An Introduction to the Principles of
Transfusion Medicine
Christopher J. Gresens, M.D.
VP & Medical Director, Clinical Services
BloodSource
Principles of Transfusion
Medicine
Objectives
• At the conclusion of this presentation, participants
will be able to summarize, from an evidence-based
perspective, …
1. The means by which blood components are manufactured,
2. The approved uses of RBCs, platelets, plasma &
cryoprecipitate,
3. The standard of care for the use of CMV-seronegative and
irradiated “cellular” blood products.
Principles of Transfusion Medicine
Outline
 Brief Historical Perspective
 The Manufacture of Blood Components
 Evidence-Based Transfusion Indications for:
o (Whole Blood)
o RBCs
o Plasma (including use for major trauma)
o Platelets
o Cryoprecipitate
o Special (CMV-negative and/or Irradiated) Products
Principles of Transfusion
Medicine
A Brief History
1665 — 1st Documented
Animal-to-Animal Transfusion
Dog-to-dog
transfusion
by Richard
Lower.
From Petz and Swisher’s Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.
1667—1st Documented
Animal-to-Human Transfusion
Jean
Baptiste
Denis
infuses 15year-old boy
with lamb’s
blood.
From Zmijewski’s Immunohematology.
1818—1st Documented
Human-to-Human Transfusion
Following a 150-year
transfusion hiatus,
James Blundell
transfuses patient
with blood from a
human donor.
From Petz and Swisher’s Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.
1800’s—All Manner of Blood
Collection Devices Utilized
(You think
present-day
donor centers
sometimes face
challenges in
recruiting repeat
blood donors?)
From Petz and Swisher’s Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.
1900—
ABH Blood Group System ID’d
From Transfusion, Vol. 1, p. 2 (1961)
Karl Landsteiner
discovers ABH system
when he types
individuals as (what we
now call) group A,
group B, and group O.
In 1902, his proteges
identify a group AB
individual for the first
time.
The Discovery of Many Other
Red Cell Antigens Followed
•
•
•
•
•
•
•
Rh (C, c, D, E, e, …)
Kell (K, k, …)
Kidd (Jka, Jkb, …)
Duffy (Fya, Fyb, …)
MNSs, …
Lewis (Lea, Leb)
… … …
Early 1900’s—Getting Blood
from Point A to Point B
From Petz and Swisher’s Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.
Direct, donor-topatient
anastamosis
performed by
American
surgeon, George
Crile.
1914—
Modern Anticoagulation is Born
Citrate first
used for blood
anticoagulatio
n purposes.
From Petz and Swisher’s Clinical
Practice of Transfusion Medicine, 2nd
ed., 1989.
1939/40—Rh and Cause of
HDFN Discovered
Levine, Wiener, and
colleagues combined
their efforts in making
these seminal
discoveries
From Netter Monograph Series
1940’s – Making Plasma
Products
• Edwin Cohn develops the
first fractionation technique
to break down the
components of plasma into
“Cohn fractions.”
• John Elliott develops a
vacuum bottle/blood
container.
1940’s – Making Plasma
Products
Charles Drew starts
the “Blood for Britain”
program leading to
the manufacture of
large quantities of
dried plasma.
From American Red Cross Museum
Blood for Britain (WW II)
 Project to collect large amounts of blood in NYC
hospitals.
 Dried plasma package developed for ease of
transport, packaging and storage.
 Army-Navy plasma package consisted of 2 tin
cans containing 400cc bottles, 1 with distilled
water, the other with dried plasma.
 Reconstituted in 3 minutes; good for 4 hours.
Dried Plasma
Packages (WW II)
1950’s and 1960’s
• 1953 – Carl Walter and W.P. Murphy, Jr.
develop the plastic collection bag.
• Around that same time, the refrigerated
centrifuge is developed.
• Both of the above push transfusion
medicine into component production.
• 1964 – Plasmapheresis is introduced as a
collection method for plasma.
But, the importance of ABO
supersedes all …
From Petz and Swisher’s Clinical
Practice of Transfusion Medicine, 2nd
ed., 1989.
Principles of Transfusion
Medicine
The Manufacture of Blood Components
How We Make Blood Components
Collection Process
(1) Via Whole Blood Donation:
Whole blood is collected from
healthy blood donors into sterile
blood bags that contain
anticoagulant-preservative.
