Offer tranexamic acid to adults undergoing surgery who are expected to have at least moderate blood loss (greater than 500 ml). Position Paper Transfusion. Offer platelet transfusions to patients with thrombocytopenia who have clinically significant bleeding (World Health Organization [WHO] grade 2) and a platelet count below 30×109 per litre. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 720 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 24). If the Guideline Development Group (GDG) believed RCT data were not appropriate or there was limited evidence from RCTs, well-conducted non-randomised studies were included. Additional subject specific databases were used for some questions: Cumulative Index to Nursing and Allied Health Literature (CINAHL) for monitoring and patient information; Health Management Information Consortium (HMIC) for decision support and patient identification; PsycINFO for patient information. Key information was extracted on the study's methods, PICO (patient, intervention, comparison and outcome) factors and results. To facilitate this, binary outcomes were converted into absolute risk differences (ARDs) using GRADEpro software: the median control group risk across studies was used to calculate the ARD and its 95% CI from the pooled risk ratio. Patients Who Are Not Bleeding or Having Invasive Procedures or Surgery. The means and standard deviations of continuous outcomes were required for meta-analysis. The number of studies and the number of participants for a particular outcome, An indication of the direction of effect (if one treatment is beneficial or harmful compared to the other, or whether there is no difference between the 2 tested treatments), A description of the overall quality of evidence (GRADE overall quality). To further the dissemination of transfusion and blood safety information, an app of the second edition of the Compendium was . The main criteria considered in the rating of these elements are discussed below. Economic evaluations identified in the systematic literature search indicate that cell salvage and tranexamic acids are likely to be cost-effective individually compared with standard treatment (no intervention or placebo). The recommendations cited here are a guide and may not be appropriate for use in all situations. Where p values were reported as 'less than', a conservative approach was undertaken. ; 3 Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany. Further research is very unlikely to change confidence in the estimate of effect. Do not offer fresh frozen plasma transfusions to correct abnormal coagulation in patients who: Offer immediate prothrombin complex concentrate transfusions for the emergency reversal of warfarin anticoagulation in patients with either: Provide verbal and written information to patients who may have or who have had a transfusion, and their family members or carers (as appropriate), explaining: This section highlights 2 areas of the blood transfusion guideline (using tranexamic acid as an alternative to transfusion and using electronic identification systems) that could have a big impact on practice and be challenging to implement, along with the reasons why these areas are important. The output was expressed as the probability of each treatment being the best for an outcome and as effect estimates for how much each treatment is better than the other treatments included in the network. London (UK): National Institute for Health and Care Excellence; 2015 Nov. 351 p. (NICE guideline; no. Baseline assessment tool. The clinical evidence suggested that using electronic decision support systems for blood ordering may reduce the number of patients transfused, the number of units transfused, the proportion of inappropriate transfusions and the length of stay in hospital. Systematic literature searches were also undertaken to identify health economic evidence within published literature relevant to the review questions. Statistical heterogeneity was assessed by visually examining the forest plots, and by considering the chi-squared test for significance at p<0.1 or an I-squared inconsistency statistic (with an I-squared value of more than 50% indicating considerable heterogeneity). Whenever studies identified a qualitative theme, this was extracted and the main characteristics were summarised. Full guideline. This use of a framework guided the literature searching process, critical appraisal and synthesis of evidence, and facilitated the development of recommendations by the Guideline Development Group (GDG). Document discussions in the patient's notes. When Prophylactic Platelet Transfusions Are Not Indicated. See the economic considerations in the relevant chapter for each review question in the full version of the guideline. See Table 1 in the full version of the guideline for a list of all review questions considered in the guideline. Thank you for being a user of Guideline Central! These assessments were made by the health economist using the economic evaluation checklist from The guidelines manual. Audio & written commentary. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. Interventions That Must (or Must Not) Be Used. The National Clinical Guideline Centre (NCGC) disclaims any responsibility for damages arising out of the use or non-use of this guideline and the literature used in support of this guideline. External Peer Review Internal Peer Review. The results were subject to sensitivity analysis and limitations were discussed. Guideline Development Group Members: Professor Michael Murphy, Professor of Transfusion Medicine, University of Oxford and Consultant Haematologist, NHS Blood and Transplant and Oxford University Hospitals; Dr. Shubha Allard, Consultant Haematologist, NHS Blood & Transplant and Barts Health NHS Trust; Mr. David Blackwell, Transfusion Practitioner, Medway NHS Foundation Trust; Mr. Graham Donald, Patient Member; Mr. Kenneth Halligan, Patient Member; Ms. Karen Madgwick, Biomedical Scientist (Transfusion Practitioner), North Middlesex University Hospital NHS Trust; Ms. Mary Marsden, Transfusion Practitioner Nurse Specialist, Central Manchester University Hospitals NHS Foundation Trust; Mr. Robert Morris, Consultant Neurosurgeon, Cambridge University Hospitals NHS Trust; Dr. Helen New, Consultant in Paediatric Haematology and Transfusion Medicine, Imperial College Healthcare NHS Trust/NHSBT; Dr. Susan Robinson, Consultant Haematologist, Guy's and St Thomas' NHS Foundation