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Lab Manual for UCSF Clinical Laboratories

Lab Manual for SFGH

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UCSF Transfusion Service


A. Contact Information

Moffitt-Long Hospital Blood Bank: 415-353-1313
Mission Bay Hospital Blood Bank: 415-476-1404
Mt. Zion Hospital Blood Bank: 415-885-7791
Lab Medicine Resident: 415-353-1721 or 443-8296. After hours: please contact the Blood Bank.


B. Specimen Requirements

Blood bank testing must be completed prior to issue of blood products.

Please see below for minimum specimen requirements. Inadequate sample volume could lead to a delay in the completion of tests and blood product set-up. The presence of gross hemolysis in specimens intended for pre-transfusion testing may interfere with the correct interpretation of test results. Grossly hemolyzed specimens are hence unacceptable and will prompt a request for repeat sample collection from a peripheral draw.

Click Here to download/open the PDF file.


C. Requests for Blood Products


I. Emergency Release of blood products

Emergency release guidance document

  1. Emergency Release of packed red blood cells:

    Refers to the emergency release of group O, Rh-negative, uncrossmatched red cells for an actively bleeding patient requiring RBC transfusion before compatibility testing can be completed. These products are not irradiated. Units are leukoreduced; but not necessarily CMV sero-negative. Such units are provided within 5 minutes.

  2. Emergency Release of thawed plasma

    For patients requiring urgent plasma transfusion, 4 previously thawed plasma units (group AB; up to 5 days post-thaw) are provided within 10 minutes.

  3. Emergency Release of platelets

    For patients requiring urgent platelet transfusion, 1 leukoreduced, apheresis platelet unit is provided within 10 minutes. This product is not irradiated and may not be CMV sero-negative. Based on availability, the product selected may not be ABO-plasma compatible with recipient (primarily of concern in infants < 4 months).

  4. Emergency Release of cryoprecipitate

    Refers to the emergency release of cryoprecipitate (# units required should be specified by caller). Based on availability, the product selected may not be ABO-plasma compatible with recipient (primarily of concern in infants < 4 months).


II. Massive Transfusion Protocol (MTP)

MTP Guidance document

The following scenarios qualify as 'Massive Transfusion.'

  1. Transfusion of 4 units RBC within an hour & anticipated ongoing requirement
  2. Loss of >30% blood volume or severe uncontrolled bleeding with risk of coagulopathy
  3. Massive hemorrhage accompanied by hypovolemic shock and/or metabolic acidosis
  4. Infusion of 10 or more units of PRBC's in the first 24 hours
  5. Pediatric patients requiring > 20mL/kg of PRBC's in the first hour of resuscitation

'Activation' of MTP facilitates the rapid ordering and delivery of large amounts of blood products for patients with life-threatening blood loss.

Adherence to protocol for notification and communication with Blood Bank is essential to avoid delays.


III. Orders for blood products

  1. Orders for blood products are placed in APEX. (Please see guidance document in sections I and II above for protocol-driven ordering for emergency release/MTP)

    Routine orders are processed within 4 hours

    STAT orders are processed within 1 hour

    Ordering blood for patients undergoing elective surgery:

    1. OR will provide a final schedule at approximately 4 PM on the day prior to the date of surgery. Blood Bank will review schedule for updates.
    2. Instructions for Providers
      1. Orders for blood products should be placed in APEX latest by 6 PM of the day before surgery
      2. Please look up Lab Results in APEX and make sure that a valid type and screen (and when needed, an ABO/Rh confirmation test) performed at UCSF is available in order to set up blood.
      3. If sample draw is scheduled to occur only on the day of surgery, adequate time should be set aside for blood bank to complete testing and set up cross match compatible units.
      4. OR should not start an elective case until all testing is completed and blood is ready.

