Neobook — clinical reference

Each recommendation has been given a grade, using the following definitions, set by the Australian National Health and Medical Research Council (NHMRC):

GRADE A	Body of evidence can be trusted to guide practice.
GRADE B	Body of evidence can be trusted to guide practice in most situations.
GRADE C	Body of evidence provides some support for recommendation(s), but care should be taken in its application.
GRADE D	Body of evidence is weak and recommendations must be applied with caution.

General PBM statements and measures

1.1	All patients should have their haemoglobin concentration (Hb) measured before listing for major elective surgery.
1.2	Patients who are anaemic (Hb <13g/dL) should be investigated before elective surgery and treated appropriately, and elective non-urgent surgery other than Caesarean section should be delayed when possible.
1.3	Where blood transfusion is anticipated, this and alternatives to transfusion, should be discussed with the patient and documented.
1.4	Red cell concentrate (RCC, previously called RBCs) should be transfused one unit at a time, and the patient’s Hb should be checked before each unit transfused, unless there is ongoing bleeding or a large deficit that needs correcting.
1.5	The use of intraoperative cell salvage and tranexamic acid (TXA) administration should be considered in all trauma, major obstetric and non-obstetric patients where blood loss >500ml is expected.
1.6	Blood components should be prescribed for paediatric patients by volume rather than number of units.
1.7	Every institution should have a massive transfusion protocol which is regularly audited and reviewed every 2 years.
1.8	Group O RCC should be readily available in the clinical area, in case of life-threatening haemorrhage.
1.9	During major haemorrhage due to trauma and obstetrics, consideration should be given to transfusing red cells and fresh frozen plasma/ freeze-dried plasma (FFP/FDP) in preference to other intravenous(IV) fluid.
1.10	Patients who continue to actively bleed should be monitored by point-of-care (POC) and/ or regular laboratory tests for coagulation, fibrinogen and platelet counts or function.

PBM measures for patients expected to bleed significantly during surgery

Preoperative		Consensus	Grade
2.1	Preoperative Hb should be measured, recorded, and optimised as required.	Yes	A
2.2	Elective surgery should be postponed in patients with untreated anaemia.	Yes	A
2.3	Review and consider stopping antiplatelet and anticoagulant medication the recommended number of days before surgery.	Yes	B
2.4	Consider minimally invasive or laparoscopic surgical technique.	Yes	B
2.5	POC testing should be available with appropriate training.	Yes	C
Intraoperative		Consensus	Grade
2.6	Position patient carefully to optimise venous drainage.	Yes	B
2.7	Use patient warming to maintain temperature > 36°C.	Yes	A
2.8	Consider cell salvage if blood loss > 500ml anticipated.	Yes	B
2.9	Consider giving TXA if blood loss > 500ml anticipated.	Yes	C
2.10	The dose of TXA should be 15mg/kg.	Yes	C
2.11	Apply restrictive transfusion threshold (Hb 7–8g/dL) depending on patient characteristics and haemodynamics).	Yes	B
2.12	Consider use of topical haemostatic agents.	Yes	C
Postoperative		Consensus	Grade
2.13	Maintain oxygen delivery, targeting oxygen saturation levels >92%.	Yes	A
2.14	Single unit blood transfusion policy, with subsequent re-assessment of Hb concentration and clinical need between RCC units.	Yes	A
2.15	Consider postoperative drains for cell salvage.	Yes	A

General perioperative measures and management

Anaemia		Consensus	Grade
3.1	Patients who are anaemic (Hb <13g/dL) should be investigated and the cause treated appropriately.	Yes	A
3.2	Patient pathways and pre-assessment clinics should be established to allow timely and appropriate management, and elective surgery should be delayed if required.	Yes	B

