5 blood transfusion ‘do not do’ recommendations from ANZSBT

The Australian and New Zealand Society of Blood Transfusion (ANZSBT) has reminded clinicians not to use peri-operative transfusion to address untreated preoperative anaemia in one of its top five recommendations on low value practices.

ANZSBT said that practice is associated with decreased overall survival rates but not with recurrence free survival in its draft Choosing Wisely recommendations.

The negative associations are suggested to be linked to the clinical circumstances surrounding the need for the transfusions, rather than the transfusions themselves, said the society arguing that it is preferable to identify and manage anaemia before surgery.

Transfusing more units of blood than necessary has also been flagged as a practice to watch with the ANZSBT recommending a ‘restrictive transfusion strategy (Haemoglobin (Hb) of 70-80g/L)’ for the majority of hospitalised, stable (non-bleeding) adult patients.

“The decision to give a red blood cell transfusion should not be dictated by Hb alone and should also include an assessment of the patient’s underlying condition, any clinical signs and symptoms and response to previous transfusions” the draft document states.

The group has also recommended against transfusing red blood cells for iron deficiency where there is no haemodynamic instability, which it says has become a routine medical response ‘despite cheaper and safer alternatives in some settings’.

“Pre-operative patients with iron deficiency and patients with chronic iron deficiency without haemodynamic instability (even with low haemoglobin levels) should be given oral and/or intravenous iron,” the group advised.

But possible exceptions where reliable ingestion of iron may not occur or gastrointestinal issues exist were also noted.

Meanwhile attempts to curtail blood wastage and increasing costs associated with transfusion sees recommendations against ordering group and crossmatch when a group and antibody screen would be appropriate.

“Modern on-site laboratories can issue compatible blood within minutes if the patient has a valid group and screen and no clinically significant red cell antibodies,” notes NZSBT adding that cross-matching blood unnecessarily increases ‘total inventory levels, increases the average age at which units are transfused, increases blood wastage and creates additional work and costs associated with transfusion’.   

“If an on-site laboratory is not available, then cross-matching should be guided by a Maximum Surgical Blood Ordering Schedule (MSBOS) to minimise wastage,” it adds.

Finally the practice of transfusing standard doses of fresh frozen plasma (FFP) to correct a mildly elevated (<1.8) international normalised ratio prior to a procedure has also been been put on watch with ANZSBT warning that there is no evidence to support use in that setting.

“The evidence supports the use of Vitamin K and suggests the use of FFP correlated with an increased risk of intra-operative bleeding and/or increased risk of transfusion reactions.”

The draft recommendation are open for public consultation until September 16 and can be accessed here.

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