Blood Component Therapy

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Cryoprecipitated Antihemophilic Factor (AHF); Cryoprecipitated AHF, Pooled cryoprecipitate, cryoprecipitate [1,5]
Each unit of precipitate is prepared from one bag of fresh frozen plasma. Contains concentrated levels of fibrinogen, Factor VIII:C, Factor VIII:vWF (von Willebrand factor), Factor XIII, and fibronectin .

Indicated for bleeding associated with fibrinogen level <100 mg/dL and Factor XIII deficiency.
Hemophilia A or von Willebrand’s disease (vWD) should only be treated with cryoprecipitate when appropriate Factor VIII concentrates or Factor VIII concentrates containing FVIII: vWF are not available. DDAVP is the treatment of choice for type 1
vWD.

Dose for the treatment of hypofibrinogenemia

One cryoprecipitate unit per 10 kg of body weight.
In the absence of heavy consumption or bleeding one unit of cryoprecipitate per 10 kg of body weight raises plasma fibrinogen concentration by ~ 50 mg/dL

Start infusion slowly at 2 mL per minute.
If no sign of reaction after the first 15 minutes then may infuse as rapidly as the patient’s circulatory system can tolerate [6].

The number of cryoprecipitate units required to raise the plasma fibrinogen can be estimated by using the calculator below;

Blood volume (mL) = Weight (Kg) x 70mL/Kg
Plasma volume (mL)= Blood volume (mL) x (1.0-hematocrit)
Fibrinogen required (mg) = (desired fibrinogen level (mg/dL) - initial fibrinogen level (mg/dL)) X (plasma volume (mL)/100).
Bags of cryo required = Fibrinogen required (mg) X 1 bag cryo /150 mg fibrinogen
See Precautions

Each unit of cryoprecipitate should contain at least 80 IU Factor VIII:C and 150 mg of fibrinogen in 5-20mL of plasma. May be transfused as individual units or pooled.

Fresh frozen plasma (FFP) [1]
Noncellular portion of blood, including fibrinogen, antithrombin III, factors V and VIII

Indicated for :

Massive transfusion with coagulopathic bleeding.
Active bleeding or risk of bleeding due to deficiency of multiple coagulation factors.
Thrombotic thrombocytopenic purpura.
Urgent reversal of warfarin effect (for reversal of heparin use protamine).
Bleeding or prophylaxis of bleeding for a known single coagulation factor or plasma deficiency for which no concentrate is available.
Deficiencies of other isolated plasma proteins and factors where concentrates are not readily available (antithrombin, protein C and protein S deficiencies),
Antithrombin III deficiency in a patient requiring heparin.
Therapy of acute angioedema.
Preoperative prophylaxis in hereditary C1-inhibitor deficiency.

Laboratory thresholds at which therapeutic or prophylactic replacement may be indicated in an appropriate clinical setting:

Prothrombin time (PT) greater than 1.5 times the mid-range of normal,
Activated partial thromboplastin time (APTT) greater than 1.5 times the top of the normal range
Factor assay less than 25%

Dose

Usual dose is 10-20 mL/kg, though more may be required depending upon the clinical situation such as massive bleeding.

Start infusion slowly at 2 mL per minute.
If no sign of reaction after the first 15 minutes then increase rate to 200-300 mL/hour nonemergency setting. Adjust flow rate according to the volume that the the patient’s circulatory system can tolerate [6].

See Precautions

1unit ~ 250 mL . Each unit contains all coagulation factors.

Platelets, whole blood derived random donor platelets (RDPs)
Platelets Pheresis single donor platelets (SDPs)
Preparations include Platelets pre-storage pooled, Platelets Irradiated; Platelets Pooled Irradiated; Platelets Pheresis Irradiated; Platelets Leukocytes Reduced; Platelets Pheresis Leukocytes Reduced; and Platelets Pheresis, Leukocytes Reduced, Irradiated

Indicated for

Bleeding due to critically decreased platelet count or abnormally function platelets

Prophylaxis of bleeding with platelet count <10 x 10^9/L or < 20 x 10^9/L in unstable non-bleeding patients. , or preoperatively to maintain platelet count above

Bone marrow failure with count <10 x 10^9/L or <20 x 10^9/L in unstable presence of risk factors such as fever, antibiotics and sepsis.

Prior to surgery/invasive procedure to maintain count >50 x 10^9/L or >100 x 10^9/L for high-risk surgery (e.g.. neurosurgery, ocular, etc).A threshold of 80,000 x 10^9/L has been proposed for spinal epidural anesthesia.

Some inherited or acquired platelet function disorders depending on clinical features and setting.

Primary immune thrombocytopenia (ITP) with life threatening bleeding , or before splenectomy with platelet count<10 x 10^9/L

Treatment of bleeding due to thrombocytopenia.

Massive hemorrhage/transfusion in presence of thrombocytopenia and/or functional abnormalities.

Microvascular bleeding/ disseminated intravascular coagulation with platelet count <50 x 10^9/L or <100 x 10^9/L in presence of

Dose

Four to ten units of pooled random donor Platelets (RDP)
OR
One single donor Platelets Pheresis (SDP)

Start infusion slowly at 2 mL per minute.
If no sign of reaction after the first 15 minutes then increase rate to 200-300 mL/hour nonemergency setting. Adjust flow rate according to the volume that the the patient’s circulatory system can tolerate [6].

