Minimise the need for a transfusion

If used appropriately, blood components and plasma-derived blood products can save lives and provide clinical benefit to many patients.

The decision whether to transfuse should be carefully considered taking into account the full range of available therapies, and balancing the evidence for efficacy and improved clinical outcome against the potential risks. Transfusion shouldn’t be a default decision.

Avoiding or minimising the use of allogeneic blood components is both in the patient’s interests and avoids wasting a limited and valuable resource.

Successful and safe transfusion practice depends on administering a blood component of the right type, in the right amount, in the right way, at the right time to the right patient.

Approaches to minimise the need for a blood transfusion

1. Ask yourself:
   • What improvement in the patient’s condition am I aiming to achieve?
   • Can I minimise blood loss to reduce the patient's need for transfusion?
   • Are there other treatments I should give before making the decision to transfuse, such as intravenous fluids, oxygen, iron replacements or other haematinics?
   • Has the patient given informed consent after a discussion about the potential risks and benefits of blood component therapy in their particular case?
     To assist with your decision-making, refer to the Transfusion Checklist and the National Blood Authority Patient Blood Management Guidelines. The decision to transfuse is the prescriber’s responsibility.
2. Identify high-risk patients and develop a specific management plan ahead of time.
3. Use appropriate surgical techniques.
4. Use appropriate anaesthetic techniques including:
   • spinal and epidural anaesthesia
   • hypotensive anaesthesia
   • reduction of venous pressure at the surgical site
   • haemodilution or normovolaemic anaemia, and
   • normothermia whenever possible.
5. Consider pharmacological optimisation of haemostasis (e.g. antifibrinolytic agents).
6. Transfuse in accordance with patient blood management guidelines.
7. Use of blood conservation techniques.

Surgical patients

Any patient planning to have elective surgery must be assessed for anaemia and iron deficiency, and asked about a history of abnormal bleeding.

Other underlying medical conditions or intake of medication that may be associated with impaired haemostatic function or abnormal laboratory tests of haemostasis may require postponement of elective surgery until the abnormality has been confirmed or identified.

A congenital abnormality of haemostasis (e.g. haemophilia) should be managed in consultation with a Specialist Haemophilia Treatment Centre.

Other haematological disorders that may predispose a patient to bleeding or thromboembolism should be managed in consultation with a Haematologist or Transfusion Medicine Specialist.

Acutely haemorrhaging patients

In acutely haemorrhaging patients, pre-emptive and early intervention with the use of one or more blood components may prevent uncontrolled bleeding and improve outcomes.

It’s important to differentiate between 'controlled' bleeding, usually during surgery, and the more complex clinical problem of critical bleeding requiring massive transfusion.

Clinicians should consider:

• Is this patient a potential 'bleeder'?
  • What is the haemostatic defect?
  • What therapy is available to prevent or minimise bleeding?
• If the patient is without a pre-existing haemostatic defect, to what point can the patient be haemodiluted before requiring transfusion of specific blood components?
• Are there blood conservation techniques appropriate for this patient (what, when and how)
• At what point are allogeneic red cells indicated?
• At what point does attention to systemic haemostasis become a consideration (i.e. need for FFP and platelet support)?
• At what point does the Massive Transfusion Protocol need to be initiated?