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Blood transfusion

About

What is covered

This NICE Pathway covers the assessment for and management of blood transfusions in adults, young people and children over 1 year old.

Updates

Updates to this NICE Pathway

14 December 2016 Blood transfusion (NICE quality standard 138) added.
1 March 2016 Spectra Optia for automatic red blood cell exchange in patients with sickle cell disease (NICE medical technologies guidance 28) added to red blood cells.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on blood transfusions in adults, young people and children over 1 year old in an interactive flowchart

What is covered

This NICE Pathway covers the assessment for and management of blood transfusions in adults, young people and children over 1 year old.

Updates

Updates to this NICE Pathway

14 December 2016 Blood transfusion (NICE quality standard 138) added.
1 March 2016 Spectra Optia for automatic red blood cell exchange in patients with sickle cell disease (NICE medical technologies guidance 28) added to red blood cells.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Blood transfusion (2015) NICE guideline NG24
Intraoperative red blood cell salvage during radical prostatectomy or radical cystectomy (2008) NICE interventional procedures guidance 258
Intraoperative blood cell salvage in obstetrics (2005) NICE interventional procedures guidance 144
Spectra Optia for automatic red blood cell exchange in people with sickle cell disease (2016) NICE medical technologies guidance 28
Hemosep for cell salvage (2017) NICE medtech innovation briefing 103
Blood transfusion (2016) NICE quality standard 138

Quality standards

Blood transfusion

These quality statements are taken from the blood transfusion quality standard. The quality standard defines clinical best practice for blood transfusion and should be read in full.
1Iron supplementation
2Tranexamic acid for adults
3Reassessment after red blood cell transfusions
4Patient information

Quality statements

Iron supplementation

This quality statement is taken from the blood transfusion quality standard. The quality standard defines clinical best practice for blood transfusion and should be read in full.

Quality statement

People with iron-deficiency anaemia who are having surgery are offered iron supplementation before and after surgery.

Rationale

Preoperative anaemia is associated with increased postoperative morbidity and mortality, and with increased transfusion needs. Treating iron deficiency with iron supplements can reduce the need for blood transfusion. This avoids serious risks associated with blood transfusion, for example infection, fluid overload and incorrect blood transfusions being given. It may also reduce the length of hospital stays and the cost to the NHS. Depending on the circumstances, the cause of the iron deficiency should be investigated before or after surgery.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people with iron-deficiency anaemia who are having surgery are offered iron supplementation before surgery.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people with iron-deficiency anaemia are offered iron supplementation after surgery.
Data source: Local data collection.
Process
a) Proportion of people with iron-deficiency anaemia who are having surgery and receive iron supplementation before surgery.
Numerator – the number in the denominator who receive iron supplementation before surgery.
Denominator – the number of people with iron-deficiency anaemia who are having surgery.
Data source: Local data collection.
b) Proportion of people with iron-deficiency anaemia who receive iron supplementation after surgery.
Numerator – the number in the denominator who receive iron supplementation.
Denominator – the number of people with iron-deficiency anaemia who have had surgery.
Data source: Local data collection.
Outcome
Blood transfusion rates associated with surgery.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (primary and secondary care services) ensure that systems are in place to offer iron supplementation before and after surgery to people with iron-deficiency anaemia.
Healthcare professionals (doctors, nurses and blood transfusion specialists) offer iron supplementation before and after surgery to people with iron-deficiency anaemia.
Commissioners (clinical commissioning groups) commission services that offer iron supplementation before and after surgery for people with iron-deficiency anaemia.
People who are having an operation and have anaemia caused by a lack of iron should be offered iron (usually as tablets) before and after the operation.

Source guidance

Blood transfusion (2015) NICE guideline NG24, recommendations 1.1.2 and 1.1.3

Definitions of terms used in this quality statement

Iron supplementation
People should have their haemoglobin levels checked at least 2 weeks before surgery, if possible and necessary for the procedure they are having. If they have iron-deficiency anaemia, they should be offered iron supplementation. Oral iron should be offered initially, and started at least 2 weeks before surgery. If oral iron is not appropriate, intravenous iron should be considered.
[NICE’s guideline on blood transfusion (recommendations 1.1.2 and 1.1.3) and expert consensus]

Tranexamic acid for adults

This quality statement is taken from the blood transfusion quality standard. The quality standard defines clinical best practice for blood transfusion and should be read in full.

Quality statement

Adults who are having surgery and are expected to have moderate blood loss are offered tranexamic acid.

