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. This guideline contains recommendations about general principles of blood transfusion, and applies to a range of conditions and different settings. For most intervention reviews in this guideline, parallel randomised controlled trials (RCTs) were included because they are considered the most robust type of study design that could produce an unbiased estimate of the intervention effects. Inconsistency in the networks was tested by comparing any available direct and indirect treatment comparison and testing the null hypothesis that the indirect evidence was not different from the direct evidence on the odds ratio scale using the normal distribution. If a non-UK study was included in the profile, the results were converted into pounds sterling using the appropriate purchasing power parity. Patient Blood Management Guidelines: Module 2 Perioperative The second in a series of six evidence-based guidelines was approved by the National Health and Medical Research Council (NHMRC) on 15 November 2011, and released on 9 March 2012. 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. The aim of the NMA was to include all relevant evidence in order both to answer questions on the clinical effectiveness of interventions when no direct comparison was available and to give a ranking of treatments in terms of efficacy. Assessments of potential differences in effect between subgroups were based on the chi-squared tests for heterogeneity statistics between subgroups. See Appendices F and I in the full guideline appendices for economic article selection and economic evidence tables. Reporting or publication bias was only taken into consideration in the quality assessment and included in the 'Clinical evidence profile' table if it was apparent. Where possible, searches were restricted to articles published in English. London (UK): National Institute for Health and Care Excellence; 2015 Nov. 351 p. (NICE guideline; no. Where p values were reported as 'less than', a conservative approach was undertaken. Methods, evidence and recommendations. For interpretation of the binary outcome results, differences in the absolute event rate were calculated using the GRADEpro software, for the median event rate across the control arms of the individual studies in the meta-analysis. However, there is often a closer balance between benefits and harms, and some patients would not choose an intervention whereas others would. These models were then compared based on residual deviance and deviance information criteria (DIC). In this table, the columns for intervention and control indicate summary measures and measures of dispersion (such as mean and standard deviation or median and range) for continuous outcomes and frequency of events (n/N: the sum across studies of the number of patients with events divided by sum of the number of completers) for binary outcomes. Summaries of clinical and economic evidence and quality (as presented in Chapters 1 to 11 in the full guideline appendices), Forest plots (Appendix K in the full guideline appendices), Results of network meta-analysis (Appendix L in the full guideline appendices), A description of the methods and results of the cost-effectiveness analyses undertaken for the guideline (Appendix M in the full guideline appendices), The actions health professionals need to take, The strength of the recommendation (for example the word 'offer' was used for strong recommendations and 'consider' for weak recommendations; see the "Rating Scheme for the Strength of the Recommendations" field), The involvement of patients (and their carers if needed) in decisions on treatment and care, Consistency with NICE's standard advice on recommendations about drugs, waiting times and ineffective interventions. All comments received from registered stakeholders are responded to in turn and posted on the National Institute for Health and Care Excellence (NICE) website. endobj 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 guideline population was defined to be people who are receiving a blood transfusion or are at risk of receiving a blood transfusion. A small difference in DIC between the fixed and random effects models (3–5 points) implies that the better fit obtained by adding random effects does not justify the additional complexity. It also shows the incremental costs, incremental effects (for example, quality-adjusted life years [QALYs]) and incremental cost-effectiveness ratio for the base case analysis in the evaluation, as well as information about the assessment of uncertainty in the analysis. Introduction to the "Give Blood Alliance" program 2018-02-08. The evidence for each outcome was examined separately for the quality elements. Consider tranexamic acid for children undergoing surgery who are expected to have at least moderate blood loss (greater than 10% blood volume). Reduction in inappropriate use of blood components and use of alternatives to transfusion will improve patient care and reduce hospital costs. Relevant studies were critically appraised using the appropriate checklist as specified in The guidelines manual (see the "Availability of Companion Documents" field). Blood transfusions carry risks, are costly, and the supply of blood is limited. This takes into account the quality of the evidence but is conceptually different. 