UCSF Navigation Bar

UCSF Departments of Pathology & Laboratory Medicine Home Page

Lab Manual for UCSF Clinical Laboratories

Lab Manual for SFGH

Internal Resources

Transfusion Service (x31313)


A. Blood Bank (Transfusion Service) Hours

The Blood Bank provides blood product support twenty-four hours a day, seven days a week. The Blood Bank is located at M 501, 353-1313.

The Medical Center is supported by Blood Centers of the Pacific in the management of autologous and designated donor requests. For information about blood donation, please visit http://www.bloodcenters.org


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 transfusion before compatibility testing can be completed. These products are not irradiated. Units are leukoreduced; but not necessarily CMV sero-negative.

  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

'Massive Transfusion' is defined as infusion of 10 or more units of PRBC's in the first 24 hours, loss of >30% blood volume or severe uncontrolled bleeding with risk of coagulopathy. Patients with massive hemorrhage accompanied by hypovolemic shock and/or metabolic acidosis, patients requiring > 4 units of blood during the first hour of resuscitation, or pediatric patients requiring > 20mL/kg of PRBC's in the first hour of resuscitation meet criteria for MTP.

'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. Other requests for blood products (routine orders, STAT orders and blood orders for elective surgeries)

  1. Blood Bank Requisitions:

    Each clinical service orders blood directly from the UCSF/UCSF Mt. Zion Blood Bank on requisition form 701-04, available at all nursing stations. Incomplete forms will not be accepted. The minimum information required is:

    Patient's full name
    Hospital medical record number or date of birth
    Amount and blood component wanted
    Anticipated date of transfusion
    Name of requesting physician

    When the patient is ready for transfusion, a Blood Product Pickup form (#602-063) must be faxed to the Moffitt-Long Blood Bank (3-1316) or Mt. Zion Blood Bank (5-7780), or sent with the person dispatched to pick up blood from the Moffitt-Long Blood Bank or Mt. Zion Blood Bank.

    Routine (ASAP) orders are processed within 4 hours

    STAT orders are processed within 1 hour.

  2. Automatic Blood Ordering System for Elective Surgical Patients:

    The Departments of Surgery, Anesthesiology, and Laboratory Medicine (Blood Bank) have jointly agreed to the following system for automatically ordering blood for patients scheduled for elective surgery. The Blood Bank generates Type and Screen or Type and Cross match orders for these patients in accordance with "UCSF Maximum Surgical Blood Order Schedule (MSBOS) for Automatic Blood Ordering for Elective Surgery". This system ensures that Blood Bank processing is completed on the day prior to elective surgery.

    The automatic ordering procedure covers only those surgical procedures listed on the OR schedule finalized at 1600 on the day before surgery. Essentials of the system are as follows:

    1. The Departments of Surgery, Anesthesiology, and Laboratory Medicine (Blood Bank) have jointly agreed to the following system for automatically ordering blood for patients scheduled for elective surgery. The Blood Bank generates Type and Screen or Type and Cross match orders for these patients in accordance with "UCSF Maximum Surgical Blood Order Schedule (MSBOS) for Automatic Blood Ordering for Elective Surgery". This system ensures that Blood Bank processing is completed on the day prior to elective surgery.a. The OR will provide a tentative surgery schedule approximately 2 days prior to date of surgery.
    2. Based on MSBOS, Blood Bank will determine surgical cases requiring a Type and Screen or a Type and Cross match.
    3. The OR will provide a final schedule at approximately 1600 on the day prior to date of surgery. Blood Bank will review schedule for updates.

    EXCEPTIONS: Patients and procedures NOT covered by the system for automatic ordering include:

    1. Emergency procedures and cases added to the schedule after 1600. It is the responsibility of the physician to order blood products as needed for these cases.
    2. Pediatric surgery cases other than pump cases, thoracotomy, PDA repair or some neurosurgical procedures. Guidelines for other pediatric cases have not been established.
    3. Surgical procedures that are not listed in the MSBOS.



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. 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. 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. Unifocalization procedure: All patients up to 2 years, regardless of CMV serological status
        2. Other 'complex' procedures
          1. Age < 1 year: All patients
          2. Age > 1 year: CMV-seronegative patients only
    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 (x31721 or 443-8296; after hours, UCSF Blood Bank 3-1313 or UCSF Mt. Zion Blood Bank 5-7791).