Cell salvage		Consensus	Grade
4.1	The use of cell salvage should be considered for high- or medium-risk surgery in non-obstetric adult patients where blood loss >500ml is likely.	Yes	B
4.2	The use of cell salvage should be considered for major obstetric haemorrhage.	Yes	B
4.3	In patients with malignancy or obstetric haemorrhage, a leucocyte filter must be used.	Yes	C
4.4	Bacterial contamination of the surgical field remains a relative contra-indication. Use of a leucocyte filter is advised.	Yes	C
4.5	Cell salvage may also be continued in the postoperative period.	Yes	B

Major haemorrhage – initial resuscitation

		Consensus	Grade
5.1	FDP can be substituted for FFP in the South African context.	Yes	B
5.2	15–20ml/kg is the correct initial dose of FDP.	Yes	B
5.3	15–20ml/kg is the correct initial dose of FFP.	Yes	B
5.4	Group O RCC should be readily available and transfused if haemorrhage is life-threatening.	Yes	B
5.5	POC or laboratory testing should be used to guide management.	Yes	C
5.6	During resuscitation, the following should be prevented/treated: hypothermia, acidosis, hypocalcaemia (aim for ionised calcium >1.0mmol/L); and hyperkalaemia.	Yes	A

Major haemorrhage – protocol

		Consensus	Grade
5.7	Policies should be defined in an institutional major haemorrhage protocol.	Yes	A
5.8	To avoid unnecessary delay, blood products should be released without approval from a haematologist/senior.	Yes	A
5.9	Activation of the protocol should mobilise other equipment (blood warmers, pressure infusers, cell salvage etc).	Yes	A

Critical care

		Consensus	Grade
6.1	Evidence does not support increasing oxygen delivery with RCC transfusion when the Hb is >7g/dL, unless the patient has acute cardiac ischaemia.	Yes	A
6.2	In patients with haematological malignancies, the same broad principles of restrictive use of RCC commonly apply (7–8g/dL for RCC transfusion).	No	C

Obstetrics

		Consensus	Grade
7.1	Early recognition of abnormal bleeding improves outcome.	Yes	A
7.2	As soon as abnormal bleeding is recognised, >500ml after a vaginal delivery and >1000ml after a Caesarean section, the obstetrician, anaesthesiologist and senior midwife should attend to the mother.	Yes	A
7.3	Following abnormal bleeding as described in 7.2, blood should be taken for full blood count, clotting studies, group and screen, and a venous blood gas for rapid Hb measurement and lactate.	Yes	B
7.4	Cell salvage is recommended if abnormal bleeding occurs during Caesarean section.	Yes	B
7.5	A leucocyte filter should be used for autotransfusion of processed blood.	Yes	B
7.6	POC testing is recommended in this setting.	Yes	B
7.7	Fibrinogen replacement with cryoprecipitate or fibrinogen concentrate should be considered in these circumstances, if there is bleeding.	Yes	B
7.8	Fibrinogen should be replaced in obstetric haemorrhage if less than 2g/L.	Yes	A
7.9	TXA reduces total blood loss and should be given if postpartum haemorrhage is diagnosed.	Yes	B
7.10	An initial dose of 1g is suitable for TXA.	Yes	A
7.11	Early use of FFP/FDP before RCC may be required.	No	C
7.12	If coagulation tests are not known, then FFP/FDP should be withheld until four units of RCC have been given.	No	C
7.13	If no coagulation results are available and bleeding is ongoing, then, after four units of RCC, four units of FFP/FDP should be infused and 1:1 ratio of RCC–FFP/FDP transfusion maintained until the results of haemostatic tests are known and can guide further decisions.	No	D

