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Blood Products

By

Ravindra Sarode

, MD, The University of Texas Southwestern Medical Center

Reviewed/Revised Mar 2024
View PATIENT EDUCATION

Whole blood can provide improved oxygen-carrying capacity, volume expansion, and replacement of clotting factors and was previously recommended for rapid massive blood loss. However, because component therapy is equally effective in most circumstances and is a more efficient use of donated blood, whole blood transfusions were not available in the United States for several decades. The low titer (for anti-A) whole blood type O is now being increasingly used for trauma resuscitation as a universal blood type based on data suggesting improved survival when compared with component therapy (1 Reference Whole blood can provide improved oxygen-carrying capacity, volume expansion, and replacement of clotting factors and was previously recommended for rapid massive blood loss. However, because... read more ).

Red blood cells (RBCs)

Packed RBCs are stored between 1 and 6° C temperature for up to 42 days. Packed RBCs are the component of choice to increase hemoglobin (Hb) in a patient with anemia. Indications depend on the patient. Oxygen-carrying capacity may be adequate with Hb levels as low as 7 g/dL (70 g/L) in healthy patients, but transfusion may be indicated with higher Hb levels in patients with decreased cardiopulmonary reserve or ongoing bleeding. One unit of RBCs increases an average adult’s Hb by approximately 1 g/dL (10 g/L), and the hematocrit (Hct) by approximately 3%, above the pretransfusion value. When only volume expansion is required, other fluids can be used concurrently or separately. In patients with multiple blood group antibodies or with antibodies to high-frequency RBC antigens, RBCs with rare phenotypes of antigens are used; these are usually frozen for storage.

Washed RBCs are free of almost all traces of plasma, most white blood cells, and platelets. They are generally given to patients who have severe reactions to plasma (eg, severe allergies, paroxysmal nocturnal hemoglobinuria Paroxysmal Nocturnal Hemoglobinuria (PNH) Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder characterized by intravascular hemolysis and hemoglobinuria. Leukopenia, thrombocytopenia, arterial and venous thromboses... read more , IgA immunization). In IgA-immunized patients, blood collected from IgA-deficient donors may be preferable for transfusion.

WBC-depleted RBCs (leukoreduced RBCs) are prepared with special filters that remove 99.99% of white blood cells. They are indicated for patients who have experienced nonhemolytic febrile transfusion reactions Febrile nonhemolytic transfusion reaction The most common complications of transfusion are Febrile nonhemolytic reactions (including chill-rigor reactions) The most serious complications, which have very high mortality rates, are Acute... read more , for exchange transfusions, for patients who require cytomegalovirus-negative blood that is unavailable, and possibly for the prevention of human leukocyte antigen Human Leukocyte Antigen (HLA) System The human leukocyte antigen (HLA) system (the major histocompatibility complex [MHC] in humans) is an important part of the immune system and is controlled by genes located on chromosome 6.... read more (HLA) alloimmunization to help prevent refractoriness to platelet transfusion (failure to achieve the target level of blood platelets after platelet transfusion).

Fresh frozen plasma

Fresh frozen plasma (FFP) is an unconcentrated source of all clotting factors without platelets. The FFP is stored at -18° C for up to 1 year. Indications include correction of coagulopathic bleeding secondary to clotting factor deficiencies for which specific factor replacements are unavailable or to multifactor deficiency states (eg, massive transfusion, disseminated intravascular coagulation Disseminated Intravascular Coagulation (DIC) Disseminated intravascular coagulation (DIC) involves abnormal, excessive generation of thrombin and fibrin in the circulating blood. During the process, increased platelet aggregation and coagulation... read more [DIC], liver failure Acute Liver Failure Acute liver failure is caused most often by drugs and hepatitis viruses. Cardinal manifestations are jaundice, coagulopathy, and encephalopathy. Diagnosis is clinical. Treatment is mainly supportive... read more ). FFP is used for urgent warfarin reversal only when a 4 factor-prothrombin complex concentrate (4F-PCC is the first choice) is unavailable. FFP is ineffective in managing bleeding due to direct factor Xa inhibitors or direct thrombin inhibitors. FFP can supplement RBCs when whole blood is unavailable for neonatal exchange transfusion. FFP should not be used simply for volume expansion or correction of mild to moderate coagulopathy before surgical procedures especially in patients with cirrhosis who are not bleeding, because the coagulation defects may not be corrected and there is a risk that the additional plasma given will increase portal pressure and promote bleeding.

Pathogen-inactivated plasma obtained by treatment using the solvent detergent method is available to avoid transmission of almost all pathogens. Convalescent plasma has been used in the past during Ebola and influenza H1N1 epidemics.