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


F. Policy for the Use of Leukocyte-Reduced Blood Products

All allogeneic blood products issued by the blood bank are leukoreduced. Directed-donor units collected at our Center are also leukoreduced; rare units that fail leukoreduction may be available for issue to the recipient, provided all other requirements are met. Autologous blood products collected at our donor center do not undergo leukoreduction.


G. Policy for the Use of Hemoglobin S Negative Blood

Criteria for selecting HgbS negative blood:

  1. Intra-uterine transfusions
  2. Fetus in fetal surgery
  3. Infant exchange transfusions
  4. Patients diagnosed with Sickle Cell Disease


H. 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 cover 5 units of Rh-positive apheresis platelets given over a 3-week period. In general, Rh-positive platelets from Directed Donations should not be given to Rh-negative recipients, if Rh-negative random platelets from volunteer donors are available.
  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, and who’s bleeding cannot be surgically corrected.
        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 renal failure
      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 C. 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. Platelet Count <30 k
      1. Patients with brain tumor receiving chemotherapy/transplant.
      2. Patients with sepsis receiving Xigris (recombinant human activated protein C) - UCSF Guidelines
    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 hemorrhages.

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

In general, the following uses for platelets are inappropriate:

  1. Prophylactic platelets for non-bleeding patients with platelet counts >10.
  2. Bleeding uremic patients with platelet counts >75.
  3. Cardiac surgery patients with platelet counts >=100 and who have already received one post-pump "dose" of platelets.

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

Contact the resident, x31721 or 719-8296 (after hours call UCSF Blood Bank at 3-1313 or UCSF Mt. Zion Blood Bank at 5-7791).


I. 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 (most frequently hypersplenism, fever and infection, DIC, and 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, 353-1313 or pager 443-8296. 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.

  1. 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.
  2. Once crossmatching has been approved, MD should order a ‘Miscellaneous outside lab test’ in APeX as follows:
    Test description Platelet crossmatch
    Container details 2 large (7 mL) lavender top tubes
    Specimen site/Additional info Send to blood bank BEFORE 10 AM. Tubes should be signed and dated by phlebotomist.
  3. The UCSF Blood Bank will arrange for crossmatched platelets. Anticipate a 1-2 day delay, as the products have to undergo bacterial and infectious marker testing.
  4. The Blood Bank will notify the nursing unit when crossmatched platelets become available.

Platelet Refractoriness Guide for Clinicians

HLA-matched platelets will be arranged for a patient by the Blood Bank if the patient is refractory to crossmatched platelets.

  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 tests can be arranged.
  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.
  3. The Blood Bank will notify the nursing unit when HLA-matched platelets become available.


J. Fresh Frozen Plasma (FFP)

The inappropriate use of FFP has been the focus of national concern. In addition to wasting a valuable biologic resource and unnecessary expense, it exposes the patient to all the risks of homologous transfusion except HTLV-I and CMV infection.

These guidelines for the appropriate use of this important product are adapted for the Medical Center from the efforts of the UCSF Transfusion Committee.

  1. Before FFP is ordered:
    1. Obtain a PT (since the last FFP infusion or within the past 24 hours), PTT, platelet count and fibrinogen. Use of FFP is generally appropriate with a PT >19.0 seconds or INR > 1.5, as long as the platelet count is >50 x109/L) and the fibrinogen >100 mg/dL. Other requests will require approval by the Blood Bank resident or attending physician.
    2. Draw blood for CMV serology prior to administering FFP to patients awaiting organ transplantation.
    3. Inform the Blood Bank whenever a patient is undergoing plasmapheresis to lower pre-transplantation isoagglutinin titers, so that type-specific FFP will be provided.
    4. The cause of the prolonged PT or PTT must be identified!
  2. Dose and Timing:

    The dose of FFP should be adequate for replacement of the coagulation factors. Generally, 10-15 mL/kg body weight should be given; each unit of FFP contains about 200 mL. FFP should be administered rapidly through a blood filter at the time of bleeding or within an hour of anticipated bleeding. Maximal effect declines 2-4 hrs after transfusion.

