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Updated:
23 September, 2024
Here, various blood components are described with a graphic illustration of how they are produced. Available hemostatic (bleeding control) medications are also discussed.
Production of Blood Components
A platelet unit is produced from whole blood by pooling platelets from 4-6 donors. Platelet concentrates are always leukocyte-reduced and contain < 1 x 106 leukocytes per unit. The concentrate is made from buffy coat, which is obtained by centrifuging whole blood. It also contains 100 ml of plasma.
Dosage: One to two units per 4 erythrocyte concentrates in case of major bleeding. Expected platelet increase in an adult patient is 15-30 x 109/L per transfused unit.
Indication: Major bleeding or symptomatic thrombocytopenia. Markers for good hemostasis are a platelet count (PLT) > 100 x 109/L. Levels above 60 x 109/L usually ensure stable hemostasis. PLT should always be maintained above 20 x 109/L if there is no bleeding and above 40 x 109/L if there is bleeding.
Side effects: Can cause thrombosis in micro or macrovessels. May cause allergic reactions. Thrombocytopenia in TTP can worsen.
Concentration: Contains > 240 x 109 platelets per unit suspended in about 350 ml of nutrient solution and plasma.
Warning: The most common transfusion complication is mild allergic reactions, usually caused by plasma or plasma proteins in the platelet concentrate. Anaphylactic reactions are rare (<1/100,000 transfusions), but when they occur, they are often caused by plasma. Use special filters with a small drip chamber when transfusing platelets.
Contents of blood bags (Erythrocytes)
| Content | Durability | Storage | Weight | Miscellaneous |
|---|---|---|---|---|
| Standard unit of blood Erythrocytes i 100 ml SAGMAN solution. 10 - 20 ml Plasma <1 x 106 leukocytes/unit B-EVF 50-70% | 42 days | 2-6 °C | 240-360 g | Available in stock at the blood centers. Can be irradiated for special indications. |
| Children's unit blood Erythrocytes i 15 - 25 ml SAGMAN solution. 2 - 15 ml Plasma < 1x106 Leukocytes/unit B-EVF 50-70% | 14 days | 2-6 °C | 60-85 g | Produced upon order, Can be irradiated for special indications |
| Washed unit blood SAGMAN-Erythrocytes, washed and suspended in isotonic saline. Contains no plasma. <1x106 leukocytes/unit B-EVF 40-70% | 14 days | 2-6 °C | 200-225 g | Not in stock. Prepared at the regional blood center after ordering, ordering should be done with good forethought. Only given for special indications, for example to a person with a previously established transfusion reaction caused by antibodies to IgA, to patients with a previously established transfusion reaction caused by antibodies to IgA, to patients with a previous severe allergic anaphylactic or repeated transfusion reaction |
| Exchange blood Erythrocytes O RhD neg/pos, Irradiated, without SAGMAN solution, resuspended in AB plasma <1x106 leukocytes/unit B-EVF 50% | 24 hours | 2-6°C | 260 -390 g | Used for blood exchange transfusion to newborn babies. The most common indication for blood exchange is morbus hemolyticus neonatorium, for example RhD positive newborn with immunized RhD negative mother. Prepared at the regional blood center after ordering, ordering should be done with good forethought. |
Blood transfusions should, considering the risk of bacterial growth, be completed within 4 hours from the time the unit is connected to the transfusion set until the transfusion is completed. All blood components are normally leukocyte-reduced (filtered).
Leukocyte reduction contributes to:
• Fewer febrile transfusion reactions
• Prevention of CMV infections
• Prevention of HLA immunization
• Reduced risk of postoperative infections
Erythrocytes
ERYTHROCYTES, LEUKOCYTE-REDUCED (STANDARD COMPONENT)
- Produced by filtering erythrocytes through a leukocyte filter within 36 hours of collection. Considered functionally CMV-negative erythrocytes. Stored in a nutrient solution (plasma content approx. 10-20 mL).
- Content: Hb/unit approx. 53 g (approx. 190 g/L), hematocrit approx. 60%, volume approx. 280 mL
- Shelf life: 42 days, stored at + 20 to + 60
- Indications: Bleeding or anemia
ERYTHROCYTES, LEUKOCYTE-REDUCED WASHED
- Produced by washing erythrocytes with NaCl.
- Contact the blood bank well in advance!
- Volume: approx. 300 mL
- Shelf life: 14 days
- Indication: Transfusion to patients with antibodies against IgA or to patients with hypersensitivity to other plasma proteins.
