The indication for blood transfusion depends on:

  • The degree of anaemia
  • The clinical conditions (high risk or presence of signs and symptoms of tissue hypoxia, cardiac decompensation, etc.)
  • Presence and entity of ongoing blood loss (e.g., internal or external haemorrhage) or red cells destruction (malaria, haemolysis, sepsis, etc.)

Severe anaemia in children and infants

  • Hb ≤4 g/dL (or haematocrit ≤12%), whatever the clinical condition of the patient
  • Hb ≤6 g/dL (or haematocrit ≤13-18%), in case of life threatening complications, such as, clinical features
    of hypoxia and cardiac decompensation, acidosis (usually causes dyspnoea), impaired consciousness,
    hyperparasitaemia (>20%) or cerebral malaria, septicaemia, meningitis
  • Transfuse 10-15 mL/kg of packed red cells (20 mL/kg of whole blood)

Severe anaemia in adults

  • Consider blood transfusion only in anaemia which is likely to cause/ has already caused clinical signs of hypoxia
    • Symptomatic anaemia in adults with <8 g/dL
    • Haemoglobin <10 g/dL if angina pectoris or CNS symptoms

Give the minimum number of transfusions necessary to relieve hypoxia: transfuse 1 unit in 2-4 hours (with
furosemide 40 mg IM) and re-assess. If symptoms persist give another 1-2 units

Severe anaemia in pregnancy

Pregnancy <36 weeks

  • Hb ≤5 g/dL irrespective of clinical condition
  • Hb 5-7 g/dL in case of established or incipient heart failure, pneumonia or other serious infection, malaria, preexisting heart disease

Pregnancy >36 weeks

  • Hb ≤6 g/dL
  • Hb 6-8 g/dL in case of
    • Established or incipient heart failure, pneumonia or other serious infection, malaria, pre-existing heart disease

Elective caesarean section
If history of APH, PPH, previous caesarean section

  • Hb is 8-10 g/dL
    • Establish/confirm blood group, and save freshly taken serum for cross-matching
  • Hb <8 g/dL
    • Have 2 units of blood cross-matched and made available

Pre-operative anaemia

  • ≤8 g/dL in case of:
    • Inadequate compensation for the anaemia (symptomatic anaemia)
    • Significant co-existing cardiorespiratory disease
    • Major surgery or significant blood loss expected
    • Pre-surgical correction has not been possible

Management of acute haemorrhage/hypovolemia

  • IV fluids (crystalloids: Normal saline) is the first line in treatment of hypovolaemia during acute haemorrhage
  • Whole blood or red blood cells are indicated when blood loss is >20- 30% of blood volume (>15-20 mL/kg)
  • The need for blood must be determined by:
    • Amount and speed of blood loss
    • Patient’s critical signs
    • Initial response to IV fluid resuscitation
  • Hb level is NOT a reliable indicator for blood need in acute haemorrhage

Sickle cell anaemia

  • Blood transfusion is not necessary for asymptomatic sickle cell patient with steady Hb 6-8 g/dL
  • Blood transfusion is indicated if:
    • Acute severe anaemia (Hb <5 g/dL or 2 g/dL lower than usual level for the patient) in aplastic and sequestration crisis. Aim at Hb 7-8 g/dL
    • Hb <6 g/dL in uncomplicated pregnancy
    • Hb <8 g/dL if caesarean section
    • Hb <9 g/dL in case of acute chest syndrome, and stroke
  • Use packed cells: whole blood is indicated in acute hemorrhage only

Neonatal conditions

  • Severe unconjugated hyperbilirubinaemia
  • Severe anaemia of any cause (prematurity, sepsis, etc.)
  • Transfusion in neonates should be managed at specialist level