Patient Blood Management Guidelines: Module 1

Critical Bleeding Massive Transfusion

| Appendix |

Appendix B - Transfusion risks in the context of patient blood management

Traditionally, it has been assumed that blood transfusion benefits patients; however, a benefit has not been demonstrable in many clinical scenarios. In addition, evidence is accumulating that transfusion-related acute lung injury is more common than previously thought, and that more recently identified conditions – including transfusion-related immunomodulation – may cause patients harm.

The risk of transmission of infectious diseases has reduced significantly in recent years through improved manufacturing and laboratory processes. Nevertheless, there is still a small potential for transfusion of an unrecognised infectious agent.

Despite improvements in systems management, there remains a risk of transfusion-related harm due to administrative error. Such an error has the potential to result in acute haemolytic reaction from ABO incompatibility, which may be fatal.

Of the recognised adverse events associated with transfusion, the most common is transfusion-associated circulatory overload, which is reported in up to 1% of patients receiving transfusions.

The clinical decision to undertake transfusion therapy should only be made after full consideration of the risks and benefits. Table B.1 summarises the risks and benefits; Table B.2 puts the risks into perspective; and Table B.3 presents the Calman chart, which may be useful to clinicians for explaining risks to patients.99

Table B.1 Transfusion risks and benefits

Therapy Risks Benefits
Blood transfusion, including RBCs, platelets, FFP and cryoprecipitate
Administrative error leading to transfusion of incorrect blood component, with potential for severe transfusion reaction (haemolytic) due to blood group (ABO) incompatibility

Transfusion transmitted infections (extremely rare)

Transfusion-related acute lung injury

Other transfusion reactions (mild febrile to severe anaphylaxis

Bacterial infection from contaminated blood or platelets

Transfusion-associated circulatory overload (usually iatrogenic)

Transfusion-related immunomodulation

RBC to prevent critical lack of oxygen to the body tissues

Platelets to treat or prevent bleeding

FFP to treat or prevent bleeding

Cryoprecipitate to treat or prevent bleeding

FFP, fresh frozen plasma; RBC, red blood cell

Table B.2 Transfusion risks in perspective

Transfusion risk Estimated rate a
(highest to lowest risk)
Calman rating b
Transfusion-associated circulatory overload (iatrogenic) Up to 1 in 100 transfusions High
Haemolytic reactions Delayed: 1 in 4,000–9,000
Acute: 1 in 12,000–77,000
Very low
Anaphylaxis (IgA deficiency) 1 in 20,000–50,000 Very low
Bacterial sepsis: platelets 1 in 75,000 Very low
Bacterial sepsis: RBCs 1 in 500,000 Minimal
Transfusion-related acute lung injury 1 in 5,000–190,000 Low to minimal
Hepatitis B 1 in 739,000 Minimal
HIV 1 in 5.4 million Negligible
Hepatitis C 1 in 2.7 million Negligible
Malaria 1 in 4.9 million – 10.2 million Negligible
Variant CJD (not tested) Never reported in Australia Negligible
Transfusion-associated graft-versus-host disease Rare Negligible
Transfusion-related immunomodulation Not quantified Unknown
CJD, Creutzfeldt-Jakob disease; IgA, immunoglobulin A; RBC, red blood cell
a Risk per unit transfused unless otherwise specified
b See Calman 1996 99

Source: Australian Red Cross Blood Service website (, accessed 9 December, 2009
Note: The above estimates may change over time. Refer to the Australian Red Cross Blood Service website
( for the most recent risk estimates.

Table B.3 Calman Chart a (UK risk per one year)

Rating Rate Example
Negligible < 1 in 1,000,000 Death from lightning strike
Minimal 1 in 100,000–1,000,000 Death from train accident
Very low 1 in 10,000–100,000 Death from an accident at work
Low 1 in 1,000–10,000 Death from a road accident
High > 1 in 1,000 Transmission of chicken pox to
susceptible household contacts

a See Calman 1996 99

Patient blood management involves a precautionary approach to the administration of blood components, particularly red cells. Discussion of alternative strategies is relevant for all patients, not just those who choose not to accept a transfusion.

Patient blood management aims to improve clinical outcomes by avoiding unnecessary exposure to blood components. It includes the three pillars of:

  • optimisation of blood volume and red cell mass
  • minimisation of blood loss
  • optimisation of the patient’s tolerance of anaemia.

In the process of obtaining consent, a clinician should allow the patient sufficient time to ask questions, and should answer those questions. If the patient is unable to speak or understand English, the clinician may need to involve an interpreter. In certain contexts, a trained medical interpreter may be required (rather than a family member or a friend). Written information and diagrams may be appropriate in certain circumstances to aid understanding.