Paediatrics

		Consensus	Grade
8.1	There is little direct evidence to guide the use of blood products in children, and generally the guidance intended for adults can be safely applied to children with some modifications.	Yes	C
8.2	‘Restrictive’ approaches to transfusion are appropriate for almost all children older than 3 months of age.	Yes	B
8.3	A transfusion of 10ml/kg of RCC should increase Hb by approximately 2g/dL.	Yes	A
8.4	Cryoprecipitate should be given in a dose of 5–10ml/kg.	Yes	B
8.5	Platelets should be given in a dose of 10–20ml/kg.	Yes	B
8.6	FFP/FDP may be given in doses of 10–15ml/kg.	Yes	B
8.7	TXA can be used in children: a loading dose of 15mg/kg followed by infusion 2mg/kg/h should be used in trauma.	Yes	B
8.8	The guidance suggested for major haemorrhage in adults can be generally applied, though requires an awareness of the size of the child and the clinical context of the bleeding.	Yes	B
8.9	Higher transfusion thresholds are often applied to neonates and children with congenital heart disease.	No	C
8.10	Cell salvage can be useful in children, even if the absolute volume of blood loss is less than 500ml.	No	C

Trauma

		Consensus	Grade
9.1	Ensure clinical treatment is constantly directed towards haemorrhage control (damage-control protocols).	Yes	A
9.2	Do not try to normalise blood pressure during active haemorrhage.	Yes	A
9.3	Maintain a minimum acceptable preload and blood pressure with volume resuscitation alone; this may need to be modified in the presence of trauma in head and spinal injuries.	Yes	A
9.4	During uncontrolled haemorrhage, avoid clear fluids for volume resuscitation unless there is profound hypotension and no imminent availability of blood products.	Yes	B
9.5	In cases of trauma-induced coagulopathy, deliver blood products empirically at first.	Yes	A
9.6	Use laboratory or RCC tests of coagulation to guide therapy as soon as available.	Yes	B
9.7	Give TXA 1g immediately, but avoid if more than 3 hours after injury, unless there is evidence of ongoing hyperfibrinolysis.	Yes	A
9.8	Whilst haemorrhage is being controlled, administration of RCC and FFP/FDP in a ratio of 1:1.	Yes	B
9.9	The use of vasopressors should be avoided during active haemorrhage.	No	D

Cardiac surgery

		Consensus	Grade
10.1	There is no difference in outcome and thus no need to use liberal transfusion triggers (9.5g/dL intraoperatively or ICU, or 8.5g/dL in non-ICU ward) versus a restrictive transfusion trigger (7.5g/dL in cardiac surgical patients).	Yes	A
10.2	The effect of cardiopulmonary bypass on platelet function may make the use of a higher platelet count (>75) necessary after bypass.	Yes	A
10.3	There is no clear evidence of the benefit of platelet function analysis except in those patients who have taken P2Y12 receptor inhibitors such as clopidogrel within 5 days of surgery.	No	C

Predicting perioperative bleeding

		Consensus	Grade
10.4.1	Preoperative fibrinogen levels may be considered to identify patients at high risk of bleeding.	EACTS/ EACTA	C
10.4.2	Routine use of viscoelastic and platelet function testing is not recommended to predict bleeding in patients without antithrombotic treatment.	EACTS/ EACTA	C
10.4.3	Platelet function testing may be considered to guide the decision on the timing of cardiac surgery in patients who have recently received P2Y12 inhibitors or who have ongoing dual antiplatelet therapy (DAPT).	EACTS/ EACTA	B

