Transfusion of blood products - NYSORA

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Transfusion of blood products

Learning objectives

  • Provide an evidence-based framework for the transfusion of blood products


  • Blood products are any therapeutic substance derived from human blood
  • Including whole blood and other blood components for transfusion, and plasma-derived medicinal products


Massive hemorrhage

  • Give red blood cells – fresh frozen plasma – platelets (whole blood derived units) in a 1-1-1 ratio
  • Transition to laboratory-guided treatment once hemorrhage control is achieved

Red Blood cells (RBCs)

  • 1 unit of RBCs = 350 mL 
  • 1 unit will raise hemoglobin by +/- 1 g/dL
  • Be restrictive in transfusing RBCs
  • Cutoffs for transfusion are:
    • 7 g/dL in hemodynamically stable patients
    • 8 g/dL for orthopedic surgery, cardiac surgery, and patients with preexisting cardiovascular disease
  • There is no benefit in using fresh blood 
  • Do not give unnecessary transfusions 


  • 1 unit = 1 apheresis unit = 4-6 whole blood derived units 
  • 1 unit will raise platelets by 30,000–50,000/μL
  • Giving more than 2 units is rarely useful 
  • Transfuse prophylactically at platelet count:
    • < 10,000/μL for patients with hematologic or solid malignancies, undergoing allogeneic hematopoietic stem cell transplantation
    • < 20,000/μL for elective central venous catheter (CVC) placement
    • < 50,000/μL for elective diagnostic lumbar puncture
    • < 50,000/μL for major elective non-neuraxial surgery
    • <100,000/μL for neuraxial surgery and eye surgery
  • Give platelets if thrombocytopenia and active bleeding at platelet count:
    • <30,000/µL for bleeding WHO grade II
    • <50,000/µl for bleeding WHO grade III/IV (i.e. massive bleeding)

Fresh Frozen Plasma (FFP)

  • 1 unit of FFP derived from whole blood = 250 mL
  • FFP contains normal levels of coagulation factors, albumin and immunoglobulins
  • Abnormal coagulation tests (PT/aPTT) are poor predictors of bleeding risk in a non-bleeding patient 
  • Don’t give plasma transfusions to correct minor coagulation test abnormalities in non-bleeding patients
  • Standard dose is 15-20 mL/kg and raises clotting factors by +/- 25%
  • Give FPP in case of:
    • Massive transfusion
    • Warfarin therapy-related intracranial hemorrhage
    • Disseminated intravascular coagulation (DIC), liver disease or thrombotic thrombocytopenic purpura (TTP) and active bleeding
    • Specific coagulation factor deficiencies without available coagulation factor concentrate
    • Dilutional coagulopathy

Adverse events

Febrile non-hemolytic transfusion reactions (FNHTRs)FNHTRsFNHTRs
Transfusion associated circulatory overload (TACO)
Transfusion related acute lung injury (TRALI)
Transfusion transmitted infectionTransfusion transmitted infectionTransfusion transmitted infection
Allergic/anaphylactic reactionsPlatelet alloimmunizationAllergic or anaphylactic reactions
Acute and delayed hemolytic transfusion reactions
Hemolytic reaction
Transfusion associated graft versus host disease (TA-GVHD)

Suggested reading

  • Storch EK, Custer BS, Jacobs MR, Menitove JE, Mintz PD. Review of current transfusion therapy and blood banking practices. Blood Rev. 2019;38:100593.
  • Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016;316(19):2025-2035.
  • Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482.

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