PLATELLET ,FFP &

CRYOPRECIPITATE
TRANSFUSION
RIAZ AHAMED D
PLASMA PRODUCTS

• Plasma is the portion of whole blood that remains after the cellular elements (ie,
red and white blood cells) and platelets have been removed by centrifugation.
• Generally speaking, transfusion of plasma is indicated whenever hemostasis is
inadequate and the benefit of correcting the insufficient hemostasis (ie, reduced
bleeding) is believed to outweigh the risks of the plasma transfusion.
INDICATIONS 

 Active bleeding in the setting of known or strongly suspected coagulation

abnormalities
 Massive transfusion of packed red blood cells
 Prior to invasive and surgical procedures for which there is a HIGH risk of
bleeding complications (eg, thoracic, abdominal, spinal, intracranial, and some
urologic surgeries), if the patient has ANY potentially significant abnormality of
their coagulation tests ( PT, INR, or APTT)
• Prior to invasive procedures for which there is a LOW risk of bleeding
complications (eg, endoscopy, cardiac catheterization, central venous catheter
insertion), if the patient has a SEVERE abnormality of their coagulation tests (ie,
prothrombin time >2-times control, INR >2, or partial thromboplastin time >2-
times control)
• disseminated intravascular coagulation [DIC],
• bleeding associated with vitamin K antagonist anticoagulation
PLASMA PRODUCTS-

1. FFP is a licensed plasma product that must be prepared from whole blood or
apheresis and frozen within eight hours of collection (frozen at -18 to -30°C, usable
for one year, 200 to 250 mL)
2. Plasma Frozen Within 24 Hours After Phlebotomy (PF24) is plasma that is frozen
more than eight hours but less than 24 hours after collection. This product is also
referred to as Frozen Plasma. (factor VIII levels are in the range of 65 to 80 percent
of normal and protein C is decreased)
3. Thawed Plasma – Thawed Plasma is plasma that was frozen (ie, FFP or PF24),
thawed, and kept at refrigerator temperature for up to five days.(factors V and VIII
decreased)
• Liquid Plasma – Liquid Plasma is plasma that has never been frozen.(1 to 6°C.)
• Solvent/Detergent (S/D) Plasma is plasma treated with viral inactivating agents
(eg, solvents and detergents) prior to freezing.
• Plasma Cryoprecipitate Reduced is plasma from which Cryoprecipitate has been
removed. This product is also referred to as Cryo-Poor Plasma.(plasma
replacement in some patients with thrombotic thrombocytopenic purpura.)
• Dried plasma, also called freeze-dried plasma, is a liquid-free preparation that
can be stored at room temperature prior to reconstitution.
IN CLINICAL PRACTICE

• FFP, PF24, and Thawed Plasma are generally considered clinically

interchangeable (ie, of equivalent efficacy) because they contain essentially the
same amounts of coagulation factors 
INDICATIONS-VITAMIN K DEPENDENT
COAGULATION FACTOR REPLACEMENT 
• Coagulopathy of liver disease
• Liver transplant, use of Solvent/Detergent-Treated Plasma
• Disseminated intravascular coagulation (DIC)
• Elevated INR due to vitamin K antagonist therapy
• Elevated INR due to other causes of vitamin K deficiency
• Massive transfusion protocols 
• Existing guidelines suggest that plasma be considered for lowering the INR only
when the patient's INR is ≥1.6, and published studies suggest that plasma is
unlikely to fully or even partially correct an INR ≤1.85 or to reduce the risk of
clinical bleeding
MANAGEMENT OF WARFARIN-ASSOCIATED
BLEEDING
• The greatest risk of bleeding with warfarin generally occurs during the initial
phase of treatment and/or during periods of international normalized ratio (INR)
instability (eg, intercurrent illnesses, interacting medications). Bleeding risk is
also increased by some comorbidities (eg, liver disease, heart failure) and other
factors (eg, age, prior hemorrhage, concomitant [NSAID] use)
TREATMENT 

• – The optimal approach for managing a patient with warfarin-associated

bleeding or supratherapeutic INR depends on the presence of clinically significant
bleeding,
• the degree of INR elevation,
• and the underlying thrombotic risk/indication for anticoagulation 
•  – Patients with serious or life-threatening bleeding and a prolonged INR (eg, >2)
should have warfarin withheld and should receive vitamin K (10 mg) by slow
intravenous infusion, along with a rapid reversal agent. We suggest a 4-factor
prothrombin complex concentrate (PCC) rather than a 3-factor PCC and/
or Fresh Frozen Plasma (FFP) 
• Vitamin K administration can be repeated every 12 hours for a persistently
elevated INR
SURGERY