Management of preoperative anticoagulant and antiplatelet drugs

		Consensus	Grade
10.5.1	In patients undergoing coronary artery bypass grafting (CABG), aspirin (ASA) should be continued throughout the preoperative period.	EACTS/ EACTA	C
10.5.2	In patients at high risk of bleeding or refusing blood transfusions and undergoing non-coronary cardiac surgery, stopping ASA should be considered at least 5 days preoperatively.	EACTS/ EACTA	C
10.5.3	It is recommended that ASA be restarted as soon as there is no concern over bleeding (within 24 hours) after isolated CABG.	EACTS/ EACTA	B
10.5.4	In patients taking DAPT who need to have non-emergent cardiac surgery, postponing surgery for at least 3 days after discontinuation of ticagrelor, 5 days after clopidogrel, and 7 days after prasugrel should be considered.	EACTS/ EACTA	B
10.5.5	It is recommended that GP IIb/IIIa inhibitors be discontinued at least 4 hours before surgery.	EACTS/ EACTA	C
10.5.6	To reduce the risk of bleeding, preoperative bridging of oral anticoagulation with unfractionated heparin/ low molecular weight heparin (UFH/LMWH) is only indicated in patients at high risk of thrombotic events.	EACTS/ EACTA	B
10.5.7	It is recommended that prophylactic LMWH be discontinued at least 12 hours before surgery and fondaparinux 24 hours before surgery. A longer interval may be necessary for patients with impaired renal function and/or therapeutic doses.	EACTS/ EACTA	B
10.5.8	It is recommended that oral anticoagulants (OACs) be bridged with UFH.	EACTS/ EACTA	B
10.5.9	Bridging OACs with subcutaneous LMWH should be considered an alternative to bridging with UFH.	EACTS/ EACTA	B
10.5.10	Elective cardiac surgery should be performed if the international normalised ratio (INR) is <1.5 in patients taking vitamin K antagonists (VKAs). When surgery cannot be postponed, coagulation factors should be used to reverse the effect.	EACTS/ EACTA	C
10.5.11	In patients having elective cardiac surgery, direct oral anticoagulants (DOACs) should be stopped at least 48 hours before surgery. A longer interval may be necessary for patients with impaired renal function.	EACTS/ EACTA	C

Preoperative surgical planning

		Consensus	Grade
10.6.1	Oral or IV iron alone prior to cardiac surgery may be considered in mildly anaemic patients (Hb 10–13g/dL) or in severely anaemic patients (Hb ≤10g/dL) to improve erythropoiesis.	EACTS/ EACTA (adjusted)	C
10.6.2	Erythropoietin with iron supplementation should be considered to reduce postoperative transfusions in patients with non-iron deficiency (e.g.,EPO, vitamin D, or folate acid deficiency) undergoing elective surgery.	EACTS/ EACTA	B
10.6.3	Preoperative erythrocyte transfusion is not routinely recommended in preoperative anaemic patients to prevent postoperative acute kidney injury (AKI).	EACTS/ EACTA	C

Intraoperative management

		Consensus	Grade
10.7.1	It is recommended that the members of the multidisciplinary team discuss the optimal surgical strategy based on clinical status, comorbidities, bleeding risk, and team expertise.	EACTS/ EACTA	C
10.7.2	Off-pump CABG surgery may be considered in selected patients to reduce perioperative transfusions.	EACTS/ EACTA	B
10.7.3	Minimal invasive extracorporeal circulation (MiECC) systems should be considered over standard conventional cardiopulmonary bypass (CPB) systems to reduce perioperative transfusions.	EACTS/ EACTA	B
10.7.4	Minimally invasive heart valve surgery may be considered to reduce blood loss and the need for transfusions.	EACTS/ EACTA	B
10.7.5	Routine use of topical sealants in cardiac surgery is not recommended.	EACTS/ EACTA	B
10.7.6	Topical sealants may be considered in clinical situations where conventional approaches to surgical and medical improvement of haemostasis are insufficient, and where bleeding problems are more local than generalised.	EACTS/ EACTA	C

Management of cardiopulmonary bypass

		Consensus	Grade
10.8.1	Implementation of institutional measures to reduce haemodilution by fluid infusion and CPB during cardiac surgery to reduce the risk of bleeding and the need for transfusions is recommended.	EACTS/ EACTA	C
10.8.2	The use of a closed extracorporeal circuit may be considered to reduce bleeding and transfusions.	EACTS/ EACTA	B
10.8.3	The use of a biocompatible coating to reduce perioperative bleeding and transfusions may be considered.	EACTS/ EACTA	B
10.8.4	The routine use of cell salvage should be considered to prevent transfusions.	EACTS/ EACTA	B
10.8.5	(Modified) ultrafiltration may be considered as part of a blood conservation strategy to minimise haemodilution.	EACTS/ EACTA	B
10.8.6	Retrograde and antegrade autologous priming should be considered as part of a blood conservation strategy to reduce transfusions.	EACTS/ EACTA	A
10.8.7	Normothermia during CPB (temperature >36°C) and maintenance of a normal pH (7.35–7.45) may contribute to a reduced risk of postoperative bleeding.	EACTS/ EACTA	B

