Transfusion Medicine Guide

Table of Contents

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.

Specimen Requirements

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

Please see Nursing Procedures Manual, Blood Product Transfusion/Administration (General), for minimum sample volume requirements as well as sample labeling requirements. Inadequate sample volume could lead to a delay in the completion of tests and blood product set-up. Samples with incorrect/incomplete/truncated labels will be rejected. 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.

Requests for Blood Products

Emergency Release 

Emergency release guidance document

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.

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 5 minutes.

Emergency Release of platelets

For patients requiring urgent platelet transfusion, 1 leukoreduced, apheresis platelet unit is provided within 5 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).

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). It takes 40 min to thaw a prepare cryoprecipitate for issue.

Massive Transfusion Protocol (MTP)

MTP Guidance document

The following scenarios qualify as 'Massive Transfusion.'

  • Transfusion of 4 units RBC within an hour & anticipated ongoing requirement
  • Loss of >30% blood volume or severe uncontrolled bleeding with risk of coagulopathy
  • Massive hemorrhage accompanied by hypovolemic shock and/or metabolic acidosis
  • Infusion of 10 or more units of PRBC's in the first 24 hours
  • 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.

Orders for Blood Products

Orders for blood products are placed in APEX. (Please see guidance document 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:

  • 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. 
  • Instructions for Providers
    • Orders for blood products should be placed in APEX latest by 6 PM of the day before surgery
    • Please look up Lab Results in APEX and make sure that a valid type and screen (and when needed, a Blood Type Confirmation test) performed at UCSF is available in order to set up blood. 
    • 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. 
    • OR should not start an elective case until all testing is completed and blood is ready.
  • Picking up blood from the Blood Bank
    • 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. 
    • 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.
    • For patients currently in the OR: RN prints the OR-version of the pick-up slip and hands it to PCA. 
    • 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.


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.

CMV is inactivated by the pathogen reduction process.  Hence, psoralen-treated platelets are equivalent to CMV seronegative platelets.  Please see the below section on Platelets for additional information.


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:

Neonatology and PEDIATRIC Services

  • Intrauterine transfusions
  • Infants < 4 months of age
    • Regardless of diagnosis or CMV serological status (maternal antibodies may impact test results)
  • Infants on ECMO/ECLS/Exchange Transfusion Protocol
    • Age < 1 year: All infants regardless of CMV serological status
    • Age ≥ 1 year: CMV-seronegative patients only

Patients on the Pediatric Hematology-Oncology/BMT service qualifying for CMV seronegative blood products:

1.    Patients who did not have an initial CMV IgG/IgM drawn prior to receiving IVIG infusions and have no history of CMV infection should be considered CMV seronegative
2.    Except for patients with SCID, CMV seronegative products are NOT required if patient or donor is CMV seropositive
3.    Pathogen reduced products are considered equivalent to CMV seronegative products


1.    All patients regardless of type of transplant (see below for patients with SCID):

•    CMV seronegative patients receiving umbilical cord blood transplants 
•    CMV seronegative patients receiving HSCT/marrow from CMV seronegative donor
•    CMV seronegative patients receiving autologous transplants 

2.    Patients with SCID  

•    All patients; regardless of CMV serological status of patient or donor [patients with CMV reactivation & receiving anti-viral treatment do not require CMV seronegative blood products]


•    CMV seronegative patients 


•    CMV seronegative patients receiving chemotherapy for leukemia/lymphoma or tumors like neuroblastoma, rhabdomyosarcoma, glioblastoma, etc.
•    CMV seronegative patients with inherited/acquired immunodeficiency disorders like SCID, Wiskott-Aldrich syndrome, thymic aplasia, DiGeorge syndrome etc.

  • Solid organ transplants in neonates or patients on the pediatric service
    • Age < 1 year:
      • All patients currently listed for lung, liver, kidney, pancreas or small bowel transplants regardless of CMV serological status of donor
      • All patients with a diagnosis like HUS or other illnesses where lung, liver, kidney, pancreas or small bowel transplantation may be required in the near future to treat the disease or end organ failure
      • All patients awaiting transplant
    • Age ≥ 1 year
      • CMV seronegative patients currently listed for lung, liver, kidney, pancreas or small bowel transplants from CMV-seronegative donors 
      • CMV seronegative patients with a diagnosis like HUS or other illnesses where lung, liver, kidney, pancreas or small bowel transplantation may be required in the short-term to treat the disease or end organ failure. 
  • Pediatric cardiothoracic surgery patients
    • All infants < 4 months
    • After 4 months of age, only patients with a diagnosis/suspected DiGeorge syndrome or other severe immunodeficiency syndromes will be supported with CMV seronegative products
  • Pediatric heart transplant patients
    • Age < 2 years: All infants regardless of CMV serological status
    • Age ≥ 2 years: CMV-seronegative patients only


