/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/blood-products/,

/clinical/cckm-tools/content/cpg/blood-products/name-97481-en.cckm

20170386

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Blood Products

Indications for Blood Product Transfusion – Adult – Inpatient/Ambulatory

Indications for Blood Product Transfusion – Adult – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Blood Products


1
Indications for Blood Product
Transfusion – Adult –
Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 3
METHODOLOGY ...................................................................................................................... 4
INTRODUCTION ....................................................................................................................... 5
RECOMMENDATIONS .............................................................................................................. 5
Administration Of All Products ............................................................................................................. 5
Red Blood Cells ................................................................................................................................... 5
Platelets ............................................................................................................................................... 7
Cryoprecipitate .................................................................................................................................... 8
Plasma Products ................................................................................................................................. 9
Special Products/Procedures21 ......................................................................................................... 11
UW HEALTH IMPLEMENTATION ............................................................................................12
APPENDIX A. EVIDENCE GRADING SCHEMES ....................................................................14
APPENDIX B. INTERIM REVISIONS .......................................................................................16
REFERENCES .........................................................................................................................17
CPG Contact for Content:
Name: Thomas Raife, MD- Pathology- Lab Medicine
Phone Number: (608) 265-8492
Email Address: traife@wisc.edu
CPG Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

2
Coordinating Team Members:
Charles Heise, MD- Surgery- General Surgery
Charles Acher, MD- Surgery- Vascular Surgery
Joshua Medow, MD- Neurological Surgery- General
Eliot Williams, MD- Medicine- Hematology/Oncology
Muhammad Munir, MD- Medicine- Hospitalists
Scott Wilson, MD- Medicine- Hospitalists
Christopher Turner, MD- Anesthesiology- General
Michael Hannaman, MD- Anesthesiology- General
Laura Hammel, MD- Anesthesiology- Transplant
Andrew Schroeder, MD- Anesthesiology- Cardiothoracic
Timothy Graham, MD- Anesthesiology- Critical Care
Martha Wynn, MD- Anesthesiology- Vascular Surgery
Jeffrey Wells, MD- Medicine- Pulmonary
Erin Billmeyer, NP- Medicine- Pulmonary
Jenna Potter, NP- Medicine- Pulmonary
Margaret Murray, CNS- Cardiothoracic Surgery
Bethaney Campbell, MN, RN, AOCNS- Bone Marrow Acquisition
Dean Lawler- Clinical Labs- Administration
Robin Grimes- Clinical Labs- Transfusion Service
Anne Rose, PharmD- Pharmacy- Inpatient Services
Zach Tilson- Quality, Safety and Innovation (QSI)
Alison Meier- Population Health
Bradley Ehlenfeldt- Information Services- Clinical Systems
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Kristen Sipsma- Center for Clinical Knowledge Management (CCKM)
Review Individuals/Bodies:
James Maloney, MD- Surgery- Cardiothoracic
Brian Sharp, MD- Emergency Medicine
Andrew Lee, MD- Emergency Medicine
John Weiss, MD- Pathology- General
William Rose, MD- Pathology- General
Joseph Connor, MD- Pathology
Ravi Dhingra, MD- Cardiology
Committee Approvals/Dates:
Tissue and Blood Products Committee (09/16/2015)
Inpatient Anticoagulation Committee
ξ Interim revisions (01/09/2017)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 09/24/2015)
ξ Interim revisions (05/26/2016; 03/23/2017)
Release Date: March 2017 Next Review Date: September 2017
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
This guideline contains recommendations for the indications of blood product transfusion and is
heavily influenced by recommendations released by the American Association of Blood Banks
(AABB).
Key Practice Recommendations
1. Transfusion rates should be dependent upon the hemodynamic stability of the patient and
disease processes.
2. Transfusing the minimum number of blood product units necessary to relieve symptoms, or
return a patient to safe range or targeted levels, is recommended.
3. In cases of life-threatening hemorrhage after trauma or during a surgical procedure, massive
transfusion protocols may be implemented to minimize the adverse effects of hypovolemia
and dilutional coagulopathy.1 Per UW Health policy 8.94, blood products may be ordered as
clinically indicated under the Massive Transfusion Protocol when blood loss of more than
one total blood volume is expected in a short period of time.
4. Evidence has demonstrated no mortality benefit using a liberal transfusion threshold
(hemoglobin levels > 10 g/dL), whereas a restrictive transfusion threshold (hemoglobin
levels of 7-8 g/dL) has demonstrated fewer cardiovascular events in non-cardiac surgery
patients.
Companion Documents
1. UW Health Management of Non-ST Elevation Acute Coronary Syndromes – Adult –
Inpatient Clinical Practice Guideline
2. UW Health Procoagulant Therapy for Non-Hemophilic Bleeding Patients – Adult –
Inpatient/Ambulatory Clinical Practice Guideline
3. UW Health Darbepoetin and Epoetin in Non-Nephrology Patients – Pediatric/Adult –
Inpatient/Ambulatory Clinical Practice Guideline
4. UW Health Mechanical Circulatory Device – Adult – Inpatient/Ambulatory Clinical Practice
Guideline
5. UW Health Management with Antithrombotic Therapy in Periprocedural, Regional
Anesthesia and/or Pain Procedure Settings – Adult – Inpatient/Ambulatory Clinical Practice
Guideline
6. UW Health Massive Transfusion Protocol
Scope
Disease/Condition(s): Any disease or condition requiring blood transfusion.
Clinical Specialty: Hematology/Oncology, Transplant, Surgery, Hospitalists, Critical Care,
General Medicine, Gynecology, Pathology, Anesthesiology, Emergency Medicine
Intended Users: Physicians, Physician Assistants, Nurse Practitioners, Nursing
CPG objective(s): To outline evidence-based recommendations and indications for blood
product transfusion (including red blood cells, platelets, plasma, and cryoprecipitate).
Target Population: Adult patients (18 years or older) admitted to an inpatient service, seen
within the emergency department, operating room, or HOD clinic.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



