Table 3.

National Anesthesia and Transfusion Societies’ Recommendations for Transfusion

	AABB—USA	ASA—USA	ESA—Europea	BCSH—UK	NBA—Australia	AAGBI—UK
Year	RBC guidelines: 2012; plasma guidelines: 2010; platelet guidelines: 2014	2015	2013	2015	2015	2016
Aims	RBC guidelines: “to focus on Hb concentration thresholds and other clinical variables that might trigger RBC transfusion.” Plasma guidelines: To help direct appropriate transfusion of plasma	Improve the perioperative management of blood transfusion and adjuvant therapies and to reduce the risk of adverse outcomes associated with transfusions, bleeding, or anemia	To identify patients for whom the perioperative bleeding risk is increased; to correct preoperative anemia and patients' tolerance to bleeding; [to deliver] targeted procoagulant interventions to reduce bleeding, morbidity, mortality, and costs	To provide recommendations for the hematological management of major hemorrhage in any clinical situation	To improve clinical outcomes by avoiding unnecessary exposure to blood components. “Three pillars” are described: optimization of blood volume and red cell mass, minimization of blood loss, and optimization of anemia tolerance	To formalize guidance on the clinical indications and risks of transfusion, blood conservation, and the transfusion process
Did the guidelines have a section with specific recommendations for pregnant women?	No	Obstetric patients referenced in platelet and cryoprecipitate recommendations	Yes	Yes	Yes. Patient Blood Management Guidelines: Module 5—Obstetrics and Maternity. (Other modules reviewed critical bleeding/massive transfusion, perioperative, medical, and critical care settings)	Yes
RBC	A restrictive transfusion strategy was recommended (Hb trigger between 7-8 g/dL) for hospitalized patients. Restrictive strategy in hospitalized patients with preexisting cardiovascular disease: consider transfusion for symptomatic patients or a Hb level <8 g/dL. Transfusion decisions should be influenced by symptoms, as well as Hb level	Consider a restrictive RBC transfusion strategy. Justification for treating Hb levels between 6 and 10 g/dL should take into account rate/magnitude of blood loss, intravascular volume status, signs of organ ischemia, and adequacy of cardiopulmonary reserve. Reassess RBC requirements after each unit if possible	A target Hb level between 7-9 g/dl is recommended during active bleeding; ESA recommends PPH management by a multidisciplinary team, predelivery risk assessment, and early recognition of severe PPH	Rate of RBC administration guided by rate of blood loss and hemodynamic compromise. The aim is to maintain an Hb level that supports adequate oxygen delivery to tissues. Hospitals should ensure that emergency group O RBC or group-specific RBC are available for life-threatening hemorrhage. Until group known use O RhD-negative units in females <50 y	Use of RBC is life-saving for patients requiring massive transfusion. MTP use for critical bleeding may reduce the risk of morbidity/mortality. For nonbleeding patients, consider single unit RBC transfusion, followed by clinical reassessment. RBC transfusion for a Hb <7 g/dL may be associated with reduced mortality but may not be required for well-compensated patients or where specific therapy is available	Transfuse RBC for major hemorrhage (group O Rh-negative RBC should be available and transfused for life-threatening hemorrhage for women of childbearing potential). An Hb threshold = 7 g/dL is a guide for RBC transfusion
