Summary of Recommendations

Grading of recommendations

Each recommendation has been given a grade, using the following definitions, set by the Australian National Health and Medical Research Council (NHMRC) (Boxes 1 and 2).

Box 1. Grading of recommendations

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.

 Box 2. Recommendations

General PBM measures

1.1	Minimise blood sampling for diagnostic testing.
1.2	Investigate and treat specific causes of anaemia when identified
1.3	Apply restrictive transfusion thresholds unless evidence exists to the contrary
1.4	A single-unit blood transfusion policy with reassessment of the ongoing need for transfusion after each unit should be used except when there is active bleeding.
1.5	Non-transfusion methods to reduce the need for blood products should be utilised when possible.
1.6	Coagulation should be optimised by correcting temperature and electrolyte (calcium) abnormalities to reduce the need for blood products
1.7	Point-of-care testing should be available with appropriate training.
1.8	Elective surgery in patients requiring critical care should be postponed in the presence of untreated anaemia.
1.9	Every effort should be made to minimise bleeding during procedures in the ICU.

 

Red Cells
		Consensus	Grade
2.1	A restrictive transfusion strategy is recommended in critically ill patients	Yes	B
2.2	The need for RCC transfusions should not be dictated solely by Hb concentration.	Yes	B
2.3	The need for RCC transfusions should include a clinical assessment of the patient's need for transfusion.	Yes	B
2.4	An individualised approach to the need for RCC transfusion should be followed, using Hb and clinical assessment.	Yes	B
2.5	An appropriate transfusion trigger in the general critically ill patient is Hb <7 g/dL.	Yes	B
2.6	In the general critically ill patient, transfusion is unlikely to be beneficial with Hb >7 g/dL.	Yes	B
2.7	In a patient with sepsis/septic shock, an appropriate transfusion trigger is Hb <7 g/dL.	Yes	B
2.8	In a patient with acute coronary syndrome, an appropriate transfusion trigger is Hb <8 - 9 g/dL.	Yes (R)*	C
2.9	In a patient with a traumatic brain injury, an appropriate transfusion trigger is Hb <7 - 9 g/dL	Yes (R)*	C
2.10	In a patient with a subarachnoid haemorrhage, an appropriate transfusion trigger is Hb <8 - 9 g/dL.	Yes (R)*	C
2.11	In a patient with other acute cerebrovascular events, an appropriate transfusion trigger is Hb 7 - 8 g/dL.	Yes (R)*	C
2.12	In a resuscitated, non-bleeding trauma patient, an appropriate transfusion trigger is Hb <7 g/dL.	Yes (R)*	C
2.13	In a non-resuscitated trauma patient with significant active bleeding, transfusion triggers may be unreliable. In other scenarios, an appropriate transfusion trigger is Hb 7 - 10 g/dL. In both cases, transfusion must be individualised based on the patient’s physiological status and access/availability of blood products.	Yes (R)*	D
2.14	Where feasible, RCCs should be transfused one unit at a time, with clinical assessment after each unit to determine if further units are required.	Yes	B
2.15	Target Hb levels need only be above the trigger	Yes	C
2.16	Leucodepleted packed red blood cells should not be routinely used in the critically ill, in the SA context.	Yes	D
2.17	The are no other specific forms (whole blood, irradiated, specific donor) of RCC transfusion routinely indicated in critically ill patients.	Yes	D

 

Non-transfusion interventions to reduce RCC transfusions
		Consensus	Grade
3.1	There is no role for erythropoietin in general critically ill anaemic patients as an alternative to RCC transfusion.	Yes	B
3.2	There is no role for routine use of IV Fe in general critically ill anaemic patients as an alternative to RCC transfusion	Yes	B
3.3	The use of cell salvage should be considered in the critically ill where appropriate.	Yes	C
3.4	There is currently no role for the routine use of artificial oxygen carriers in the general critically ill patient in SA.	Yes	D

 

Platelets
		Consensus	Grade
4.1	In critically ill patients without acute bleeding and who are not undergoing invasive procedures, platelets should be administered at a platelet count ≤10 × 109 /L. Platelet transfusion should be considered if the level is <20 × 109 /L if active bleeding, or infection, or rate of platelet decline is such that platelet count is expected to drop below 10 in the next 24 hours.	Yes	B
4.2	A platelet count ≥50 × 109 /L is generally acceptable for invasive procedures in the ICU.	Yes	C
4.3	A platelet count ≥20 × 109 /L may be acceptable for CVC placement in the absence of any other bleeding risk.	Yes	D
4.4	A platelet count ≥50 × 109 /L is generally acceptable for surgical procedures.	Yes	C
4.5	Neurosurgery and posterior ophthalmic surgery may require a higher platelet count ≥100 × 109 /L.	Yes	C
4.6	A platelet count ≥20 - 30 × 109 /L is generally acceptable for bronchoscopy with BAL.	ND†	C
4.7	A platelet count ≥10 × 109 /L is generally acceptable for lumbar puncture in patients with haematologic malignancies and >40 × 109 /L in patients without haematologic malignancies, but lower in patients with ITP.	ND†	C
4.8	A platelet count ≥75 × 109 /L is generally acceptable for epidural catheter placement.	ND†	C
4.9	A platelet count ≥20 × 109 /L is generally acceptable for bone marrow aspiration/biopsy	ND†	C
4.10	In a patient with clinically significant bleeding, platelets should be administered if the platelet count is <50 × 109 /L	Yes	D
4.11	Where available, point-of-care viscoelastic testing may be used to guide therapy with platelets instead of the platelet count.	Yes	C
4.12	In the setting of large volume blood transfusion, a ratio of 1 unit of platelets for each 1 unit of RCCs should be transfused (1 pooled unit of platelets = 5 units).	Yes	C
4.13	Platelets should be transfused 1 pooled unit at a time, followed by reassessment to determine if additional platelet transfusion is required.	Yes	D