4
Major Outcomes Considered:
1. Reduced length of stay (total hospital admission, ICU admission)
2. Improved mortality rates
3. Reduced rates of stroke or myocardial infarction
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database (i.e., PUBMED) searches were conducted by CCKM and workgroup
members to collect evidence for review. Expert opinion and clinical experience was also
considered during evidence discussions.

Methods Used to Formulate the Recommendations:
The workgroup members adopted recommendations developed by external organizations
and/or arrived at a consensus through discussion of the literature and expert experiences. All
recommendations developed by the workgroup were reviewed and approved by other UW
Health committees as appropriate.

Methods Used to Assess the Quality and Strength of the Evidence:
Recommendations developed by external organizations, such as the AABB, maintained the
evidence grade assigned within the original source document and were adopted for use at UW
Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the workgroup using the Grading of
Recommendations Assessment, Development and Evaluation (GRADE) algorithm (see Figure
1).

Figure 1. GRADE Methodology adapted by UW Health

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the various rating schemes used within this document.




Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



5
Introduction
Blood transfusions should maximize clinical and patient outcomes, while minimizing cost and
potential exposure to infections or other patient risks. Evidence has demonstrated improved
patient outcomes (reduced lengths of stay and mortality) concurrent with decreasing blood
product utilization, as well as improvements in readmission rates and cost.2,3 The following
guidelines outline key indications for the transfusion of blood products at UW Health.
Recommendations
ADMINISTRATION OF ALL PRODUCTS
Transfusion rates are dependent upon the hemodynamic stability of the patient and disease
processes. Transfusing more than the minimum number of blood product units necessary to
relieve symptoms, or return a patient to safe range or targeted levels, is not recommended.4
(UW Health Moderate quality evidence, strong recommendation)

In general, transfusion of any blood product should be completed within 4 hours. Units should
not be infused after the expiration date or time written on the label, without exception.
RED BLOOD CELLS
The decision to transfuse red blood cells should always be dependent on patient presentation
and individual characteristics, degree of severity of anemia, presence and severity of
comorbidities, and the clinical judgement of the physician. An equation which calculates the
appropriate number of packed red blood cell units needed to meet a target hemoglobin or
hematocrit level may be referenced and is included as an appendix to this guideline.

In making transfusion decisions, it is important to consider patient symptoms, as well as
hemoglobin concentrations.5,6 (AABB Low quality evidence, weak recommendation) Monitoring for
perfusion of vital organs (i.e., blood pressure, heart rate, oxygen saturation,
electrocardiography) is recommended, in addition to observing clinical symptoms and physical
exam features.1 Symptoms indicative of red blood cell transfusion may include chest pain of
cardiac origin, congestive heart failure, unexplained tachycardia, or hypotension unresponsive
to fluid replacement.5,6

R1 and R2: With the exception of some patients with upper GI bleeds, patients with severe,
active bleeding should receive a red blood cell transfusion. (UW Health Low quality evidence,
strong recommendation)

Patients with suspected bleeding or a drop in hemoglobin of 3 g/dL or greater may also receive
a blood transfusion. (UW Health Very low quality evidence, weak/conditional recommendation)

R3: In cases of acute upper gastrointestinal bleeding, recent evidence suggests improved
outcomes when maintaining a conservative transfusion threshold of 7 g/dL.7 Therefore,
transfusing to a target hemoglobin level greater than or equal to 7 g/dL is recommended in
patients with upper gastrointestinal bleeding. (UW Health High quality evidence, strong
recommendation)