(2) Via Apheresis: Machines with
internal centrifuges separate a donor’s
blood into individual components (e.g.,
platelets, plasma, RBCs, etc.). The
desired components are retained,
while the remainder is returned to the
donor.
Donor interview process
Finger-stick
capillary blood
sampling
CuSO4 Hemoglobin determination
Note: Other methods can also
be used for this purpose.
BP, Pulse, and
Temperature Check
The Collection Process
Arm Disinfection Prior to Donation
Phlebotomy (16 Gauge Needle)
The Collection Process
Multi-bag whole blood collection kits
Flow of whole blood into primary bag
Whole Blood Collection
Blood Component Manufacture from
Whole Blood (As Done in the USA)
Centrifuge
(low g forces)
RBCs
+
Platelet-Rich
Plasma
Centrifuge Used for
Component Manufacture
Multi-pack Collection Bag
Centrifuge - Interior
Blood Component Manufacture
from Whole Blood
• Leukoreduce
• Possibly irradiate
• Other
RBCs
+
Platelet-Rich
Plasma
Platelets
or
+
Plasma
Fresh Frozen Plasma (FFP)
or
“Plasma Frozen with 24 hours”
Blood Component Manufacture
from Whole Blood
Fresh
Frozen
Plasma
(FFP)
Cryoprecipitate
•Thaw (4° C)
•Centrifuge
+
Cryo-Reduced
Plasma
Using the “Leftovers” Wisely
Sent for
further processing
Plasma Derivatives




Albumin
Factor VIII
Immune globulin
etc.
Blood can be optimally utilized by the use of
specifically required components instead of
whole blood…
RBC
FFP
PLT
“Shotgun” Approach vs. . .
Component Therapy
The Principles of Apheresis
Remaining
blood constituents
returned
Anticoagulant
added
Plasma
Platelets
Whole Blood
(vein)
Mononuclear Cells
Granulocytes
Red Blood Cells
Blood
constituents separated by
centrifuge and selectively
collected
Whole Blood
(vein)
Caridian
BCT
Trima
Accel
Haemonetics PCS-2
Plasma Collected Via
Apheresis
Typically
200 mL
to
800 mL
FFP Made from Apheresis
Donor sample tubes being
readied for testing
Infectious Disease Testing (Abbott PRISM)
Chagas Disease
Testing (Ortho
Platform)
NAT – HIV, HBV,
HCV, and WNV
Olympus PK-7200
(ABO, Rh, syphilis)
CBC analysis by
Pentra XL-80
Platelet Bacterial
Detection QC
Testing by
BacT/ALERT
Testing
•
•
•
•
ABO
Rh
RBC Antibody Screen
Infectious Diseases




Syphilis
HBsAg
Anti-HIV-1/2
Anti-HBc
Testing
• Infectious Diseases (cont.)









Anti-HTLV-I/II
Anti-HCV
HIV Nucleic acid testing (NAT)
HBV NAT
HCV NAT
WNV NAT
T. cruzi antibody (Chagas’ Disease)
(On some units) Anti-CMV
Future ??? Parvovirus B19, malaria, etc.
Infectious Transfusion Risks
•
•
•
•
•
HIV: 1 in 2,135,000 units
HBV: 1 in 205,000-to-488,000 units
HCV: 1 in 1,935,000 units
HTLV-I/II: 1 in 514,000-2,993,000 units
CMV: << 1: 100 (when leukoreduced or CMVnegative blood used)
• WNV: ? (region-specific; very low)
• vCJD: ? (risk very, very low—even in U.K.)
“Infectious Risks of Blood Transfusion.” Blood Bulletin
(America’s Blood Centers). December 2001.
Irradiator (to prevent transfusionassociated GVHD)
Hospital Services Departments
at Our Regional Facilities
Getting it out the door …
Blood Bag Solutions
– Purposes
o To prevent clotting
o To provide nutrients for continued metabolism and
stabilization of cells
Glucose + 2 Pi +
2 ADP + 2 NAD+
Glycolysis
2 Pyruvate + 2 ATP + 2
NADH + 2 H+ + 2 H2O
– Basic Needs of Stored Blood Cells
Adequate Glucose
Appropriate pH
Adequate ATP levels
Blood Bag Solutions
The Storage Lesion: These are the metabolic
changes that occur to stored blood over time.
