Clinical Practice Recommendations: Evidence-Informed Transfusion Practice = Smarter Transfusions, Safer Patients
Written by: Troy Thompson – ORBCoN CE Regional Manager & Donna Berta – ORBCoN Clinical Project Coordinator Nursing
Revised evidence-informed Clinical Practice Recommendations for the use of blood components in adult inpatients are now available on the ORBCoN Transfusion Ontario website to support hospitals in developing or updating their specific transfusion guidelines.
Clinical-Practice-Recommendations_March_2025_final.pdf.
These recommendations are based on Choosing Wisely principles, current literature, Canadian transfusion practice standards, and expert opinion to support appropriate and patient-centered transfusion care. The document includes tables outlining clinical settings, transfusion thresholds, and recommended dosing for red blood cell, platelet and plasma transfusions. For plasma transfusions, a comprehensive weight-based dosing chart is provided to simplify and clarify the dosing of solvent detergent and frozen plasma. Below are the recommended thresholds for each blood component, with further details available in the full recommendations document.
Red Blood Cells (adult inpatients)
Dose Recommendations:
- Transfuse one unit at a time in non-urgent patient scenarios.
- Reassess symptoms and hemoglobin (Hb) before considering additional units.
- Always consider the underlying cause of anemia in the transfusion decision-making process.
- Explore alternative therapies (e.g., iron) when appropriate.
Hemoglobin Thresholds and Clinical Scenarios:
| Hb Level | Clinical Scenario |
| <60 g/L | This threshold may be appropriate for asymptomatic, otherwise healthy, younger patients. |
| <70 g/L | Likely appropriate. |
| <80 g/L | Consider patients with uncorrected pre-existing cardiovascular disease. |
| <90 g/L | Consider only for patients with clear signs and symptoms of impaired tissue oxygenation. |
| <90 -100 g/L | Likely appropriate for patients with acute myocardial infarction (MI). |
| >90 g/L | Likely inappropriate except in acute MI. |
Transfusion-Associated Circulatory Overload (TACO): identify patients at risk and implement preventative strategies as appropriate.
Platelets (adult inpatients)
Dose Recommendations:
- Transfuse one pooled or apheresis (psoralen treated) unit.
Platelet Count Thresholds and Clinical Scenarios:
| Platelet Count | Clinical Scenario |
| <10 x 10⁹/L | Hypoproliferative or non-immune thrombocytopenia (prophylaxis) |
| <30 x 109/L | Patients with cirrhosis undergoing high bleeding risk procedures |
| <50 x 10⁹/L | Undergoing invasive procedures with bleeding risk (expected blood loss > 500 mL) Major non-neuraxial surgery |
| < 50-80 x 109/L | Neuraxial anesthesia |
| <100 x 10⁹/L | Neurology indications (e.g., neuraxial surgery, head trauma, CNS hemorrhage). |
Note: Transfusion may lead to harm in some intracranial hemorrhage clinical scenarios, as specified in the document
Plasma (adult inpatients)
Dose Recommendation:
- 10–15 mL/kg based on actual body weight
- Avoid single unit plasma transfusion
INR Threshold and Clinical Scenario:
| INR Value | Clinical Scenario |
| INR ≥ 1.8 | Major bleeding Microvascular bleeding Liver disease + high-risk invasive procedure |
Note:
- Patients with liver disease have preserved thrombin generation despite elevated INR. Routine correction of an abnormal INR prior to a procedure is often unnecessary.
- For urgent warfarin reversal, use prothrombin complex concentrate (PCC), unless PCC is unavailable or contraindicated.
Conclusion
These practical, patient-focused transfusion recommendations aim to optimize outcomes, minimize risks, and reduce unnecessary blood component use. Hospitals are encouraged to adopt or adapt these recommendations for safer, standardized transfusion practices.
Additional resources linked to these updated clinical practice recommendations (algorithm, order set) are currently under review and will be aligned with the updated recommendations