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National Clinical Guideline Centre (UK). Blood Transfusion. London: National Institute for Health and Care Excellence (NICE); 2015 Nov. (NICE Guideline, No. 24.)
See introduction in Red blood cell thresholds and targets chapter.
11.1. Review question: What is the clinical- and cost-effectiveness of different doses of red blood cell transfusion?
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| Intervention |
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| Comparison |
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| Outcomes |
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| Study designs |
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For full details see review protocol in C.3, Appendix C.
11.2. Clinical evidence
We searched for randomised controlled trials comparing the effectiveness of different doses of red blood cell transfusion.
- No relevant clinical studies were identified for this review.
- One study did not meet the review protocol criteria entirely, but provided supportive evidence for decision making.284 It evaluated the effectiveness of two transfusion policies in adult patients (>18 years of age) who were scheduled to undergo a total hip replacement or total knee replacement surgery. Patients were classified to receive different dosage of RBC transfusion (1 unit, 1-2 units, 3 units) based on transfusion policies followed in hospitals. The transfusion policies were classified into restrictive and liberal and were developed taking into account patient's age and specific co-morbidities. Results are presented comparing different transfusion policies.
11.3. Economic evidence
Published literature
No relevant economic evaluations were identified.
See also the economic article selection flow chart in Appendix F.
Unit costs
Relevant unit costs are provided in Appendix N to aid consideration of cost-effectiveness.
11.4. Evidence statements
Clinical
No relevant clinical studies were identified.
Economic
No relevant economic evaluations were identified.
11.5. Recommendations and link to evidence
| Recommendations |
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|---|---|
| Relative values of different outcomes | The GDG considered all-cause mortality at 30 days, infections (including pneumonia, surgical site infection, UTI and septicaemia/bacteraemia), quality of life, acute and delayed serious adverse events and new cardiac events as the critical outcomes for decision making. Other important outcomes included the number of patients transfused, the number of units transfused and length of stay in hospital. |
| Trade off between clinical benefits and harms | No evidence was identified for this review. The GDG discussed the potential benefits of transfusing single units of RBC rather than multiple units in the first instance. These benefits included a potential reduction in the numbers of units transfused and therefore a potential reduction in transfusion-related adverse events including decreasing the risk of transfusion-associated circulatory overload and would help to make best use of the limited supply of donor blood. The GDG recognised that in some situations such as when the haemoglobin concentration was very low (for example <55 g/L) it may be appropriate to administer multiple red blood cell units. There was no specific evidence available for RBC doses in the paediatric population. The GDG felt it reasonable that the equivalent recommendations should apply for children as for adults. |
| Economic considerations | No relevant economic evaluations comparing different doses of RBC for transfusion were identified. The cost of RBC transfusion was considered by the GDG. Allogeneic RBC cost £122.09 per unit in England and North Wales.219 It was noted that this does not include hospital costs associated with a transfusion such as staff time, disposables, storage, wastage and laboratory tests. As part of the health economic model developed in this guideline, the additional cost associated with transfusion was estimated to be £70 per first unit transfused. Of note this estimate does not include costs associated with hospital stay or with the management of transfusion-related complications. Furthermore, these costs do not include consideration of the additional laboratory and clinical workload of taking or testing additional samples. The same cost per unit applies for children as it does for adults. If less than one unit is required for transfusion, the full cost of the unit is still incurred as the remaining blood cannot be used for another patient. The GDG noted that the potential clinical benefits of transfusing single units of RBC rather than multiple units in the first instance (such as a reduction in the number of units transfused and the potential resultant reduction in transfusion-related adverse events) would be likely to also reduce costs. |
| Quality of evidence | No studies were identified which met the review protocol criteria. The recommendation was based on the consensus expert opinion of the guideline development group members. |
| Other considerations | The GDG considered that the recommendation would not be applicable to patients with major haemorrhage where patients have active bleeding and blood loss can be life-threatening.(follow the recommendations in NICE's guideline on Major trauma, currently in development). For children, the GDG noted that there are formulae in common use to guide the appropriate transfusion volume per kilogram weight for a given rise in Hb. |
| Recommendations |
|
|---|---|
| Relative values of different outcomes | The GDG considered all-cause mortality at 30 days, infections (including pneumonia, surgical site infection, UTI and septicaemia/bacteraemia), quality of life, acute and delayed serious adverse events and new cardiac events as the critical outcomes for decision making. Other important outcomes included the number of patients transfused, the number of units transfused and length of stay in hospital. |
| Trade off between clinical benefits and harms | No evidence was identified for this review. The GDG discussed the potential benefits of monitoring after each transfusion after transfusing single units of RBC. In order to ensure that patients receive the correct dose of RBC, the GDG stressed the importance of reassessing the patient after administering each unit and then transfusing additional single units as required. Patients should therefore not receive too little or too much RBC and there is potential to save blood and therefore reduce the risk of transfusion related adverse events. There is minimal discomfort or inconvenience for the patient in monitoring after transfusion. The GDG felt it reasonable that equivalent recommendations should apply for children as for adults in clinical situations where repeated blood tests are feasible. The patient should be reassessed after each transfusion of red cells (volume calculated by body weight). The GDG recognised that in some situations such as when the haemoglobin concentration was very low (for example <55 g/L) it may be appropriate to administer multiple red blood cell units. This might also be indicated if the patient was at risk of bleeding or undergoing a surgical procedure with significant risk of bleeding |
| Economic considerations | The GDG highlighted that the cost of clinically reassessing and checking haemoglobin levels was negligible and would be offset by savings as a result of transfusing fewer units of RBC. |
| Quality of evidence | No studies were identified which met the review protocol criteria. The recommendation was based on the consensus expert opinion of the guideline development group members. |
| Other considerations | The GDG considered that the recommendation would not be applicable to patients with major haemorrhage where patients have active bleeding and blood loss can be life-threatening.( (follow the recommendations in NICE's guideline on Major trauma, currently in development). |
- Red blood cell: doses - Blood TransfusionRed blood cell: doses - Blood Transfusion
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