2 0 obj Healthcare professionals are expected to take National Institute for Health and Care Excellence (NICE) clinical guidelines fully into account when exercising their clinical judgement. See the "Availability of Companion Documents" field for the full version of this guidance and related appendices. Data for continuous outcomes, such as number of units of allogeneic blood transfused and length of stay in hospital, were analysed using an inverse variance method for pooling weighted mean differences and, where the studies had different scales, standardised mean differences were used. The National Institute for Health and Care Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. For some review questions (alternatives to blood transfusion), the review population was limited to surgical patients who are receiving blood transfusions. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. The aim of the synthesis of qualitative data was to describe the main factors that may influence the experience of care of the person receiving blood transfusion and to enable the GDG to develop recommendations to improve this experience. Monitor the international normalised ratio (INR) to confirm that warfarin anticoagulation has been adequately reversed, and consider further prothrombin complex concentrate. Observe patients who are having or have had a blood transfusion in a suitable environment with staff who are able to monitor and manage acute reactions. In type A cats given type B blood, the transfusion reaction is unlikely to be fatal, but Key information was extracted on the study's methods, PICO (patient, intervention, comparison and outcome) factors and results. Literature reviews, posters, letters, editorials, comment articles, unpublished studies and studies not in English were excluded. National Guidelines on Screening Donated Blood for TTIs. If your body is missing one or more of the components that make up … Also available for download in ePub and eBook formats from the NICE Web site. The assessment of net benefit was moderated by the importance placed on the outcomes (the GDG's values and preferences), and the confidence the GDG had in the evidence (evidence quality). 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. information technology to influence transfusion practices, and details blood management in the perioperative period. Available from the, Blood transfusion. The GDG considered the side effects of intravenous (IV) iron, as all preparations carry a small risk of adverse reactions which can be life threatening if not treated promptly. The main criteria considered in the rating of these elements are discussed below. The reasons or criteria used for downgrading were specified in the footnotes. Some recommendations can be made with more certainty than others. Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Clinical Guideline Centre (NCGC) on behalf of the National Institute for Health and Care Excellence (NICE). Only consider giving more than a single dose of platelets in a transfusion for patients with severe thrombocytopenia and bleeding in a critical site, such as the central nervous system (including eyes). This was either done formally in an economic model, or informally. 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. National Guidelines on Appropiate Clinical Use of Blood. Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. Costing statement. This Guide is an educational resource for health care workers on the provision of blood products and transfusion medicine services in Canada. This guidance is subject to a 6-week public consultation and feedback as part of the quality assurance and peer review of the document. If no sensitivity analysis was found to completely resolve statistical heterogeneity then a random-effects (DerSimonian and Laird) model was employed to provide a more conservative estimate of the effect. When Prophylactic Platelet Transfusions Are Not Indicated. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation). Diseases or conditions requiring blood transfusion, Evaluation Management Prevention Treatment, Critical Care Hematology Internal Medicine Surgery, Advanced Practice Nurses Allied Health Personnel Hospitals Nurses Patients Physician Assistants Physicians Public Health Departments, To develop a cross cutting clinical guideline on the assessment for and management of transfusion, Adults (aged 16 years and above) and children (over 1 year and under 16 years of age). Estimated log odds ratios (with their 95% credible intervals) were calculated for comparisons of the direct and indirect evidence, The probability that each treatment was best, based on the proportion of Markov chain iterations in which each treatment had the highest probability of achieving the outcomes selected in the network(s), A ranking of treatments compared to baseline groups (presented as the median rank and its 95% credible intervals). 