Summary of recommendations and practice points

The CRG developed recommendations where sufficient evidence was available from the systematic review of the literature. The recommendations have been carefully worded to reflect the strength of the body of evidence. Each recommendation has been given a grade, using the following definitions, set by the NHMRC:

Summary of recommendations and practice points
GRADE A	Body of evidence can be trusted to guide practice
GRADE B	Body of evidence can be trusted to guide practice in most situations
GRADE C	Body of evidence provides some support for recommendation(s), but care should be taken in its application
GRADE D	Body of evidence is weak and recommendations must be applied with caution.

The CRG developed practice points where the systematic review found insufficient high-quality data to produce evidence-based recommendations, but the CRG felt that clinicians require guidance to ensure good clinical practice. These points are based on consensus among the members of the committee.

Appendix F gives the recommendations and practice points by clinical condition.

Recommendations

Summary of recommendations

Identifier and Grade	Guidance
R1 Grade C	In ACS patients with a Hb concentration >100 g/L, RBC transfusion is not advisable because of an association with increased mortality.	3.2.2
R2 Grade A	In cancer patients with anaemia, the routine use of ESAs is not recommended because of the increased risks of mortality and thromboembolic events.	3.3.1
R3 Grade B	In patients with CHF, identification and treatment of iron deficiency (absolute and functional) is recommended to improve functional or performance status. This is consistent with the 2011 update to the Guidelines for the Prevention, Detection and Management of Chronic Heart Failure in Australia, 2006.² Note: The studies reviewed only included patients treated with IV iron, and of NYHA functional classes II or III.	3.3.2
R4 Grade B	In anaemic patients with CKD, ESA therapy to a low to intermediate Hb target may be used to avoid RBC transfusion, after consideration of risks and benefits for the individual patient (Grade B). Note: The CARI guidelines recommend a Hb target between 100-115 g/L⁵	3.3.3
R5 Grade C	In anaemic patients with CKD, ESA therapy to a low to intermediate Hb target may be used to relieve fatigue, after consideration of risks and benefits for the individual patient (Grade C). Note: The CARI guidelines recommend a Hb target between 100-115 g/L⁵	3.3.3
R6 Grade B	In anaemic patients with CKD, ESA therapy to a Hb target of over 130 g/L is not recommended because of increased morbidity.	3.3.3
R7 Grade B	In anaemic patients with non dialysis-dependent CKD, type 2 diabetes and a history of malignancy, the routine use of ESAs is not recommended because of the increased risk of cancer- related mortality.	3.3.3
R8 Grade B	In patients undergoing chemotherapy and haematopoietic stem cell transplantation, the recommended strategy for prophylactic use of platelets is transfusion at a platelet count of <10 × 10⁹/L in the absence of risk factors, and at <20 × 10⁹/L in the presence of risk factors (e.g. fever, minor bleeding).	3.5.3

ACS, acute coronary syndrome; CHF, chronic heart failure; CKD, chronic kidney disease; ESA, erythropoiesis-stimulating agent; Hb, haemoglobin; IV, intravenous; NYHA, New York Heart Association; R, recommendation; RBC, red blood cell; TTP, thrombotic thrombocytopenic purpura