• Patients who require emergency (eg, same day) surgery and warfarin reversal

should have warfarin held and should receive vitamin K and a rapid reversal
agent as done for serious bleeding. We suggest a 4-factor PCC rather than FFP
(Grade 2B).
• -Individuals who can wait 24 hours and require warfarin reversal may be
managed by holding warfarin and giving vitamin Kwithout the use of a PCC.
• -Management of warfarin around the time of elective surgery is presented
separately.
• Minimal bleeding – Minimal bleeding can be treated as outlined for more
significant bleeding (eg, with PCC) depending on the perceived likelihood of
progression to more severe bleeding
• INR >10 without bleeding – For individuals with an INR >10 without bleeding,
 warfarin therapy should be held and 2.5 to 5 mg of vitamin K administered orally.
Nonbleeding patients should not be given a PCC or FFP solely to correct a
supratherapeutic INR
• INR 4.5 to 10 without bleeding – For individuals with an INR between 4.5 and 10
without bleeding, warfarin is held temporarily (eg, one or two doses) with or
without administration of a small dose of oral vitamin K (eg, 1 to 2.5 mg).
Warfarin generally is resumed at a lower dose once the INR is in the therapeutic
range.
• NR <4.5 without bleeding – For individuals with an INR <4.5 without bleeding, one
or more doses of warfarin may be omitted and/or the dose is reduced slightly. If
the INR elevation is minimal and/or expected to be transient, no dose reduction
may be necessary. Additional therapies such as vitamin K are not indicated in
this setting.
PROTHROMBIN COMPLEX CONCENTRATES

• 4-factor PCC -contain all of the vitamin K-dependent coagulation factors (ie,

factors II, VII, IX, and X) in an unactivated form 
• 3-factor PCC – 3-factor PCC (eg, Profilnine) contains only factors II, IX, and X, in
an unactivated form
• Activated PCC – Activated PCC (aPCC) contains factors II, VII, IX, and X; factor VII
is mostly present in the activated form, which is potentially more prothrombotic.
The only aPCC available in the United States is Factor Eight Inhibitor Bypassing
Activity (FEIBA)
REPLACEMENT OF SPECIFIC COAGULATION
FACTORS
• FFP, PF24, and Thawed Plasma are not concentrates of any of the specific
circulating plasma proteins and, in general, should not be used as primary therapy for
a specific coagulation factor defect (eg, hemophilia A, hemophilia B, factor VII
deficiency, factor XIII deficiency) when specific coagulation factor concentrates are
available.
• Exceptions-
• -FFP may be used in some cases for the management of inherited factor XI
deficiency
• -rare inherited coagulation factor deficiencies (eg, X, VII, II)
• -Plasma exchange
DOSE AND INFUSION RATE

• dose of plasma is approximately 10 to 15 mL/kg (ie, approximately three to five units) in

most adults
• Infusion rates depend on the volume load that can be tolerated by the patient. The
following general guidelines apply:
• ●Healthy individual – 2 to 3 mL/kg/hour (ie, approximately one unit in 1.5 hours)
• ●Individual with volume overload or heart failure – 1 mL/kg/hour (ie, approximately one
unit in approximately four hours) (see 'Volume overload' below)
• ●Individual undergoing plasma exchange – 60 mL/minute; this can be raised to 100 mL/
minute if the situation warrants and this rate is tolerated by the patient's veins. The rate can
be this high because fluid is simultaneously being removed during the infusion.
ABO MATCHING

• Due to the normal presence of A and/or B alloantibodies in patients with blood types A, B,
and O, donor plasma must be either ABO-identical or ABO-compatible with the recipient.
• A patient with type A blood can accept plasma from donors who are type A (identical) or
type AB (compatible)
• ●A patient with type B blood can accept plasma from donors who are type B (identical) or
type AB (compatible)
• ●A patient with type O blood can accept plasma from donors who are type O (identical) or
types A, B, or AB (compatible)
• ●A patient with type AB blood can only accept plasma from donors who are type AB
(identical)
RISKS

• Infection
• Volume overload
• Febrile and allergic reactions
• Anaphylactic reactions
• Anaphylactic reactions following transfusion of plasma may occur in patients with
IgA deficiency and antibodies to IgA 
• Transfusion-related acute lung injury (TRALI)-new acute respiratory distress (eg,
hypoxemia, infiltrates on chest radiography) within six hours of transfusion
PLATELET

• Platelet indications — Indications for the transfusion of platelets in critically ill

patients may be therapeutic (ie, stop active bleeding) or prophylactic (ie, prevent
bleeding)
• Patients with a platelet count <10 X 10 platelets/microliter. The purpose is to
3 

prevent spontaneous hemorrhage.

