Blood Component Therapy

Packed red blood cells

FFP/FDP

Cryoprecipitate

Platelets

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Before administration of any blood component, the patient’s details should be checked against those on the bag (see red blood cell transfusion section). Blood components have specific storage and expiry times. Every effort must be made to avoid wastage.

In haematological malignancy, the clinical team must be consulted before administering blood components because of the need for specific requirements. The transfusion threshold may be different to non-haematological patients. A small subset of patients requires transfusion with irradiated blood components to prevent them developing transfusion-associated graftversus-host disease (TA-GVHD), which is rare, but usually fatal. Patients with the following conditions require irradiated blood: congenital immunodeficiency states, for example DiGeorge’s syndrome; allogeneic bone marrow transplant recipients and donors; autologous bone marrow-transplanted patients; Hodgkin’s lymphoma; purine analogue therapy (e.g. fludarabine, cladribine) as well as newer agents clofarabine and bendamustine; and patients who receive antithymocyte globulin (ATG), or certain monoclonal antibody therapies (e.g. antiCD52 monoclonal antibody therapy (alemtuzumab).⁶²

Packed red blood cells

		Consensus	Grade
14.1	A general Hb threshold of 7g/dL should apply as a guide for red cell transfusion.	Yes	B
14.2	Uncertainty remains for patients with ischaemic heart disease, including ACS and after cardiac surgery, and higher thresholds (8g/dL) may be more appropriate in such circumstances.	Yes	A

RBC transfusion is potentially life-saving for the treatment of blood loss and is the recommended therapy for restoring the diminished oxygen-carrying capacity in most circumstances.

The goals of RBC therapy are twofold;

1. to increase oxygen-carrying capacity of blood to meet tissue demand, and
2. to replace the oxygen-carrying elements of the intravascular volume lost during acute blood loss.

In patients who do not have active bleeding and in normovolaemic patients, the Hb should be measured before and after every unit of RCC transfused. Near-patient measurement of Hb may be particularly useful, but laboratory measurement remains the gold standard. Haemoglobin concentration is dependent on both red cell mass and plasma volume and it may fall due to haemodilution due to IV fluid administration. In the bleeding patient, inadequate fluid resuscitation may result in a falsely elevated Hb concentration despite significant blood loss. In the absence of blood products, or immediate need for blood products, the initial intravascular volume replacement strategies should mainly be synthetic crystalloid and colloid fluids. The controversy on choice of synthetic colloid solutions is beyond the scope of this guideline.

Optimum Hb transfusion trigger

Recent publications comparing more liberal transfusion strategies (typical transfusion trigger Hb 9–10g/dL) with more restrictive strategies (typical transfusion trigger Hb 7–8g/dL) did not show any difference in patient outcomes.^{63, 64} Therefore, a general Hb threshold of 7g/dL should apply as a guide for red cell transfusion. Uncertainty remains for patients with ischaemic heart disease, including ACS and after cardiac surgery,⁶⁵ and higher thresholds (8g/ dL ) may be more appropriate in such circumstances (including patients going for major surgery and diminished oxygen reserve estimates). A recent context-specific meta-analysis showed restrictive transfusion strategies were associated with an increased risk of complications in situations combining high risk patients with major surgery.⁶⁶ Those with cardiovascular disease undergoing cardiac or vascular procedures seemed to have more events reflecting inadequate oxygen supply, higher mortality rates, or both. It remains difficult to identify such patients in every clinical situation, and new transfusion algorithms should aim to integrate additional clinical parameters, such as patient comorbidities, and particular clinical settings.

FFP/FDP

		Consensus	Grade
15.1	The recommended initial therapeutic dose is 15–20ml/kg.	Yes	A
15.2	Indications for FFP/FDP use include the following:	Yes
15.2.1	- Maintenance of coagulation factors during major haemorrhage, particularly trauma and obstetrics.	Yes	A
15.2.2	- Acute DIC with bleeding.	Yes	C
15.2.3	- In patients who are actively bleeding and whose INR is >1.5 (or POC equivalent).	Yes	B
15.2.4	- Immediate reversal of warfarin-induced haemorrhage when PCC is not available (PCC is the first choice).	Yes	B
15.2.5	- Thrombotic thrombocytopenic purpura (preferably using pathogen-inactivated FFP or FDP) usually with plasmapheresis if no response.	Yes	A
15.2.6	- Replacement of coagulation factors when specific factors are not available in the presence of active bleeding or to prevent bleeding during an invasive procedure (uncommon).	Yes	C
15.3	FFP/FDP is not recommended for routine use in patients with cirrhosis/liver disease unless significant coagulopathy and haemorrhage are identified.	Yes	B