  3. Monitoring:

    The patient's PT should be determined immediately before and immediately after the transfusion of FFP. Laboratory monitoring is necessary before and after each infusion of FFP. Administration of FFP should not be continued if bleeding does not decrease when the PT is corrected to ≤ 1.3 times normal.

  4. Use of FFP in Adult and Pediatric Patients:
    1. Appropriate Indications:
      1. Correcting Multiple Coagulation Factor Deficiency:

        Multiple coagulation factor deficiency should be suspected in a patient with a prolonged Prothrombin Time (PT) and activated partial thromboplastin time (PTT), if the prolongations are not due to a single coagulation factor deficiency, heparin or other inhibitor. The most common causes of multiple coagulation factor deficiency include:

        oral anticoagulants liver disease
        massive transfusion disseminated intravascular coagulation
        plasmapheresis vitamin K deficiency
      2. In patients with clinical bleeding or oozing, or in patients prior to an invasive procedure, use of FFP is generally appropriate with a PT > 19 seconds or INR > 1.5, as long as the platelet count is >50 x 109/L and the fibrinogen is >100 mg/dL.
        1. For patients transferred or admitted to UCSF for active/suspected bleeding and/or known to have coagulopathy/abnormal PT/INR at outside hospital; FFP can be approved without waiting for results of lab tests at UCSF.
      3. FFP may be indicated to prevent dilutional coagulopathy in patients with elevations in PT < 19 seconds or INR < 1.5, if administration of substantial amounts of intravenous fluid is required or anticipated. Other requests will require approval by the Blood Bank physician.
      4. Intraoperatively, when there is generalized bleeding which cannot be controlled by sutures or cautery, the PT is prolonged to >1.3x the mid-range of normal in the absence of heparin or a pathological circulating anticoagulant, and the platelet count is >50 x109/L.
      5. Congenital Deficiences of Clotting Factors II, V, VII, X, XI or XIII:

        Hematology consultation should be obtained. FFP should not be used to treat Factor IX deficiency, for which purified Factor IX concentrates are available from Pharmacy.

      6. Correction of Warfarin Overdosage:

        If bleeding must be controlled, patients should receive injectable Vitamin K1. FFP should only be given if life-threatening bleeding must be controlled and the 8-12 hrs necessary for Vitamin K1 to be effective cannot be tolerated.

        Correction may not be necessary for emergency surgery. Fully anticoagulated patients can undergo major surgery such as mitral commissurotomy, pneumonectomy, cholecystectomy or gastric resection for peptic ulcer without uncontrollable bleeding.

      7. Complications during tPA infusion: 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.
        1. FFP dose: 2 units, every 6 hours for 24 hours after tPA.
      8. Treatment of symptoms other than bleeding which are due to deficiencies of plasma factors: thrombotic thrombocytopenic purpura (TTP) and hereditary C1-esterase inhibitor deficiency with life-threatening angioedema.
      9. Support for patients with acute fulminant hepatic failure (pre-liver transplant) and for 48 hours post-liver transplant until adequate graft function is assured. 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. If the patient is bleeding and an invasive procedure has been performed and/or is planned within 8 hours, additional FFP should be given. If the patient is not bleeding and no procedure is planned, the FFP drip should be adjusted as follows:
        PT >18.0 seconds continue drip at same rate
        PT 16.0-18.0 seconds decrease FFP drip by 50%
        PT <16.0 seconds stop FFP drip
      10. If RBC transfusion is needed in bleeding patients whose PT is prolonged to <1.3 times normal, FFP is indicated to prevent further dilutional coagulopathy. Alternatively, whole blood can be used, if available, rather than RBCs and FFP.
      11. FFP is indicated in patients who have received or will receive one or more blood volumes of packed RBCs and/or cell-saver units (10 units for an adult) within 24 hours.
    2. Uses of Unknown Benefit:
      1. Control of bleeding in patients with disseminated intravascular coagulation (DIC). Cryoprecipitate is the product of choice in patients with DIC, bleeding and hypofibrinogenemia.
      2. Correction of a PT which is prolonged to <1.3x normal in patients with bleeding or prior to an interventional procedure in a critical area (brain, eye, airway).
      3. Control of bleeding due to thrombolytic agent overdose.
      4. Replacement of plasma factors during plasmapheresis for hemolytic uremic syndrome.
      5. Treatment of recurrent venous thrombosis due to Protein C or S deficiency.
      6. FFP within 48 hours of liver transplantation in patients who are bleeding.
    3. Inappropriate Uses:
      1. Volume expansion.
      2. Prophylaxis of patients with massive bleeding who do not have significantly abnormal coagulation tests. FFP should not be given prophylactically to massively transfused patients treated with primarily whole blood.
      3. Treatment of non-bleeding patients who have prolonged coagulation times and who are not anticipating an invasive procedure.
      4. Treatment of immunoglobulin deficiency. These patients should be given intravenous gamma globulin preparations which do not impose the risk of AIDS.
      5. Treatment of patients with uremia and bleeding (see chart below).
      6. Treatment of Factor VIII, Factor IX or Antithrombin III deficiency, for which purified, therapeutically superior components are available from Pharmacy.