ERYTHROCYTES FOR EXCHANGE TRANSFUSION IN NEWBORNS
- Produced from leukocyte-reduced erythrocytes – no older than 5 days.
- Content: erythrocytes in freshly thawed plasma, hematocrit approx. 50%.
- Shelf life: 24 hours.
- Compatibility testing with sample from mother or child.
Switch to another ABO group
The basic rule in transfusion is to give blood of the same ABO group as the recipient (group-identical). In some cases, deviations from this rule can be made according to the following guidelines.
Erythrocytes
O-blood can be given to all
A-blood can be given to A and AB
B-blood can be given to B and AB
AB-blood can only be given to AB
Plasma
AB-plasma can be given to all
A-plasma can be given to A and O
B-plasma can be given to B and O
O-plasma can only be given to O
Plasma (human plasma)
Contains centrifuged and separated human blood plasma from the blood bank with the addition of 63 mL citrate solution. Plasma contains reduced levels of the labile coagulation factors, FVIII and factor V, and essentially stable levels of the other coagulation factors.
Fresh frozen plasma (FFP) is frozen within 8 hours of collection and contains at least 70% of FVIII and other labile coagulation factors. Each plasma unit comes from a donor, and the levels of coagulation factors are not controlled and can vary. Takes 30-45 minutes to thaw, so it cannot be provided urgently. Stored frozen for up to 3 years. In leukocyte-depleted/double-centrifuged units, there are <1 x 106 leukocytes/unit.
Dosage: To introduce sufficient quantities of the factors present in plasma to have an effect, approximately 30% of the patient’s estimated plasma volume must be transfused (20-30 mL/kg body weight). To ensure adequate levels of FV and FVIII, at least 50% must be FFP. The minimum effective transfusion volume is 10-15 mL/kg. To raise fibrinogen concentration from 0.5 g/L to 1.5 g/L, at least 4 units of plasma are needed (an increase of 0.25 g/L per plasma unit). Since the desired fibrinogen level in severe bleeding is >2.5 g/L, plasma treatment often needs to be supplemented with fibrinogen concentrate.
Indication: Peri- or postoperative bleeding. Complex deficiency of coagulation factors, such as coagulopathy due to severe liver failure or massive transfusion. As replacement in coagulation factor deficiency in acute situations where a specific coagulation factor concentrate, such as factor V or XI, is not available or when an exact laboratory diagnosis is not possible. To rapidly reverse the effects of oral anticoagulants (coumarin or indanedione). In potentially dangerous bleeding associated with fibrinolysis treatment, such as with tissue plasminogen activators, in patients who do not respond to conventional treatment. In connection with plasma exchange, e.g., for thrombotic thrombocytopenic purpura (TTP).
Side effects: Risk of hypervolemia and heart failure, risk of transfusion-related acute lung injury (TRALI), possible increased risk of certain malignancies, risk of edema.
Volume: 210-280 mL/unit.
Warning: Patients with latent heart failure may develop manifest failure and pulmonary edema.
Contraindications: Unstable angina pectoris, decompensated heart failure.
Plasma Unit Content
| Content | Durability | Storage | Weight | Miscellaneous |
|---|---|---|---|---|
| Standard unit Plasma Na-Citrate solution 50 – 60 mL Leukocytes <1 x 106/unit. | 14 days 3 years (frozen) | 2-6°C < -65°C | 260-320 g | Available in stock at the blood centers. ATTENTION! Few units may be defrosted. |
Platelet Concentrates (Platelets)
A platelet unit is produced from whole blood by pooling platelets from 4-6 donors. Platelet concentrates are always leukocyte-reduced and contain < 1 x 106 leukocytes per unit. The concentrate is made from buffy coat, which is obtained by centrifuging whole blood. It also contains 100 ml of plasma.
- 350 ml of nutrient solution and plasma
- Contains over 240 x 109 platelets
- Leukocyte-reduced
- Usually pooled from 4-6 donors
- Increases platelet count (PLT) by 15-30 x 109 within 10 minutes
Dosage: One to two units per 4 erythrocyte concentrates in case of major bleeding. Expected platelet increase in an adult patient is 15-30 x 109/L per transfused unit.
Indication: Major bleeding or symptomatic thrombocytopenia. Markers for good hemostasis are PLT > 100 x 109/L. Levels above 60 x 109/L usually ensure stable hemostasis. PLT should always be maintained above 20 x 109/L if there is no bleeding and above 40 x 109/L if there is bleeding.
Side effects: Can cause thrombosis in micro or macrovessels. May cause allergic reactions. Thrombocytopenia in TTP can worsen.