  2. Picking up blood from the Blood Bank
    1. When the patient is ready for transfusion, RN should release the Blood Product Pickup slip linked to the 'prepare order' in Apex. Duplicate pick-up slips will print in the blood bank and in the patient's unit.
    2. A pick-up slip with the patient's name and medical record number must be presented to the Blood Bank at the time blood is picked up.
    3. For patients currently in the OR: RN prints the OR-version of the pick-up slip and hands it to PCA.
    4. The generic "on-demand" pick-up slip is not linked to a blood product 'prepare' or ‘transfuse’ order and does not capture the special requirements ordered by provider. The ‘on-demand’ pick-up slip should be used with caution. Use is restricted to downtime situations or APEX-related printing problems. Link to Nursing Procedures



D. CMV-Seronegative Blood Products

Profoundly immunosuppressed patients are at risk for transfusion-transmitted CMV infection (TT-CMV). The risk of TT-CMV can be decreased by using leukocyte-reduced blood products or CMV-seronegative blood products. All blood products used at UCSF are prestorage leukocyte-reduced by standardized prestorage filtration technology. Data assessing the equivalency of CMV-seronegative and leukocyte-reduced blood components in reducing TT-CMV support the use of prestorage leukocyte-reduced blood in lieu of CMV-seronegative blood components. CMV is a cell-associated virus. Frozen components such as cryoprecipitate and fresh frozen plasma do not increase risk for TT-CMV.


As the supply of CMV-seronegative blood products is limited (less than 50% of blood donors are CMV-seronegative); guidelines have been developed to restrict the use of these products for selected high-risk patients. The CMV antibody status of the patient and where applicable, the CMV antibody status of the organ/stem cell donor guide the decision-making process.

The following groups qualify for CMV-seronegative blood products:

  1. Neonatology and PEDIATRIC Services
    1. Intrauterine transfusions
    2. Infants < 4 months of age
      1. Regardless of diagnosis or CMV serological status (maternal antibodies may impact test results)
    3. Infants on ECMO/ECLS/Exchange Transfusion Protocol
      1. Age < 1 year: All infants regardless of CMV serological status
      2. Age > 1 year: CMV-seronegative patients only
    4. Bone marrow/stem cell transplants in neonates or patients on the pediatric service
      1. Allogeneic transplants:
        1. Standard transplants:
          1. CMV-seronegative patients if the donor is CMV-seronegative
        2. T-cell depleted transplants
          1. CMV-seronegative patients regardless of CMV-serological status of donor
        3. T-cell depleted and haploidentical transplants
          1. All patients regardless of CMV-serological status of patient or donor.
      2. Autologous transplants:
        1. CMV-seronegative patients who are candidates for autologous bone marrow/stem cell transplant - e.g. patients with neuroblastoma, rhabdomyosarcoma, Ewing's tumor glioblastoma, osteogenic sarcoma or Wilm's tumor etc
      3. Patients awaiting transplant - e.g. for diseases like aplastic anemia
        1. Age < 1 year: All infants regardless of CMV status
        2. Age > 1 year: CMV seronegative patients only
    5. Other severely immunosuppressed neonates or patients on the pediatric service
      1. CMV-seronegative patients on the pediatric/neonatology service receiving chemotherapy or radiation therapy for leukemia/lymphoma or solid tumors like neuroblastoma/rhabdomyosarcoma/ Ewing's tumor/glioblastoma/osteogenic sarcoma/ Wilm's tumor/other tumors are supported with CMV-seronegative products.
      2. Inherited/acquired immunodeficiency disorders- e.g. SCIDS, Wiskott-Aldrich syndrome, thymic aplasia, DiGeorge syndrome etc regardless of CMV serological status (recent IVIG or CMVIg may impact test results)
    6. Solid organ transplants in neonates or patients on the pediatric service
      1. Age < 1 year, regardless of CMV serological status:
        1. All patients currently listed for solid organ transplants regardless of CMV serological status of donor, if donor < 1 year
        2. All patients currently listed for solid organ transplants, if donor > 1 year old is CMV seronegative
        3. All patients with a diagnosis like HUS or other illnesses where organ transplantation may be required in the near future to treat the disease or end organ failure
        4. All patients awaiting transplant
      2. Age > 1 year
        1. CMV seronegative patients currently listed for heart, lung, liver, kidney, pancreas or small bowel transplants from CMV-seronegative donors
        2. CMV seronegative patients with a diagnosis like HUS or other illnesses where organ transplantation may be required in the short-term to treat the disease or end organ failure.
    7. Pediatric cardiothoracic surgery patients
      1. Cardiac anomalies like truncus arteriosus/interrupted aortic arch, which are strongly associated with the DiGeorge syndrome
      2. Patients undergoing 'Complex'* cardiac procedures
        1. All patients up to 2 years, regardless of CMV serological status
    8. -'Complex'* cardiac procedures