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. Searching for unpublished literature was not undertaken. See the economic considerations in the relevant chapter for each review question in the full version of the guideline. Monitoring for Acute Blood Transfusion Reactions. Alternatives to Blood Transfusion for Patients Having Surgery. Provide the patient and their general practitioner (GP) with copies of the discharge summary or other written communication that explains: For guidance on communication and patient-centred care for adults, see the NICE guideline on patient experience in adult NHS services. The GDG uses 'offer' (and similar words such as 'refer' or 'advise') when confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA), Acute upper gastrointestinal bleeding: management, The National Clinical Guideline Centre was commissioned by the National Institute for Health and Care Excellence to undertake the work on this guideline. Guideline 1 Informed Consent for Administration of Blood, Blood Components and or Plasma Protein Products Page 3 of 5 MTBPRM 2019 Manitoba Transfusion Best Practice Resource Manual 2019 1.8 The physician/authorized practitioner must document, in the patient’s health record, why informed consent was not obtained. Guidelines International Network database (, National Institutes of Health Consensus Development Program (, National Health Service (NHS) Evidence Search (. Potentially relevant studies were identified for each review question from the relevant search results by reviewing titles and abstracts. These criteria are detailed in Sections 4.3.6 to 4.3.9 in the full version of the guideline. For guidance on blood transfusions for people with acute upper gastrointestinal bleeding, see the recommendations under "Resuscitation and Initial Management" in the NGC summary of the NICE guideline Acute upper gastrointestinal bleeding: management. 23: Specification for the uniform labelling of blood, blood components and blood donor samples 24: Specification for the uniform labelling of human tissue products using ISBT 128 25: Standards for electronic data interchange within the UK Blood Transfusion Services Model inputs were based on the systematic review of the clinical literature supplemented with other published data sources where possible. Guideline recommendations should be based on the expected costs of the different options in relation to their expected health benefits (that is, their 'cost-effectiveness') rather than the total implementation cost. At any time, you may opt out of tracking or request account deletion. Audio & written commentary. The section of the guideline also gives information on resources to help with implementation. When clinical and economic evidence was of poor quality, conflicting or absent, the GDG drafted recommendations based on their expert opinion. There are no notes to display. *By signing up I agree to the privacy terms listed here, Type of Evidence Supporting the Recommendations, Methods Used to Collect/Select the Evidence, Description of Methods Used to Collect/Select the Evidence, Methods Used to Assess the Quality and Strength of the Evidence, Rating Scheme for the Strength of the Evidence, Description of the Methods Used to Analyze the Evidence, Methods Used to Formulate the Recommendations, Description of Methods Used to Formulate the Recommendations, Description of Method of Guideline Validation, Composition of Group That Authored the Guideline, Financial Disclosures/Conflicts of Interest, *By signing up I agree to the privacy terms listed, Benefits/harms Of Implementing The Guideline Recommendations, Rating Scheme For The Strength Of The Recommendations, Institute Of Medicine (iom) National Healthcare Quality Report Categories, National Institute for Health and Care Excellence (NICE) Web site, Anaemia management in chronic kidney disease, Stroke. External Peer Review Internal Peer Review. After each single-unit red blood cell transfusion (or equivalent volumes calculated based on body weight for children or adults with low body weight), clinically reassess and check haemoglobin levels, and give further transfusions if needed. Identified potentially relevant studies for each review question from the economic search results by reviewing titles and abstracts. The GDG identified the use of cell salvage, tranexamic acid or both in combination in people undergoing surgery as the highest priority area for original economic modelling. Blood Transfusion welcomes international submissions of Original Articles, Review Articles and Letters on all the fields related to Transfusion Medicine. For example, all RCTs started as High and the overall quality became Moderate, Low or Very low if 1, 2 or 3 points were deducted respectively. The Guideline Development Group (GDG) noted the potential for side effects of oral iron, for example, nausea and gastric discomfort, and the risk of accidental overdose in children. 