Cryoprecipitate

Cryoprecipitate is a concentrate prepared from FFP and also stored at -18° C. Each concentrate usually contains approximately 80 units each of factor VIII and von Willebrand factor and approximately 250 mg of fibrinogen. It also contains ADAMTS13 (an enzyme that is deficient in congenital thrombotic thrombocytopenic purpura Thrombotic Thrombocytopenic Purpura (TTP) Thrombotic thrombocytopenic purpura (TTP) is an acute, fulminant disorder characterized by thrombocytopenia and microangiopathic hemolytic anemia. Other manifestations may include alterations... read more Thrombotic Thrombocytopenic Purpura (TTP) ), and factor XIII. Although originally used for hemophilia Hemophilia Hemophilias are common hereditary bleeding disorders caused by deficiencies of either clotting factor VIII or IX. The extent of factor deficiency determines the probability and severity of bleeding... read more and von Willebrand disease Von Willebrand Disease Von Willebrand disease (VWD) is a hereditary quantitative deficiency or functional abnormality of von Willebrand factor (VWF), which causes platelet dysfunction. Bleeding tendency is usually... read more , cryoprecipitate is currently used as a source of fibrinogen in acute DIC with bleeding, treatment of uremic bleeding, cardiothoracic surgery (fibrin glue), obstetric emergencies such as placental abruption Placental Abruption (Abruptio Placentae) Placental abruption (abruptio placentae) is premature separation of the placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include... read more and HELLP syndrome Complications Preeclampsia is new onset or worsening of existing hypertension with proteinuria after 20 weeks gestation. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Diagnosis... read more (hemolysis, elevated liver enzymes, and low platelet count), and rare factor XIII deficiency when human coagulation factor XIII concentrate is unavailable. In general, it should not be used for other indications. A pathogen-inactivated pooled cryoprecipitate is available that can be used as a source of fibrinogen. It has the advantage that it can be thawed and stored at room temperature for up to 5 days unlike standard cryoprecipitate that needs to be thawed from -18° C and used within 4 hours.

White blood cells (WBCs)

Granulocytes may be transfused when sepsis occurs in a patient with profound persistent neutropenia Neutropenia Neutropenia is a reduction in the blood neutrophil count. If it is severe, the risk and severity of bacterial and fungal infections increase. Focal symptoms of infection may be muted, but fever... read more (neutrophils < 500/mcL [0.5 × 109/L]) who is unresponsive to antibiotics. Granulocytes are stored at room temperature and must be given within 24 hours of harvest; however, testing for HIV, hepatitis, human T-cell lymphotropic virus, and syphilis may not be completed before infusion. Because of improved antibiotic therapy and medications that stimulate granulocyte production during chemotherapy, granulocytes are seldom used.

Immune globulins

Rh immune globulin (RhIg), given IM or IV, prevents development of maternal Rh antibodies that can result from fetomaternal hemorrhage Pathophysiology Hemolytic disease of the fetus and neonate is hemolytic anemia in the fetus or neonate caused by transplacental transmission of maternal antibodies to fetal red blood cells. The disorder usually... read more . The standard dose of intramuscular RhIg (300 mcg) must be given to an Rh-negative mother immediately after abortion or delivery (live or stillborn) unless the infant is Rho(D) and Du negative or the mother’s serum already contains anti-Rho(D). If fetomaternal hemorrhage is > 30 mL, a larger dose is needed. If hemorrhage of this amount is suspected, testing of the volume of fetomaternal hemorrhage begins with the screening rosette test, which, if positive, is followed by a quantitative test (eg, Kleihauer-Betke test).

