Peri-operative transfusions as a means of addressing untreated preoperative anaemia is associated with decreased overall survival rates but not with recurrence free survival. There is some new evidence that these negative associations are due to the clinical circumstances requiring transfusions rather than the transfusions themselves, but this still suggests that it is preferable to identify and manage anaemia prior to surgery.

Boshier et al, ‘Effect of perioperative blood transfusion on the long-term survival of patients undergoing esophagectomy for esophageal cancer: a systematic review and meta-analysis. Diseases of the esophagus. 2017; 31: 1-10. Doi: 10.1093/dote/dox134.

Cata et al, ‘Impact of anaesthestics, analgesics, and perioperative blood transfusion in paediatric cancer patients: A comprehensive review of the literature’, Anaesthesia and Analgesia. 2019 December; 129(6): 1653-1665. Doi: 10.1213/ANE.0000000000004314.

Connor et al, ‘Peri-operative allogeneic blood transfusion is associated with poor overall survival in advanced epithelial ovarian cancer; potential impact of patient blood management on cancer outcomes’, Gynecologic Oncology. 2018 June; 151: 294-298. Doi: https://doi.org/10.1016/j.ygyno.2018.08.040.

Dent et al, ‘Competing risks analysis of the association between perioperative blood transfusion and long-term outcomes after resection of colon cancer’, Colorectal Disease. 2020 August; 22(8): 871-884. Doi: https://doi.org/10.1111/codi.14970 Accessed 13/11/2020

Glance et al, ‘Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery’, Anesthesiology. 2011 Feb;114(2):283-92. doi: 10.1097/ALN.0b013e3182054d06.

Iwata et al, ‘Perioperative blood transfusion affects oncologic outcomes after nephrectomy for renal cell carcinoma: A systematic review and meta-analysis, Urologic Oncology. 2019 January; 37: 273-281. Doi: https://doi.org/10.1016/j.urolonc.2019.01.018.

Nakanishi et al, ‘Long-lasting discussion: Adverse effects of intraoperative blood loss and allogeneic transfusion on prognosis of patients with gastric cancer, World Journal of Gastroenterology. 2019 June 14; 25(22): 2743-2751. Doi: 10.3748/wjg.v25.i22.2743.

Tai et al, ‘The association of allogeneic blood transfusion and the recurrence of hepatic cancer after surgical resection’, Association of Anaesthetists. 2019 April; 75(4): 464-471. Doi: https://doi.org/10.1111/anae.14862.

Blood transfusion 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 hemodynamic instability (even with low haemoglobin levels) should be given oral and/or intravenous iron. Possible exceptions are where reliable ingestion of iron may not occur or gastrointestinal issues exist.  

Aapro et al, ‘Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines’, Annals of Oncology. 2018; 29(Supplement 4); iv96-iv110.

Friedman et al, ‘Iron deficiency anemia in women across the life span’, J Women’s Health (Larchmt). 2012 Dec; 21(12):1282–9.

Lin et al, ‘Efficacy and safety of erythropoietin and intravenous iron in perioperative blood management: a systematic review’, Transfus Med Rev. 2013 Oct;27(4):221–34.

Litton et al, ‘Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials’, BMJ. 2013 Aug 15;347:f4822. doi: 10.1136/bmj.f4822.

Lopez et al, ‘Red blood cell transfusion after a global strategy for early detection and treatment of iron deficiency anaemia: three-year results of a prospective observational study’, Transfusion 2018; 58; 1399-1407.

Mueller, et al ‘Patient Blood Management: Recommendations from the 2018 Frankfurt Consensus Conference’, JAMA. 2019; 321(10); 983-997.

Ng et al ‘Iron therapy for preoperative anaemia’, Cochrane Database of Systematic Reviews. 2019; volume (12)

Richards et al ‘Preoperative intravenous iron to treat anaemia before major abdominal surgery (RPEVENTT): a randomised, double-blind, controlled trial’. 2020. 396; 1353-1361

Spahn et al ‘Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial’, The Lancet. 2019; 393 (10187); 2201-2212.

