27th May 2023

Alternatives to red blood cell transfusion

Key principles

In all stable, non-bleeding patients, where appropriate, transfusion should be avoided due to associated risks. Three principles can be adopted: to maximise red cell mass, minimise bleeding and optimise physiological reserve. Pre-operative optimisation of patients should address any identified anaemia.  Review and consider altering medications which may increase the risk of bleeding. Blood conservation techniques may include intraoperative or postoperative cell salvage and reinfusion, the use of tissue sealants (sprays which promote haemostasis) or anti-fibrinolytic drugs such as tranexamic acid. In extreme scenarios, minimising blood tests and therefore blood loss may need to be considered.

It is important to respect patient autonomy after an informed decision is made with capacity. If this is a faith-based decision, for example in Jehovah’s Witnesses, it is important to assess an individual’s preferences to whole blood, specific blood components and the derivatives of blood components (albumin, cryoprecipitate, clotting factor concentrate and immunoglobulins). Check for advanced decision documents, place a copy in the notes and document a conversation around transfusion alternatives. Involve the hospital’s liaison for Jehovah’s Witnesses. In the case of critically ill patients with temporary incapacity, if there is no clear evidence of an Advance Decision, then life-saving treatment must be given. Where legal guardians of children under 16 refuse blood transfusion and in the opinion of the treating clinician, that transfusion is essential, then a Specific Issue Order can be rapidly obtained from a court. Autologous donation is rarely done, as the shelf-life of red cells is only 35 days making it logistically challenging to deliver and it doesn’t protect against errors such as incorrect re-infusion.

Iron therapy

The speed of response to oral iron depends on the Hb deficit and the presence of continued blood loss, but at least 3 months of treatment after recovery of Hb is needed to restore body stores. Due to side effects like constipation, tolerance may be variable and lower doses may need to be considered for more protracted periods. IV iron may be used in patients intolerant of oral iron or in patients with anaemia of chronic disease where response to oral iron may be poorer. With newer preparations now available, IV iron prescription has become much safer, but is contraindicated in the first trimester of pregnancy, chronic liver disease or in acute or chronic infection.

Erythropoietin (EPO)

EPO is produced in the kidneys in response to reduced oxygen and increases red blood cell production in the bone marrow. Recombinant EPO is used in the treatment of anaemia from renal failure and in myelodysplastic syndrome (MDS). Baseline EPO levels should be taken:

• <100IU/L are likely to respond to EPO therapy
• >500IU/L are unlikely to respond
• If levels are 100-500IU/L, then a trial of treatment could be discussed with the patient

Recombinant EPO can cause hypertension and thromboembolic problems. Haematocrit should be carefully monitored. Recombinant EPO should not be started in the presence of iron deficiency, without concurrently managing the iron deficiency.