Management of intraoperative anticoagulation

		Consensus	Grade
10.9.1	Heparin level-guided heparin management should be considered over ACT-guided heparin management to reduce bleeding.	EACTS/ EACTA	B
10.9.2	Heparin level-guided protamine dosing may be considered to reduce bleeding and transfusions.	EACTS/ EACTA	B
10.9.3	Protamine should be administered in a protamine-to-heparin dosing ratio <1mg:100IU to reduce bleeding.	EACTS/ EACTA	B
10.9.4	Antithrombin (AT) supplementation is ideally indicated in patients with AT deficiency to improve heparin sensitivity. Since AT supplementation is currently not available in South Africa, FFP or FDP should be used.	EACTS/ EACTA (adjusted)	B
10.9.5	AT supplementation is not recommended to reduce bleeding following CPB.	EACTS/ EACTA	C
10.9.6	In patients with heparin-induced thrombocytopenia (HIT) antibodies for whom surgery cannot be postponed, anticoagulation with fondaparinux should be considered when the bleeding risk is acceptable. The use of heparin in the pre- and postoperative periods should be avoided.	EACTS/ EACTA (adjusted)	C

Management of intravascular volume

		Consensus	Grade
10.10.1	The use of goal-directed haemodynamic therapy to reduce transfusions is not recommended.	EACTS/ EACTA	C
10.10.2	The use of modern low-molecular weight starches in priming and non-priming solutions to reduce bleeding and transfusions is not recommended.	EACTS/ EACTA	C
10.10.3	Limitation of haemodilution is recommended as part of a blood conservation strategy to reduce bleeding and transfusions.	EACTS/ EACTA	B
10.10.4	Preoperative autologous blood donation in patients with high Hb levels (>11g/dL) may be considered to reduce postoperative transfusions.	EACTS/ EACTA	B
10.10.5	Acute normovolaemic haemodilution may be considered to reduce postoperative transfusions.	EACTS/ EACTA	B

Management of procoagulant interventions

		Consensus	Grade
10.11.1	Antifibrinolytic therapy (TXA, aprotinin, and EACA) is recommended to reduce bleeding and transfusions of blood products and to reduce re-operations for bleeding (TXA and aprotinin).	EACTS/ EACTA	A
10.11.2	The prophylactic use of FFP/FDP to reduce bleeding is not recommended.	EACTS/ EACTA (adjusted)	B
10.11.3	The use of prothrombin complex concentrate (PCC) or FFP/FDP may be considered to reverse the action of VKAs.	EACTS/ EACTA (adjusted)	B
10.11.4	In patients with factor XIII activity <70% after CPB, the administration of FFP/FDP and/or cryoprecipitate may be considered to reduce bleeding.	EACTS/ EACTA	B
10.11.5	Prophylactic fibrinogen or cryoprecipitate administration is not recommended.	EACTS/ EACTA (adjusted)	B
10.11.6	In the bleeding patient with a low fibrinogen level (<1.5g/L), fibrinogen substitution (cryoprecipitate) may be considered to reduce postoperative bleeding and transfusions.	EACTS/ EACTA (adjusted)	B
10.11.7	In patients where bleeding is related to coagulation factor deficiency, PCC or FFP/FDP administration should be considered to reduce bleeding and transfusions.	EACTS/ EACTA	B
10.11.8	The prophylactic use of desmopressin (DDAVP) to reduce bleeding is not recommended.	EACTS/ EACTA	B
10.11.9	In bleeding patients with platelet dysfunction on the basis of an inherited or acquired bleeding disorder, the use of DDAVP should be considered to reduce bleeding and the requirement for transfusions.	EACTS/ EACTA	C
10.11.10	The prophylactic use of recombinant human factor VIIa (rFVIIa) to prevent bleeding is not recommended.	EACTS/ EACTA	B
10.11.11	In patients with refractory, non-surgical bleeding, off-label use of rFVIIa may be considered to reduce bleeding.	EACTS/ EACTA	B