Concentration: Contains > 240 x 109 platelets per unit suspended in about 350 ml of nutrient solution and plasma.
Warning: The most common transfusion complication is mild allergic reactions, usually caused by plasma or plasma proteins in the platelet concentrate. Anaphylactic reactions are rare (<1/100,000 transfusions), but when they occur, they are often caused by plasma. Use special filters with a small drip chamber when transfusing platelets.
Platelet Unit Content
| Content | Durability | Storage | Weight | Miscellaneous |
|---|---|---|---|---|
| Default unit Thrombocytapheresis, pathogen reduced Platelets from a donor. Plasma approx. 70 mL. ACD solution 13 mL. SSP+ solution 124 mL Amotosalen <7.5 µL (psoralen) Leukocytes <1 x 106/unit. Platelets >200 x 109/unit. | 7 days | 20-24 °C with constant stirring | 205+30 g | Available in stock at some blood centers |
| Children unit Platelets >50 x 109/unit. | 102 – 115 g | Can be produced at some blood centers if needed. | ||
| Thrombocytapheresis Platelets from a donor. Plasma approx. 70 mL. ACD solution 13 mL SSP+ solution 124 mL Leukocytes <1 x 106/unit. Platelets >200 x 109/unit. | 7 days | 20-24 °C with constant stirring | 205+30 g | Not normally in stock, but can be made to order. Can occur in shortage situations. Can be irradiated for special indications. |
| Buffycoat Platelets from multiple donors. Made from light cell concentrate. Leukocytes <1 x 106/unit. | 7 days | 20-24 °C with constant stirring | Can be purchased in case of shortages. Can be irradiated for special indications. Occurs as pathogen-reduced. | |
| Frozen platelets Platelets from multiple donors. Made from light cell concentrate. Platelets > 200 x 109/unit Leukocytes <1 x 106/unit. DMSO (dimethyl sulfoxide) approx. 5% | Frozen: 4 years Thawed: 5 hours | Frozen: minus 70 °C | Frozen: approx. 10 mL Thawed: 200 mL | Available in stock at some blood centers. Can be exchanged for fresh apheresis platelets if workload and stock of fresh apheresis platelets warrants this. The platelets are pooled with ABO-compatible plasma after thawing to a final volume of approximately 200 mL. |
Platelet Transfusion Threshold and Indication
| Transfusion Threshold (Platelet x 10⁹ /L) and Indication | |
|---|---|
| PLT ≤ 20: | Insertion of CVL/CDL (tunneled/non-tunneled) |
| PLT < 30: | Minor surgery Less severe bleeding |
| PLT < 40: | Lumbar puncture |
| PLT ≤ 50: | Major surgery Severe bleeding DIC with bleeding Percutaneous liver biopsy |
| PLT < 80: | Epidural catheter (insertion/removal) Spinal anesthesia |
| PLT ≤ 100: | Neurosurgery or posterior eye surgery Major/multiple trauma Massive bleeding Traumatic/spontaneous brain hemorrhage |
| Condition | Recommendation |
| Reversible/chronic bone marrow failure during intensive chemotherapy: | < 10: if no other risk factors are present < 20: if there are risk factors for bleeding/fever/sepsis/antibiotic use/ICU care/coagulation disorder (DIC without bleeding). |
| Immune-induced thrombocytopenia: | Only in cases of severe bleeding. Before emergency surgery/procedure if there is no response to treatment. |
| ITP, PTP, HIT: | < 50: for epidural catheter placement or spinal anesthesia. For ITP: add IVIG. For PTP: IVIG is the first line of treatment. |
| TTP/HUS: | Contraindicated except in life-threatening bleeding (applies to both adults and children). |
| Acquired platelet dysfunction regardless of Platelets: | First, consider general hemostatic measures, discontinuation of antiplatelet therapy +/- reversal of anticoagulants, and tranexamic acid (Cyklokapron). Consider platelet transfusion in cases of: Significant bleeding after cardiac surgery. Significant bleeding during emergency surgery while on antiplatelet therapy. Platelets < 1 caused by abciximab (ReoPro). |
| Congenital platelet dysfunction (Glanzmann's Thrombasthenia [GT], Bernard-Soulier Syndrome [BSS]) regardless of Platelets: | For bleeding prevention, NovoSeven is used for GT, and tranexamic acid and Octostim for BSS. Consider platelet transfusion if: Drug contraindication/ineffectiveness or high risk of bleeding (for GT and BSS). For GT: administer HLA-matched platelets (contact the blood bank's on-call physician). |
Albumin
In Sweden, human albumin is available in three concentrations – 40, 50, and 200 g/L. A standard bottle of 100 ml of 20% albumin thus contains 20 g of albumin.