Adult Services

  • Adult patients who DO NOT REQUIRE CMV-seronegative blood products. These patients will be supported with LEUKOREDUCED (‘CMV-safe’) blood products:
    • All STANDARD allogeneic or autologous hematopoietic stem cell transplant patients, regardless of CMV serological status of recipient and donor (see exceptions below)
    • Patients receiving STANDARD myelosuppressive chemotherapy or radiation therapy for leukemia, lymphoma, myeloma, etc., regardless of CMV serological status
    • Patients receiving chemotherapy or radiotherapy for solid tumors, regardless of CMV serological status
    • Patients undergoing liver, kidney, pancreas or small bowel transplant, regardless of CMV serological status of patient and donor
    • CMV seronegative patients receiving a heart and/or lung transplants from a CMV seropositive donor
  • Adult patients who qualify for CMV-seronegative blood products:
    • Patients with inherited/acquired immunodeficiency disorders like SCID, Wiskott-Aldrich syndrome, thymic aplasia, DiGeorge syndrome etc. (patients receiving treatment for CMV infection do not require CMV seronegative blood products)
    • The following CMV seronegative hematopoietic stem cell transplant recipients:
      • T-cell depleted transplants, regardless of CMV serological status of the donor
      • Cord blood transplants
      • All patients with SCID; regardless of CMV serological status of patient or donor
      • Transplants that are part of research protocols of trials that mandate CMV-seronegative blood components
    • CMV seronegative patients undergoing heart and/or lung transplant, ONLY if the donor is also CMV seronegative
    • CMV seronegative patients awaiting heart and/or lung transplant (donor CMV serological status is unknown)
    • CMV seronegative patients with AIDS


  • 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.


  • Patients with active CMV viremia receive CMV unscreened products.


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.

T-lymphocytes are inactivated by the pathogen reduction process.  Hence, psoralen-treated platelets are equivalent to irradiated platelets.  Please see the below section on Platelets for additional information.

Irradiated cellular blood components are indicated for:

  • Intrauterine transfusions
  • Infants < 4 months of age
  • Neonates and pediatric patients undergoing exchange transfusions (NICU or PICU protocols only)
  • Infants less than 1 year undergoing ECMO/ECLS
  • Infants less than 2 years undergoing (or listed for) heart transplant
  • Pediatric hematology or oncology patients (all patients)
  • Adult hematology or oncology patients (all patients)
  • Patients with following diagnoses or therapy:
    • Cellular immunodeficiency syndromes (SCIDS, Wiskott-Aldrich syndrome, thymic hypoplasia, DiGeorge syndrome, etc), or aplastic anemia
    • Stem cell transplantation
    • Fludarabine, cladribine, bendamustine, clofarabine or deoxycoformycin (pentostatin) therapy
    • Alemtuzumab (anti-CD52, Campath or Lemtrada) therapy
  • Directed donations from relatives will be irradiated prior to release from the Blood Bank
  • Bone marrow or HPC donor receiving allogeneic blood products 

Blood products are NOT routinely irradiated for

  • Solid organ transplant patients receiving routine post-transplant immunosuppressive therapy
  • 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


AABB Clinical Practice Guideline for Platelet Transfusion

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.

Additional Information on Psoralen-treated Platelets

If no platelet count has been ordered since the last platelet transfusion or during the last 24 hours, a platelet count must be obtained.

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.

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 of RhIg (300µg or 1500 IU) adequately covers 7 units of Rh-positive apheresis platelets given over a 3-week period.

Volume reduced platelets are indicated for patients with:

  • Fluid overload problems.
  • Repeated severe allergic reactions.
  • Prior hemolysis from the transfusion of ABO incompatible platelets.