  2. Adult Services
    1. Adult patients who DO NOT REQUIRE CMV-seronegative blood products. These patients will be supported with LEUKOREDUCED (‘CMV-safe’) blood products:
      1. All STANDARD allogeneic or autologous hematopoietic stem cell transplant patients, regardless of CMV serological status of recipient and donor (see exceptions below)
      2. Patients receiving STANDARD myelosuppressive chemotherapy or radiation therapy for leukemia, lymphoma, myeloma, etc., regardless of CMV serological status
        1. Exceptions for selected high-risk patients may be considered on a case by case basis ONLY
      3. Patients receiving chemotherapy or radiotherapy for solid tumors, regardless of CMV serological status
      4. Patients undergoing liver, kidney, pancreas or small bowel transplant, regardless of CMV serological status of patient and donor
      5. CMV seronegative patients receiving a heart and/or lung transplants from a CMV seropositive donor
    2. Adult patients who qualify for CMV-seronegative blood products:
      1. The following CMV seronegative hematopoietic stem cell transplant recipients:
        1. T-cell depleted transplants, regardless of CMV serological status of the donor
        2. Cord blood transplants
        3. Transplants that are part of research protocols of trials that mandate CMV-seronegative blood components
      2. CMV seronegative patients undergoing heart and/or lung transplant, ONLY if the donor is also CMV seronegative
      3. CMV seronegative patients awaiting heart and/or lung transplant (donor CMV serological status is unknown)
      4. Pregnant women:
        1. CMV seronegative patients
        2. Any woman whose fetus is undergoing intrauterine surgery
      5. CMV seronegative patients with AIDS

Note: Leukocyte-reduced products are provided when CMV-seronegative products are unavailable. The blood bank technologist or resident will contact the clinical team if a patient does not qualify for CMV seronegative products based on the above guidelines.



E. Irradiation of Blood Components

Graft versus host disease (GVHD) may occur whenever immunologically competent allogeneic lymphocytes are transfused into a severely immunocompromised recipient. Prophylactic irradiation of blood products prior to transfusion inhibits the ability of transfused lymphocytes to proliferate and is the most efficient way to prevent post-transfusion GVHD. Irradiation of blood components does not prevent the transmission of viruses.

Irradiated cellular blood components are indicated for:

  1. Intrauterine transfusions
  2. Infants < 4 months of age
  3. Neonates and pediatric patients undergoing exchange transfusions (NICU or PICU protocols only)
  4. Infants less than 1 year undergoing ECMO/ECLS
  5. Pediatric hematology or oncology patients (all patients)
  6. Adult hematology or oncology patients (all patients)
  7. Patients with following diagnoses or therapy:
    1. Cellular immunodeficiency syndromes (SCIDS, Wiskott-Aldrich syndrome, thymic hypoplasia, DiGeorge syndrome, etc), or aplastic anemia
    2. Stem cell transplantation
    3. Fludarabine/Cladribine therapy
    4. Alemtuzumab (anti-CD52, Campath or Lemtrada) therapy
  8. Directed donations from relatives will be irradiated prior to release from the Blood Bank

Blood products are NOT routinely irradiated for

  1. Solid organ transplant patients receiving routine post-transplant immunosuppressive therapy
  2. HIV/AIDS patients

If an order does not fall within the above guidelines, the physician will be asked to seek approval by contacting the Blood Bank resident.

Articles for further reference: Vox Sang 2008 TA-GVHD Tran Med Rev 1997 - Blood Product Irradiation


F. Platelets

Platelets are available in the Blood Bank at all times. Platelets are our most limited resource and are also the blood component which carries the greatest risk of transmitting infection.