• ●Patients with a platelet count <50 X 10 platelets/microliter who are actively
3 

bleeding, are scheduled to undergo an invasive procedure, or have a qualitative intrinsic

platelet disorder.
• ●Patients with a platelet count <100 X 10 platelets/microliter who have a
3 

central nervous system injury, have multisystem trauma, are undergoing neurosurgery, or
require an intrathecal catheter for anesthesia.
• ●Patients with a normal platelet count who have ongoing active bleeding and a reason for
platelet dysfunction, such as a congenital platelet disorder, chronic antiplatelet therapy, or
uremia.
IN THESE CONDITIONS, PLATELET TRANSFUSION IS
TYPICALLY RESERVED FOR LIFE-THREATENING BLEEDING

• Heparin-induced thrombocytopenia (HIT)

• ●Thrombotic thrombocytopenia purpura (TTP)
• ●Hemolytic-uremic syndromes (HUS)
• ●Disseminated intravascular coagulation (DIC)
• ●Thrombocytopenia associated with antiplatelet alloantibodies
• ●Immune thrombocytopenia (ITP)
PLATELET PREPARATIONS

• Pooled concentrates from whole blood – Platelets may be separated from the other
components of whole blood by sequential steps that involve centrifugation at
different speeds. While this technique is less expensive than the alternative, more
donors are required because the yield is lower. Six to 10 donors may be required per
platelet transfusion.
• ●Single donor apheresis concentrates – Platelets may also be obtained by
apheresis, a procedure in which the whole blood from a donor passes through a
device that separates and collects the platelets, then returns the remainder of the
whole blood to the patient. This technique is more expensive, but the yield is high
and fewer donors are necessary. Only one donor is required per platelet transfusion
• Platelet response — Each unit of transfused platelets should increase the
platelet count by 5 to 10 X 103 platelets/microliter in an average 70 kg adult.
Thus, a transfusion of six units of platelets can be expected to increase the
platelet count by 30 X 103 platelets/microliter. Platelet destruction may decrease
the response to a platelet transfusion.

• When the platelet destruction is due to the presence of alloantibodies, single

donor platelets and HLA-matched platelets may be more effective
COMPLICATIONS

• Acute complications of blood product transfusions include immunologic

reactions (eg, acute hemolytic reaction, delayed hemolytic reaction, febrile
nonhemolytic reaction, and immunomodulation), volume overload, hypothermia,
coagulopathy, citrate toxicity, acute lung injury, and posttransfusion purpura.
CRYOPRECIPITATE

• Cryoprecipitate is the insoluble material that comes out of solution after plasma is frozen
and thawed at 4°C (between 1 and 6°C). The resulting precipitate (Cryoprecipitated
antihemophilic factor [AHF]; cryo) is then frozen and can be used for up to one year.
• Cryoprecipitate contains fibrinogen (factor I), factor VIII, fibronectin, factor XIII, and von
Willebrand factor (VWF).
• 10-15ml/unit
• each unit raises the plasma fibrinogen concentration by approximately 7 to 10 mg/dL
• Use-bleeding in patients with fibrinogen disorders, liver disease, disseminated intravascular
coagulation (DIC),
• Cryoprecipitate may also be used in the rare setting of bleeding in individuals
with hemophilia A, von Willebrand disease (VWD), or factor XIII deficiency when
a purified/recombinant factor is unavailable
• Cryoprecipitate is ineffective for reversing anticoagulation and for replacing
coagulation factors other than factors VIII, XIII, fibrinogen, or von Willebrand
factor
• Hypofibrinogenemia- .2 bag /kg (increase fibrinogen approx 50 -100mg/dl)
• Factor 13 deficiency 1 bag/ 10 kg once
• Bleeding in vWD 1 bag /10 kg every 6 -12 hours