Following is an example for CPDA-1 RBCs.
Parameter
0 Days
35 Days
% Viable Cells
100
71
pH
7.55
6.71
[K+] (mmol/L)
5.1
78.5
[Plasma Hgb] (mg/L)
78
658
[2,3-DPG] (% of initial)
100
< 10
From AABB Technical Manual, 16th ed.
Mean Coagulation Factor Activity in
Thawed Apheresis FFP Stored at 16° C for 5 Days
%
P Value Day 1Decrease
5
Day 1-5
Factor
Day 1
Day 3
Day 5
Fibrinogen (mg)
322.3
315.9
316.2
1.9
Not significant
Factor II (%)
90.9
88.2
88.5
2.6
Not significant
Factor V (%)
95.4
90.1
87.0
8.8
<0.0001
Factor VII (%)
93.6
92.4
90.2
3.6
Not significant
Factor VIII (%)
89.5
76.4
76.7
14.3
0.0016
Factor X (%)
100.3
99.1
101.5
0.0
Not significant
Factor XI (%)
105.0
108.9
106.5
0.0
Not significant
From Sidhu et al. J of Clin Apheresis. 2006; 21:224-226
Top-10 Reasons for Giving
Blood …
10.
9.
8.
7.
6.
It makes me feel good about myself.
How else can I instantly lose one pound?
To put up my feet and relax without guilt.
All my friends & family do it, so I do, too.
It’s a nice way to meet people with similar
philosophies.
Top-10 Reasons for Giving
Blood …
5.
4.
The good-looking nurses (and doctors).
Because, even though I have few material
possessions to give, I always (God
willing) will have enough blood to share.
3. Because I know that, whatever they take
from me, I can replace.
2. How else can I experience so much
satisfaction with my clothes on?
…and the Number 1 Reason
for Giving Blood …
1.
To help save the lives of others.
Principles of Transfusion
Medicine
Transfusion Indications for Blood Components
Whole Blood
• Clinical Indications: Provides O2
delivery, plasma, and volume in
hypovolemic shock patients.
• Contraindications
– Thrombocytopenia (unless unit is VERY
fresh)
– Factor VIII or V deficiencies
– Normovolemic chronic anemia
Whole Blood
• Transfusion Criteria
o Must be ABO-identical
o Should be crossmatch compatible
• Dosage: One unit should raise a 70 kg
patient’s Hct (Hgb) by approximately
3% (1 g/dL) in the absence of ongoing
bleeding or hemolysis
Difference Between a Whole Blood and a Red Cell Unit
Recommended Targets for RBC Transfusions
(To be Revisited)
• Clinical Indications: To restore O2-carrying
capacity in clinically significant (acute or chronic)
anemias.
 Asymptomatic anemia: Typically, in stable patients,
Hgb thresholds of 7-to-8 g/dL should be crossed before
transfusion would be considered.
 Bleeding/acute blood loss: Transfuse at the
discretion of physician.
 Occasional exceptions, such as the need to
transfuse pre-renal transplant patients, regardless of
their Hcts (i.e., to induce immune tolerance), exist.
PC Hebert, et al. Does Transfusion Practice
Affect Mortality in Critically Ill patients?
AmJRespCritCareMed 1997; 155: 1618-1623.
 Design
o Retrospective review of 4,470 critically ill patients
o Examined impact of transfusions on mortality
 Results: Patients with anemia, a high APACHE II
score (> 20), and a cardiac diagnosis had a
significantly lower mortality rate when given 1 to 3
or 4 to 6 units of allogeneic red cells …
o 55% mortality rate [no transfusions] versus …
o 35% mortality rate [1 to 3 units] or …
o 32% mortality rate [4 to 6 units], respectively, p = 0.01
PC Hebert, et al. Does Transfusion Practice
Affect Mortality in Critically Ill patients?
AmJRespCritCareMed 1997; 155: 1618-1623.
Authors’ Conclusions
o Anemia increases the risk of death in critically
ill patients with cardiac disease.
o Blood transfusions appear to decrease this
risk.