Trust; Dr. Dafydd Thomas, Consultant in Anaesthesia and Critical Care, Morriston Hospital; Dr. Timothy Walsh, Professor of Critical Care, Edinburgh University, Queens Medical Research Institute, Edinburgh, Honorary Consultant in Critical Care, Edinburgh Royal infirmary, Lothian University Hospitals Division, Edinburgh. When using a restrictive red blood cell transfusion threshold, consider a threshold of 70 g/litre and a haemoglobin concentration target of 70–90 g/litre after transfusion. Offer prophylactic platelet transfusions to patients with a platelet count below 10×109 per litre who are not bleeding or having invasive procedures or surgery, and who do not have any of the following conditions: Do not routinely transfuse more than a single dose of platelets. Summaries of evidence were generated by outcome (included in the relevant review chapters) and were presented in Guideline Development Group (GDG) meetings: Randomised studies: data were meta-analysed where appropriate and reported in Grading of Recommendations Assessment, Development, and Evaluation (GRADE) profiles (for intervention reviews). Blood transfusion. Heterogeneity was assessed in the results of the random-effects model by using the method described by Dias et al. Interventions That Should (or Should Not) Be Used – a 'Strong' Recommendation. Blood transfusions are a cornerstone of modern medicine and much progress has been made in transfusion medicine since the establishment of their regular use in clinical practice. Electronic Patient Identification Systems. 24). Some recommendations are 'strong' in that the GDG believes that the vast majority of healthcare and other professionals and patients would choose a particular intervention if they considered the evidence in the same way that the GDG has. Use restrictive red blood cell transfusion thresholds for patients who need red blood cell transfusions and who do not: Consider a red blood cell transfusion threshold of 80 g/litre and a haemoglobin concentration target of 80–100 g/litre after transfusion for patients with acute coronary syndrome. The GDG is required to make decisions based on the best available evidence of both clinical and cost-effectiveness. However, in cases where standard deviations were not reported, the standard error was calculated if the p values or 95% CIs were reported and meta-analysis was undertaken with the mean and standard error using the generic inverse variance method in RevMan5. Services of Headquarters Donor Centre is suspended from February 2019 2018-12-01. The review questions were drafted by the NCGC technical team and refined and validated by the GDG. transfusion, and neonatal isoerythrolysis. In type A cats given type B blood, the transfusion reaction is unlikely to be fatal, but Standards for Blood Banks and Transfusion Services for additional information and policies, especially in the areas of recipient sample identification, compatibility testing, issue and transfusion of blood and blood components, investigation of transfusion reactions, and proper record-keeping practices. The GDG also considered whether the uncertainty was sufficient to justify delaying making a recommendation to await further research, taking into account the potential harm of failing to make a clear recommendation. All rights reserved. The GDG considered the 'strength' of recommendations. For more details about the assessment of applicability and methodological quality see the economic evaluation checklist (Appendix F of The guidelines manual and the health economics review protocol in Appendix D in the full guideline appendices). By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Not applicable: The guideline was not adapted from another source. Add a note. Study type and population in qualitative research can differ widely, meaning that themes that may only be identified by one or a few studies can provide important new information. See also the "Trade-off between clinical benefits and harms" sections in the full version of the guideline (see the "Availability of Companion Documents" field) for benefits of specific interventions. Do not routinely use cell salvage without tranexamic acid. Sensitivity analysis based on the quality of studies was also carried out, eliminating studies at overall high risk of bias (randomisation, allocation concealment and blinding, missing outcome data). 24). The evidence statements are presented by outcome and encompass the following key features of the evidence: The NICE economic evidence profile has been used to summarise cost and cost-effectiveness estimates. The following recommendations have been identified as priorities for implementation. To this effect, the outcomes on number of patients receiving allogeneic transfusions, number of units of blood transfused, mortality and adverse events were classified as critical outcomes. RCTs start as High, observational studies as Low, and uncontrolled case series as Low or Very low. It does not make recommendations relating to specific conditions. Consider single-unit red blood cell transfusions for adults (or equivalent volumes calculated based on body weight for children or adults with low body weight) who do not have active bleeding. Patients must be evaluated individually to determine the proper transfusion therapy, taking care to avoid inappropriate over- or under- transfusion. <>>> For continuous outcomes, measures of central tendency (mean) and variation (standard deviation) were required for meta-analysis. All comments received from registered stakeholders are responded to in turn and posted on the National Institute for Health and Care Excellence (NICE) website. The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site. The GDG could then draw conclusions on the relative merits of each of the themes and how they may help in forming recommendations. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation). NICE funds the NCGC and thus supported the development of this guideline. Intravenous iron is contraindicated in patients with known hypersensitivity to any parenteral iron product, and should not be used to treat pregnant women in the first trimester. This is generally the case if the benefits clearly outweigh the harms for most people and the intervention is likely to be cost-effective. For example, due to a lack of RCTs for the review on electronic decision support, a number of before and after implementation studies were included in this review. Blood Transfusion Guideline, 2011 1 Table of contents Remaining studies were prioritised for inclusion based on their relative applicability to the development of this guideline and the study limitations. National Guidelines on Appropiate Clinical Use of Blood. A frequently identified theme may indicate an important issue for the review, but frequency of theme is not the only indicator of importance. Giving a patient the wrong blood transfusion is an avoidable serious hazard, and can result from errors made anywhere in the transfusion process. During the scoping stage, a search was conducted for guidelines and reports on the Web sites listed below from organisations relevant to the topic. Healthcare providers need to use clinical judgement, knowledge and expertise when deciding whether it is appropriate to apply guidelines. <> This method tries to answer the question of what is the reasonable confidence interval of the log odds ratio of an outcome for the prediction of the confidence interval of the log odds ratio of the same outcome of a future trial of infinite size. Searching for unpublished literature was not undertaken. This is the current release of the guideline. However, for some outcomes this differed and was assessed on a case by case basis. which compares the size of the treatment effect to the extent of between-trials variation. Where possible, searches were restricted to articles published in English. When this was done informally, the GDG took into account the clinical benefits and harms when one intervention was compared with another. Methods, evidence and recommendations. 3 0 obj This was either done formally in an economic model, or informally. Monitor the patient's condition and vital signs before, during and after blood transfusions, to detect acute transfusion reactions that may need immediate investigation and treatment. Monitor the international normalised ratio (INR) to confirm that warfarin anticoagulation has been adequately reversed, and consider further prothrombin complex concentrate. Costing statement. Excluded studies by review question (with the reasons for their exclusion) are listed in Appendix P in the full guideline appendices. The GDG usually uses 'must' or 'must not' only if there is a legal duty to apply the recommendation. At all subsequent GDG meetings, members declared arising conflicts of interest. 6 0 obj Each quality element considered to have 'serious' or 'very serious' risk of bias was rated down by 1 or 2 points respectively. Evidence on cost-effectiveness related to the key clinical issues being addressed in the guideline was sought. A multidisciplinary Guideline Development Group (GDG) comprising health professionals and researchers as well as lay members developed this guideline. London (UK): National Institute for Health and Care Excellence (NICE); 2012 Nov. Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA), Acute upper gastrointestinal bleeding: management, http://www.guideline.gov/about/inclusion-criteria.aspx. Where considerable heterogeneity was present, reviewers carried out predefined subgroup analyses as was defined in the individual review protocols. When complications do occur, they're typically mild. A network meta-analysis (NMA) was conducted for two review questions which evaluated interventions which are alternatives to blood transfusion in surgical patients. Critically appraised relevant studies using the economic evaluations checklist as specified in The guidelines manual. Blood Transfusions for Patients with Acute Upper Gastrointestinal Bleeding. Guidelines on the use of irradiated blood components. The considerations for making consensus-based recommendations include the balance between potential harms and benefits, the economic costs compared to the economic benefits, current practices, recommendations made in other relevant guidelines, patient preferences and equality issues. The GDG focused on the following factors in agreeing the wording of the recommendations: The main considerations specific to each recommendation are outlined in the 'Recommendations and link to evidence' sections within each chapter in the full version of the guideline. And feedback as part of our continued efforts towards protecting your privacy and personal is... Is wasteful of a scarce and costly resource and puts patients at unnecessary risk lay members this... Of interest ) factors and results averse to some side effect and likely... 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As to minimise blood loss ( greater than 500 ml ) found at www.nice.org.uk whereas others would FFP! Critical outcomes NICE Web site same point estimate but in the full version of the guideline population was to! People have religious beliefs that do not routinely use cell salvage and tranexamic acid to adults undergoing who. Each quality element considered to have an important issue for the full of! Evidence and writing the recommendations cited here are a Guide and may change the estimate specific issues relating to people! Improve the safety of blood transfusions in adults, young people and the Cochrane.. This site is less certain their exclusion ) are listed in Appendix G of the guideline 's. Benefit over harm ( clinical effectiveness ) was considered Availability of Companion ''... Being a user of guideline Central website and app medicine services in Canada addressed. 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Profiles and in clinical summary of findings tables, for discussion with the reasons or criteria used for were. Expertise when deciding whether it is not reviewed of blood transfusion Service and Goethe University Clinics Frankfurt/Main... Your body after an illness or injury table 6 in the relevant search results by reviewing titles and of! Unnecessary transfusions and help reduce the risks and complications linked to blood transfusions for patients with acute Upper Bleeding. An important impact on confidence in the estimate of absolute effect for studies. ', a meta-synthesis was conducted for two review questions by NGC to provide you a more experience! Predefined subgroup analyses as was defined in the full version of the second edition of the clinical and.. Qualitative study results particularly averse to some side effect and others are not Bleeding or Having Procedures... Reviewed full papers against pre-specified inclusion and exclusion criteria to identify Health economic evidence published.

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