Albumin is given as a volume expander or when you want to raise a low albumin value. Normal S-Albumin varies with age and is approximately 40 g/L. Critically and/or long-term ill patients often have significantly lower albumin concentrations, leading to hypoalbuminemic alkalosis. Administering albumin involves acidification. Albumin 200 g/L is hyperoncotic and has the potential to mobilize fluid from the interstitium. Different manufacturers have chosen to dissolve the albumin in either NaCl or balanced crystalloid.
Fibrinogen (Riastap)
Human fibrinogen concentrate.
Dosage: To calculate the individual dose, the functional fibrinogen level should be determined. If the patient’s fibrinogen level is unknown, an intravenous dose of 70 mg per kg body weight is recommended. The target level (> 2 g/l) for significant bleeding (e.g., head injuries or brain bleeding) should be maintained for seven days. The dose of fibrinogen (mg/kg body weight) to be given = [target level (g/l) – measured level (g/l)]/ 0.017 (g/l per mg/kg body weight). Typically, 1-2-4 g are given intravenously at a time, repeated as needed after checking bleeding parameters. One gram of fibrinogen increases plasma levels by approximately 0.5 g/l.
Indication: Major bleeding, traumatic bleeding. Treatment of bleeding in patients with congenital hypo- or afibrinogenemia with bleeding tendency. The normal fibrinogen level in plasma is 1.5-4.5 g/l. The critical fibrinogen level in plasma, below which bleeding can occur, is 0.5-1.0 g/l. In the case of a major surgical intervention, it is essential to closely monitor the replacement therapy through coagulation analyses.
Concentration: Powder for solution 1 g.
Side effects: Thromboembolic events, including myocardial infarction and pulmonary embolism. Lack of effect.
Warning: Increased risk of thrombosis exists in patients with congenital deficiency when treated with human fibrinogen concentrate, especially at high doses or with repeated dosing. Patients receiving human fibrinogen concentrate should be closely monitored for signs and symptoms of thrombosis.
Contraindications: Hypersensitivity to the active ingredient or any excipient.
Coagulation Factor Concentrate (Confidex)
Hemostatics, hemostatics. Coagulation factor concentrate. The coagulation factors II, VII, IX, and X, synthesized in the liver with the help of vitamin K, are collectively referred to as the prothrombin complex. In addition to the coagulation factors, CONFIDEX contains the vitamin K-dependent coagulation inhibitors Protein C and Protein S.
Dosage: The dose is based on the INR before treatment and the target INR value. INR before treatment should be measured as close to the time of dosing as possible to calculate the appropriate dose of Confidex.
Dosage of Confidex based on INR
| INR value before treatment | 2,0–3,9 | 4,0–6,0 | >6,0 |
|---|---|---|---|
| Approximate dose ml/kg body weight | 1 | 1.4 | 2 |
| Approximate dose IU (factor IX)/kg body weight | 25 | 35 | 50 |
Indication: Major bleeding, bleeding in liver failure.
- Treatment of bleeding and perioperative bleeding prophylaxis in acquired deficiency of the coagulation factors in the prothrombin complex, such as deficiency due to treatment with vitamin K antagonists, or in case of overdose of antagonists, when rapid correction of the deficiency is required.
- Treatment of bleeding and perioperative prophylaxis in congenital deficiency of one of the vitamin K-dependent coagulation factors when purified specific coagulation factor products are not available.
Concentration: Powder for solution 250/500/1000 IU. Dissolved as 250 IU/10 ml.
Side effects: Thromboembolic events, including myocardial infarction and pulmonary embolism. Lack of effect. Headache. Elevated body temperature.
Warning: Patients receiving a vitamin K antagonist may have an underlying hypercoagulable condition, and infusion of prothrombin complex concentrate may worsen this. There is a risk of thrombosis or disseminated intravascular coagulation when patients with either congenital or acquired deficiency are treated with human prothrombin complex concentrate, especially with repeated dosing.
Contraindications: Known allergy to heparin or history of heparin-induced thrombocytopenia. If disseminated intravascular coagulation is present, treatment with prothrombin complex preparations should be given only after the consumptive stage has passed.
Octaplas (SD Plasma)
SD plasma is a cell-free, blood group-specific human plasma with a standardized content of coagulation factors. Octaplas contains reduced levels of labile coagulation factors, FVIII and factor V, and essentially stable levels of other coagulation factors.