Rationale

Tranexamic acid can reduce the need for blood transfusion in adults having surgery. This avoids serious risks associated with blood transfusion, for example infection, fluid overload and incorrect blood transfusions being given. It may also reduce the length of hospital stays and the cost to the NHS.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who are having surgery and are expected to have moderate blood loss are offered tranexamic acid.
Data source: Local data collection.
Process
Proportion of adults who are having surgery and are expected to have moderate blood loss who receive tranexamic acid.
Numerator – the number of adults in the denominator who receive tranexamic acid.
Denominator – the number of adults who are having surgery and are expected to have moderate blood loss.
Data source: Local data collection.
Outcome
Blood transfusion rates associated with surgery.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that systems are in place to offer tranexamic acid to adults who are having surgery and are expected to have moderate blood loss.
Healthcare professionals (doctors, nurses and blood transfusion specialists) offer tranexamic acid to adults who are having surgery and are expected to have moderate blood loss.
Commissioners (clinical commissioning groups) commission services that offer tranexamic acid to adults who are having surgery and are expected to have moderate blood loss.
Adults who are expected to lose more than half a litre of blood during an operation are offered tranexamic acid. This helps blood to clot better and reduces blood loss during surgery.

Source guidance

Blood transfusion (2015) NICE guideline NG24, recommendation 1.1.5

Definitions of terms used in this quality statement

Moderate blood loss
Adults who are expected to have blood loss greater than 500 ml during surgery, as recorded on the World Health Organization surgical safety checklist.
[NICE’s guideline on blood transfusion, recommendation 1.1.5 and the World Health Organization surgical safety checklist]

Reassessment after red blood cell transfusions

This quality statement is taken from the blood transfusion quality standard. The quality standard defines clinical best practice for blood transfusion and should be read in full.

Quality statement

People are clinically reassessed and have their haemoglobin levels checked after each unit of red blood cells they receive, unless they are bleeding or are on a chronic transfusion programme.

Rationale

Clinical reassessment and measurement of haemoglobin levels after each unit of red blood cells transfused helps healthcare professionals to decide whether further transfusions are needed. This helps avoid the serious risks associated with red blood cell transfusions, for example infection, fluid overload and incorrect blood transfusions being given. It may also reduce the length of hospital stays and the cost to the NHS. For children and for adults with low body weight, red blood cell transfusion volumes should be calculated based on body weight.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people are clinically reassessed after each unit of red blood cells they receive, unless they are bleeding or are on a chronic transfusion programme.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people have their haemoglobin levels checked after each unit of red blood cells they receive, unless they are bleeding or are on a chronic transfusion programme.
Data source: Local data collection.
Process
a) Proportion of red blood cell transfusions where a clinical reassessment of the person is carried out after each unit of blood transfused, unless they are bleeding or on a chronic transfusion programme.
Numerator – the number in the denominator where a clinical reassessment is carried out after each unit of blood transfused.
Denominator – the number of red blood cell transfusions in people who are not bleeding or on a chronic transfusion programme.
Data source: Local data collection.
b) Proportion of red blood cell transfusions where the haemoglobin level of the person is checked after each unit of blood transfused, unless they are bleeding or on a chronic transfusion programme.
Numerator – the number in the denominator where the haemoglobin level of the person is checked after each unit of blood transfused.
Denominator – the number of red blood cell transfusions in people who are not bleeding or on a chronic transfusion programme.
Data source: Local data collection.
Outcome
Incidence of serious adverse events after red blood cell transfusion.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that systems are in place to clinically reassess people and check their haemoglobin levels after each unit of red blood cells transfused, unless they are bleeding or on a chronic transfusion programme.
Healthcare professionals (doctors, nurses and blood transfusion specialists) clinically reassess people and check their haemoglobin levels after each unit of red blood cells transfused, unless they are bleeding or on a chronic transfusion programme.
Commissioners (clinical commissioning groups) commission services that clinically reassess people and check their haemoglobin levels after each unit of blood transfused, unless they are bleeding or on a chronic transfusion programme.
People who have a red blood cell transfusion have an assessment and their haemoglobin levels checked after the transfusion to see if they need another one, unless they are bleeding or need regular blood transfusions.

Source guidance

Blood transfusion (2015) NICE guideline NG24, recommendations 1.2.1 and 1.2.6

Definitions of terms used in this quality statement

Clinical assessment
This includes:
  • asking the person if their anaemia symptoms have resolved
  • asking the person about any new symptoms that might indicate an adverse response to transfusion (such as circulatory overload)
  • reviewing the vital signs taken before, during and after the transfusion
  • any further clinical assessment that could be needed.
[Expert consensus]

Patient information

This quality statement is taken from the blood transfusion quality standard. The quality standard defines clinical best practice for blood transfusion and should be read in full.

Quality statement

People who may need or who have had a blood transfusion are given verbal and written information about blood transfusion.