R4: Evidence has demonstrated no mortality benefit using a liberal transfusion threshold
(hemoglobin levels > 10 g/dL), whereas a restrictive transfusion threshold (hemoglobin levels of
7-8 g/dL) has demonstrated fewer cardiovascular events in noncardiac surgery patients.8,9
Restrictive strategies have also demonstrated reductions in cost, without negative impacts on
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



6
patient outcomes.2 The AABB recommends adhering to a restrictive transfusion strategy (7 to 8
g/dL) in hospitalized, hemodynamically stable patients.6 (AABB High quality evidence, strong
recommendation) Intensive care patients may receive a transfusion at hemoglobin concentrations
of 7 g/dL or less, whereas postoperative surgical patients who are hemodynamically stable may
receive a transfusion at hemoglobin concentrations of 8 g/dL or less or for symptoms.6

R5: Routine blood transfusion in hemodynamically stable patients with non-ST elevation acute
coronary syndromes and hemoglobin levels greater than 8 g/dL is not recommended.10 (AHA
Class III, LOE B) Hemodynamically stable patients with pre-existing cardiovascular disease (e.g.,
CAD) should be considered for transfusion at a hemoglobin level of 8 g/dL or less or when
presenting with symptoms.6,8 (AABB Moderate quality evidence, weak recommendation)

A target Hgb greater than 8 g/dL is recommended in patients who have recently undergone a
bone marrow transplant or who are myelosuppressed. (UW Health Low quality evidence,
weak/conditional recommendation)

R6:
The Extracorporeal Life Support Organization recommends that patients receive a transfusion to
normal hemoglobin of 12 to 14 g/dL. Many ECMO centers follow this approach, although the
optimal transfusion threshold remains unknown.11,12 (UW Health Very low quality evidence,
weak/conditional recommendation)

The European Association for Cardiothoracic Surgery recommends the consideration of aiming
for adequate hemoglobin levels (> 10 g/dL) in patients with spinal cord injury undergoing
thoracic and thoracoabdominal aortic surgery and endovascular aortic repair.13 (EACTS Class IIa,
Level of Evidence C)

The use of packed red blood cell transfusion to treat anemia might be reasonable in patients
with aneurysmal subarachnoid hemorrhage who are at risk of cerebral ischemia. The optimal
hemoglobin goal is still to be determined.14 (AHA/ASA Class IIb, Level of Evidence B)

An important goal of therapy in patients with Sickle Cell Disease is the transfusion of red blood
cells to prevent sickling by reducing the proportion of sickle cells, as opposed to simply
improving oxygen carrying capacity. Optimal transfusion thresholds vary patient to patient,
however the hemoglobin and hematocrit levels may be maintained as high as 10 g/dL or 30%
respectively.15,16 (UW Health High quality evidence, weak/conditional recommendation)

R7: In cases of life-threatening hemorrhage after trauma or during a surgical procedure,
massive transfusion protocols may be implemented to minimize the adverse effects of
hypovolemia and dilutional coagulopathy.1 Per UW Health policy 2.2.2, red blood cells may be
ordered as clinically indicated under the Massive Transfusion Protocol when blood loss of more
than one total blood volume is expected in a short period of time.

Table 1. Indications for Red Blood Cell Transfusion in Adults
Indication
Code Reason for Order
R1 Life-threatening hemorrhage or anticipated/ongoing surgical blood loss
R2 Suspected bleeding, symptomatic or drop in Hgb > 3 g/dL or Hct drop > 10
R3 Target Hgb > 7 g/dL or Hct > 21% in acute upper GI bleeds
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



7
R4 Target Hgb > 7 g/dL or Hct > 21% in stable, nonbleeding patients
R5
Target Hgb > 8 g/dL or Hct > 24% in patients who are myelosuppressed/bone
marrow transplant or symptomatic and with diseases significantly impairing
tissue O2 delivery, acute coronary syndromes (e.g., MI, unstable angina)
R6 High risk patients
(e.g., ECMO, TAAA, stroke/cerebral vasospasm, Sickle Cell Disease)
R7 Massive Transfusion Protocol
R8 Other (specify in comments):____________________________________
Dose: 1 unit of packed cells generally raises Hgb by 1 g/dL, Hct by 3% in adults
PLATELETS
The decision to transfuse platelets should be dependent on patient presentation and individual
characteristics, presence and severity of comorbidities, and the clinical judgement of the
physician.

