Blood Product Utilization Guidelines

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Blood Product Utilization Guidelines

Last update: March 20, 2020

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Blood utilization principles

Blood product transfusion thresholds must be strictly followed, and all product release outside of these thresholds will require approval of pathology staff

  • If a blood product order does not meet a transfusion threshold or there is a critical shortage, the order will be triaged and the ordering physician will be contacted by Pathology.

Blood products to be on hold for procedure should be ordered as usual, but for inventory control and to minimize the chance of wastage will remain physically in the blood bank until they need to be transfused (outside of massive transfusions).

  • OR staff will need to send a runner to the blood bank to pick up products.

As the front-line stewards of a non-renewable and potentially finite resource with direct knowledge of the supply of blood products available, all final decisions about the release of blood products are at the final discretion of the attending pathologist.

  • Anyone found to be attempting to circumvent the guidelines by ordering a massive transfusion protocol (MTP), emergency release of blood products, or misleading about the degree of bleeding will be reported.

Strategies to minimize blood loss

  • Discontinue any daily blood draws that are not absolutely needed.
  • Necessary adult labs can be drawn in pediatric tubes in patients at risk of iatrogenic anemia.
  • When possible, add-on needed test to a previously collected sample, or consider using point-of-care tests.
  • Correct anemia with IV iron or erythropoietin, when indicated.
  • Consider medical hemostatic adjuncts in bleeding patients:
    • Antifibrinolytics such as tranexamic acid (TXA) or aminocaproic acid (Amicar) for thrombocytopenia and/or hypofibrinogenemia
    • DDAVP for thrombocytopenia, especially in the setting of uremia
    • Factor VII for bleeding patients (ideally if pH can be corrected to >7.2)
  • Consider TEG-guided resuscitation, which has been shown to decrease use of blood products with equivalent or better outcomes.
  • Consider use of chest tube autotransfusion and/or intraoperative cell salvage when appropriate.

Red blood cell transfusion guidelines

Standard transfusion thresholds

  • Hemoglobin level < 7 g/dL
  • Hospitalized adult patients who are not actively bleeding
  • Hemoglobin level < 8 g/dL
  • Hospitalized adult patients with pre-existing cardiovascular disease
  • Hemoglobin level < 10 mg/dL
  • Hospitalized adult patients with acute coronary syndrome
  • A single RBC unit is the standard for non-bleeding, hospitalized patients
  • Only order an additional unit after assessing the patient and obtaining a post-transfusion hemoglobin level after the first unit
  • “Why give two when one will do?”

Emergency critical shortage transfusion thresholds

During critical times of blood product shortage, the RBC transfusion thresholds will be lowered: first for stable patients who are not bleeding, and then if necessary, for patients with pre-existing cardiovascular disease or those with acute coronary syndrome.

  • Every RBC unit ordered may be triaged by transfusion medicine.
  • In order to obtain a 2nd unit, a post transfusion CBC may be required
  • Outpatient transfusions may be stopped.
  • Units may be split, and ½ units provided.
  • RBC transfusions may be limited to only patients with life-threatening bleeding if necessary, to preserve a limited RBC inventory.


  • Carson JL et al. Clinical Practice Guidelines from the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016; 316(19):2025-2035
  • American Association of Blood Banks. Five Things Physicians and Patients Should Question. Choosing Wisely; 2014. Available from:
  • Society for the Advancement of Blood Management. Five Things Physicians and Patients Should Question. Choosing Wisely; 2018. Available from:


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