 

Plasma
		Consensus	Grade
5.1	FFPs and FDPs should be considered clinically interchangeable.	Yes	N/A
5.2	Invasive procedures can generally be performed safely with INR <2.	Yes	C
5.3	FDPs/FFPs are indicated prior to invasive procedures if INR >2.	Yes	C
5.4	In the bleeding patient, FFPs/FDPs should be administered if INR >2.	Yes	C
5.5	Where available, point-of-care viscoelastic testing, instead of the INR, may be used to guide therapy with FFPs/FDPs.	Yes	C
5.6	Empiric FFP/FDP therapy may be indicated in specific circumstances e.g. large volume haemorrhage, TTP.	Yes	B
5.7	A dose of 15 mL/kg of FFP/FDP should be utilised when indicated. This may need to be increased to 30 mL/kg in specific conditions.	Yes	C
5.8	In the setting of large-volume haemorrhage, a ratio of 1 unit of FFPs/FDPs to 1 unit of packed RCC should be transfused.	Yes	C

 

Cryoprecipitate
		Consensus	Grade
6.1	Cryoprecipitate should be given in patients with significant bleeding if fibrinogen <2.0 g/L.	Yes	B
6.2	Cryoprecipitate should not be given in the absence of significant bleeding even if fibrinogen levels are low.	Yes	C
6.3	Cryoprecipitate administration should be guided by point-of-care viscoelastic testing where available.	Yes	C
6.4	The recommended dose of cryoprecipitate for adults is 1 unit/10 kg (SANBS recommends administration of a fixed dose of 10 units, while WCBS recommends administering 1 pooled unit).	Yes	C

 

Tranexamic acid
		Consensus	Grade
7.1	Tranexamic acid should be administered empirically in critically ill patients with severe trauma within 3 hours of the injury	Yes	B
7.2	The dose of tranexamic acid in severe trauma is 1 g IV stat and then 1 g IV over 8 hours.	Yes	B
7.3	Tranexamic acid should be administered empirically in bleeding postpartum obstetric patients.	Yes	B
7.4	The dose of tranexamic acid in bleeding obstetric patients is 1 g stat, and 1 g after 30 minutes if bleeding persists.	Yes	B
7.5	Empiric use of tranexamic acid may be considered in patients with upper gastrointestinal bleeding.‡	No	D
7.6	The use of tranexamic acid may be considered in patients with TBI, if administered within 3 hours of injury.	ND†	C
7.7	Empiric tranexamic acid therapy is not indicated in other settings in ICU.	Yes	D
7.8	Where available, point-of-care viscoelastic testing should be used to guide therapy with tranexamic acid.	Yes	C

 

Coagulation testing and monitoring
		Consensus	Grade
8.1	Point-of-care viscoelastic testing is the preferred test of coagulation function to direct therapy in critically ill patients.	Yes	C
8.2	The aPTT has a limited role in monitoring critically ill bleeding patients and is generally limited to monitoring the effect of heparin and screening for possible coagulopathies in the absence of viscoelastic testing.	Yes	C
8.3	The INR has a limited role in monitoring critically ill bleeding patients and is generally limited to monitoring the effect of warfarin and screening for possible coagulopathies in the absence of viscoelastic testing.	Yes	C
8.4	Fibrinogen levels are recommended in critically ill bleeding patients to guide the use of cryoprecipitate in the absence of viscoelastic testing.	Yes	C

 

Administration
		Consensus	Grade
9.1	The use of blood and blood products should be directed by established protocols.	Yes	B
2.2	The use of blood and blood products should be subjected to gatekeeping controls.	Yes	B

 

Ethics
		Consensus	Grade
10.1	Informed consent should be obtained from the patient or surrogate prior to the transfusion of blood products if time allows.	Yes	N/A
10.2	In the adult patient who is unable to provide informed consent, and where a clear advanced directive against the use of blood products does not exist, blood products may be transfused in the emergency setting if deemed potentially lifesaving.	Yes	N/A
10.3	In the paediatric patient, where the surrogate refuses consent for the use of blood products, legal advice should be sought prior to the administration of blood products unless there is an emergency life-threatening situation necessitating immediate transfusion.	Yes	N/A
10.4	The use of blood products should be triaged in a resource-limited environment.	Yes	N/A

PBM = patient blood management;
ICU = intensive care unit;
RCC = red cell concentrate;
Hb = haemoglobin;
Fe = iron;
CVC = central venous catheter;
N/A = not applicable;
FFP = fresh frozen plasma;
FDP = fibrin degradation products;
INR = international normalised ratio;
TTP = thrombotic thrombocytopenic purpura;
SANBS = South African National Blood Services;
WCBS = Western Cape Blood Services;
IV = intravenous
TBI = traumatic brain injury;
aPPT = activated partial thromboplastin time.
*(R) indicates that while consensus was not reached on a single value, consensus was reached on the range indicated.
† ND indicates that the recommendation was not subject to the Delphi process; this was due to the availability of new study data that were published after the Delphi process.
‡ Review undertaken prior to the publication of the HALT-IT trial.
Refer to section 7.1 Tranexanamic acid: Upper gastrointestinal tract bleeding.

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Critical Care Society of Southern Africa Adult Patient Blood Management Guidelines: 2019 - Round-table meeting, CCSSA Congress, Durban, 2018_SAJCC_July 2020, Vol. 36, No. 1