PC Hebert et al. A Multicenter, Randomized,
Controlled Clinical Trial of Transfusion
Requirements in Critical Care NEJM 1999; 340:
409-417
 Background: To determine if restrictive vs. liberal
transfusion strategies in critically ill patients yield
equivalent results
 Methods: 838 euvolemic, critically ill patients were
randomly assigned to receive transfusions only if:
o Hgb < 7 (afterwards, maintained at 7-9 g/dL) or
o Hgb < 10 (afterwards, maintained at 10-12 g/dL)
PC Hebert et al. A Multicenter, Randomized,
Controlled Clinical Trial of Transfusion
Requirements in Critical Care NEJM 1999; 340:
409-417
 Results
o 30-day mortality rates were similar in the two groups
18.7% for restrictive vs. …
23.3% for liberal group (p = 0.11), but …
o Mortality rates in restrictive group were significantly
lower in two specific subgroups – e.g., among:
“Patients who were less acutely ill” (8.7% for
restrictive vs. 16.1% for liberal; p = 0.03)
Patients < 55 years old (5.7 in restrictive vs. 13.0%
for liberal; p = 0.02)
o No difference was seen in patients with clinically
significant heart disease (20.5 vs. 22.9%; p = 0.69)
W-C Wu, et al. Blood Transfusion in Elderly
Patients with Acute Myocardial Infarction.
NEJM 2001; 345:1230-1236
• Design: Retrospective analysis of 78,974 patients > 65
years old who were hospitalized for acute MI
• Results
o Lower hematocrits on admission were associated with
higher 30-day mortality rates – Example …
 Mortality rate for 1,273 patients with Hct < 27% who were not transfused was near 50% (almost 3x that of patients with normal Hcts)
o Blood transfusion was associated with a reduction in
30-day mortality among patients whose hematocrit on
admission fell into the categories ranging from:
5.0 to 24.0 percent (adjusted odds ratio, 0.22; 95 percent
confidence interval, 0.11 to 0.45) to …
30.1 to 33.0 percent (adjusted odds ratio, 0.69; 95
percent confidence interval, 0.53 to 0.89).
W-C Wu, et al. Blood Transfusion in Elderly
Patients with Acute Myocardial Infarction.
NEJM 2001; 345:1230-1236
Conclusion: “The judicious use of
transfusion in elderly patients with MI
is associated with improved outcomes
for patients with Hcts of < 30% and
may be effective in patients with Hcts
as high as 33%.”
JL Vincent et al. Anemia and Blood
Transfusion in Critically Ill Patients. JAMA
2002; 288: 1499-1507
 Design: 2-part, multi-center international study
(retrospective) involving 3,534 patients from
146 W. European ICUs
 Results: Patients transfused with RBCs had
significantly higher 28-day mortality than those
(matched for disease severity) who were not
transfused (22.7% vs. 17.1%; p = 0.02)
 Conclusion: “Study provides evidence of an
association between transfusions and diminished
organ function as well as between transfusions
and mortality.”
SV Rao. Relationship of Blood Transfusion and
Clinical Outcomes in Patients With Acute Coronary
Syndromes JAMA 2004; 292: 1555-1562
 Design: Retrospective analysis of 24,112 enrollees in 3
international trials of patients with acute coronary
syndromes
 Results: Transfusion was associated with an increased
hazard for 30-day death (adjusted hazard ratio: 3.94)
(Findings are at odds with some previous studies)
 Conclusions: Authors, though they recognize the
limitations of study, nonetheless suggest “caution
regarding the routine use of blood transfusion to
maintain arbitrary hematocrit levels in stable patients
with ischemic heart disease.”
Recommended Target Hematocrits
for RBC Transfusions (Revisited)
• Lower limit (or “transfusion trigger”) for general
medical and surgical patients remains at Hgb (Hct)
levels of 7.0 g/dL (21%).
• Some patient groups (e.g., elderly with acute MI’s)
seem to have better outcomes when Hct is in 3033% range.
“Current data suggest restraining transfusions favors
positive patient outcomes—except when significant
underlying cardiac disease is present.”
“The Transfusion Trigger Updated: Current Indications for Red Cell
Therapy.” Blood Bulletin, Vol. 6; July, 2003.