Platelets should not be transfused in patients with thrombotic thrombocytopenic purpura (TTP)
or heparin-induced thrombocytopenia (HIT), unless a life-threatening hemorrhage has
occurred.17(AFP Grade C) Routine prophylactic platelet transfusion for patients who are
nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass is not
recommended. It is suggested to transfuse only in patients having bypass who exhibit
perioperative bleeding with thrombocytopenia and/or evidence of platelet dysfunction.18 (AABB
Very low quality evidence, weak recommendation)

P1: Patients with a platelet count of 10 K/µL or less should receive a transfusion to reduce the
risk of spontaneous bleeding.18,19 (AABB Moderate quality evidence, strong recommendation) This
recommendation includes patients with a hematological disorder undergoing chemotherapy or
stem cell transplantation.20 Prophylactic platelet transfusion is recommended to reduce the risk
for spontaneous bleeding in hospitalized patients with therapy-induced hypoproliferative
thrombocytopenia.18

P2: The AABB suggests platelet transfusion in patients having elective central venous catheter
placement and platelet counts less than 20 K/µL may receive platelet transfusions.18 (AABB Low
quality evidence, weak recommendation) Bone marrow transplant patients with minor bleeding
(e.g., petechiae, nose bleeds, etc.) or fever of 38°C may receive a transfusion to maintain
platelet counts of 20 K/µL or greater. (UW Health Moderate quality evidence, weak/conditional
recommendation)

P3: Prophylactic transfusion is suggested in patients with a platelet count of 50 K/µL or less and
who are having an elective diagnostic lumbar puncture or major elective nonneuraxial surgery.18
(AABB Very low quality evidence, weak recommendation) Transfusion is also suggested in patients
who are significantly bleeding with a platelet count of 50 K/µL or less. (UW Health Very low quality
evidence, weak/conditional recommendation)

P4: Platelets are conventionally transfused prophylactically for a preprocedure platelet count of
80 K/µL to 100 K/µL for patients undergoing surgery involving the central nervous system.18 (UW
Health Low quality evidence, weak/conditional recommendation) Patients undergoing ocular surgery
or epidural catheter and lumbar drain placement may receive a transfusion when they exhibit a
platelet count of less than 100 K/µL. (UW Health Very low quality evidence, weak/conditional
recommendation)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



8
P5: Patients with ongoing bleeding and documented or suspected platelet dysfunction due to
anti-platelet medication (e.g., Plavix, aspirin) or other disease processes may be candidates for
platelet transfusion. (UW Health Very low quality evidence, weak/conditional recommendation)

P6: In cases of life-threatening hemorrhage after trauma or during a surgical procedure,
massive transfusion protocols may be implemented to minimize the adverse effects of
hypovolemia and dilutional coagulopathy.1 Per UW Health policy 2.2.2, platelets may be ordered
as clinically indicated under the Massive Transfusion Protocol when blood loss of more than one
total blood volume is expected in a short period of time.

Table 2. Indications for Platelet Transfusion in Adults
Indication
Code Reason for Order
P1 Target Plts > 10 K/µL
P2 Target Plts > 20 K/µL and central venous catheter placement within 6 hours or minor bleeding in BMT/leukemia-induction patients
P3 Target Plts > 50 K/µL and significant bleeding or invasive procedure/surgery planned within six hours (e.g., lumbar puncture, nonneuraxial surgery)
P4 Target Plts > 100 K/µL with major CNS/eye surgery, for up to 48 hrs. post op, epidural catheters and lumbar drains
P5 Platelet dysfunction and ongoing bleeding
P6 Massive Transfusion Protocol
P7 Other (specify in comments):____________________________________
Dose: Suggested guidelines:
Single Donor Platelets- 1 SD unit ~ 250-400 mL and (3.0)x1011 platelets
Suggested dose:
ξ Patients > 40 kg = 1 SD unit
ξ Patients < 40 kg = 10-20 ml/kg body weight
Note: Platelet transfusions are contra-indicated for TTP; HUS; HIT unless there is the
potential for life-threatening bleeding
CRYOPRECIPITATE
The decision to transfuse cryoprecipitate should be dependent on patient presentation and
individual characteristics, presence and severity of comorbidities, and the clinical judgement of
the physician.

The use of cryoprecipitate is not recommended to make fibrin glue, due to the potential related
adverse reactions. (TMAG Level III and IV evidence, Grade B and C recommendation) According to
the American Society of Anesthesiologists, the literature is insufficient to evaluate intraoperative
or postoperative transfusion of cryoprecipitate to manage actual or potential coagulopathy.1 It is
recommended to assess fibrinogen levels in patients with excessive bleeding before
administering cryoprecipitate.1

