Australian and New Zealand Society of Blood Transfusion

The Australian and New Zealand Society of Blood Transfusion comprises over 400 members from diverse scientific, medical and nursing backgrounds working within the area of blood transfusion and related fields.

The broad aims of the ANZSBT are the:

  • advancement of knowledge in blood transfusion and transfusion medicine
  • promotion of improved standards in the practice of blood transfusion
  • collaboration with international and other regional societies interested in blood
  • promotion of interest in research into blood transfusion and allied subjects
  • formulation of guidelines in key areas of transfusion practice.

Download the Australian and New Zealand Society of Blood Transfusion's Top-5 recommendations (PDF) and watch the recommendations video.

You can also download the Top-5 recommendations at a glance (PDF) and the Top-5 recommendations infographic (PDF)


Watch the launch

Dr Anastazia Keegan talks about what the ANZSBT does, shares how they developed their list with support from the Evolve team, and the use of their Top-5 recommendations.


Top-5 recommendations on low-value practices

These recommendations do not apply to emergency situations, severe acute bleeding and acute phase of major trauma resuscitation.

1. Do not use peri-operative transfusion for otherwise reversible anaemia prior to elective surgery.

Rationale and evidence

Rationale

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.

Evidence

Boshier, Ziff C, Adam ME, 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.

Cata, Juan MD, Owusu-Agyemang, 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.

Connor, O’Shea, McCool, 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.

Dent OF, Ripley JE, Chan C, 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.

Glance LG, Dick AW, Mukamel DB, et al, Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery, Anesthesiology. 2011 Feb;114(2): 283-92.

Iwata T, Kimura S, Feorster B, 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.

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.

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.


2. Do not transfuse red blood cells for iron deficiency where there is no haemodynamic instability.

Rationale and evidence

Rationale

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.

Evidence

Aapro M, Beguin Y, Bokemyer C, 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 A, Chen Z, Ford P, et al, Iron deficiency anemia in women across the life span, J Women’s Health (Larchmt). 2012 Dec; 21(12): 1282–9.

Lin DM, Lin ES & Tran MH, 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, Xiao J & HoKM, 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.

Lopez MANL, Cobos AMM & Gonzalez FS, 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 MM, Remoortel HV, Meybohm P, et al, Patient Blood Management: Recommendations from the 2018 Frankfurt Consensus Conference, JAMA. 2019; 321(10); 983-997.

Ng O, Keeler BD, Mishra A, et al, Iron therapy for preoperative anaemia, Cochrane Database of Systematic Reviews. 2019; volume (12).

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

Spahn DR, Schoenrath F, Spahn GH, 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 S, Zhang F, Du M, 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.


3. Do not transfuse more units of blood than necessary.

Rationale and evidence

Rationale

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.

Evidence

Hill S, Carless PA, Henry DA, 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.

Carson JL, Terrin ML, Noveck H, et al, Liberal or restrictive transfusion in high-risk patients after hip surgery, N Engl J Med. 2011 365(26): 2453–2462.

Gu WJ, Gu XP, Wu XD, 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.

Kheiri B, Abdalla A, Osman M, 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.

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

Mazer CD, Whitlock RP, Fergusson DA, et al 2018, Six-month outcomes after restrictive or liberal transfusion for cardiac surgery, N Engl J Med. 2018 379: 1224-33.

Szczepiorkowski ZM & Dunbar NM, Transfusion guidelines: when to transfuse, Hematology Am. Soc. Hematol. Educ. Program. 2013; 2013: 638-644.

Villanueva C, Colomo A, Bosch A, et al 2013, Transfusion strategies for acute upper gastrointestinal bleeding, N Engl J Med. 2013 368:11-21.

Zhang W, Zheng Y, Yu K, et al 2020, Liberal transfusion versus restrictive transfusion and outcomes in critically ill adults: a meta-analysis, Transfusion Medicine and Hemotherapy. 2020


4. Do not order a group and crossmatch when a group and antibody screen would be appropriate.

Rationale and evidence

Rationale

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.

Evidence

Frank S, Oleyar M, Ness P, 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.

Hall TC, Pattenden C, Hollobone C, et al, Blood Transfusion Policies in Elective General Surgery: How to Optimise Cross-Match-to-Transfusion Ratios, Transfus Med Hemother. 2013; 40:27–31.

Novis DA, Renner S, Friedberg R, et al, Quality indicators of blood utilization, Arch Pathol Lab Med. 2002 Feb; 126(2): 150-156.

Palmer T, Wahr JA, O’Reilly M, 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.

Patient Blood Management Guidelines: Module 2 Perioperative (Recommendations 1 to 3; Practice Points 1 to 3; Section 3.1 and 3.3), National Blood.


5. Do not transfuse standard doses of fresh frozen plasma to correct a mildly elevated (<1.8) international normalized ratio prior to a procedure.

Rationale and evidence

Rationale

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.

Evidence

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.

Carson, J.L., Ness, P.M., Pagano, M.B., et al. Plasma trial: Pilot randomized clinical trial to determine safety and efficacy of plasma transfusions. Transfusion. 2021; 61: 2025–2034.

Darwood, M.Y., Hashmi, Z.A. Dasika, et al. Is ultra-slow intravenous Vitamin K administration superior to Fresh Frozen Plasma for acute reversal of elevated INR? (PDF). Chest. 2005; 128(4_MeetingAbstracts): 300S.

Jia, Q., Brown, M.J., Clifford, L., et al. 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.

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.

Shaikh, H., Shaikh, S., Lee, D, et al, Fresh frozen plasma: under-dosed and over-transfused. Vox Saguinis. P-702. 2018; 113(7): 296.

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.

Raval, J.S., Waters, J.H., Triulzi, D.J. et al, Complications following an unnecessary peri-operative plasma transfusion and literature review. Asian Journal of Transfusion Science. 2014; 8(2): 139-141.

Warner, M.A., Woodrum, D.A., Hanson, A.C., et al, Prophylactic plasma transfusion before interventional radiology procedures is not associated with reduced bleeding complications. Mayo Clinic Proceedings. 2016; 91(8): 1045-55.

Yang L, Stanworth S, Hopewell S, et al, Is fresh frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion. 2012 Aug; 52: 1673 – 86.




How this list was developed

As part of the Evolve program, the RACP Policy and Advocacy team has worked with the Australian and New Zealand Society of Blood Transfusion (ANZSBT) to develop and finalise this top-5 list that pertains to the specialty.

Per usual processes, the list of low value practices was first identified by the ANZSBT Council and condensed to the top-5 recommendations, through a membership survey, extensive research and rounds of redrafting under the guidance of the ANZSBT Council. The list was subjected to an extensive review and consultation process that involved RACP-affiliated specialty societies and other key colleges via the Choosing Wisely program. Feedback from the consultation has been integrated into the top-5 recommendations by the ANZSBT and approved by its Council in December 2021.

Version 1 published January 2022.

 

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