        Please note that the PTT is relatively insensitive to deficiencies of Factor IX; levels must decrease to 10% of normal for this measurement to reliably be prolonged. Factor IX levels should be specifically measured to determine the need for purified Factor IX concentrates prior to surgery or in the bleeding patient with Factor IX deficiency.

    4. Uses in Neonatal Patients:
      1. Appropriate Indications:
        1. Vitamin K Deficiency. The primary treatment is vitamin K1. FFP should be given concomitantly with vitamin K1 only when the patient has life-threatening bleeding.
        2. Congenital deficiencies of factors II, V, VII, X, XI, XIII. Hematology consultation is advised.
        3. AT deficiency: Pediatric cardiac surgery patients- e.g. in the setting of post-operative chylous effusion.
      2. Uses of Unknown Benefit:
        1. Treatment of bleeding in patients who have DIC.
        2. Treatment of Protein C or S deficiency (neonatal purpura fulminans).
        3. Volume expansion in acidotic, unstable neonates regardless of lab values
      3. Inappropriate Uses:
        1. Treatment of non-bleeding patients who have prolonged coagulation times but who are not anticipating an invasive procedure.
        2. Treatment of patients with immunoglobulin deficiency.
        3. Replacement fluid during therapeutic phlebotomy of polycythemic infants.
    5. Citations from which these guidelines are derived may be obtained from the Blood Bank.


K. Cryoprecipitate

Each unit (~15-20 mL) contains approximately 80 units of Factor VIII and 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. For patients transferred or admitted to UCSF for active/suspected bleeding and/or known to have coagulopathy/abnormal fibrinogen levels at outside hospital; cryoprecipitate can be approved without waiting for results of lab tests at UCSF.
    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 are preferred over cryoprecipitate for the treatment of bleeding patients with hemophilia or von Willebrand's disease. Obtain hematology consultation.

One uncontrolled and unconfirmed study has suggested that uremic patients who are bleeding may respond to cryoprecipitate. A trial of cryoprecipitate may be undertaken after proven interventions have failed (see chart below).


(from the Medical Center at UCSF Transfusion Committee, 4/92)


  1. the PT/PTT are normal
  2. bleeding is not from anatomic defect


Treatment Rationale Reference
1. Dialysis Improve platelet function Watson AJ, Whelton A. J Clin Pharmacol 1985;25:315-7. .br Remuzzi G. Lancet 1988;i:1205-8. .br                
2. Keep hematocrit >24% Bleeding time increases when the hematocrit is below 24%; maintain RBC reserves in a bleeding patient. Fernandez F et al. Brit J Haematol 1985;59:139-48. .br Moia M et al. Lancet 1987;ii:1227-9.
3. Keep platelet count >75 x109/L Increase concentration of partially functional platelets None, but has some rationale
4. Give conjugated equine estrogens 0.6 mg/kg iv qd for 5 days Maximal correction in 5 days; lasts 14 days Livio M et al. New Engl J Med 1986;315:731-5. .br Shemin D et al. Amer J Med 1990;89:436-40.
5. Give DDAVP 0.3 µg/kg iv q12-24 hrs for 2 days Releases von Willebrand Factor from endothelium; effective in 30-60 minutes. May not be effective with repeated doses (tachyphylaxis). Mannucci PM et al. New Engl J Med 1983;308:8-12.
6. Give a one-time trial of cryoprecipitate (one concentrate/7kg) for acute bleeding unresponsive to steps 1-5 Increases von Willebrand Factor concentration Janson PA et al. New Engl J Med 1980;303:1318-22.

