NHS Blood and Transplant (NHSBT) has advised that its red cell and group A platelet stock levels are low and in a pre-amber alert status for both. It has asked all hospitals to conserve stock from 16 to 30 January 2023 to help prevent going into an amber or red alert.  

We would like to draw attention to the new guidance issued by NHSBT (detailed below), and to our previous guidance, recommending that use of tranexamic acid is considered in all adult surgical patients and administered if more than 500ml of blood loss is likely. We also recommend that theatre teams consider adding this prompt to the perioperative care theatre checklist process. 

Results from the recentPOISE-3 clinical trialconfirm the quality, safety and cost-effectiveness of using tranexamic acid in surgery, where more than 500ml of blood loss is anticipated. This evidence further supports theNICE quality statement on blood transfusionand complements the recent Centre for Perioperative Care guidelineAnaemia in the Perioperative Pathway. 

Increasing the use of tranexamic acid in this way will help reduce the need for blood transfusion, which is particularly important at times of limited availability and should become standard practice. 

In addition, NHSBT is asking hospitals to:  

  • Decrease stockholding of red cells and platelets where it is safe to do so.  
  • Ensure arrangements are in place to respond to any potential future amber or red status alert.  
  • Report any delays to transfusion or any avoidable transfusion to Serious Hazards of Transfusion (SHOT).  

To preserve O D negative red cell supplies  

  • Use O D positive red cells for O D negative males, and females over 50, for single transfusion episodes, and in emergencies where their blood group is unknown.  
  • Reserve O D negative red cells for females of childbearing potential and those patients who are group O negative receiving regular or repeated red cell transfusions or have anti-D antibodies.
  • Use alternatives to transfusion where appropriate.

- Treat haematinic deficiencies with the appropriate supplement (iron, B12 or folate), unless the patient has haemodynamic compromise.  

- If preoperative haemoglobin is low or intraoperative blood loss could be greater than 500ml (in adults) use tranexamic acid and cell salvage unless contraindicated. Contraindications to either tranexamic acid or cell salvage should be documented. Ensure that operating theatres have adequate access to cell salvage equipment and appropriately trained staff to deliver cell salvage when it is indicated.  

  • Use a restrictive red cell transfusion threshold, haemoglobin of 70 g/L unless patient is bleeding, has acute coronary syndrome, or is on a chronic transfusion programme.  
  • Minimise iatrogenic anaemia (reduce frequency or volume of blood sampling where appropriate). For the latter, reactivating policies that were introduced during the period of shortages of blood sample tubes may be helpful.  
  • Do not proceed with major, deferrable surgery in patients with severe anaemia until it has been properly diagnosed and treated.  

To preserve group A platelet supplies 

  • Only request platelets for a specific identified requirement.  
  • Accept appropriate substitutions of platelet components.  
  • Ensure platelet transfusions are given in accordance with good clinical practice and national guidelines for adults and children.  
  • Where possible use ABO-matched platelets.  
  • Use D positive platelets for males and post-menopausal women, reserving D negative platelets for females of child-bearing potential. If D negative platelets are not available for females of child-bearing potential, consider using anti-D prophylaxis where appropriate.  
  • Optimise pre-operative preparation of patients e.g., stop anti-platelet agents prior to surgery whenever possible.  
  • Where possible extend time interval between prophylactic doses of platelets if patient is clinically stable.  
  • Do not give prophylactic platelet transfusions to well patients with no evidence of bleeding who have had an autologous stem cell transplant.  
  • Consider alternatives or additions to platelet transfusion e.g. 

- Tranexamic acid - trauma, surgical bleeding and short-term for patients with chronic thrombocytopenia and bleeding.  

- Desmopressin for patients with uraemia or inherited platelet disorders at risk of bleeding or bleeding.  

- Fibrinogen or cryoprecipitate to maintain fibrinogen concentration at 1.5-2g/l if trauma or surgical bleeding.