Management of transfusion strategies

		Consensus	Grade
10.12.1	Implementation of a PBM protocol for the bleeding patient is recommended.	EACTS/ EACTA	C
10.12.2	The use of RCCs of all ages is recommended, because the storage time of the RCC does not affect the outcomes.	EACTS/ EACTA	A
10.12.3	The use of leucocyte-depleted RCCs is recommended to reduce infectious complications.	EACTS/ EACTA	B
10.12.4	Perioperative treatment algorithms for the bleeding patient based on viscoelastic POC tests should be considered to reduce the number of transfusions..	EACTS/ EACTA	B
10.12.5	It is recommended that one transfuse RCCs on the basis of the clinical condition of the patient rather than on a fixed Hb threshold.	EACTS/ EACTA	B
10.12.6	A haematocrit of 21–24% may be considered during CPB when an adequate DO₂ (4 273 ml O₂/min/m²) level is maintained.	EACTS/ EACTA	B
10.12.7	Platelet concentrate should be transfused in bleeding patients with a platelet count below 50 (x10⁹/L) or patients on antiplatelet therapy with bleeding complications.	EACTS/ EACTA	C

Anticoagulation management during extracorporeal life support

		Consensus	Grade
10.13	Argatroban (not available in South Africa) may be considered as alternatives for heparin anticoagulation for prolonged extracorporeal life support/ extracorporeal membrane oxygenation (ECLS/ECMO) therapy to prevent HIT type 2. In South Africa, Fondaparinux is an available alternative, (long half-time is a concern).	EACTS/ EACTA (adjusted)	C

Neuroanaesthesia

		Consensus	Grade
11.1	Anaemia is associated with poor outcomes in traumatic and elective neurosurgery and should be corrected preoperatively using a standardised approach for identifying and treating reversible causes, thus avoiding unnecessary blood product transfusions.	Yes	B
11.2	In traumatic brain injury (TBI), and provided there is no other indication for transfusion, a restrictive (>7–8 g/dL) transfusion threshold should be used as it decreases the risk of severe progressive haemorrhagic injury and thromboembolism.	Yes	C
11.3	Until better evidence is available, a transfusion target of 9g/dL should be used for aneurysmal subarachnoid haemorrhage (SAH).	Yes	C
11.4	TXA should be used in paediatric cranial vault surgery and early (immediate administration on presentation within 3 hours of injury) in mild to moderate TBI.	Yes	B
11.5	Perioperative blood conservation strategies are favoured and include the pharmacological correction of anaemia, the use of TXA, and cell salvage.	Yes	B
11.6	Preoperative autologous donation and acute normovolaemic haemodilution are not recommended as blood conservation techniques.	Yes	C
11.7	Intraoperative nonsteroidal anti-inflammatory agents are not recommended for intracranial procedures.	Yes	C

Coagulation, laboratory and monitoring

Laboratory tests		Consensus	Grade
12.1	Activated partial thromboplastin time (aPPT), prothrombin time (PT), and INR have little relevance in acute ongoing haemorrhage.	Yes	N/A
RCC testing		Consensus	Grade
13.1	The use of validated POC tests is a more relevant reflection of coagulation status and are preferred.	Yes	B
13.2	Patients at high risk (>10% risk of thrombotic events per year) of thrombosis should be considered for bridging anticoagulation, or in the following circumstances:^3-5 - Embolic stroke or systemic embolic event within the previous three months. - Mechanical mitral valve. • Mechanical aortic valve and additional stroke risk factors. - Atrial fibrillation and very high risk of stroke (e.g. CHADS2 score of 5 or 6, stroke or systemic embolism within the previous 12 weeks, concomitant rheumatic valvular heart disease with mitral stenosis). - Venous thromboembolism (VTE) within the previous three months (preoperative and postoperative bridging). - Recent coronary stenting (e.g. within the previous 12 weeks). - Previous thromboembolism during interruption of chronic anticoagulation.	Yes	B
13.3	Bridging anticoagulation usually consists of LMWH.	Yes	C