Measure platelet count from 10 minutes to 3 hours after transfusion.

Each RDP can be expected to increase an adult's platelet count by 7-10,000 x 10^9/Lfor each RDP given

A single apheresis can be expected to increase an adult's platelet count by 30,000 - 60,000 x 10^9/L for each SDP given

Patients at risk for transfusion-associated graft-versus host disease (TA-GVHD) should received gammairradiated platelets.
Due to the significant risk of fatal thrombosis, platelets should only be transfused in the setting of life threatening hemorrhage in the presence if thrombotic thrombocytopenic purpura (TTP) or heparin-induced thrombocytopenia with thrombosis (HITT)

See Precautions

1 unit platelets (RDP) should
contain ≥5.5 x 10^10 platelets per bag in approximately 50 mL of plasma.
1 Platelets Pheresis (SDP) should contain ≥3.0 x 10^11 platelets per bag in about 250 mL of plasma

Red Blood Cells (Packed Cells, Red Cells, Packed Red Blood Cells, RBCs) [1]
Preparations include Leukocytes Reduced(LR-RBC); Apheresis; Deglycerolized; Irradiated; Low Volume; Washed.

Indicated for symptomatic deficiency of oxygen-carrying capacity due to an inadequate circulating red cell mass, exchange transfusion , and red cell exchange
"Transfusion is rarely indicated when the hemoglobin level is above 10 g/dL and is almost always indicated in patients when the hemoglobin level is below 6 g/dL."[1]
Dose

One unit of compatible red blood cells will increase the hemoglobin level in an average sized adult who is not bleeding or hemolyzing by approximately 1 g/dL or Hct by 3%

Start infusion slowly at 2 mL per minute.
If no sign of reaction after the first 15 minutes then increase rate to 150-300 mL/hour nonemergency setting. Adjust flow rate according to the volume that the the patient’s circulatory system can tolerate [6].

Red Blood Cells are capable of transmitting cytomegalovirus, mediating graft-versus-host disease and causing febrile, nonhemolytic reactions. For recipients at particular risk from these transfusion related complications, use of CMV reduced-risk (i.e. CMV seronegative or LR-RBC), gamma-irradiated and leukoreduced preparations should be considered.

1 unit = 220 mL
Each unit contains approximately 42.5-80 g of hemoglobin or 128-240 mL of pure red cells, 50 mL of donor plasma, in addition to preservative and anticoagulant solutions.

PRECAUTIONS

All blood components must be transfused through a filter designed to remove clots and aggregates. Unless otherwise indicated by the patient’s clinical condition, the rate of infusion should initially be slow, since life-threatening reactions may occur after the infusion of only a small volume of blood components Thereafter, the rate of infusion can be more rapid, as tolerated by the patient’s circulatory system. Transfusion of blood components must be COMPLETE within 4 hours [5]

Incidence of Adverse Events [4]

Acute hemolytic reaction <= 1:38,000, anaphylaxis <=1:20,000, transfusion related lung injury <= 1:5,000, delayed hemolytic <= 1 in 4,000, febrile nonhemolytic reaction RBC ~ 1 in 526, febrile nonhemolytic reaction platelets 1 in 900, circulatory overload <1%, simple allergic reaction <=1 in 3

Estimated Risk for Selected Transfusion Transmitted infections [3]

Infectious agent	Estimated risk of transmission per unit transfused (U.S.)
Bacteria Septic reaction	1 in 75,000 (platelets) 1 in 500,000 (RBCs)
Bacteria Fatality	1 in 500,000 (platelets) 1 in 10,000,000 (RBCs)
Hepatitis B	1 in 220,000
Hepatitis A	less than 1 in 1,000,000
Hepatitis C	1 in 1,800,000
Human immunodeficiency virus (HIV 1 and 2)	1 in 2,300,000
Human T-cell lymphotropic virus (HTLV 1 and II)	1 in 2,993,000
Malaria (plasmodium)	1 in 4,000,000

REFERENCES

1. Miller Y, et al. Practice Guidelines for Blood Transfusion: A Compilation from Recent Peer-Reviewed Literature 2nd ed American Red Cross 2007
http://www.redcross.org/www-files/Documents/WorkingWiththeRedCross/practiceguidelinesforbloodtrans.pdf

2. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage.Obstet Gynecol. 2006 Oct;108(4):1039-47. PMID: 17012482

3. Fiebig EW and Busch MP. Infectious Disease Screening. In Roback JD et al eds. American Association of Blood Banks (AABB) Technical Manual ; 16th edition (July 8,2008)pp 242 -250

4. Bakdash S, Yazer MH.What every physician should know about transfusion reactions. CMAJ. 2007 Jul 17;177(2):141-7. PMID: 17638948

5. Guidance for Industry An Acceptable Circular of Information for the Use of Human Blood and Blood Components Docket Number FDA-2002-D-0223
http://www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/
guidances/blood/ucm187348.pdf

6. Sink BLS . Administration of Blood Components. In Roback JD et al eds. American Association of Blood Banks (AABB) Technical Manual ; 16th edition (July 8,2008)p 620