Other references:

  1. Bolan CD, Alving BM. Pharmacologic agents in the management of bleeding disorders. Transfusion 1990;30:541-551.
  2. Woolley AC. Platelet dysfunction in uremia. The Kidney 1987;19:15-20.


L. 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 and/or hyperkalemia.
  5. IgA deficient patients at risk for an anaphylactic transfusion reaction (2 L saline wash is recommended).
  6. Patients with a history of severe transfusion reactions after a consultation with a Blood Bank Physician.
  7. 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.


M. Granulocytes

The usefulness of granulocyte transfusion for treatment of life threatening bacterial or fungal infection remains controversial. A handful of past controlled clinical trials of granulocyte transfusion therapy in neutropenic patients have yielded mixed results. A multicenter clinical trial is currently under consideration, by the new Transfusion and Hemostasis Clinical Network funded by the National Institutes of Health, to evaluate the effectiveness of the therapy and the safety of medicating donors for granulocyte mobilization. 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 must make a blood donation for testing prior to donating granulocytes (pre-donation).

  1. The ordering physician must contact the Blood Bank Resident (353-1721) or the Blood Bank Attending (353-1313) on service for an approval.

    Designated Donors

  2. Potential donors need to be recruited. The physicians on the clinical service should approach the 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).
  3. Potential donors must 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. For appropriateness of CMV-seronegative and/or irradiated units, refer to indications for CMV-seronegative and irradiated units.
  4. An appointment for granulocyte apheresis needs to be made with the Special Donations Coordinator at the Blood Centers of the Pacific-Irwin Center (415-749-6657). The UCSF Blood Bank Resident should be involved in coordinating donors’ schedule.
  5. 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.

    Community Donors

  6. Community donors may be available through the Blood Centers of the Pacific. If needed, the Blood Bank Resident should contact the physician on call at the Blood Centers of the Pacific (415-749-6657) to ask for the availability of their community donors. The following information will be required: (1) the patient’s diagnosis, ABO/Rh type, height, and weight, (2) the name of the attending physician on the clinical service, (3) indication for granulocyte transfusion, (4) and expected duration of therapy. Community donors are not available for stimulation using G-CSF.

    Administering Granulocytes

  7. The granulocytes must be infused within 24 hours of collection. Therefore, the Blood Bank Attending must authorize the release of untested units. The ordering physician must sign emergency release forms (both UCSF and the Blood Centers of the Pacific forms).
  8. Routine premedication of the recipient is not recommended.
  9. 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.
  10. The granulocyte transfusion should be given daily or QOD during the period of neutropenia depending on donor availability. The yield of granulocytes in each unit should be a minimum of 10 x 109 cells.


  1. Hübel et al., Current Status of Granulocyte (Neutrophil) Transfusion Therapy of Infectious Diseases, The Journal of Infectious Diseases; 2001; 183:321-8.
  2. Standards for Blood Banks and Transfusion Services, 20th Edition, AABB.
  3. Dutcher et al., Granulocyte transfusion therapy and amphotericin B: adverse reactions? American Journal of Hematology; 1989; 31:102-8.
  4. Dale et al., Return of granulocyte transfusions Current Opinions in Pediatrics; 2000; 12:18-22.
  5. Anderlini et al., Allogeneic Blood Stem Cell Transplantation: Considerations for Donors, Blood; 1997; 90: 903-8.


N. Blood Components Available

  1. Blood Components available at Moffitt Blood Bank
    1. Packed red cells: Average hematocrit-70%. Administer through a filter.
    2. Whole Blood (limited quantity available): ): Indicated if massive hemorrhage is anticipated or encountered. Administer through a filter.
    3. Fresh Frozen Plasma: Crossmatch is not required. Blood Bank personnel need 20-30 minutes to thaw. Administer through a filter. See Guidelines for the Use of Fresh Frozen Plasma (FFP) in previous section.
    4. Apheresis Platelets: Crossmatch is not required. Store at room temperature until infused. Administer through a platelet transfusion filter. See Guidelines for the Release of Platelets above.
    5. Cryoprecipitate: Crossmatch is not required. Blood Bank personnel will thaw and pool (allow 30-40 minutes). Store at room temperature until infusion. Administer through a filter within four hours of thawing. Factor VIII concentrate is available through the Pharmacy.
    6. Rh Immune Globulin: Prevents Rh-D sensitization in Rh-D negative women. Administer within 72 hours following abortion, miscarriage, ectopic pregnancy or amniocentesis in a Rh negative woman, or following the delivery of an Rh-positive infant by an Rh-D negative women.