Plasma	Plasma should be given to trauma patients requiring massive transfusion. Could not recommend for or against FFP:RBC transfusion ratio of 1:3 or more in trauma patients during massive transfusion. Could not recommend for or against plasma transfusion to patients undergoing surgery in the absence of massive transfusion	Correction of excessive microvascular bleeding if INR >2. For correction of excessive microvascular bleeding in massively transfused patients with >1 blood volume or when PT/INR/APTT cannot be measured in a timely fashion. Urgent reversal of warfarin therapy. Correction of known coagulation factor deficiencies	For life-threatening hemorrhage, a fixed product ratio or individualized procoagulant intervention and factor substitution were recommended	Transfuse FFP in at least a 1:2 ratio with RBC, before transitioning to goal-directed transfusion using laboratory tests. Once bleeding is controlled, consider FFP (15–20 mL/kg) if PT or APTT >1.5× normal. If laboratory results are not available, transfuse FFP in at least a 1:2 ratio with RBC, before blood product use guided by laboratory results	For major obstetric hemorrhage, suggest transfusion of 15 mL/kg FFP	PPH associated with atony or trauma is unlikely to be associated with hemostatic impairment unless diagnosis is delayed. If laboratory coagulation status unknown, withhold FFP until 4 units RBC have been administered, then use a 1:1 ratio RBC:FFP until results of hemostatic tests are known. Point-of-care testing, with measurement of fibrinogen levels, is recommended
PLTs	No recommendations for PLT transfusion for patients experiencing perioperative blood loss	PLT count <50 × 109/L in the presence of excessive bleeding. Rarely indicated if the platelet count >100 × 109/L	See plasma recommendation. PLT count <100 × 109/L at the onset of labor, particularly combined with plasma fibrinogen concentration<2.9 g/L indicates an increased risk of PPH.	Therapeutic goal = PLT count > 50 × 109/L. Transfuse if PLT count <100 × 109/L and ongoing bleeding	For major obstetric hemorrhage, suggest transfusion of 1 adult therapeutic dose of PLTs. A PLT count >50 ×109/L is acceptable for VD or CD	If patient is actively bleeding, transfuse to a therapeutic goal = PLT count >75 × 109/L. In the obstetric setting, PLT transfusion is rarely required and should only be given once the PLT count is known
Fibrinogen replacement therapies	Not discussed	Cryoprecipitate is indicated when laboratory evidence indicates fibrinolysis, or when the fibrinogen concentration <80–100 mg/dL in the presence of excessive bleeding. The ASA note that cryoprecipitate may be indicated at higher fibrinogen concentrations in actively bleeding obstetric patients. Consider cryoprecipitate as an adjunct in massively transfused patients when fibrinogen concentrations cannot be measured in a timely fashion	For perioperative bleeding, consider fibrinogen supplementation if the fibrinogen concentration <1.5–2.0 g/L or functional fibrinogen deficit detected by thromboelastography or rotational thromboelastometry. A higher fibrinogen trigger value may be needed for treating hypofibrinogenemia in obstetric patients. Cryoprecipitate indicated if there is a lack of available fibrinogen concentrate for the treatment of bleeding and hypofibrinogenemia	Therapeutic goal = plasma fibrinogen concentration >1.5 g/L. For obstetric hemorrhage, early fibrinogen supplementation if levels <2 g/dL and ongoing bleeding	For major obstetric hemorrhage, suggest 3–4 g cryoprecipitate. Consider fibrinogen concentrate when available and acceptable to women	Plasma fibrinogen levels <3 g/L are associated with progression to major obstetric hemorrhage. Fibrinogen should be replaced with either cryoprecipitate or fibrinogen concentrate
MTP	In the context of plasma transfusion only. No recommendations are given for MTP components	Recommended for massively bleeding patients. No recommendations are given for MTP components	In life-threatening PPH, use a transfusion protocol with a fixed product ratio or individualized procoagulant intervention and factor substitution	Described as part of a major hemorrhage protocol (nonspecific to obstetric hemorrhage)	Activate MTP early. The MTP should be modified for the obstetric patient because fibrinogen level of 2 g/L indicates critical physiological derangement and is associated with severe PPH	Most major hemorrhage packs contained 4 U RBC and 4 U FFP ± PLTs. If hemorrhage is life-threatening, transfuse group O Rh-negative RBC to women of childbearing potential. Group-specific RBC should be rapidly prepared by the laboratory after receiving a blood sample