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. Identifying Transfusion Strategies for Severely Injured Patients. These assessments were made by the health economist using the economic evaluation checklist from The guidelines manual. It does not make recommendations relating to specific conditions. However, for some outcomes this differed and was assessed on a case by case basis. Excluded studies by review question (with the reasons for their exclusion) are listed in Appendix P in the full guideline appendices. The GDG uses 'consider' to reflect a recommendation for which the evidence of benefit is less certain. Good Practice Papers. The model was based on original work from the University of Bristol. A blood transfusion is a way of adding blood to your body after an illness or injury. • Universal blood groups for red blood cells (RBC) and plasma (FFP) available for immediate use. Red Blood Cell Transfusion: 2016 Clinical Practice Guidelines from the AABB. Search strategies were quality assured by cross-checking reference lists of highly relevant papers, analysing search strategies in other systematic reviews, and asking GDG members to highlight any additional studies. 24). Evidence from 14 randomised controlled trials (RCTs) comparing erythropoietin (EPO) with placebo/no EPO showed an increase in mortality and the number of patients with thrombotic complications in the EPO group compared to the placebo group, but there was considerable uncertainty in the effect estimates. Guidelines for National External Quality Assessment Scheme in Blood Group Serelogy (NEQAS-BGS) National Clinical Guideline Centre. 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. Offer tranexamic acid to adults undergoing surgery who are expected to have at least moderate blood loss (greater than 500 ml). Refer to Appendix F in the full guideline appendices for a flow diagram of economic article selection for the guideline. A hierarchical Bayesian NMA was performed using the software WinBUGS version 1.4. With great pleasure we present the new online edition of the Canadian Blood Services’ Clinical Guide to Transfusion. Blood Transfusions in Obstetrics (Green-top Guideline No. London (UK): National Institute for Health and Care Excellence; 2015 Nov. 351 p. (NICE guideline; no. Each quality element considered to have 'serious' or 'very serious' risk of bias was rated down by 1 or 2 points respectively. Members were either required to withdraw completely or for part of the discussion if their declared interest made it appropriate. x��VMo�8���#U�4�_����&i�v7@ Readers with questions regarding guideline content are directed to contact the guideline developer. D-�6C��%2r� ��}hڕ�Pv�M"wU���E��\�T#��M�k(ƿ�byJ��QW�^䰦�%���5��>[��w�g'��:ג�a��?4�m�mB�EMV������)��R=K�M�����#��)��*$�k���>�u_��#��ZO]��E>�@��~p��g7����bŕFI!� Jm�Q!��t�x+b�jS�zE�Q�^'o��n6/x�Ӊ�(��W���%#��i���B��:�ﻊu�~�=4��������#�P�%�^�~� ���@���2Dd�cY��S�=$�5UX��N���W���w*���,�SV�犠b*_�1�p���gS.��s��B�a�Zj�zdP#MA+# R6�)G�U�*��|p������j1�K��B�h>���E�y����=��i��G�(��xV#L4p�Fv��.���@0��ѷ�ꎡM]�\�RG�m���W��%�s�����b�^�)hTԙ�֍�nȐZd�v4/а�/f�iV�oB�箊�� � �>���z�a�E���F&*�@f����W�UB�~�q�k}\#R���c�X#��]E�2���KGitp|_߿Nu�O�$�R��?�I��ߧ�~ Affiliations 1 German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany. However, if the difference in DIC between a fixed and random effect model was smaller than 5 points and the models made very similar inferences, then reviewers reported the fixed-effects model results as that makes fewer assumptions than the random-effect model, contains fewer parameters and is easier to interpret clinically. The GDG also discussed the relative importance of different outcomes when drafting the protocol for each review question and the outcomes were classified as critical or important. The GDG was involved in the design of the model, selection of inputs and interpretation of the results. For example, if a high quality, directly applicable UK analysis was available, then other less relevant studies may not have been included. ��C�F�]����]���CRJ�Xt���2M���7�1�o�͛����+o����%�=�\�R�r)�h�z:������za`s�N6��BXz`�~5�|�N���%�vH�[ o�Si/5HD�[��r J��9�I�őȑ�$J^H@\-&����v�ng_Y�bIg{� s^�kB� mYJ�e)������������v�a+�f�-3S��k�l��ӡٵ�f� All searches were conducted in MEDLINE, EMBASE, and The Cochrane Library. Reassess the patient's clinical condition and check their platelet count after each platelet transfusion, and give further doses if needed. Inconsistency was identified if the mean estimates (mean odds ratios) of the direct comparisons were outside the confidence intervals of the odds ratios as generated from the NMA output. The economic evidence profile shows an assessment of applicability and methodological quality for each economic evaluation, with footnotes indicating the reasons for the assessment. %���� The strength of recommendation is defined at the end of the "Major Recommendations" field. The GDG uses 'consider' when confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The questions, the study types applied, the databases searched and the years covered can be found in Appendix G in the full guideline appendices. Offer oral iron before and after surgery to patients with iron-deficiency anaemia. Search. A frequently identified theme may indicate an important issue for the review, but frequency of theme is not the only indicator of importance. 