  1. If no platelet count has been ordered since the last platelet transfusion or during the last 24 hours, a platelet count must be obtained.
  2. Only apheresis platelets are available at our blood bank. The standard dose for adults is one apheresis product, which is equivalent to a 6-pack of platelet concentrates. Pedi- (1/2) and quad (1/4) - apheresis units are also available.
  3. If Rh-positive platelets are given to an Rh-negative female recipient (up to 50 yrs), administration of Rh immune globulin (RhIg) should be considered. One dose does of RhIg (300µg or 1500 IU) adequately covers 7 units of Rh-positive apheresis platelets given over a 3-week period.
  4. Volume reduced platelets are indicated for patients with
    1. Fluid overload problems.
    2. Repeated severe allergic reactions.
    3. Prior hemolysis from the transfusion of ABO incompatible platelets.
  5. Orders under the following conditions can be filled without approval (all platelet counts are x109/L, equivalent to x103/µL):
    1. Regardless of platelet Count
      1. When a recent platelet count is not available:
        1. For patients transferred to UCSF for active/suspected bleeding
        2. Patient transferred to UCSF and known to have low platelet counts at outside facility
      2. Post-cardiopulmonary bypass - one dose
      3. Patients with platelet dysfunction
        1. Patients who have received acetylsalicylic acid (ASA, aspirin) within the previous 72 hours, , if the patient is experiencing uncontrolled bleeding or requires surgery.
        2. Within 72 hrs of treatment with abciximab (Reopro), if the patient is experiencing uncontrolled bleeding or requires surgery.
        3. Within 5 days of treatment with clopidogrel (Plavix) if the patient is experiencing uncontrolled bleeding or requires surgery.
        4. Patients with inherited platelet function disorders like Glanzmann’s thrombasthenia/ Bernard-Soulier syndrome, who are actively bleeding
        5. Patients with neurological deterioration, significant bleeding or other complications following tPA thrombolysis therapy. (Neurovascular Service guidelines for the use of intravenous tPA in acute stroke recommend FFP, cryoprecipitate and platelet transfusions in patients who develop acute neurological deterioration, significant bleeding, or other complications during tPA infusion).
    2. Platelet Count <100 k
      1. Patients with head bleed or bleeding into the eye or orbit
      2. Patients with an intracranial pressure monitor (ICPM)
      3. Postoperative period in patients with surgery of the brain, spine, eye or airway
      4. Postoperative period in cardiac surgery patients (for up to 24 hours after coming off the bypass pump)
      5. Postoperative period (up to 24 hours) for neonates
      6. Patients with DIC who are bleeding
      7. Infants with sepsis
      8. Infant weight ≤ 1500 g
      9. Patients on ECMO/ECLS
      10. Pediatric patients with suspected or newly diagnosed leukemia undergoing lumbar puncture while they still have circulating blasts

    3. Platelet Count <75 k
      1. Bleeding in the first 24 hrs post-liver transplantation
      2. Bleeding in patients with untreated renal failure (with uremia)
      3. Infants getting a transthoracic intracardiac line removed
      4. Massive transfusion
      5. Prior to and up to two days after an invasive procedure to avoid arterial bleeding from a blind site, e.g. ERCP with sphincterotomy
      6. Removal of epidural catheters

    4. Platelet Count <50 k
      1. Patients with sickle cell disease undergoing bone marrow transplantation
      2. Prior to an invasive procedure, including lumbar puncture (for exception see B. Platelet count <100K)
      3. Patients receiving heparin or other anticoagulants (exception: for patients with possible/confirmed HIT diagnosis getting argatroban platelets are relatively contraindicated unless they are bleeding)
      4. Within 72 hrs of treatment with the Fab fragment of antibody to GPIIb/IIIa (Reopro®), whether or not actively bleeding
      5. Patients getting discharged with plan for outpatient platelet transfusion support at UCSF or another facility.
      6. Other patients with significant active bleeding (not covered under sections B and C above)
    5. Platelet Count <30 k
      1. Patients with brain tumor receiving chemotherapy/transplant.
    6. Platelet Count <20 k
      1. Presence of mucositis or fever
    7. Platelet Count <10 k
      1. Prophylaxis

In the absence of special circumstances like neurosurgical bleeding or other exceptions as noted above, platelet counts >50 k are adequate for hemostasis in  most patients with significant ongoing active bleeding. Use of FFP/cryoprecipitate for replacement of coagulation factors/fibrinogen and other measures for control of anatomical causes of bleeding should be considered.

Platelet transfusions are generally not used in the treatment of patients with ITP, except when complicated by significant bleeding. Platelets are relatively contraindicated in patients with TTP (prior to the initiation of plasma exchange), or HIT.