Rationale

It is important that people fully understand the benefits and risks of a blood transfusion, so they can give informed consent. Discussing the alternatives, and knowing that they cannot donate blood after a blood transfusion, helps people to decide if they want one. However, some blood transfusions are not planned and are carried out in an emergency. In these cases information should be given after the transfusion, including advice about the implications of the transfusion. Helping people to understand the process and its implications can improve their experience of receiving a blood transfusion.

Quality measures

Structure
Evidence of local arrangements to ensure that people who may need or who have had a blood transfusion are given verbal and written information about blood transfusion.
Data source: Local data collection.
Process
a) Proportion of people who may need a blood transfusion who are given verbal and written information about blood transfusion.
Numerator – the number in the denominator who are given verbal and written information about blood transfusion.
Denominator – the number of people who may need a blood transfusion.
Data source: Local data collection.
b) Proportion of people who have had a blood transfusion who are given verbal and written information about blood transfusion.
Numerator – the number in the denominator who are given verbal and written information about blood transfusion.
Denominator – the number of people who have had a blood transfusion.
Data source: Local data collection.
Outcome
Patient satisfaction with information they are given about blood transfusion.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that systems are in place to give verbal and written information about blood transfusion to people who may need or who have had a blood transfusion.
Healthcare professionals (doctors, nurses and blood transfusion specialists) give verbal and written information about blood transfusion to people who may need or who have had a blood transfusion.
Commissioners (clinical commissioning groups) commission services that give verbal and written information about blood transfusion to people who may need or who have had a blood transfusion.
People who may need a blood transfusion, or who have had one unexpectedly (for example, because of serious bleeding during an operation), have information about blood transfusion explained to them verbally and in writing.

Source guidance

Blood transfusion (2015) NICE guideline NG24, recommendation 1.8.1

Definitions of terms used in this quality statement

People who may need a blood transfusion
People who have had a blood sample taken and sent to the blood transfusion laboratory for grouping and/or antibody screening.
[Expert consensus]
Verbal and written information
This should cover:
  • the reason for the transfusion
  • the risks and benefits
  • the transfusion process
  • any transfusion needs specific to them
  • any alternatives that are available, and how they might reduce their need for a transfusion
  • that they are no longer eligible to donate blood.
[NICE’s guideline on blood transfusion]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.
Blood transfusion
Collecting and re-using blood lost during radical surgery to remove the prostate gland or bladder
Intraoperative blood cell salvage in obstetrics
Spectra Optia for automatic red blood cell exchange in people with sickle cell disease

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Major haemorrhage can be defined as any of the following:
  • The loss of more than 1 blood volume within 24 hours (around 70 mL/kg, or more than 5 litres in a 70 kg adult).
  • A loss of 50% of total blood volume in under 3 hours.
  • Bleeding in excess of 150 mL/minute in adults.
  • As a practical clinical definition, bleeding which leads to:
    • a systolic blood pressure of less than 90 mm/Hg or
    • a heart rate of more than 110 beats per minute in adults.

World Health Organization Bleeding Grades

World Health Organization Bleeding Grade
Examples
1
  • Oropharyngeal bleeding, with the total duration of all episodes no more than 30 minutes in the last 24 hours.
  • Epistaxis, with the total duration of all episodes no more than 30 minutes in the last 24 hours.
  • Petechiae of oral mucosa or skin.
  • Purpura up to 2.5 cm (1 inch) in diameter.
  • Spontaneous haematoma in soft tissue or muscle.
  • Positive stool occult blood test.
  • Microscopic haematuria or haemoglobinuria.
  • Abnormal vaginal bleeding (spotting).
2
  • Epistaxis, with the total duration of all episodes over 30 minutes in 24 hours.
  • Purpura over 2.5 cm (1 inch) in diameter.
  • Joint bleeding.
  • Melanotic stool.
  • Haematemesis.
  • Gross/visible haematuria.
  • Abnormal vaginal bleeding (more than spotting).
  • Haemoptysis.
  • Visible blood in body cavity fluid.
  • Retinal bleeding without visual impairment.
  • Bleeding at invasive sites.
3
  • Bleeding needing red blood cell transfusion over routine transfusion needs.
  • Bleeding associated with moderate haemodynamic instability.
4
  • Bleeding associated with severe haemodynamic instability.
  • Fatal bleeding.
  • Central nervous system bleeding on imaging study with or without dysfunction.

Glossary

international normalised ratio
(transient ischaemic attack; defined as stroke symptoms and signs that resolve within 24 hours)
World Health Organisation

Paths in this pathway

Pathway created: November 2015 Last updated: September 2020

© NICE 2021. All rights reserved. Subject to Notice of rights.

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