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

9
C1:Cryoprecipitate is most commonly administered for prevention or treatment in patients with
hypofibrinogenemia (defined as fibrinogen < 100 mg/dL) or dysfibrinogenemia.21 (UW Health Very
low quality evidence, weak/conditional recommendation)
C2: Transfusion of cryoprecipitate should be considered in patients with a documented Factor
XIII deficiency.21 (UW Health Very low quality evidence, weak/conditional recommendation)
C3: In cases of life-threatening hemorrhage after trauma or during a surgical procedure,
massive transfusion protocols may be implemented to minimize the adverse effects of
hypovolemia and dilutional coagulopathy.1 Per UW Health policy 2.2.2, cryoprecipitate may be
ordered as clinically indicated under the Massive Transfusion Protocol when blood loss of more
than one total blood volume is expected in a short period of time.
Table 3. Indications for Cryoprecipitate Transfusion in Adults
Indication
Code Reason for Order
C1 Fibrinogen deficiency (< 100 mg/dL)
C2 Factor XIII deficiency
C3 Massive Transfusion Protocol
C4 Other (specify in comments):____________________________________
Dose: Suggested guideline = 1 unit/10 kg
PLASMA PRODUCTS
The decision to transfuse plasma should be dependent on patient presentation and individual
characteristics, presence and severity of comorbidities, and the clinical judgement of the
physician.
F1: Plasma is typically administered to prevent non-traumatic/non-surgical bleeding or correct
non-traumatic/non-surgical bleeding caused by single or multiple coagulation factor
abnormalities, when a specific coagulation factor concentrate is not available.21 Patients with
active hemorrhage and multifactor coagulopathy, determined by an INR value of 1.8 or greater,
may be considered for plasma transfusion. (UW Health Very low quality evidence, weak/conditional
recommendation) The AABB cannot recommend for or against transfusion of plasma in patients
undergoing surgery in the absence of massive transfusion, however patients with multifactor
coagulopathy (INR > 1.8) undergoing an invasive procedure may be considered for transfusion.
(UW Health Very low quality evidence, weak/conditional recommendation)
F2: Administration of plasma is NOT recommended for the reversal of warfarin. (UW Health Low
quality evidence, weak/conditional recommendation) Perioperative administration of vitamin K has
been demonstrated to reduce the risk for nonsurgical bleeding. In a retrospective review of
acute/critical care patients, administration of fresh frozen plasma did not alter INR values at 48
hours or more after vitamin K administration.23 For non-emergent reversal prior to a procedure
or surgery, administration of phytonadione (vitamin K) is recommended.23 (UW Health Low quality
evidence, weak/conditional recommendation) Dosing information for vitamin K is outlined within the
UW Health Procoagulant Therapy Clinical Practice Guideline. Note: Data describing the
potential risks of anticoagulation reversal in patients with a mechanical circulatory device is
extremely limited and requires a careful balance of benefits and harms. Refer to the UW Health
Mechanical Circulatory Device Clinical Practice Guideline for more information.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

10
F3: Administration of plasma alone is NOT recommended for the reversal of warfarin. (UW
Health Low quality evidence, weak/conditional recommendation) When administered with vitamin K,
use of prothrombin complex concentrate (PCC) has demonstrated a more rapid INR reversal
than fresh frozen plasma (FFP) in patients who needed urgent vitamin K antagonist reversal.24-28
Additional advantages of PCC also include a longer duration of action and reduced total
administration volume than FFP for similar INR reductions.26-29 For emergent reversal of
warfarin, administration of prothrombin complex concentrate (PCC) and phytonadione (vitamin
K) is generally recommended.24,25,27-33 (UW Health Moderate quality evidence, weak/conditional
recommendation) Dosing information for PCC and vitamin K are outlined within the UW Health
Procoagulant Therapy Clinical Practice Guideline.
Note: Data describing the potential risks of anticoagulation reversal in patients with a
mechanical circulatory device is extremely limited and requires a careful balance of benefits and
harms. Refer to the UW Health Mechanical Circulatory Device Clinical Practice Guideline for
more information.
F4 : Plasma may be administered therapeutically via plasmapheresis.21 (UW Health Low quality
evidence, strong recommendation)
F5: In cases of life-threatening hemorrhage after trauma or during a surgical procedure,
massive transfusion protocols may be implemented to minimize the adverse effects of
hypovolemia and dilutional coagulopathy.1,38 Per UW Health policy 2.2.2, plasma may be
ordered as clinically indicated under the Massive Transfusion Protocol when blood loss of more
than one total blood volume is expected in a short period of time.
Table 4. Indications for Plasma Transfusion in Adults
Indication
Code Reason for Order
F1 Active hemorrhage or correction of coagulopathy for INR > 1.8 (NOT on warfarin)
F2* Invasive procedure that will begin in more than 24 hours (on warfarin)
F3* Immediate reversal of warfarin
F4 Plasmapheresis
F5 Massive Transfusion Protocol
F6 Other (specify in comments):____________________________________
Dose: Suggested guideline = 10-15 mL/kg body weight
*While not true indications for plasma transfusion, these are included in the list to support implementation into the
electronic health record and changes to historical clinical practice.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