For VWD type 2B patients with major bleeds and surgery, VWF–containing concentrates should be given first; platelets may be indicated for severe thrombocytopenia. For patients with platelet-type VWD, platelet transfusions are indicated for treatment of hemorrhage.

When considering platelet transfusions in the above situations, a hematology consult is strongly recommended.

For any orders which do not fall within the above guidelines, contact the Blood Bank medical staff for approval


G. Cross-Matched or HLA-Matched Platelets

One-third to 3/4 of leukemic patients become alloimmunized to platelet antigens. Lack of appropriate increments following transfusion of random platelets is the best indicator of alloimmunization if non-immune causes (hypersplenism, bleeding, fever, DIC liver disease) and other immune causes (ITP, post-transfusion purpura) have been excluded

Platelet alloimmunization can be due to antibodies directed against HLA and/or platelet-specific antigens. Testing a refractory patient's serum against the platelets of several donors (platelet crossmatch) may identify donors whose platelets may survive in the sensitized individual's circulation for a longer period of time.

If refractoriness to transfusion with random platelets has been documented on TWO occasions by a 10 minute - one hour post-transfusion corrected count increment of <7.5, the patient's physician can arrange for a platelet crossmatch. The physician should contact the Blood Bank resident (pager 443-8296, or call the Blood Bank after 5 PM and on weekends). Please describe the clinical diagnosis and status of the patient, including current drug treatment, bleeding manifestations, body surface area (or height and weight), need for CMV antibody-negative products, and the presence of any non-immune causes of platelet consumption.

  1. Platelet crossmatching is done at the Blood Centers of the Pacific Immunohematology Reference Laboratory, and can only be sent out on weekdays Mon-Fri BEFORE 11am. PLATELET CROSSMATCHING IS NOT AVAILABLE ON NIGHTS, WEEKENDS, and HOLIDAYS.
  2. The UCSF Blood Bank resident will arrange for crossmatched platelets. Anticipate a 1-2 day delay, as the products have to undergo bacterial and infectious marker testing.

Platelet Refractoriness Guide for Clinicians

HLA-matched platelets will be arranged for a patient by the Blood Bank resident if the patient is refractory to crossmatched platelets, or based on availability on a case-by-case basis.

  1. HLA Class I typing of the patient and HLA Class I antibody screen must be done prior to requesting HLA-matched platelets. When clinically indicated, the Blood Bank resident will assist providers in the ordering of the necessary tests.
  2. Once the HLA typing results are available, a 2- to 7-day delay in availability for the HLA-matched platelets can be anticipated, depending on the HLA type and antibody profile of the patient.