RBC Transfusions
• Contraindications
 Pharmacologically treatable anemias
 Most coagulation deficiencies
• Transfusion Criteria
 Must be ABO-compatible (group O is “universal”);
 Should be crossmatch-compatible;
• Dosage: One unit generally will raise the Hct (Hgb)
of a 70-kg, non-bleeding/hemolyzing patient by 3%
(1 g/dL).
e
Leukoreducing Platelets
from the Get-Go
• Leukoreduction
system (LRS)
minimizes WBCs in
platelets
From Caridian BCT website
Clinical Indications for Platelets
• Overview: Platelet transfusions are used for
the treatment and/or prevention of bleeding in
patients with thrombocytopenia or (less often)
platelet function defects
Clinical Indications for Platelets
• Major indications include:
 Decreased Production
o Leukemias
o Chemotherapy
o Congenital disorders
 Increased Destruction/Loss
o DIC
o Massive transfusions
 Platelet Function Defects
o Myeloproliferative disorders
o Aspirin/Plavix
o Glanzmann’s thrombocytopenia
Petechiae and
Purpura
Clinical Indications for Platelets
1910: Duke demonstrated that platelets from
transfused whole blood decrease bleeding
time and control bleeding.1
1962: Gaydos, et al. first documented
relationship between platelet count and
spontaneous bleeding in leukemia patients
(hemorrhage not seen until platelet count fell
to < 50,000/uL).2
1. Duke WW. JAMA 1910; 55: 1185-92.
2. Gaydos, et al. NEJM 1962; 266: 905-9.
% Days With Hemorrhage
100
RELATIONSHIP BETWEEN PLATELET
COUNT AND HEMORRHAGE
90
80
All Bleeding
70
Skin & Epistaxis Excluded
Grossly Visible Bleeding
60
(hematuria, melena,
hematemesis)
50
40
30
20
10
0
Platelets / L
Gaydos, et al.; NEJM 1962;266:905.
Clinical Indications for Platelets
1978: Slichter & Harker showed that blood loss in
stable aplastic patients accelerated only when
platelet count < 10,000/uL (moreover, bleeding
increased substantially with platelet count of <
5,000/uL).1
1986: NIH-Sponsored Consensus Conference …2
Plt ct > 50,000: Bleeding probably not due to low plt ct
Plt ct < 5,000: Severe bleeding risk
Plt ct 5-10K:   risk of spontaneous bleeding
Plt ct 10-50K:  risk of bleeding during hemostatic challenge
1. Slichter & Harker. Clin Hemat 1978; 7: 523-39.
2. Consensus Conference on Platelet Transfusion Therapy. JAMA 1987; 257:
1777-80.
Stool Blood Loss (ml/days)
100
Fecal Blood Content Versus
Low Platelet Counts
80
60
Slichter & Harker. Clin Haematol 1978;7:523.
40
20
5
10
15
20
Platelet Count x 103 / l
25
Clinical Indications for Platelets
A. Guidelines for Prophylactic Platelet
Transfusions
1. No Clinical Factors—Maintain platelet count
> 10,000/uL
2. Significant Clinical Factors (e.g., sepsis, DIC,
VOD, GVHD)—Maintain platelet count
> 20,000/uL
B. If Patient is Bleeding or Pre-Surgery, maintain
platelet count > 50,000/uL
C. Exceptions … (To be discussed)
Dosing Platelets
A. For Infants/Children: 5-10 mL platelets/kg
B. For Adults (> 40 kg): 1 plateletpheresis unit (rarely
2)
C. Formula for Calculating Dose:
Platelet Dose = Desired Increment x BV  0.67
D. Expectations: Ideally, an appropriate dose of
platelets should raise the platelet count by 30,00060,000/uL (more discussion to come …)
F. Important: Obtain a platelet count within 24 hours of
transfusion (ideally, within 1 hours—especially if
refractoriness suspected)
Special Platelet Topics
A. Platelet Selection Criteria
1. ABO Matching
a. 1st Choice: ABO identical (e.g., A to A)
b. 2nd Choice: Plasma compatible (AB to A)
c. 3rd Choice: Plasma incompatible (A to AB)
2. Rh Matching: It sometimes is necessary to
give Rh- positive platelets to an Rh-negative
patient. If the patient is a female of childbearing potential, consider the use of RhIg.