Other immune globulins are available for postexposure prophylaxis for patients exposed to a number of infectious diseases, including cytomegalovirus Cytomegalovirus (CMV) Infection Cytomegalovirus (CMV, human herpesvirus type 5) can cause infections that have a wide range of severity. A syndrome of infectious mononucleosis that lacks severe pharyngitis is common. Severe... read more , hepatitis A Hepatitis A Hepatitis A is caused by an enterically transmitted RNA virus that, in older children and adults, causes typical symptoms of viral hepatitis, including anorexia, malaise, and jaundice. Young... read more , hepatitis B Hepatitis B, Acute Hepatitis B is caused by a DNA virus that is often parenterally transmitted. It causes typical symptoms of viral hepatitis, including anorexia, malaise, and jaundice. Fulminant hepatitis and... read more , measles Measles Measles is a highly contagious viral infection that is most common among children. It is characterized by fever, cough, coryza, conjunctivitis, an enanthem (Koplik spots) on the oral mucosa... read more Measles , rabies Rabies Rabies is a viral encephalitis transmitted by the saliva of infected bats and certain other infected mammals. Symptoms include depression and fever, followed by agitation, excessive salivation... read more , respiratory syncytial virus Respiratory Syncytial Virus (RSV) and Human Metapneumovirus Infections Respiratory syncytial virus and human metapneumovirus infections cause seasonal lower respiratory tract disease, particularly in infants and young children. Disease may be asymptomatic, mild... read more , rubella Rubella (See also Congenital Rubella.) Rubella is a viral infection that may cause adenopathy, rash, and sometimes constitutional symptoms, which are usually mild and brief. Infection during early pregnancy... read more Rubella , tetanus Tetanus Tetanus is acute poisoning resulting from a neurotoxin produced by Clostridium tetani. Symptoms are intermittent tonic spasms of voluntary muscles. Spasm of the masseters accounts for... read more Tetanus , smallpox Smallpox Smallpox is a highly contagious disease caused by the smallpox virus, an orthopoxvirus. Case fatality rate is about 30%. Natural infection has been eradicated. The main concern for outbreaks... read more Smallpox , and chickenpox Chickenpox Chickenpox is an acute, systemic, usually childhood infection caused by the varicella-zoster virus (human herpesvirus type 3). It usually begins with mild constitutional symptoms (eg, fever... read more Chickenpox (for usage, see under specific disease).

Platelets

Platelet concentrates are used

Platelet concentrates are also sometimes used before invasive surgery, particularly with extracorporeal circulation for > 2 hours (which often makes platelets dysfunctional). One platelet concentrate unit increases the platelet count by approximately 10,000/mcL (10 × 109/L), and adequate hemostasis is achieved with a platelet count of approximately 10,000/mcL (10 × 109/L) in a patient without complicating conditions, and approximately 50,000/mcL (50 × 109/L) for those undergoing surgery. Therefore, platelet concentrates derived from a pool of 4 to 5 units of whole blood are commonly used in adults.

Platelet concentrates are usually prepared by automated devices that harvest the platelets and return unneeded components (eg, RBCs, plasma) to the donor. This procedure, called plateletpheresis Therapeutic cytapheresis Apheresis refers to the process of separating the cellular and soluble components of blood using a machine. Apheresis is often done on donors where whole blood is centrifuged to obtain individual... read more , provides enough platelets from a single donation (equivalent to 4 to 5 whole blood platelet units) for transfusion to an adult, which, because it minimizes infectious and immunogenic risks, is preferred to multiple donor transfusions in certain conditions.

Certain patients may not respond to platelet transfusions (called refractoriness), possibly because of splenic sequestration, platelet consumption due to disseminated intravascular coagulation, or destruction due to HLA or platelet-specific antigen alloimmunization (and immune-mediated destruction). If patients are refractory to transfusion, they are tested for alloimmunization if possible. Patients with immune-mediated destruction may respond to pooled whole blood platelets (because of greater likelihood that some units are HLA compatible), platelets from family members, or ABO- or HLA-matched platelets. HLA alloimmunization may be mitigated by transfusing WBC-depleted RBCs and WBC-depleted platelet concentrates.

Pathogen-inactivated platelets, inactivated by using a chemical (amotosalen), are also available for clinical use. Most platelets are stored at 20 to 22° C for up to 5 to 7 days. Platelets can also be stored at 1 to 6° C for up to 14 days. During cold storage, platelets are partially activated and thus, hemostatically more functional than room temperature storage platelets; therefore, cold storage platelets are used during surgery or in a patient who is bleeding.

Other products

Many attempts have been made to develop blood substitutes using inert chemicals (eg, perfluorocarbons) or hemoglobin solutions to carry and deliver oxygen to tissues. Although these hemoglobin substitutes had promising ability to deliver oxygen to tissues during an emergency, several clinical trials have failed due to increased mortality and severe adverse cardiovascular toxicities (eg, hypotension). Attempts to regenerate platelets and RBCs from various stem cell sources are underway.

Hematopoietic stem cells Hematopoietic Stem Cell Transplantation Hematopoietic stem cell (HSC) transplantation is a rapidly evolving technique that offers a potential cure for hematologic cancers ( leukemias, lymphomas, myeloma) and other hematologic disorders... read more from autologous or allogenic donors can be transfused as a way of reconstituting hematopoietic function (particularly immune function) in patients undergoing myeloablative or myelotoxic therapy.

Reference

Drugs Mentioned In This Article

Drug Name Select Trade
Balfaxar, Kcentra
View PATIENT EDUCATION
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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