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. When no relevant published studies were found, and a new analysis was not prioritised, the GDG made a qualitative judgement about cost-effectiveness by considering expected differences in resource use between options and relevant UK National Health Service (NHS) unit costs, alongside the results of the clinical review of effectiveness evidence. Some people have religious beliefs that do not allow the transfusion of blood. A generic inverse variance option in RevMan5 was used if any studies reported solely the summary statistics and 95% confidence interval (95% CI) or standard error; this included any hazard ratios reported. A blood transfusion is a routine medical procedure in which donated blood is provided to you through a narrow tube placed within a vein in your arm.This potentially life-saving procedure can help replace blood lost due to surgery or injury. Fixed-effects (Mantel-Haenszel) techniques were used to calculate risk ratios (relative risk) for the binary outcomes, such as number of patients receiving allogeneic blood transfusions, mortality, incidence of infections and serious adverse events. The GDG could then draw conclusions on the relative merits of each of the themes and how they may help in forming recommendations. Studies published in languages other than English were not reviewed. All … During the scoping stage, a search was conducted for guidelines and reports on the Web sites listed below from organisations relevant to the topic. Giving a patient the wrong blood transfusion is an avoidable serious hazard, and can result from errors made anywhere in the transfusion process. Message from the Chief Executive and Medical Director of BTS (Chinese only) 2018-01-10 ... 2020 Hong Kong Red Cross Blood Transfusion Service. The following recommendations have been identified as priorities for implementation. Therefore, for the purpose of the qualitative review in this guideline, the categorisation of themes was exhaustive, that is, all themes were accounted for in the synthesis. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. Updated to reflect the most up-to-date published evidence available, these guidelines provide pragmatic advice to assist clinicians in making decisions about the use of red blood cell transfusions. For example, the Guideline Development Group (GDG) uses 'offer' to reflect a strong recommendation, usually where there is clear evidence of benefit. The following procedure was adopted when using GRADE: The GDG assessed the evidence by outcome in order to determine if there was, or potentially was, a clinically important benefit, a clinically important harm or no clinically important difference between interventions. In addition, a National Institute for Health and Care Excellence (NICE) pathway titled "Blood Transfusion Overview" is provided on the NICE Web site. By updating our privacy policy with clearer language, our goal is to help you better understand what data we collect and how we use that information. 24). – US Government Rights. Remaining studies were prioritised for inclusion based on their relative applicability to the development of this guideline and the study limitations. Refer to Appendix E in the full guideline appendices (see the "Availability of Companion Documents" field) for flow diagrams of clinical selection, which detail the total number of studies included for each guideline topic. Full guideline. Reassess the patient's clinical condition, repeat the fibrinogen level measurement and give further doses if needed. The most common cause of death associated with transfusion was transfusion associated circulatory overload. 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. 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. The group met approximately every 5 to 6 weeks during the development of the guideline. 24). 6 0 obj Evidence from observational studies (which had not previously been downgraded) was upgraded if there was: a large magnitude of effect, a dose–response gradient, and if all plausible confounding would reduce a demonstrated effect or suggest a spurious effect when results showed no effect. When the only evidence was based on studies that summarised results by presenting medians (and interquartile ranges), or only p values were given, this information was assessed in terms of the study's sample size and was included in the GRADE tables without calculating the relative or absolute effects. Electronic Patient Identification Systems. National Standards for Blood Transfusion Service. See Table 6 in the full version of the guideline for more details. NICE's report 'Social value judgements: principles for the development of NICE guidance' sets out the principles that GDGs should consider when judging whether an intervention offers good value for money. 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).