Special Platelet Topics
B.Contraindications to Platelet Transfusions
1.
TTP/HUS (unless bleeding)
2.
ITP and HIT (unless bleeding)
3.
DIC (unless bleeding or platelet count
< 20,000/uL)
4.
(Controversial) Chronic aplastic anemia or
MDS (unless bleeding)*
5.
Plasma coagulation defects unrelated to
platelets
* Consensus Conference: Platelet Transfusion Therapy. JAMA 1987;
257: 1777-80
+
Other Plasma
Components
FFP within
BloodSource’s Walkin Freezer
Plasma – A Complex Liquid
• Plasma is more than just the liquid
component of blood. It contains:
o Coagulation factors
o Immunoglobulins
o Albumin
o Proteins/Enzymes
o Anions and cations (e.g., Na+, Cl-, K+, …)
o…
Plasma Transfusions
• Clinical Indications
 Coagulopathy (with active bleeding)
documented by (at least one of): INR > 1.5,
PTT > 1.5 x mean normal; coag factor assay
of < 25% activity;
 Emergent reversal of warfarin effect;
 Documented acquired or congenital
coagulation factor deficiency (when specific
factor concentrate is unavailable);
 Plasma exchange for TTP/HUS.
Use of Plasma in Major
Trauma
M.A. Borgman, et al. “The Ratio of Blood
Products Transfused Affects Mortality in
Patients Receiving Massive Transfusions
at a Combat Support Hospital.” J Trauma.
2007; 63: 805-813.
Use of Plasma in Major
Trauma
Methods
 Retrospective chart review of 246 patients at U.S.
Army support hospital, each of whom received a
massive transfusion.
 Patients were sorted into 3 groups according to
transfused plasma : RBC ratio:
o “Low” = 1:8
o “Medium” = 1:2.5
o “High” = 1:1.4
 Mortality rates and causes of death were compared.
From J Trauma. 2007; 63: 805-813
Use of Plasma for Major
Trauma
Results
Ratio of Plasma:RBCs
Overall Mortality
(p < 0.001)
Hemorrhage Mortality
(p < 0.001)
Low (1:8)
65%
93%
Medium (1:2.5)
34%
78%
High (1:1.4)
19%
37%
Logistical regression showed that plasma-to-RBC ratio was independently
associated with survival.
From J Trauma. 2007; 63: 805-813
Use of Plasma for Major
Trauma
Conclusions
 “In patients with combat-related trauma requiring
massive transfusion, a high 1:1.4 plasma to RBC ratio
is independently associated with improved survival to
hospital discharge, primarily by decreasing death
from hemorrhage.”
 “For practical purposes, massive transfusion
protocols should utilize a 1:1 ratio of plasma to RBCs
for all patients who are hypocoagulable with traumatic
injuries.”
From J Trauma. 2007; 63: 805-813
Plasma Transfusions
• Contraindications: Should not be used as a:




Volume expander in absence of factor deficiency;
Nutritional source or wound healing “factor;”
Substitute for a readily available factor concentrate;
Antidote to heparin (protamine is correct choice)
• Transfusion Criteria: Must be ABO-compatible
with patient (with only the rarest of exceptions);
• Dosage: Determined by clinical situation and body
size; generally, 15-20 mL/kg for loading dose and
10 mL/kg to maintain hemostasis.
Cryoprecipitate Transfusions
 Clinical Indications
 Correction of factor VIII deficiency or von
Willebrand’s disease when a specific factor
concentrate isn’t available;
 Factor XIII deficiency
 Hypofibrinogenemia (e.g., in DIC or dilutional
coagulopathy related to bleeding)
 Source of fibrin glue (last choice option)
JL Callum, et al. Cryoprecipitate: The Current State of
Knowledge. TransfusMedRev 2009; 23: 177.
JD Roback, et al (editors). Technical Manual, 16th ed. AABB,
Bethesda, MD, 2008.
Cryoprecipitate Transfusions
 Clinical Indications
 Correction of factor VIII deficiency or von
Willebrand’s disease when a specific factor
concentrate isn’t available;
 Factor XIII deficiency
 Hypofibrinogenemia (e.g., in DIC or dilutional
coagulopathy related to bleeding)
 Source of fibrin glue (last choice option)
JL Callum, et al. Cryoprecipitate: The Current State of
Knowledge. TransfusMedRev 2009; 23: 177.
