Internet]. 2013 Jun [cited 2017 May 5].
Choosing Wisely Canada transfusion recommendation #9 

Don’t transfuse O-negative blood except to O-negative patients and in emergencies for female patients of child-bearing potential of unknown blood group. Males and females without childbearing potential can receive O Rh-positive red cells. O-negative red cell units are in chronic short supply, in some part due to over utilization for patients who are not O-negative. To ensure O-negative red cells are available for patients who truly need them, their use should be restricted to: (1) patients who are O-Rh-negative; (2) patients with unknown blood group requiring emergent transfusion who are female and of child-bearing age. Type specific red cells should be administered as soon as possible in all emergency situations.

Sources:

  1. British Committee for Standards in Haematology, et al. Guidelines on the management of massive blood loss. Br J Haematol. 2006 Dec;135(5):634-41. PMID: 17107347.
  2. Medical Officer’s National Blood Transfusion Committee (UK). The appropriate use of group O RhD negative red cells. Manchester (UK): National Health Service; 2008.
  3. United Blood Services. A New Standard of Transfusion Care: Appropriate use of O-negative red blood cells [Internet]. [Cited 2017 May 5].