Practice points

Summary of practice points

Identifier	Guidance
PP1	RBC transfusion should not be dictated by a Hb concentration alone, but should also be based on assessment of the patient’s clinical status.	3.2.1
PP2	Where indicated, transfusion of a single unit of RBC, followed by clinical reassessment to determine the need for further transfusion, is appropriate. This reassessment will also guide the decision on whether to retest the Hb level.	3.2.1
PP3	Direct evidence is not available in general medical patients.^a Evidence from other patient groups and CRG consensus suggests that, with a: Hb concentration <70g/L,RBC transfusion may be associated with reduced mortality and is likely to be appropriate. However, transfusion may not be required in well- compensated patients or where other specific therapy is available. Hb concentration of 70–100g/L,RBC transfusion is not associated with reduced mortality. The decision to transfuse patients (with a single unit followed by reassessment) should be based on the need to relieve clinical signs and symptoms of anaemia, and the patient’s response to previous transfusions. No evidence was found to warrant a different approach for patients who are elderly or who have respiratory or cerebrovascular disease. Hb concentration > 100g/L,RBC transfusion is likely to be unnecessary and is usually inappropriate. Transfusion has been associated with increased mortality in patients with ACS. ^a Recommendations and practice points for medical patients in a critical care setting will be found in the Patient Blood Management Guidelines: Module 4 – Critical Care.³ Recommendations and practice points for specific medical subgroups (ACS, CHF, cancer, acute upper gastrointestinal bleeding and chronically transfused) appear elsewhere in this module.	3.2.1
PP4	In patients with iron deficiency anaemia, iron therapy is required to replenish iron stores regardless of whether a transfusion is indicated.	3.2.1
PP5	In patients with ACS and a Hb concentration <80 g/L, RBC transfusion may be associated with reduced mortality and is likely to be appropriate. (See PP1 and PP2).	3.2.2
PP6	In patients with ACS and a Hb concentration of 80 – 100 g/L, the effect of RBC transfusion on mortality is uncertain and may be associated with an increased risk of recurrence of MI. Any decision to transfuse should be made with caution and based on careful consideration of the risks and benefits. (See PP1 and PP2).	3.2.2
PP7	In all patients with heart failure, there is an increased risk of transfusion-associated circulatory overload. This needs to be considered in all transfusion decisions. Where indicated, transfusion should be of a single unit of RBC followed by reassessment of clinical efficacy and fluid status. For further guidance on how to manage patients with heart failure, refer to general medical or ACS sections, as appropriate (R1, R3, PP3–PP6).	3.2.3
PP8	In patients with cancer, the aetiology of anaemia is often multifactorial; where appropriate, reversible causes should be identified and treated.	3.2.4 3.3.1
PP9	There is a lack of specific evidence relating to the effects of RBC transfusion in patients with cancer. Any decision to transfuse should be based on the need to relieve clinical signs and symptoms of anaemia. When treating patients with cancer, refer also to the general medical population PP1–PP4.	3.2.4
PP10	In well-compensated patients with acute upper gastrointestinal blood loss that is non-critical, there is no evidence to favour a liberal transfusion policy. Therefore, a more restrictive approach may be appropriate. There are no data to support a specific Hb treatment target in these patients.	3.2.5
PP11	For critically bleeding patients, refer to Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion (2011).⁴	3.2.5
PP12	In anaemic patients with cancer receiving ESAs, evaluate iron status to guide adjuvant iron therapy.	3.3.1
PP13	ESA use is less effective in patients with chronic renal failure who have absolute or functional iron deficiency.	3.3.3
PP14	For comprehensive information about ESA and iron therapy in patients with CKD, refer to CARI iron guidelines.⁵	3.3.3
PP15	In patients with IBD, determine the cause of anaemia and treat reversible causes. IV iron may be required in patients who are intolerant of oral iron, or to avoid aggravation of intestinal inflammation.	3.3.5
PP16	The routine use of FFP in medical patients with coagulopathy (including those with liver impairment) is not supported. Tests for coagulation correlate poorly with bleeding risk in liver impairment. The underlying causes of coagulopathy should be assessed. Where FFP transfusion is considered necessary, the risks and benefits should be considered for each patient, and expert guidance sought.	3.4.1
PP17	For guidance on the use of FFP in specific patient groups, refer to: Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion (2011)⁴ Patient Blood Management Guidelines: Module 2 – Perioperative (2012)⁶ Warfarin Reversal: Consensus Guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis (2004) ⁷ AHCDO guidelines for patients with specific factor deficiencies (www.ahcdo.org.au) TTP: Guidelines for the Use of Fresh-Frozen Plasma, Cryoprecipitate and Cryosupernatant (2004).⁸	3.4.1
PP18	The routine use of cryoprecipitate or fibrinogen concentrate in medical patients with coagulopathy is not advised. The underlying causes of coagulopathy should be identified; where transfusion is considered necessary, the risks and benefits should be considered for each patient. Specialist opinion is advised for the management of DIC.	3.4.2
PP19	For guidance on the use of cryoprecipitate or fibrinogen concentrate in specific patient groups, refer to: Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion (2011)⁴ AHCDO guidelines for patients with specific factor deficiencies (www.ahcdo.org.au) TTP: Guidelines for the Use of Fresh-Frozen Plasma, Cryoprecipitate and Cryosupernatant (2004).⁸	3.4.2
PP20	Platelet transfusion may be indicated for the prevention and treatment of haemorrhage in patients with thrombocytopenia or platelet function defects. Platelet transfusions are not indicated in all causes of thrombocytopenia, and may be contraindicated in certain conditions (e.g. TTP and HIT). Thus, the cause of the thrombocytopenia should be established and expert opinion sought.	3.4.3
PP21	In patients with chronic failure of platelet production (e.g. myelodysplasia or aplastic anaemia), a specific threshold for transfusion may not be appropriate. These patients are best managed on an individual basis, in consultation with a relevant expert.⁹ Long-term prophylactic platelet transfusions may be best avoided because of the risk of complications (e.g. alloimmunisation and platelet refractoriness). Therapeutic platelet transfusions could be considered for treatment of bleeding.	3.4.3
PP22	In patients undergoing chemotherapy and haematopoietic stem cell transplantation, there is no evidence to support: a lower trigger for prophylactic platelet transfusion for patients with risk factors (e.g. fever, minor bleeding) a strategy of therapeutic-only platelet transfusions (i.e. for treatment of clinically significant bleeding). Further research to determine the safety and efficacy of a lower platelet transfusion trigger is underway.	3.5.3
PP23	In patients with thalassaemia, the evidence does not support any change to the current practice of maintaining a pretransfusion Hb concentration of 90 – 100 g/L, with transfusions at about monthly intervals.	3.6.1
PP24	In patients with myelodysplasia who are regularly and chronically transfused, there is no evidence to guide particular Hb thresholds. Decisions around appropriate triggers and frequency of transfusion need to be individualised, taking into account anaemia-related symptoms, functional or performance status, and the patient’s response to previous transfusions.	3.6.2

ACS, acute coronary syndrome; AHCDO, Australian Haemophilia Centre Directors’ Organisation; CARI, Caring for Australasians with Renal Impairment; CHF, chronic heart failure; CKD, chronic kidney disease; CRG, Clinical/Consumer Reference Group; DIC, disseminated intravascular coagulation; ESA, erythropoiesis-stimulating agent; FFP, fresh frozen plasma; Hb, haemoglobin; HIT, heparin-induced thrombocytopaenia; IBD, inflammatory bowel disease; IV, intravenous; MI, myocardial infarction; PP, practice point; R, recommendation; RBC, red blood cell; TTP, thrombotic thrombocytopenic purpura