JD Roback, et al (editors). Technical Manual, 16th ed. AABB,
Bethesda, MD, 2008.
Cryoprecipitate Transfusions
• Contraindications: Always first consider
safer, more effective therapies, e.g.,
 DDAVP or Humate-P™ for vWD;
 Factor VIII concentrate (if available) for
hemoph. A;
 Tisseel™ for fibrin sealant;
• Transfusion Criteria: ABO generally is not
very important, unless a lot is transfused
quickly (e.g., on the order of > 30 units over
72 hours).
Cryoprecipitate
Transfusions
 The Problem with Traditional “Fibrin Glue:”
o Bovine thrombin (used to make it) can cause
formation of antibodies against thrombin or other
coagulation factors (e.g., factor V)
o These “inhibitor antibodies” can cross react with
human coagulation factors and cause bleeding
MB Streiff and PM Ness. Acquired Factor V Inhibitors: A Needless
Iatrogenic Complication of Bovine Thrombin Exposure. Transfusion
2002; 42: 18-26
Cryoprecipitate Transfusions
• Dosage
Total Bags Needed = [Total Factor Required]
[Units of Factor per Bag]
Total Factor Required
= [Pt’s Plasma Volume] x [Desired - Initial Level]
Plasma Volume Of Ave. Adult
= [kg body wt.] x [70 mL/kg] x [1 - Hct]
Specialized Blood
Components
• CMV-seronegative
• Irradiated
• (Leukoreduced)
Indications for CMV-Seronegative
Blood
 Pre-/post-hematopoietic stem cell transplant
(if pt. is CMV-neg)
 Low birth weight (< 1,200 g) neonate
(if mom is CMV-neg)
 Intrauterine fetal transfusion
(regardless of mom’s CMV serology)
 Pregnancy (if mom is CMV-neg)
 Congenital immunodeficiency (if pt. is CMV-neg)
 Pre-/post-solid organ transplant (if pt. is CMV-neg)
 HIV infection/AIDS (if pt. is CMV-neg)
 Other possible indications: Hematologic/solid malignancy;
neonatal exchange (if pt. is CMV-neg)
JD Roback, et al (editors). Technical Manual, 16th ed. AABB, Bethesda,
MD, 2008.
Indications for Irradiated Blood
 Pre-/post-hematopoietic stem cell transplant
 Hodgkin’s disease
 Low birth weight neonate (< 1,200 g)
 Neonatal exchange transfusion
 Intrauterine fetal transfusion
 Related donor
 HLA-matched donor or crossmatch-compatible
platelet donor
 Treatment with either fludarabine or 2-CDA
JD Roback, et al (editors). Technical Manual, 16th ed. AABB,
Bethesda, MD, 2008.
Top 10 Bogus Reasons for
Transfusing a Patient …
10.
My patient could use some extra calories.
9.
For wound healing purposes.
8.
My patient is specifically requesting it, and who am I
to say no?
7.
(For autologous blood) It’s the patient’s blood
anyway, so what harm could come of it?
6.
Since it’s been out of storage for > 30
minutes, and the blood bank won’t take it back.
… Top 10 Bogus Reasons for
Transfusing a Patient …
5.
Because I’m “only” a resident, and my attending
ordered it.
4.
(For FFP) The patient requires volume support.
3.
(For platelets) My non-bleeding patient has ITP with
a platelet count of < 5,000/uL.
2.
Because the Tour de France is coming up.
… And the Number 1
Bogus Reason for Transfusing a
Patient …
1.
Hey! It’s only blood. What’s the big deal?
Principles of Transfusion Medicine
Summary
 Brief Historical Perspective
 The Manufacture of Blood Components
 Evidence-Based Transfusion Indications for:
o (Whole Blood)
o RBCs
o Plasma (including use for major trauma)
o Platelets
o Cryoprecipitate
o Special (CMV-negative and/or Irradiated) Products
Principles of Transfusion Medicine
Q & A???
Please
donate
blood
...
… You
never know
whose life
you might
save.
From Action Comics # 403 (1970)
Thank You …
To all of our friends/colleagues in
the audience…
Chris.Gresens@BloodSource.org