FFP is leucodepleted plasma rapidly frozen to below -25°C to maintain the integrity of labile coagulation factors. The use of FFP has increased significantly in the past few years.⁶⁷ Coagulation tests (PT or INR and aPTT) should preferably be obtained prior to the administration of FFP in a bleeding patient. Transfusion of FFP is not indicated if PT, INR, and aPTT are normal (unless a patient has a condition such as thrombotic thrombocytopaenic purpura (TTP) or something like Factor XIII deficiency where both PT and aPTT may be normal).⁶⁸

FFP needs to be thawed before use. Once out of the fridge, it must be used within 30 min, and once thawed, it should never be refrozen. The approximate volume per bag is 300ml.

FFP contains all the factors of the soluble coagulation system, including the labile factors V and VIII to a varying degree. The fibrinogen content of four units of FFP is approximately 2g, compared with approximately 4g fibrinogen in two pools of cryoprecipitate. FFP should be the same group as the patient. If the blood group is unknown, group AB FFP is preferred, as it does not contain any anti-A or anti-B. If group O FFP is given to non-group O children, it should be high-titre (HT) negative. The recommended therapeutic dose is 15ml/kg.

FDP has a haemostatic function similar to that of FFP. It is stored as dry powder at room temperature (below 25°C) with a shelf life greater than that of FFP. Electrolyte and protein levels are comparable with those of FFP. Coagulant activities of factors I, II, V, VII, VIII, IX and X may be 10–30% lower than those of FFP and stable during storage for up to one year. The ability to store at ambient temperature eliminates errors that occur with cold chain storage and would allow availability in remote, rural and underdeveloped locations. The median time of reconstitution is 1.5 minutes with consequent reduced time to transfusion and early intervention. It is available either as a 50ml or 200ml pack size and infused through a standard blood administration set.

Indications for FFP/FDP use include the following:^69-71

• replacement of coagulation factors during major haemorrhage, particularly trauma and obstetrics;
• DIC with bleeding;
• in patients who are actively bleeding and whose INR is > 1.5 (or POC equivalent);
• immediate reversal of warfarin-induced haemorrhage when PCC is not available (PCC is the first choice);
• thrombocytopenic purpura usually with plasmapheresis preferably using pathogeninactivated FFP; and
• replacement of coagulation factors when specific factors are not available in the presence of active bleeding or in order to prevent bleeding, in the case of surgery or invasive procedures (uncommon).^72-74

There is a very limited role for FFP in the management of (mild–moderate) coagulation abnormalities frequently seen in many non-bleeding critically ill patients before invasive procedures. FFP is not recommended for routine use in patients with cirrhosis/liver disease unless significant coagulopathy or haemorrhage is identified, as again current understanding indicates that isolated abnormalities of the PT or aPPT do not reflect a ‘balanced haemostasis’. FFP should not be used simply as routine circulatory volume replacement.

Cryoprecipitate

		Consensus	Grade
16.1	Indications for cryoprecipitate include the following:
16.1.1	Hypofibrinogenaemia due to major haemorrhage and massive transfusion.	Yes	A
16.1.2	- During major haemorrhage, fibrinogen should be maintained >1.5g/L, except in active obstetric haemorrhage where fibrinogen should be maintained >2g/L.	Yes	A
16.1.3	- Bleeding associated with thrombolytic therapy.	Yes	C
16.1.4	- Disseminated intravascular coagulation with fibrinogen <1.0g/L.	Yes	B
16.1.5	- Advanced liver disease, to maintain fibrinogen level >1.0g/L.	Yes	B
16.1.6	- Combined liver and renal failure with bleeding.	No	C
16.2	The initial dose of cryoprecipitate should be 1 unit/10kg (typically 15–20ml/kg).	Yes	A

Cryoprecipitate is also a leucodepleted plasma product containing concentrated factor VIII, von Willebrand factor, fibrinogen, factor XIII and fibronectin, produced by further processing of FFP. Note that it is not appropriate for warfarin reversal, as it does not contain the vitamin K-dependent factors. It is stored at -25°C; once thawed for administration, it can be kept at ambient temperature for 4 h, and should not be kept in the fridge again.⁶²

In South Africa, cryoprecipitate is mainly in individual units of 15–20ml, but may also be prepared as a pool of 10 units. Each single unit has approximately 400–450mg of fibrinogen.

The adult dose is 1 unit/10kg (100IU/10kg); transfuse using a standard blood-giving set with a 170- to 200-micron filter (standard blood administration set).