H. Fresh Frozen Plasma (FFP)

  1. All FFP orders are reviewed. If patient diagnosis and/or lab values do not meet guidelines, Blood Bank will contact the ordering provider.
  2. All routine coagulation parameters should be checked before FFP is ordered. This includes complete blood count, platelet count, PT, INR, PTT, and fibrinogen.
  3. Risks related to transfusion of allogeneic blood products should be considered.
  4. Prophylactic transfusions should be used sparingly.
    1. There is no direct relationship between bleeding and mildly abnormal results of coagulation tests. While orders for FFP are approved by Blood Bank if PT > 19 seconds, INR > 1.5, or PTT > 1.5 times the upper limit of the reference range, borderline elevations do not predict an increased bleeding risk and are not necessarily corrected by FFP infusions.
    2. Transfusion of FFP may however be indicated for patients with severely abnormal INR and/or PTT results prior to a planned invasive procedure.
      1. Administer FFP within an hour of procedure as maximal effect declines 2-4 hours after transfusion.
  5. The cause of abnormal coagulation results should be established and the underlying condition should be treated.
  6. Before transfusing FFP, provider should be aware that:
    1. Satisfactory hemostasis may be achieved when coagulation factor levels are at least 30% of normal, and when the fibrinogen level is above 100 mg/dL.
    2. Adult dose of plasma is 10-15 mL/kg body weight. Each unit contains approximately 250-300 mL of plasma.
    3. FFP transfusions should not be based solely on the patient’s abnormal INR and/or PTT. The patient’s clinical condition as well as the risk and consequences of bleeding should inform decision making.
    4. Clinical status and coagulation tests should be monitored to assess response to treatment.
  7. Clinical indications for use of FFP
    1. Single-factor deficiencies:
      1. Frozen plasma is indicated for replacement of single congenital factor deficiencies (e.g. factor V, XI, XIII, AT, Protein C, Protein S, C1 esterase inhibitor, etc.), provided the specific fractionated product, concentrate or recombinant factor is unavailable or the clinician preference/judgment is to use FFP.
    2. Multiple-factor deficiencies, hypo/dysfibrinogenemia, and/or DIC:
      1. While it is important to manage the underlying cause of DIC, transfusion support may be required. FFP is indicated in patients with multiple-factor deficiencies associated with severe bleeding and/or DIC.
      2. FPP or platelets/cryoprecipitate is usually transfused only when there is active bleeding.
    3. Need for urgent reversal of warfarin effect:
      1. Four-factor prothrombin complex concentrate (4-factor PCC; K-centra) is now available for urgent reversal of Vitamin K antagonists. 4-factor PCC is generally considered as the first-line therapy for urgent warfarin reversal.
      2. Clinical teams may continue to use FFP in severe urgent clinical situations, such as life-threatening hemorrhage, or when K-centra is contraindicated.
    4. Invasive procedures:
      1. Given the design of currently available assays for INR/PTT, mild to moderate abnormal coagulation results may not predict risk of bleeding. Coagulation factor activity of 30% or higher is adequate to maintain hemostasis.
      2. There is little evidence in the current literature to suggest that mild to moderate abnormalities of the INR and PTT predict an increased risk of bleeding or that these patients will benefit from infusion of FFP prior to a procedure.
    5. Vitamin K deficiency:
      1. Many hospitalized patients have inadequate vitamin K intake, are likely to become deficient, and may have a prolonged INR/PTT.
      2. Oral or intravenous vitamin K should be given.
      3. Coagulation factors usually return to hemostatic levels approximately 12 hours after vitamin K administration.
      4. FFP should NOT be used to correct abnormal lab tests resulting from vitamin K deficiency, unless urgent invasive procedures are planned or the patient is actively bleeding.
    6. Liver disease:
      1. Although patients with liver disease often have coagulation abnormalities, spontaneous bleeding seldom occurs without a precipitating event such as liver biopsy.
      2. Routine use of FFP transfusions prior to liver biopsies for patients with mild to moderately abnormal results of hemostasis (INR and PTT less than 1.5 times the upper limit of the reference range) is not supported by good quality evidence.
      3. Studies have shown that the response to FFP in these patients is unpredictable and FFP rarely corrects coagulation abnormalities.
    7. g. FFP drip:
      1. i. Approved only for patients with acute fulminant hepatic failure (pre-liver transplant) and for 48-96 hours post-liver transplant, until adequate graft function is assured
      2. ii. PT should be measured every 6 hours. If the PT is >1.3 times normal, an initial bolus of 15 mL FFP/kg body weight should be administered, followed by an FFP drip at 2 mL/min.
      3. iii. If the patient is bleeding and an invasive procedure has been performed and/or is planned within 8 hours, additional FFP should be given.
      4. iv. If the patient is not bleeding and no procedure is planned, the FFP drip should be adjusted as follows:
      5. v. PT >19 seconds: continue drip at same rate
      6. vi. PT 16-19 seconds: decrease FFP drip by 50%
      7. vii. PT <16 seconds: stop FFP drip
    8. Coagulopathy from daily/frequent plasmapheresis:
      1. Cryoprecipitate may be indicated if plasma fibrinogen is < 100 mg/dL.
      2. Notify Blood Bank if FFP is ordered for patients undergoing plasmapheresis to decrease isoagglutinin titers in the setting of ABO-mismatched solid organ transplantation. BB will follow protocol and select FFP units that are ABO compatible with both donor and recipient.
    9. During intraoperative cardiopulmonary bypass:
      1. Coagulopathy during CPB is multifactorial; platelet dysfunction, heparin and dilution, all play a role.
      2. Transfusion requirements during CPB should be guided by “near-patient” coagulation tests, like TEG, when available.
    10. Massive transfusion protocol
    11. Therapeutic Plasma Exchange for treatment of Thrombotic Thrombocytopenic Purpura or Catastrophic Antiphospholipid Syndrome.
    12. Complications during tPA infusion:
      1. Neurovascular Service guidelines for the use of intravenous tPA in acute stroke recommend FFP, cryoprecipitate and platelet transfusions in patients who develop acute neurological deterioration, significant bleeding, or other complications during tPA infusion.
      2. FFP dose: 2 units, every 6 hours for 24 hours after tPA.
    13. Neonates:

      In addition to the indications listed above.

