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Blood Products
Blood products (blood components) are derived from whole blood donations or by apheresis and are used to replace specific deficiencies. Modern transfusion medicine follows a component therapy approach — giving only what the patient needs.
1. Whole Blood
Rarely used today except in military/damage control settings. Modern practice fractionates it into components to maximize utility. When used, it provides RBCs, plasma, and platelets simultaneously.
2. Packed Red Blood Cells (pRBCs)
| Feature | Detail |
|---|---|
| Preparation | Separated from whole blood; leukoreduced in most settings |
| Storage | 1–6°C for up to 42 days (with additive solutions) |
| Volume | ~350 mL per unit |
| Hematocrit | ~55–80% |
| Compatibility | ABO and RhD matching required |
Indications:
- Symptomatic anemia unresponsive to medical therapy
- Hemoglobin < 7 g/dL in stable ICU patients
- Hemoglobin < 8 g/dL in cardiovascular disease or major orthopedic surgery
- Active hemorrhage / hemorrhagic shock
Expected response: Each unit raises Hgb by ~1 g/dL and Hct by ~3% in a 70 kg adult.
Special preparations:
- Leukoreduced (LR): Removes WBCs → reduces HLA alloimmunization, febrile non-hemolytic reactions (FNHTRs), and CMV transmission
- Irradiated: Gamma-irradiation inactivates donor T-lymphocytes → prevents transfusion-associated graft-versus-host disease (TA-GvHD) in immunocompromised patients
- CMV-negative: Used in CMV-seronegative immunosuppressed patients
- Washed: Removes plasma proteins → for severe allergic/anaphylactic reactions or IgA deficiency
3. Platelets
| Feature | Detail |
|---|---|
| Preparation | Pooled from 4–6 whole blood donations or single-donor apheresis |
| Storage | 20–24°C (room temperature), with continuous agitation, up to 5–7 days |
| Volume | ~50 mL (single unit) / ~250–300 mL (apheresis unit) |
| ABO compatibility | Preferred but not mandatory |
Indications:
- Platelet count < 10,000/µL (prophylactic in stable patients)
- Platelet count < 50,000/µL before invasive procedures / surgery
- Platelet count < 100,000/µL in CNS surgery or active microvascular bleeding
- Qualitative platelet disorders with active bleeding
Key note: Apheresis platelets carry lower bacterial contamination risk than pooled units (fewer venipunctures, single donor). Platelets have the highest risk of bacterial contamination of all blood products because they are stored at room temperature.
4. Fresh Frozen Plasma (FFP)
| Feature | Detail |
|---|---|
| Preparation | Plasma separated and frozen within 8 hours of collection |
| Storage | −18°C or colder, up to 12 months |
| Volume | 200–250 mL per unit |
| Contents | All clotting factors, fibrinogen, natural anticoagulants (protein C, S, antithrombin) |
| ABO compatibility | Required |
Indications (Table 17-7, Barash):
- Correction of inherited factor deficiencies when no specific concentrate exists (e.g., Factor V deficiency), with PT/aPTT >1.5× control or INR >2.0
- Acquired multi-factor deficiencies with clinical bleeding (liver disease, DIC)
- Massive transfusion / post-traumatic coagulopathy
- Reversal of warfarin when PCCs unavailable
- Treatment of TTP, HELLP, HUS
- Heparin resistance from antithrombin deficiency (when AT concentrate unavailable)
- Hereditary angioedema when C1-esterase inhibitor unavailable
Dose: Initial dose 10–20 mL/kg to achieve ≥30% factor activity.
Note: FFP is not recommended prophylactically for mild INR elevation (1.5–1.9) without clinical bleeding — evidence fails to show benefit.