Indications for cryoprecipitate include the following:

• hypofibrinogenaemia due to major haemorrhage and massive transfusion. There is increased use of cryoprecipitate in major trauma, obstetric haemorrhage and cardiac surgical bleeding. During major haemorrhage, fibrinogen should be maintained >1.5g/L, except in active obstetric haemorrhage where fibrinogen should be maintained >2g/L;
• bleeding associated with thrombolytic therapy;
• disseminated intravascular coagulation with fibrinogen < 1.0g/L;
• advanced liver disease, to maintain fibrinogen level >1.0g/L; and
• combined liver and renal failure with bleeding (no consensus amongst the SASA guideline working group).

Platelets

		Consensus	Grading
17.1	Indications for platelets include the following:.
17.1.1	- Prevention and treatment of bleeding due to thrombocytopenia or platelet function defects.	Yes	B
17.1.2	- If patient is actively bleeding, transfuse to a platelet count >50 x 109/L (>75 x 109/L for neurosurgical and ophthalmic bleeding).	Yes	B
17.2	If not bleeding, the following triggers should be applied:
17.2.1	- Routine prophylactic use: 10x109/L.	Yes	B
17.2.2	- Prophylactic use with additional risk factors (e.g. sepsis): 10–20 x 109/L.	Yes	C
17.2.3	- Other major surgery or invasive procedures: 50x109/L.	Yes	C
17.2.4	- Neuraxial blockade: 50x109/L.	Yes	B
17.2.5	- Prophylactic use in closed compartment surgery (eye, brain): 100 x 109/L.	Yes	B

Platelets are either made from pooled buffy coat-derived platelets from 4–6 whole blood donations, suspended in platelet additive solution and the plasma of one of the four donors (who is male), or as an adult therapeutic dose obtained from a single donor by apheresis donation. Both can be used interchangeably, except for haematology, transplant or chronically transfused patients, where limited exposure to human leukocyte antigen (HLA) antigens is required to avoid problems during transplant or to prevent HLA sensitisation and platelet refractoriness.

There is increased use of platelets in the last few years. The greatest demand is for haemoncology patients; platelets should not be administered to patients with chemotherapy-induced thrombocytopenia in the absence of bleeding, unless their platelet count is <10 x 10⁹/L.

The risk of transmission of bacterial infection (1 in 12 000) is higher than other blood components because platelets are stored at 22°C. This risk is reduced by bacterial screening before release.

Platelets do not have to be the same group as the patient, but where group O platelets are given to a non-group O child they should be selected to be HT negative. D-negative children and women of childbearing potential should receive D-negative platelets because of the small risk of developing immune anti-D.

Platelet concentrate should be stored at 22°C with constant gentle agitation in an approved incubator. Platelets must not be placed in a refrigerator. Transfusion should ideally be commenced within 30 min of removal from the platelet storage incubator. Each pack contains 250–350ml; platelet count in the pack is >2.4 x 10¹⁰/L per adult dose, and transfusion should lead to an increase in the patient’s platelet count by approximately 30 x 109 /L. The patient’s platelet count should be repeated after transfusion.

A standard adult therapeutic dose should be infused over a period of 30 min through a standard blood administration set or platelet administration set incorporating a 170- to 200-micron filter (standard blood administration set). Do not give through a set that has already been used for red cells. No drugs should be added directly to the unit of platelets.

Indications for platelets include the following:

• prevention and treatment of bleeding due to thrombocytopenia or platelet function defects; and/or
• if patient is actively bleeding, transfuse to a platelet count >50 x 10⁹/L or until bleeding stops (higher targets (e.g. 75–100 x 10⁹/L) may be required in patients with neurosurgical or eye bleeds).

If not bleeding, the following triggers should be applied:

• routine prophylactic use: 10 x 10⁹/L;
• prophylactic use with additional risk factors (e.g. sepsis): 10–20 x 10⁹/L;
• other major surgery or invasive procedures: 50 x 10⁹/L;
• neuraxial blockade: 50 x 10⁹/L, and
• prophylactic use in closed compartment surgery (eye, brain): 100 x 10⁹/L.

In South Africa, the availability of platelets is centralised at blood banks, and thus access will depend on the demand and distance from nearest blood bank. Clinicians need to be aware of local laboratory arrangements and normal time interval for obtaining platelets from central storage.

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South African Society of Anaesthesiologists (SASA) Guidelines for Patient Blood Management 2020. Confirmed as current version on the SASA website as of November 2024.