      Dosage is determined by the amount of fetal-maternal bleeding; one vial will suppress the immunization potential of 15 mL of fetal red cells.

      Rh immune globulin should also be considered for Rh-negative patients who have received Rh-positive platelets (see section on platelets).

      Requests for Win Rho for the treatment of patients with ITP should be referred to the Pharmacy.

  2. By Special Order from UCSF Blood Bank
    1. Pediatric Units: Available as packed cells in 75 mL packs (quad pack RBC) or in syringes for smaller volumes.


O. Issuing Blood

  1. Cross matched blood is available for issue until midnight of the third day following the draw date of recipient's blood specimen. For e.g. blood cross matched using a sample drawn anytime on Monday is available for issue until 23:59 of Thursday.
  2. A Blood Bank pick-up form with the patient's name and medical record number must be presented to the UCSF or UCSF Mt. Zion Blood Bank at the time blood is issued to confirm patient identification. The unit of blood or blood component is issued with the Transfusion Form. Administration (filter) sets appropriate for general transfusion are available in the Operating Room and on the nursing units.
  3. Only one unit of Red Cells or Whole Blood may be taken from the Blood Bank at any one time for any one patient (exceptions: ED, ICUs, Labor and Delivery, OR, PACU). Blood cannot be returned for credit more than 30 minutes after removal from controlled temperature storage in the Blood Banks. Ward refrigerators are not suitable for blood storage.

P. Administering Blood

  1. Responsibilities of the Transfusionist
    1. By policy of the Executive Medical Board, the person administering a transfusion must be either a physician or a specially-trained and certified nurse.
    2. Before starting the transfusion, the transfusionist must:
      1. Compare the name and hospital medical record number on the patient's wristband with the name and hospital medical record number on the blood bag. These must be identical.
      2. Compare the donor's ABO, Rh and number on the labels attached to both front and back of the blood bag. These must be identical.
      3. Request that a second licensed individual (physician, nurse or nurse/patient care assistant, perfusionist) independently check the above items and record the time of the check and of the start of the transfusion in the Nursing Notes.
      4. Sign the Transfusion Record, which is issued with each unit of blood.
      5. Verify that a valid signed "Blood Transfusion Consent" is in the patient's chart.
    3. After administration of the unit of blood, the transfusionist is responsible for completing the "Physician" section of Transfusion Record, indicating the volume of blood given and the reaction, if any. The Transfusion Record must be placed in the patient's chart.
  2. Responsibilities of the Nurse

    In addition to assisting in accurately identifying the recipient and checking the consistency of the donor identification on the blood bag as noted above, the nurse must enter the volume of blood given on the patient's parenteral fluid flow sheet and in the Nursing Notes in the patient's chart.


Q. Transfusion Reactions

  1. Stop the transfusion and notify the physician. Check the patient's vital signs and symptoms.
  2. Fill out the "Report of Possible Transfusion Reaction" (Form 705-033), and send it to the Blood Bank together with:
    1. All blood bags and IV solutions and administration set(s) from this transfusion series (dispose of the needles on the nursing unit - transporting the sets with the needles attached could cause injury).
    2. Specimen of the patient's blood (a 6cc EDTA lavender top), carefully collected so as to avoid hemolysis - remove the needle from the syringe before expelling the blood into the tubes. The sample must be labeled with the patients full first and last names; the hospital medical record number or date of birth; the date drawn; and the full, legible signature of the person who drew the specimen. The sample should also be marked "post-transfusion reaction".
    3. The first post-transfusion urine specimen if a hemolytic reaction is suspected.


R. Autologous and Directed Donations

Autologous and Directed Donations for patients at UCSF 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 Form DCF020BCP" 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.


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

UCSF home page UCSF home page About UCSF Search UCSF UCSF Medical Center