11
SPECIAL PRODUCTS/PROCEDURES21
Component modifications are not medically indicated for all transfusion recipients, but provide
benefit for selected patient populations, as outlined in the table below.
Leukoreduction
ξ Leukocyte-reduced components are indicated to:
1. Decrease the frequency of recurrent febrile nonhemolytic transfusion reactions
2. Reduce the incidence of HLA alloimmunization
3. Reduce the risk of transfusion-transmissible CMV (i.e., CMV safe)
ξ All cellular blood products are leukocyte reduced (CMV safe)
CMV seronegative
ξ Transfusion of CMV-seronegative blood is indicated in CMV-seronegative recipients who
are at risk for significant CMV disease
ξ Transmission of CMV infection is associated with cellular blood components
ξ CMV-seronegative blood is selected by performing testing for antibodies to CMV
Irradiation
ξ Irradiated blood is indicated for use in patients at risk for Graft-Versus-Host-Disease
(GVHD) from transfusion, as listed below.
ξ Blood components that contain viable lymphocytes may be irradiated to prevent
proliferation of T lymphocytes, which is the immediate cause of GVHD.
ξ Irradiated blood is prepared by exposing the component to a source of radiation.
Indication
Codes Patient Characteristics
Blood Product
Characteristics
CMV
Seronegative Irradiation
S1 Patients during the first four months of life X X
S2 Patients < 1 year of age with unexplained illness such as growth
failure, persistent diarrhea, recurrent or unusual infections, etc. X
S3 Heart/lung transplant candidate/recipient X
S4 Patients with aplastic anemia or unexplained cytopenias, particularly if treated with antilymphocyte or antithymocyte globulin X
S5 Patients with lymphopenia (absolute lymphocyte count < 500/mL) and bone marrow suppression X
S6 Peripheral stem cell/bone marrow transplant candidate/recipient X
S7 Hematological malignancies including Hodgkin’s disease,
lymphoma, leukemia and myelodysplastic syndromes X
S8
Severe immunosuppression- non-hematologic cancer patients
treated with multiagent chemotherapy or combined
chemo/radiotherapy within the past year
X
S9
Immunodeficient patients (e.g., congenital immunodeficiency who
exhibit defective cell medicated immunity, DiGeorge syndrome,
Wiscott Aldrich syndrome, SCID)
X
S10 Intrauterine transfusions X X
S11 Patients receiving donor units from blood relatives X
S12 Recipients of HLA matched or crossmatched platelets X
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

12
UW Health Implementation
Potential Benefits:
ξ Improved oxygen carrying capacity
ξ Improved clotting
Potential Harms:
ξ Delayed hemolytic reaction (DHTR)
ξ Hepatitis B, Hepatitis C, HIV-AIDS infection/transmission
ξ Transmission of other infectious diseases (i.e., cytomegalovirus, HTLV-1, malaria)
ξ Iron overload
ξ Transfusion-associated Graft vs. Host Disease
Guideline Metrics:
1. Retrospective analysis of patient scenario and blood product indication selected
2. Retrospective analysis of blood product indication by service line and/or provider
Pertinent UW Health Policies & Procedures
1. UW Health 2.2.2 Massive Transfusion Protocol (Adult and Pediatric)
2. UWHC 2.04 Blood and Blood Component - OR
3. UWHC 4.32 Caring for Patients Who Refuse Blood Transfusions
4. UWHC 7.03 Human Tissue Standards
5. UWHC 8.12 Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)
6. UWHC 8.37 Donation of Autologous/Directed Blood Products
Patient Resources
1. Health Facts For You #6346- Blood Transfusion
2. Health Facts For You #5056- If You Need A Blood Transfusion
3. Health Facts For You #5057- Autologous Blood Donation
4. Health Information: Blood Transfusion
5. Health Information: Blood Transfusions: Should I Bank Blood Before Surgery?
Implementation Plan/Clinical Tools
1. Guideline will be housed on the Clinical Practice Guideline uConnect webpage.
2. Release of the guideline will be advertised in the Clinical Knowledge Management Corner
within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in appropriate Health Link or equivalent
tools, including:
Beacon Supportive Care Protocols
CSC SC PRBC ONLY TRANFUSION OP [4591]
CSC PLATELET TRANSFUSION OP [4516]
CSC SC OTHER BLOOD PRODUCTS TRANSFUSION OP [4520]
CSC SC BMT HIGH RISK [2237]
Delegation Protocols
Blood and Bone Marrow Transplant (BMT) Service Transfusion – Adult/Pediatric [50]
Brain Dead Donor – Adult/Pediatric – Inpatient [89]
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