SD plasma is virus-inactivated using the solvent detergent (SD) method. It has a slightly lower but standardized content of coagulation factors compared to blood bank plasma. SD plasma is a registered medicinal product ordered through the pharmacy. The product is blood group-specific and cell-free. SD plasma is produced from more than 1,000 donors. Some loss of coagulation factors occurs during manufacture.
Dosage: To provide an adequate amount of the factors present in plasma to have an effect, approximately 30% of the patient’s estimated plasma volume must be transfused (20-30 mL/kg body weight). To ensure adequate levels of FV and FVIII, at least 50% must be FFP. The minimum effective transfusion volume is 10-15 mL/kg. To raise fibrinogen concentration from 0.5 g/L to 1.5 g/L, at least 4 units of plasma are needed (an increase of 0.25 g/L per plasma unit). Since the desired fibrinogen level in severe bleeding is >2.5 g/L, plasma treatment often needs to be supplemented with fibrinogen concentrate.
Indication: Peri- or postoperative bleeding. Complex deficiency of coagulation factors. Shortening or normalization of prolonged bleeding time in uremia, liver cirrhosis, and prolonged bleeding time without identifiable etiology. To quickly reverse the effects of oral anticoagulants (coumarin or indanedione).
Side effects: Risk of hypervolemia and heart failure, possible increased risk of certain malignancies, risk of edema.
Volume: 200 mL/unit.
Warning: Patients with latent heart failure may develop manifest failure and pulmonary edema.
Contraindications: Unstable angina pectoris, decompensated heart failure.
Haemate (FVIII/VWF)
Human coagulation factor concentrate. Hemostatics, hemostatics. Contains Factor VIII and von Willebrand factor in a ratio of 1:2.4. Bleeding prophylaxis during surgery or major injury: To prevent excessive bleeding during or after surgery, administration should begin 1 to 2 hours before surgery. The infusion is repeated with an appropriate dose every 12-24 hours.
Dosage: 40-50 IU/kg for severe bleeding.
Indication: Major bleeding, traumatic bleeding. Treatment of bleeding in patients with congenital bleeding tendency. Von Willebrand disease in mild or severe form. Massive bleeding with ongoing bleeding. Hemophilia A with Factor VIII deficiency.
Side effects: Thromboembolic events, including myocardial infarction and pulmonary embolism. Lack of effect.
Concentration: Powder for solution 1000 IU Factor VIII and 2400 IU von Willebrand factor. Powder for solution 500 IU Factor VIII and 1200 IU von Willebrand factor.
Warning: During treatment, it is recommended to measure Factor VIII levels to adjust the dose and dosing interval. Hypersensitivity reactions may occur. There is an increased risk of thrombosis.
Contraindications: Hypersensitivity to the active substance or any excipient.
Ocplex (Prothrombin Complex Concentrate/PCC)
Hemostatics. Prothrombin complex concentrate. The coagulation factors II, VII, IX, and X, which are synthesized in the liver with the help of vitamin K.
Dosage: The dose is determined by INR before treatment and the target INR. Normally, 2-3000 IU Ocplex is given. The single dose should not exceed 3,000 IU (120 ml Ocplex).
Dosage of OcPlex after INR value in ml/kg (25 E/ml)
| Initial INR-value | Dose (ml/kg) (25 E/ml) |
|---|---|
| 2 - 2,5 | 0,9 - 1,3 |
| 2,5 - 3 | 1,3 - 1,6 |
| 3 - 3,5 | 1,6 - 1,9 |
| > 3,5 | > 1,9 |
Indication: Major bleeding, bleeding in liver failure. Treatment of bleeding and perioperative bleeding prophylaxis in acquired deficiency of the prothrombin complex’s coagulation factors, such as deficiency caused by treatment with vitamin K antagonists (Waran) or in case of Waran overdose, when rapid correction of the deficiency is required. Correction of elevated PK/INR.
Concentration: Powder for solution 500 IU.
Side effects: Thromboembolic events, including myocardial infarction and pulmonary embolism. Lack of effect.
Warning: Patients receiving a vitamin K antagonist may have an underlying hypercoagulable condition, and infusion of prothrombin complex concentrate may worsen this. In rare cases (> 0.01% and < 0.1%), substitution therapy can lead to the formation of circulating antibodies that inhibit one or more of the human prothrombin complex factors.
Contraindications: Known allergy to heparin or history of heparin-induced thrombocytopenia.
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