Packed red blood cells

		Consensus	Grade
14.1	A general Hb threshold of 7g/dL should apply as a guide for red cell transfusion.	Yes	B
14.2	Uncertainty remains for patients with ischaemic heart disease, including acute coronary syndrome (ACS) and after cardiac surgery, and higher thresholds (8g/dL) may be more appropriate in such circumstances.	Yes	A

FFP/FDP

		Consensus	Grade
15.1	The recommended initial therapeutic dose is 15–20ml/kg.	Yes	A
15.2	Indications for FFP/FDP use include the following:
15.2.1	Maintenance of coagulation factors during major haemorrhage, particularly trauma and obstetrics.	Yes	A
15.2.2	Acute disseminated intravascular coagulation (DIC) with bleeding.	Yes	C
15.2.3	In patients who are actively bleeding and whose INR is >1.5 (or POC equivalent).	Yes	B
15.2.4	Immediate reversal of warfarin-induced haemorrhage when PCC is not available (PCC is the first choice).	Yes	B
15.2.5	Thrombotic thrombocytopenic purpura (preferably using pathogen-inactivated FFP or FDP), with plasmapheresis if no response.	Yes	A
15.2.6	Replacement of coagulation factors when specific factors are not available in the presence of active bleeding or to prevent bleeding during an invasive procedure (uncommon).	Yes	B
15.3	FFP/FDP is not recommended for routine use in patients with cirrhosis/liver disease unless significant coagulopathy and haemorrhage are identified.	Yes	B

Cryoprecipitate

		Consensus	Grade
16.1	Indications for cryoprecipitate include the following:
16.1.1	Hypofibrinogenaemia due to major haemorrhage and massive transfusion.	Yes	A
16.1.2	During major haemorrhage, fibrinogen should be maintained >1.5g/L, except in active obstetric haemorrhage where fibrinogen should be maintained >2g/L.	Yes	A
16.1.3	Bleeding associated with thrombolytic therapy.	Yes	C
16.1.4	DIC with fibrinogen <1.0g/L.	Yes	B
16.1.5	Advanced liver disease, to maintain fibrinogen level >1.0g/L.	Yes	B
16.1.6	Combined liver and renal failure with bleeding.	No	C
16.2	The initial dose of cryoprecipitate should be 1 unit/10kg (typically 15–20ml/10kg).	Yes	A

Platelets

		Consensus	Grade
17.1	Indications for platelets include the following:
17.1.1	Prevention and treatment of bleeding due to thrombocytopenia or platelet function defects.	Yes	B
17.1.2	If patient is actively bleeding, transfuse to a platelet count > 50x10⁹/L (>75x10⁹/L for neurosurgical and ophthalmic bleeding).	Yes	B
17.2	If not bleeding, the following triggers should be applied:
17.2.1	Routine prophylactic use: 10x10⁹/L.	Yes	B
17.2.2	Prophylactic use with additional risk factors (e.g. sepsis): 10–20x10⁹/L.	Yes	C
17.2.3	Other major surgery or invasive procedures: 50x10⁹/L.	Yes	C
17.2.4	Neuraxial blockade: 50x10⁹/L.	Yes	B
17.2.5	Prophylactic use in closed compartment surgery (eye, brain): 100x10⁹/L.	Yes	B