Zhang et al ‘Efficacy and safety of iron supplementation in patients with heart failure and iron deficiency: a meta-analysis’, British Journal of Nutrition. 2019. 212; 841-848.

Every unit of blood transfused presents benefits and risks to the patients. Risks associated with transfusion include:

• febrile reactions
• allergic reactions and anaphylaxis
• haemolytic reactions
• transfusion- transmitted infections
• transfusion-associated acute lung injury, transfusion-associated circulatory overload
• alloimmunisation.

Each unit transfused must have a clear indication and unnecessary transfusions must be avoided.

A restrictive transfusion strategy (Haemoglobin (Hb) of 70-80g/L) should be used 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.

A single unit of red cell transfusions is the standard of care for non-bleeding, hospitalised patients. Additional units should only be prescribed after clinical re-assessment of the patient and their haemoglobin value.

Carson et al 2016, ‘Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion’, Cochrane Database of Systematic Reviews Oct 16; 2016, Issue 10. DOI: 10.1002/14651858.CD002042.pub4.

Carson et al, ‘Liberal or restrictive transfusion in high-risk patients after hip surgery’, N Engl J Med 2011 365(26):2453–2462. DOI: 10.1056/NEJMoa1012452. Accessed 25/11/2020.

Gu et al 2018, ‘Restrictive versus liberal strategy for red blood-cell transfusion a systematic review and meta-analysis in orthopaedic patients’, J Bone and Joint Surgery 100-A(8):686-695. doi: 10.2106/JBJS.17.00375.

Kheiri et al 2019, ‘Restrictive versus liberal red blood cell transfusion for cardiac surgery: a systematic review and meta-analysis of randomised controlled trials. Journal of Thrombosis and Thrombolysis 47(2):179-185. doi.org/10.1007/s11239-018-1784-1. Accessed 25/11/2020.

LaCroix et al,’ Transfusion strategies for patients in pediatric intensive care units’, N Engl J Med. 2007 Apr 19;356(16):1609-19.

Mazer et al 2018, ‘Six-month outcomes after restrictive or liberal transfusion for cardiac surgery’, N Engl J Med 2018 379:1224-33. DOI: 10.1056/NEJMoa1808561.

Szczepiorkowski et al, ‘Transfusion guidelines: when to transfuse’, Hematology Am. Soc. Hematol. Educ. Program. 2013; 2013:638-644. doi.org/10.1182/asheducation-2013.1.638.

Villanueva et al 2013, ‘Transfusion strategies for acute upper gastrointestinal bleeding’, N Engl J Med 2013 368:11-21. DOI: 10.1056/NEJMoa1211801.

Zhang et al 2020, ‘Liberal transfusion versus restrictive transfusion and outcomes in critically ill adults: a meta-analysis’, Transfusion Medicine and Hemotherapy 2020 https://doi.org/10.1159/000506751.

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. 

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. 

For patients with antibodies laboratories should have a policy related to cross matching blood for those patients who have difficult to match antibodies.

Frank et al, ‘Reducing unnecessary preoperative blood orders and costs by implementing an updated institution specific maximum surgical blood order schedule and a remote electronic blood release system’. Anesthesiology 2014; 121: 501-9  https://pubmed.ncbi.nlm.nih.gov/24932853/

Hall et al, ‘Blood Transfusion Policies in Elective General Surgery: How to Optimise Cross-Match-to-Transfusion Ratios’, Transfus Med Hemother 2013;40:27–31. https://pubmed.ncbi.nlm.nih.gov/23637646/

Novis et al, ‘Quality Indicators of Blood Utilization’, Arch Pathol Lab Med 2002 Feb; 126(2): 150-156. https://pubmed.ncbi.nlm.nih.gov/11825109/

