Clinical Practice Guidelines

Blood product transfusion

  • Background

    • Blood and blood product transfusions may be required for acute blood loss, or for failure of production such as bone marrow suppression.
    • Blood product therapy should only be given when the expected benefits to the patient are likely to outweigh the potential hazards.
    • All blood transfusion activity within the RCH must occur in compliance with the relevant policies (needs link) and hospital clinical guidelines (link needed).

    Indications for Transfusion

    Indications for Red Blood Cells

    • Hb <70g/L; although lower thresholds may be acceptable in patients without symptoms and where specific therapy (eg iron) is available.

    Transfusion may be indicated at higher thresholds for specific situations:

    • Hb <70-100g/L during surgery associated with major blood loss or if evidence of impaired oxygen transport
    • Hb <80g/L; patients on a chronic transfusion regimen or during marrow suppressive therapy (for symptom control and appropriate growth)
    • Hb <100g/L; only for very select populations (eg. neonates)

    Indications for Platelets

    Table 1: Indications for Platelet transfusion

     ClinicalSituation  Indication for Platelet Transfusion
    Bone marrow failure

    Plt <10x109/L if no other risk factors for bleeding (see below)

    Plt <20x109/L if risk factors present (fever, antibiotics, haemostatic failure, risk of intracranial haemorrhage)

    Surgery/invasive procedure Plt <50x109/L. However, higher counts may be needed in surgery with high risk of bleeding eg. neurosurgery
    Platelet function Defects Transfuse if there is bleeding or high risk of bleeding, regardless of actual platelet count
    Bleeding/Massive transfusion

    Maintain Plt >50x109/L if thrombocytopaenia likely contributing to bleeding

    Maintain Plt >100x109/L in the presence of diffuse microvascular bleeding (DIC) or CNS trauma

    Indications for Fresh Frozen Plasma

    FFP is appropriate for the following:

    • Warfarin effect, in the presence of life-threatening bleeding in addition to the use of vitamin K and vitamin-k dependent clotting factor concentrates for bleeding with abnormal coagulation
    • Liver disease, if bleeding with abnormal coagulation.
    • Acute DIC when there is bleeding and abnormal coagulation
    • Following massive transfusionor cardiac bypass for bleeding in the presence of abnormal coagulation

    Indications for Cryoprecipitate

    Cryoprecipitate is indicated for:

    • Fibrinogen deficiency, in the setting of clinical bleeding, an invasive procedure, trauma or DIC.

    Pre-transfusion Assessment

    1. The indication to transfuse (see above)
    2. Document reason for transfusion and discussion of consent (also see hospital guideline: Blood transfusion, consent and documentation)
    3. Collect pre-transfusion sample (except in infants on ASBT protocol).
      • A sample for cross-matching must be collected in a 1.4ml red EDTA tube (NOT bullet tubes). Patients known to have red cell antibodies or haemolytic anaemia will require a larger sample.
      • Correctly identify the patient during the collection of the pre-transfusion sample.  Identification must include 3 unique identifiers ie full name, DOB, UR. This, together with completing the bedside check prior to blood administration are the most vital steps in preventing serious transfusion errors.
    4. Request the appropriate blood component and special requirements:
      • Leukocyte depleted blood products should be given to:
        • Immuno-compromised patients (oncology, transplant recipients, ICU patients, and other congenital and acquired immune deficiencies)
        • Patients requiring chronic transfusions
        • Infants under 12 months
        • Intrauterine or exchange transfusions
      • Irradiated blood products should be given to:
        • All immuno-compromised patients, including all oncology patients, cardiac neonates and all patients in ICU, to prevent graft-versus host disease.
      • CMV negative products:
        • Leucocyte depleted blood products, are considered an acceptable alternative to CMV seronegative products at RCH
    5. Calculate & prescribe the transfusion volume with consideration to pack sizes
    6. Prescribe the blood product and rate of administration on the fluid order chart (see Table 2 below) 
      • All transfusions must be completed within 4 hours of spiking a pack.

    Table 2: Transfusion volumes and rates

     Blood product

     Formula for calculating
    transfusion volume

     Pack sizes


    Red Blood Cells

    Packed cells (mls)
    = wt (kg) x Hb rise required(g/L) x 0.4 

    (eg.10kg child requiring Hb to rise from 60 to 110g/L: 10 x 50 x 0.4=200ml)


    50 -60 ml/Pedipack

    Transfusion will be started at a slower rate (eg. Half the rate) for the first 15minutes. If no adverse effects occur, increase the transfusion to a 2-4hourly rate depending on the patient's condition and fluid balance


    5 - 20 ml/kg

    (5 - 10 ml/kg will raise platelet count by 50 - 100x 109 /L)

    Neonatal/ paediatric <40kg patients:

    • Paediatric (single donor) -40 - 60 ml
    • Apheresis (single donor) split into
      4 - 8 x 40 - 60 ml packs

    Paediatric > 40kg or adult:

    • Apheresis (single donor) >200ml or split into 2 x > 100ml packs
    • Pooled from 4-5 donors - >160ml 

    3ml/kg/hr over 2-3 hours.

    (occasionally platelets are
    given over 30 minutes, but
    this may contribute to an
    increased risk of some reactions (fever/chills) and
    fluid overload)


    10 - 20 ml/Kg 


    50ml/pack (for neonatal use)

     Start at no more than 5ml/min.


    5-10 ml/kg

    30-40 ml/pack  Start at no more than 5ml/min.

    Management of Transfusion

    Administer as per  Administration of fresh blood products hospital guideline

    The key steps include:

    1. A formal checking process prior to commencement of transfusion
    2. The use of correct equipment (filters, pump, consideration of blood warmer)
    3. Correct transfusion documentation including patient observations, start and finish times

    Complications during transfusion:

    • The most common immediate adverse reactions to transfusion are fever, chills and urticaria.
    • The most potentially significant reactions include acute haemolytic transfusion reactions, bacterial contamination of blood products and transfusion related acute lung injury.
    • During the early stages of a reaction it may be difficult to ascertain the cause.
    • All suspected transfusion reactions must be reported to the issuing blood bank immediately. The on-call haematologist will contact the clinical area to provide advice regarding investigation and ongoing transfusion support.

    After transfusion:

    • Document the effect of transfusion on the patient's condition including Hb if repeated.


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