13
EAP Records
Red Blood Cells (Adult) [BLB0006]
Plasma (Adult) [BLB0003]
Platelets (Adult) [BLB0004]
Cryoprecipitate (Adult) [BLB0005]

Order Sets/Smart Sets
IP – Blood Transfusion – Adult – Supplemental [996]
IP – BMT - Blood Transfusion – Supplemental [4179]
IP – Apheresis – Adult – Procedure [1424]
IP – Comprehensive Donor Blood Product/Transfusion Orders [4069]
IP – Brain Dead Donor (BDD) Delegation Protocol – Adult – Intensive Care – Supplemental
[4078]

Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach for most
patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all
patients. It is understood that some patients will not fit the clinical condition contemplated by a
guideline and that a guideline will rarely establish the only appropriate approach to a problem.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



14
Appendix A. Evidence Grading Schemes

Figure 1. GRADE

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true
effect, but it is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated
effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and
circumstances are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.






Figure 2. American Family Physician
A Consistent, good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, disease-oriented evidence, usual practice, expert opinion, or case
series

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



15
Figure 2. AHA/ASA Grading Scheme




Figure 4. European Association for Cardiothoracic Surgery
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



16
Appendix B. Interim Revisions
Date Summary of Interim Revision(s) Section (Page #)
05/2016 Revised R3 to be greater than or equal to 7 g/dL Recommendations (6)
05/2016 Added red blood cell equation Appendix
03/2017 Revised plasma indications Recommendations (9-10)



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



17
References
1. Management ASoATFoPB. Practice guidelines for perioperative blood management: an updated
report by the American Society of Anesthesiologists Task Force on Perioperative Blood
Management*. Anesthesiology. 2015;122(2):241-275.
2. Wehry J, Cannon R, Scoggins CR, Puffer L, McMasters KM, Martin RC. Restrictive blood
transfusion protocol in liver resection patients reduces blood transfusions with no increase in
patient morbidity. Am J Surg. 2015;209(2):280-288.
3. Goodnough LT, Maggio P, Hadhazy E, et al. Restrictive blood transfusion practices are
associated with improved patient outcomes. Transfusion. 2014;54(10 Pt 2):2753-2759.
4. Hematology ASo. Ten Things Physicians and Patients Should Question. Choosing Wisely 2013;
http://www.choosingwisely.org/societies/american-society-of-hematology/, 2015.
5. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after
hip surgery. N Engl J Med. 2011;365(26):2453-2462.
6. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice
guideline from the AABB*. Ann Intern Med. 2012;157(1):49-58.
7. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal
bleeding. N Engl J Med. 2013;368(1):11-21.
8. Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P, Physicians CGCotACo. Treatment
of anemia in patients with heart disease: a clinical practice guideline from the American College
of Physicians. Ann Intern Med. 2013;159(11):770-779.
9. Carson JL, Sieber F, Cook DR, et al. Liberal versus restrictive blood transfusion strategy: 3-year
survival and cause of death results from the FOCUS randomised controlled trial. Lancet.
2015;385(9974):1183-1189.
10. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of
Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation.
2014;130(25):e344-426.
11. Gray BW, Haft JW, Hirsch JC, Annich GM, Hirschl RB, Bartlett RH. Extracorporeal life support:
experience with 2,000 patients. ASAIO J. 2015;61(1):2-7.
12. Agerstrand CL, Burkart KM, Abrams DC, Bacchetta MD, Brodie D. Blood conservation in
extracorporeal membrane oxygenation for acute respiratory distress syndrome. Ann Thorac Surg.
2015;99(2):590-595.
13. Etz CD, Weigang E, Hartert M, et al. Contemporary spinal cord protection during thoracic and
thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular
domain of the European Association for Cardio-Thoracic Surgery†. Eur J Cardiothorac Surg.
2015;47(6):943-957.
14. Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of
aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the
American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711-1737.
15. Howard J, Malfroy M, Llewelyn C, et al. The Transfusion Alternatives Preoperatively in Sickle Cell
Disease (TAPS) study: a randomised, controlled, multicentre clinical trial. Lancet.
2013;381(9870):930-938.
16. Vichinsky EP, Haberkern CM, Neumayr L, et al. A comparison of conservative and aggressive
transfusion regimens in the perioperative management of sickle cell disease. The Preoperative
Transfusion in Sickle Cell Disease Study Group. N Engl J Med. 1995;333(4):206-213.
17. Sharma S, Sharma P, Tyler L. Transfusion of Blood and Blood Products: Indications and
Complications. American Family Physician. 2011;83(6):719-724.
18. Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: a clinical practice
guideline from the AABB. Ann Intern Med. 2015;162(3):205-213.
19. Nahirniak S, Slichter SJ, Tanael S, et al. Guidance on platelet transfusion for patients with
hypoproliferative thrombocytopenia. Transfus Med Rev. 2015;29(1):3-13.
20. Estcourt L, Stanworth S, Doree C, et al. Prophylactic platelet transfusion for prevention of
bleeding in patients with haematological disorders after chemotherapy and stem cell
transplantation. Cochrane Database Syst Rev. 2012;5:CD004269.
21. Becker J, Shaz B. Guidelines for Patient Blood Management and Blood Utilization. Bethesda,
Maryland: AABB; 2011.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org