Drugs and novel therapies

		Consensus	Grade
18.1	TXA should be administered empirically in critically ill patients with severe trauma within 3 hours of the injury.	Yes	A
18.2	The dose of TXA in severe trauma is 1g stat and then 1g over 8 hours.	Yes	A
18.3	TXA should be administered empirically in bleeding obstetric patients.	Yes	B
18.4	The dose of TXA in bleeding obstetric patients is 1g stat, and 1g after 30 min if bleeding persists or recurs within 24 hours.	Yes	B
18.5	Empiric use of TXA is not recommended in patients with upper gastrointestinal bleeding.	Yes	B
18.6	TXA is recommended for patients with TBI and Glasgow coma scale (GCS) 8-13 presenting within 3 hours of injury.	Yes	B
18.7	Where available, POC viscoelastic testing should be used to guide therapy with TXA.	Yes	C
18.8	With the use of warfarin: INR to be kept between 2.0 and 2.5 according to indication. Perioperative use: stop 3–5 days before surgery; INR reduction to <1.5 if you are using bridging therapy. Bridging necessary only in patients with a very high thrombotic risk.	Yes	B
18.9	Direct acting anticoagulants – stop 48 hours before surgery. If renal impairment then stop earlier: If creatinine clearance >80ml/min/1.73m²>48 hr. If creatinine clearance 50–79ml/min/1.73m²>72 hr. If creatinine clearance <50ml/min/1.73m²>96 hr.	Yes	B
18.10	Antiplatelet therapy: Aspirin – don’t stop unless operating on a non-compressible site. Ticagrelor – stop 3 days before surgery. Clopidogrel – stop 5 days before surgery. Prasugrel – stop 7 days before surgery. If need to continue due to high risk of thrombosis, consider options such as GP IIb/IIIa.	Yes	B
18.11	GP IIb/IIIa antagonists – stop at least 4 hours before surgery. (Stop Abciximab earlier as a longer time is required for recovery of platelet function 24–48 hours).	Yes	B
18.12	LMWH – stop at least 12 hours before surgery if used prophylactically, and 24 hours before surgery if used in therapeutic doses. The anticoagulation effect can partially be reversed by protamine sulphate, but not completely. Consider bridging with LMWH/UFH only in patients with a high risk for thrombosis who are on oral anticoagulants. Enoxaparin – stop at least 12 hours before surgery. Fondaparinux – stop 24 hours before surgery. Stop for longer duration in patients with impaired renal function.	Yes	B

Administration

		Consensus	Grade
19.1	The use of blood and blood products must be directed by established protocols.	Yes	B
19.2	The use of blood and blood products must be subjected to gatekeeping controls.	Yes	C

Ethics

		Grade
20.1	Both blood donors and recipients must be protected through safe blood management practices.	N/A
20.2	Blood transfusion services must comply with the provisions of the standards of practice for blood transfusions in South Africa.	N/A
20.3	All blood and blood products require informed consent prior to transfusion.	N/A
20.4	If consent cannot be provided by the patient, consent may be provided by a person mandated in writing by the patient, a person authorised by any law or court order or any surrogate decision maker.	N/A
20.5	Advanced directives (or ‘living wills’), while having no legal force, should be ethically honoured.	N/A
20.6	An adult may refuse blood and blood products solely on religious grounds if the patient is of sound mind and understands the risks and consequences of such refusal.	N/A
20.7	No parent or guardian may refuse blood or blood products for a minor solely on religious grounds if the blood or blood product would be life-preserving.	N/A
20.8	If a clinician is uncertain of any reason a patient would refuse blood and there is a clear indication for the use of blood or a blood product to preserve life, the best interests of the patient must prevail.	N/A
20.9	Blood and blood products should be triaged in a resource-limited environment.	N/A
20.10	Health authorities should ensure that blood services are progressively developed to ensure the needs of the patients are met.	N/A

Click here for the PDF.

South African Society of Anaesthesiologists (SASA) Guidelines for Patient Blood Management 2020. Confirmed as current version on the SASA website as of November 2024.

Summary of Recommendations

Grading of recommendation