Palmer et al, ‘Reducing unnecessary cross-matching: a patient-specific blood ordering system is more accurate in predicting who will receive a blood transfusion than the maximum blood ordering system’, Anesth Analg. 2003 Feb;96(2):369-75. https://pubmed.ncbi.nlm.nih.gov/12538179/

Patient Blood Management Guidelines: Module 2 Perioperative (Recommendations 1 to 3; Practice Points 1 to 3; Section 3.1 and 3.3), National Blood Authority Australia, 2012. https://www.blood.gov.au/pbm-module-2

There is no evidence to support the prophylactic administration of fresh frozen plasma (FFP) to correct a mildly elevated international normalized ratio (INR) prior to procedure. 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.

Abdel-Wahab et al, ‘Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities’, Transfusion. 2006 Aug;46(8):1279-1285. https://pubmed.ncbi.nlm.nih.gov/16934060/

Carson, J.L., Ness, P.M., Pagano, M.B., Philipp, C.S., Bracey, A.W., Brooks, M.M., Nosher J.L., Hogshire, L., Noveck, H. Triulzi, D.J. ‘Plasma trial: Pilot randomized clinical trial to determine safety and efficacy of plasma transfusions’. Transfusion. 2021;61:2025–2034. https://onlinelibrary.wiley.com/doi/full/10.1111/trf.16508.

Darwood, M.Y., Hashmi, Z.A. and Dasika, U.K. ‘Is ultra-slow intravenous Vitamin K administration superior to Fresh Frozen Plasma for acute reversal of elevated INR?. Chest. 2005; 128(4_MeetingAbstracts):300S. DOI: 10.1378/chest.128.4_MeetingAbstracts.300S.

Jia, Q., Brown, M.J., Clifford, L., Wilson, G.A., Truty, M.J., Stubbs, J.R., Schroeder, D.R., Hanson, A.C., Gajic, O. and Kor, D.J. ‘Prophylactic plasma transfusion for surgical patients with abnormal preoperative coagulation tests: a single-institution propensity-adjusted cohort study. Lancet Haematology. 2016; 3(3):e139-48. DOI: 10.1016/S2352-3026(15)00283-5.

Patient Blood Management Guidelines: Module 2 Perioperative (Recommendation 21; Practice Points 17 and 18; Section 3.7 and 3.8.1), National Blood Authority Australia, 2012. https://www.blood.gov.au/pbm-module-2

Shaikh, H., Shaikh, S., Lee, D. and Mewawalla, P. ‘Fresh frozen plasma: under-dosed and over-transfused’. Vox Saguinis. 2018; 113(7): 296. DOI: https://doi-org.smhslibresources.health.wa.gov.au/10.1111/vox.12658.

Soundar, E.P., Besandre, R., Hartman, S.K., Teruya, J. and Hui, S.R. ‘Plasma is ineffective in correcting mildly-elevated PT-INR in critically ill children: a retrospective observational study’. Journal of Intensive care. 2014; 2(1):64. DOI: 10.1186/s40560-014-0064-1.

Raval, J.S., Waters, J.H., Triulzi, D.J. and Yazer, M.H. ‘Complications following an unnecessary peri-operative plasma transfusion and literature review’. Asian Journal of Transfusion Science. 2014; 8(2): 139-141. DOI: 10.4103/0973-6247.137458.

Warner, M.A., Woodrum, D.A., Hanson, A.C., Schroeder, D.R., Wilson G.A. et al. ‘Prophylactic plasma transfusion before interventional radiology procedures is not associated with reduced bleeding complications’. Mayo Clinic Proceedings. 2016; 91(8): 1045-55. DOI: https://pubmed.ncbi.nlm.nih.gov/27492911/.

Yang et al, ‘Is fresh frozen plasma clinically effective? An update of a systematic review of randomized controlled trials’. Transfusion. 2012 Aug;52: 1673 – 86 https://pubmed.ncbi.nlm.nih.gov/22257164/.