Variants:
- Thawed plasma: FFP thawed and stored at 1–6°C for up to 5 days; equivalent efficacy
- Liquid plasma / Plasma Frozen within 24 hours (PF24): Slightly lower Factor V and VIII levels; practical for trauma centers
5. Cryoprecipitate
| Feature | Detail |
|---|---|
| Preparation | Cold-insoluble precipitate from thawed FFP; re-frozen |
| Storage | −18°C or colder, up to 12 months |
| Volume | ~15–20 mL per unit; typically pooled (10 units) |
| Contents | Concentrated fibrinogen (~150–250 mg/unit), Factor VIII, vWF, Factor XIII, fibronectin |
Indications:
- Hypofibrinogenemia (fibrinogen < 100–150 mg/dL) with active bleeding
- DIC with fibrinogen depletion
- Hemophilia A and vWD when specific concentrates unavailable
- Factor XIII deficiency
- Uremic bleeding (as bridge therapy)
Dose: 1 unit per 7–10 kg body weight; raises fibrinogen by ~50 mg/dL.
6. Fibrinogen Concentrate
A plasma-derived concentrate of fibrinogen (instead of cryoprecipitate). Advantages include:
- Standardized dosing
- Pathogen-reduced
- No need for ABO matching
- Faster to prepare than cryoprecipitate
Increasingly used in major hemorrhage protocols in Europe; growing adoption in the US.
7. Plasma Derivatives (Factor Concentrates)
| Product | Contents | Use |
|---|---|---|
| Factor VIII concentrate | Factor VIII ± vWF | Hemophilia A |
| Factor IX concentrate | Factor IX | Hemophilia B |
| vWF concentrate | vWF ± FVIII | von Willebrand disease |
| Prothrombin Complex Concentrates (PCCs) | Factors II, VII, IX, X (±Protein C, S) | Warfarin reversal, acquired factor deficiencies |
| Activated PCC (aPCC / FEIBA) | Activated factors | Hemophilia with inhibitors |
| Recombinant Factor VIIa (rFVIIa) | FVIIa | Licensed: Hemophilia with inhibitors; Off-label: massive hemorrhage |
| Antithrombin (AT) concentrate | Antithrombin III | Heparin resistance from AT deficiency |
| Albumin | Human albumin 5%, 25% | Hypoalbuminemia, volume expansion |
| IVIG | IgG antibodies | Immune deficiencies, immune thrombocytopenia |
8. Emerging / Investigational Products
- Pathogen-reduced platelets and plasma (e.g., Intercept system using amotosalen + UV): inactivates bacteria, viruses, and parasites
- Cold-stored platelets (4°C): Longer shelf life, improved hemostatic function, being revisited for trauma
- Lyophilized plasma: Freeze-dried FFP for pre-hospital and austere environments
- Hemoglobin-based oxygen carriers (HBOCs): Still investigational
- Reconstituted whole blood: 1:1:1 ratio of RBCs:FFP:platelets, used in massive transfusion protocols for trauma
Transfusion Triggers — Summary Table
| Product | Threshold |
|---|---|
| pRBCs (stable ICU) | Hgb < 7 g/dL |
| pRBCs (CVD / post-cardiac surgery) | Hgb < 8 g/dL |
| Platelets (prophylactic) | < 10,000/µL |
| Platelets (invasive procedure) | < 50,000/µL |
| Platelets (CNS surgery / active bleeding) | < 100,000/µL |
| FFP | PT/aPTT > 1.5× control or INR > 2.0 with bleeding |
| Cryoprecipitate | Fibrinogen < 100–150 mg/dL with bleeding |
Compatibility Requirements
| Product | ABO Required | Rh Required |
|---|---|---|
| pRBCs | Yes (hemolysis risk) | Yes (alloimmunization) |
| FFP / Plasma | Yes | No |
| Platelets | Preferred | Preferred in females of childbearing age |
| Cryoprecipitate | Not required | No |
Emergency uncrossmatched blood: Group O RBCs (universal donor RBCs) and Group AB plasma (universal donor plasma) are used when there is no time for compatibility testing.
Source: Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th ed., Chapter 17 — Blood Products and Transfusion Practice.
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