      1. Undiagnosed bleeding/clotting disorders- empiric therapy pending results of laboratory testing.
      2. Hemorrhagic disease of the newborn:
        1. High risk infants including those with liver disease, born premature or born to mothers on medications such as INH or anticonvulsants
        2. FFP may be considered for treatment of severe disease
      3. Neonatal purpura fulminans (Protein C/Protein S/AT deficiency)
      4. Pediatric cardiac surgery: Antithrombin deficiency seen in patients with post-operative chylous effusion. Patients currently/recently on ECMO.
      5. Volume expansion in acidotic, unstable neonates regardless of PT/PTT/INR (limited data; unknown benefit)
    14. Neurosurgery
      1. Neurosurgical (cranium/spine) procedures- pre-procedure or postoperatively: FFP infusions for mildly abnormal laboratory tests of coagulation are of questionable clinical benefit (e.g. a mildly elevated PT/PTT or INR > 1.3).

Notes for BB Staff:

  • Orders for actively bleeding patients should be processed without waiting for laboratory test results. Set aside the requisitions for review by LMR during regular working hours.
  • For patients admitted to UCSF for active/suspected bleeding and/or known to have coagulopathy/abnormal PT/INR at outside hospital; FFP should be approved without waiting for results of lab tests at UCSF.
  • If PTT > 50 seconds (> 1.5 times the upper limit of the current reference range), FFP order is approved.


I. Cryoprecipitate

Each unit (~15-20 mL) contains approximately 250 mg of fibrinogen. Appropriate indications include:

  1. Patients with fibrinogen levels <100 mg/dL who are bleeding or who are at high risk for bleeding. Cryoprecipitate will be approved without waiting for results of UCSF lab tests if patients are transferred or admitted to UCSF for active/suspected bleeding and/or known to have coagulopathy/abnormal fibrinogen levels at outside hospital. Higher thresholds (< 200 mg/dL) may be appropriate in unstable patients with rapid ongoing consumptive coagulopathy, for e.g. Obstetric patients or heme-onc patients with DIC.
    1. Adults: 10 units raises fibrinogen level by 50-100 mg/dL
    2. Children: 1-2 units/10 kg raises fibrinogen level by 50-100 mg/dL
    3. Infants: 1 unit is usually sufficient to achieve hemostasis
  2. Dysfibrinogenemia
  3. Complications during tPA infusion: UCSF Neurovascular Service guidelines for the use of use of intravenous tPA in acute stroke recommend FFP, cryoprecipitate and platelet transfusions in patients who develop acute neurological deterioration, significant bleeding, or other complications during tPA infusion.
    1. Cryoprecipitate dose: 20 units.
    2. If fibrinogen level < 200 mg/dL at 1 hour, repeat cryoprecipitate dose.

Purified factors are safer and should be used instead of cryoprecipitate for the treatment of bleeding patients with hemophilia or von Willebrand's disease. Obtain hematology consultation.

Good quality data are lacking to recommend cryoprecipitate for the control of active bleeding in uremic patients.


K. Red Blood Cells


AABB Clinical Practice Guidelines for RBC transfusions


Washed RBCs

RBCs may be washed with sterile saline to remove all but traces of plasma, plasma proteins, and potassium. Appropriate indications include:

  1. Infants (<1 year of age) with single-ventricle physiology.
  2. Infants (<1 year of age) with two-ventricle physiology during a 72 hour post-op period.
  3. Infants (<1 year of age) undergoing a complex pump procedure.
  4. Pediatric cardiac patients with renal insufficiency or hyperkalemia.
  5. Other high risk (as judged by ordering MD) pediatric cardiac surgery patients, if RBC units < 5 days old are unavailable and/or potassium load poses high risk to patient.
  6. IgA deficient patients at risk for an anaphylactic transfusion reaction (2 L saline wash is recommended).
  7. Patients with a history of severe transfusion reactions, after a consultation with a Blood Bank Physician.
  8. Patient with a diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH) when group specific red cells are not available for transfusion.