18
22. Kaplon RJ, Gillinov AM, Smedira NG, et al. Vitamin K reduces bleeding in left ventricular assist
device recipients. J Heart Lung Transplant. 1999;18(4):346-350.
23. Tsu LV, Dienes JE, Dager WE. Vitamin K dosing to reverse warfarin based on INR, route of
administration, and home warfarin dose in the acute/critical care setting. Ann Pharmacother.
2012;46(12):1617-1626.
24. Goldstein JN, Refaai MA, Milling TJ, et al. Four-factor prothrombin complex concentrate versus
plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive
interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet.
2015;385(9982):2077-2087.
25. Frontera JA, Gordon E, Zach V, et al. Reversal of coagulopathy using prothrombin complex
concentrates is associated with improved outcome compared to fresh frozen plasma in warfarin-
associated intracranial hemorrhage. Neurocrit Care. 2014;21(3):397-406.
26. Nuckles KB, Pratt JH, Cameron CM, Ingemi AI. Case series of four-factor prothrombin complex
concentrate for warfarin reversal before heart transplantation. Transplant Proc. 2015;47(3):841-
843.
27. Hickey M, Gatien M, Taljaard M, Aujnarain A, Giulivi A, Perry JJ. Outcomes of urgent warfarin
reversal with frozen plasma versus prothrombin complex concentrate in the emergency
department. Circulation. 2013;128(4):360-364.
28. Chai-Adisaksopha C, Hillis C, Siegal DM, et al. Prothrombin complex concentrates versus fresh
frozen plasma for warfarin reversal. A systematic review and meta-analysis. Thromb Haemost.
2016;116(5):879-890.
29. Pratt Cleary J, Hodge L, Palmer B, Barreiro CJ, Ingemi A. 4-Factor Prothrombin Complex
Concentrate (PCC4, Kcentra®) Protocol Reduces Blood Requirements for Heart Transplantation:
A Novel Protocol. Ann Transplant. 2016;21:531-537.
30. Chapman SA, Irwin ED, Beal AL, Kulinski NM, Hutson KE, Thorson MA. Prothrombin complex
concentrate versus standard therapies for INR reversal in trauma patients receiving warfarin. Ann
Pharmacother. 2011;45(7-8):869-875.
31. Majeed A, Eelde A, Agren A, Schulman S, Holmström M. Thromboembolic safety and efficacy of
prothrombin complex concentrates in the emergency reversal of warfarin coagulopathy. Thromb
Res. 2012;129(2):146-151.
32. Johansen M, Wikkelsø A, Lunde J, Wetterslev J, Afshari A. Prothrombin complex concentrate for
reversal of vitamin K antagonist treatment in bleeding and non-bleeding patients. Cochrane
Database Syst Rev. 2015(7):CD010555.
33. Frontera JA, Lewin JJ, Rabinstein AA, et al. Guideline for Reversal of Antithrombotics in
Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care
Society and Society of Critical Care Medicine. Neurocrit Care. 2016;24(1):6-46.
34. Dentali F, Marchesi C, Giorgi Pierfranceschi M, et al. Safety of prothrombin complex concentrates
for rapid anticoagulation reversal of vitamin K antagonists. A meta-analysis. Thromb Haemost.
2011;106(3):429-438.
35. Jennings DL, Jacob M, Chopra A, Nemerovski CW, Morgan JA, Lanfear DE. Safety of
anticoagulation reversal in patients supported with continuous-flow left ventricular assist devices.
ASAIO J. 2014;60(4):381-384.
36. Willey JZ, Demmer RT, Takayama H, Colombo PC, Lazar RM. Cerebrovascular disease in the
era of left ventricular assist devices with continuous flow: risk factors, diagnosis, and treatment. J
Heart Lung Transplant. 2014;33(9):878-887.
37. Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 International Society for Heart and
Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart
Lung Transplant. 2013;32(2):157-187.
38. McQuilten ZK, Crighton G, Engelbrecht S, et al. Transfusion interventions in critical bleeding
requiring massive transfusion: a systematic review. Transfus Med Rev. 2015;29(2):127-137.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org