RCR-ACP recommendations for oncology teams for red blood cell transfusion in adults when red blood cell stocks are low

Thursday 20 October 2022

Red blood cell stocks held by the NHS Blood and Transplant Service are currently low. An amber alert has been issued, with a risk of moving to red alert.

Amber – reduced availability of blood for a short or prolonged period with impact on clinical activity (two days of stock).

Red – severe, prolonged shortage of blood with an impact on clinical activity (one day of stock).

The objective for the NHS Blood and Transplant Service is to ensure that patients who need blood can receive a transfusion. Overall red cell usage should therefore be reduced, if possible, to ensure supply remains available for patients who need blood most.

Individual hospitals are required to have Emergency Blood Management Arrangements and this document should be read in conjunction with your hospital’s plan.


1. Use the NICE blood transfusion guideline (2015) to make decisions about transfusions. In particular:

  • Use a restrictive red blood cell transfusion threshold unless the patient has a major haemorrhage or acute coronary syndrome.
  • Consider a threshold of 70 g/litre and a haemoglobin concentration target of 70-90 g/litre after transfusion.
  • Consider single-unit red blood cell transfusions for adults who do not have active bleeding.
  • Assume an increment of 10g/litre per unit in a 70 kg patient - expect a higher rise in patients of lower body weight.
  • After each single-unit red blood cell transfusion, clinically reassess and check haemoglobin levels, and give further transfusions if needed.

2. When a red blood cell transfusion would normally be considered to enable systemic anti-cancer therapy (SACT) to proceed safely:

  • Consider delaying SACT to allow the haemoglobin level to rise rather than using a transfusion when SACT is given with palliative intent.
  • Consider alternatives to red blood cell transfusion – eg. oral or intravenous iron or erythropoiesis-stimulating agents according to local protocol.
  • Consider using alternative, less myelosuppressive SACT regimens.

3. Review local protocols for red blood cell transfusions if they are used to maintain haemoglobin levels above a target level during curative radiotherapy (eg. in cervical or head and neck cancers). The evidence that transfusion improves cancer outcomes in this situation is of poor quality.

4. Consider prescribing tranexamic acid for patients with anaemia secondary to chronic blood loss from a locally advanced cancer.

5. Discuss the need for transfusion with a senior decision-maker (eg. responsible consultant) while blood stocks remain low unless there is a clinical emergency.

Useful links

National Blood Transfusion Committee Recommendations and Responses (including Red Cell, Platelet and Plasma Shortage plans, updated July 2022).

Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines Annals of Oncology 29 (Supplement 4): iv96–iv110, 2018.

Erythropoiesis-stimulating agents (epoetin and darbepoetin) for treating anaemia in people with cancer having chemotherapy NICE Technology Appraisal guidance (TA323). Nov 2014


Professor David Cunningham  


Association of Cancer Physicians

Dr Tom Roques

Vice President, Clinical Oncology

The Royal College of Radiologists