Pharmacological agentsb	Not discussed	Consider antifibrinolytics (tranexamic acid, ε-aminocaproic acid) if fibrinolysis is suspected or documented. The ASA note that the safety of antifibrinolytics has not been established in hypercoagulable patients, including pregnant patients. Consider desmopressin for patients with excessive bleeding and platelet dysfunction. PCC may be used in patients with excessive bleeding and increased INR. Fibrinogen concentrate may be used for excessive bleeding	Tranexamic acid is recommended; no dosing regimen is described. Consider prophylactic tranexamic acid before cesarean delivery. Tranexamic acid is also recommended for antepartum bleeding. Use DDAVP under specific conditions. Initial fibrinogen concentrate dose of 25–50 mg/kg	Tranexamic acid 1 g over 10 min followed by 1 g over 8 h (trauma recommendation). The use of tranexamic acid was recommended for major obstetric hemorrhage	For patients with significant blood loss, consider tranexamic acid within 3 h of hemorrhage onset. Consider prothrombin complex concentrate when available and acceptable to women	Tranexamic acid 1 g for severe PPH (>500 mL VD, >1000 mL CD)
Recombinant FVIIa	Not discussed	Consider when traditional options for treating coagulopathic bleeding have been exhausted	Consider as a last-line therapy after the platelet count and fibrinogen level have been optimized	Not recommended	Consider for life-threatening hemorrhage only if conventional measures have failed. Pay strict attention to blood loss control, and physiological, metabolic, and coagulation parameters. Suggested initial dose = 90 μg/kg	Late use in the exsanguinating patient is almost always associated with no benefit, a high risk of mortality, and thrombotic complications. Except under hematological direction, not recommended for clinical use
Cell salvage	Not discussed	Reinfuse recovered red blood cells as a blood-sparing intervention in the intraoperative period, when appropriate	Cell salvage is well tolerated (during cesarean delivery), provided that precautions are placed against rhesus isoimmunization	Access to 24-h cell salvage support should be available in cardiac, obstetric, trauma, and vascular centers	Consider cell salvage if anticipated blood loss likely to result in transfusion. Also consider for patients at risk for bleeding where transfusion is not an option. For Rh-negative mothers giving birth to Rh-positive babies, consider RhD immunoglobulin if the mother receives cell salvaged blood	Recommended with leukocyte filter, if abnormal bleeding occurs during CD
Other pregnancy-specific recommendations	Not discussed	Anemia threshold = 11.0 g/dL for pregnant women. Cryoprecipitate may be indicated at a higher fibrinogen concentration in actively bleeding obstetric patients	Thromboelastometry can identify obstetric coagulopathy and hyperfibrinolysis and guide hemostatic therapy. APTT and PT values are of limited predictive value for PPH	Not discussed	Iron therapy for iron deficiency anemia is recommended. During major obstetric hemorrhage, measure temperature, acid-base, ionized calcium, Hb, PLT, PT/INR, APTT, and fibrinogen level. For patients with abnormal coagulation tests who are not bleeding, the routine use of FFP or cryoprecipitate is not recommended. Optimize patients with preexisting hematological conditions before delivery	POC testing preferred over laboratory testing due to speed

Abbreviations: AABB, formerly, the American Association of Blood Banks; AAGBI, Association of Anaesthetists of Great Britain and Ireland; APTT, activated partial thromboplastin time; ASA, American Society of Anesthesiologists; BCSH, British Committee for Standards in Haematology; CD, cesarean delivery; ESA, European Society of Anaesthesiology; FFP, fresh frozen plasma; Hb, hemoglobin; INR, international normalized ratio; MTP massive transfusion protocol; NBA, National Blood Authority (of Australia); PCC, prothrombin complex concentrate; PLT, platelet; POC, point of care; PPH, postpartum hemorrhage; PT, prothrombin time; RBC, packed red blood cells; VD, vaginal delivery.

^aOnly the transfusion recommendations specific to obstetrics are described in this table.

^bNot including recombinant factor VII.