For removal of potassium (indications 1-4), even relatively fresh (<5 day old red cells) should be washed because potassium levels can still be high. Because potassium continues to leak out of red cells stored after washing, washing should be performed (within 6 hours). WHEN IRRADIATION IS REQUIRED, RED CELLS MUST BE IRRADIATED PRIOR TO WASHING.


L. Granulocytes

The usefulness of granulocyte transfusion for treatment of life threatening bacterial or fungal infection remains controversial. Granulocyte transfusion may be indicated in neutropenic patients with bacterial or fungal infection unresponsive to antimicrobial therapy whose bone marrow hematopoietic capacity is expected to recover. Since a unit of granulocytes outdates in 24 hours, there is not enough time to perform routine infectious disease screening. Therefore, potential donors may be asked to make a blood donation for testing prior to donating granulocytes (pre-donation).

  1. The ordering physician must contact the Blood Bank Resident.
  2. Designated Donors

  3. As Blood Centers of the Pacific does NOT recruit community donors for granulocyte donation, UCSF physicians are requested to recruit potential directed donors from among family members and friends. Please note that there may be a 5 day delay between the time a potential donor is identified and when a unit of granulocytes will be available (3 days for donor testing, 1 day for granulocyte mobilization, and 1 day for granulocyte pheresis).
  4. Potential donors may be asked to make a whole blood donation to ensure compatibility and suitability. The donors should be ABO-compatible. If D-negative donors are not available for a D-negative recipient, the administration of RhIG will be considered.
  5. An appointment for granulocyte apheresis needs to be made with the Special Donations Coordinator at the Blood Centers of the Pacific (1-800-215-6225; see section below on ‘Autologous and Directed Donations’). The UCSF Blood Bank Resident should be involved in coordinating donors’ schedule.
  6. The ordering physician should decide whether or not to stimulate the donors for granulocyte mobilization on a case by case basis. An optimal regimen based on information available in the literature is the administration of 480 µg G-CSF (s.c.) and 8 mg dexamethasone (oral) to be given approximately 12 hours before the start of the collection. The ordering physician should obtain the consent for mobilization. Some risks of G-CSF administration include bone pain, hyperviscosity, thrombocytopenia, thrombosis, ophthalmologic problems, and exacerbation of autoimmunity. Also, long-term side effects have not been fully evaluated. A complete medical evaluation of a potential granulocyte donor is recommended.
  7. The yield of granulocytes in each unit should be a minimum of 10 x 109 cells.
  8. Administering Granulocytes

  9. Granulocytes must be infused within 24 hours of collection, before infectious marker testing has been completed. Therefore, the Blood Bank Attending and the ordering provider must authorize the release of untested units.
  10. DO NOT USE A BED-SIDE LEUKOCYTE DEPLETION FILTER OR A MICROAGGREGATE FILTER. Avoid granulocyte infusion during and within 4 hours of last Amphotericin infusion since incidents of severe pulmonary reactions have been reported.
  11. The granulocyte transfusion should be given daily or QOD during the period of neutropenia depending on donor availability.


M. Autologous and Directed Donations

Autologous and Directed Donations for UCSF patients will be performed at Blood Centers of the Pacific (BCP). BCP has multiple collection sites throughout the Bay Area and the patient/donor may donate at any one of these sites.

To arrange for an autologous or directed donation, the patient/donor or physician must call BCP at 1-800-215-6225 Monday through Friday 8:30 AM to 5:00 PM to schedule an appointment. Walk-ins are NOT accepted. Prior to donation, a "Special Collections Request, FORM BS 365" must be faxed or e-mailed to BCP at FAX: 415-749-6635 or E-mail: specialdonations@bloodcenters.org. This form can be found at the following website:


NOTE: All Autologous donations must be completed at least 7 working days prior to the scheduled surgery date.

For more information on autologous and directed donations at Blood Centers of the Pacific, click here.


N. Circular of Information for the Use of Human Blood and Blood Components

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