Minimising the need for allogeneic transfusion

Clinicians should always aim to avoid or minimise the use of allogeneic blood components, both in the patient’s interests and to avoid wastage of a limited and valuable resource.

Approaches to minimise allogeneic blood transfusion

1. Prevent or minimise the need for allogeneic transfusion

  • Identify high risk patients, and develop a specific management plan ahead of time

  • Use appropriate surgical techniques

  • Anaesthetic techniques including:

    • Spinal and epidural anaesthesia

    • Hypotensive anaesthesia

    • Reduction of venous pressure at the surgical site

    • Haemodilution or normovolaemic anaemia

    • Normothermia whenever possible

  • Consider pharmacological manipulation of haemostasis (eg, DDAVP antifibrinolytic agents)

2. Transfuse in accordance with patient blood management guidelines

3. Use of alternatives to allogeneic transfusion:

Surgical patients

Any patient for whom elective surgery is planned must be asked for history of abnormal bleeding.

Other underlying medical conditions or intake of medication that may be associated with impaired haemostatic function or abnormal laboratory tests of haemostasis may require postponement of elective surgery until the abnormality has been confirmed or identified.

Establish appropriate procedures prior to surgery to minimise abnormal bleeding or thromboembolism.

A congenital abnormality of haemostasis (ie, haemophilia) should be managed in consultation with a specialist haemophilia centre.

Other haematological disorders that may predispose a patient to bleeding or thromboembolism should be managed in consultation with a Haematologist or Transfusion Medicine Specialist.

Acutely haemorrhaging patients

In acutely haemorrhaging patients, pre-emptive and early intervention may prevent or minimise later problems.

This may involve prophylactic or therapeutic use of one or more blood components, depending on a range of factors.

It is important to differentiate between 'controlled' bleeding, usually during surgery, and the more complex clinical problem of established massive bleeding.

Massive bleeding may have numerous interacting variables impacting on management, such as trauma, shock and systemic failure of the haemostatic system.

The clinician is confronted with the following decisions in the potentially or actually bleeding surgical patient:

  • Is this patient a potential 'bleeder'?

    • What is the haemostatic defect?

    • What therapy is available to prevent or minimise bleeding?

  • If the patient is without a pre-existing haemostatic defect, to what point can the patient be haemodiluted before requiring transfusion of specific blood components?

  • Are there blood conservation techniques appropriate for this patient (what, when and how)?

  • At what point are allogeneic red cells indicated?

  • At what point does attention to systemic haemostasis become a consideration (ie, need for FFP and platelet support)?