Orders under the following conditions can be filled without approval (all platelet counts are x109/L, equivalent to x103/µL):

Regardless of platelet Count

  • Orders for blood products, including platelets, are pre-approved for all patients with active bleeding/urgent need for product, regardless of site of bleeding, patient care location or results of recent platelet counts. BB tech should not call LMR for approval.
  • When a recent platelet count is not available:
  • For patients transferred to UCSF for active/suspected bleeding
  • Patient transferred to UCSF and known to have low platelet counts at outside facility
  • Post-cardiopulmonary bypass - one dose 
  • Patients with platelet dysfunction
  • Patients who have received acetylsalicylic acid (ASA, aspirin) within the previous 72 hours, , if the patient is experiencing uncontrolled bleeding or requires surgery.
  • Within 72 hrs of treatment with abciximab (Reopro), if the patient is experiencing uncontrolled bleeding or requires surgery.
  • Within 5 days of treatment with clopidogrel (Plavix) if the patient is experiencing uncontrolled bleeding or requires surgery.
  • Patients with inherited platelet function disorders like Glanzmann’s thrombasthenia/ Bernard-Soulier syndrome, who are actively bleeding
  • 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).

Platelet Count <100 k

  • Patients with head bleed or bleeding into the eye or orbit
  • Patients with an intracranial pressure monitor (ICPM)
  • Postoperative period in patients with surgery of the brain, spine, eye or airway
  • Postoperative period in cardiac surgery patients (for up to 24 hours after coming off the bypass pump)
  • Postoperative period (up to 24 hours) for neonates
  • Patients with DIC who are bleeding
  • Patients on ECMO/ECLS
  • Pediatric patients with suspected or newly diagnosed leukemia undergoing lumbar puncture while they still have circulating blasts

Platelet Count <75 k

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

Platelet Count <50 k

  • Patients with sickle cell disease undergoing bone marrow transplantation
  • Prior to apheresis or dialysis procedures
  • Prior to an invasive procedure, including lumbar puncture (for exception see Platelet count <100K) and IM injection
  • Patients receiving heparin or other anticoagulants (exception: for patients with possible/confirmed HIT diagnosis getting argatroban platelets are relatively contraindicated unless they are bleeding)
  • Within 72 hrs of treatment with the Fab fragment of antibody to GPIIb/IIIa (Reopro®), whether or not actively bleeding
  • Patients getting discharged with plan for outpatient platelet transfusion support at UCSF or another facility.
  • Other patients with significant active bleeding (not covered above)

Platelet Count <30 k

  • Patients with brain tumor receiving chemotherapy/transplant.
  • Patients receiving defibrotide for treatment of hepatic veno-occlusive disease (VOD).
  • ICN (Neonatal ICU) patients, including premature infants - prophylaxis

Platelet Count <20 k

  • Presence of mucositis or fever

Platelet Count <10 k

  • 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

HLA-matched/Cross Matched Platelets for Platelet Refractoriness

Refractoriness to platelet transfusion can be due to immune-mediated and/or non-immune mediated mechanisms. Antibody-mediated destruction of platelets can result from HLA antibodies, platelet autoantibodies (ITP or drug-induced thrombocytopenia) or rarely, antibodies directed against platelet-specific antigens. Poor increments due to underlying medical conditions is a more common cause for refractoriness. Fever, infection, ongoing bleeding, splenomegaly, DIC, post-HSCT, hepatic VOD, GVHD, etc. can lead to a suboptimal response to platelet transfusions. 

Patients may have immune-mediated refractoriness if immediate post-transfusion (10-60 min post-infusion) platelet counts show inadequate increments. If poor response to transfusion with random platelets has been documented on at least TWO occasions by performing immediate post-transfusion (10-60 min post-infusion) platelet counts, please consult the Blood Bank resident (pager 443-8296, Mon-Fri 8AM-5PM) or call the Blood Bank (after 5PM and on weekends/holidays).

HLA-matched/cross matched platelets are patient-specific. For new patients qualifying for support with matched products, the Blood Bank will need to contact the blood supplier to procure the products. 

For patients previously supported with HLA-matched/cross matched platelets, providers should contact the Transfusion Service at least 2-3 days in advance of first anticipated platelet transfusion to allow enough time to procure these special products.

How to place orders for special tests and HLA-matched/cross matched platelets

A. HLA Class I antibody test:

Order ‘Platelet Refractory Testing’ panel:

  • Includes HLA Class I antibody test (reflexed to HLA Class I typing, if positive)
  • Testing is performed by the UCSF Immunogenetics and Transplantation Lab (ITL) located at Laurel Heights Campus; 415-476-3883
  • Only performed Mon-Fri during regular hours
  • If samples arrive in the ITL lab by 8 AM, results of Class I antibody testing are usually provided to the Transfusion Service by 6 PM, the same day
  • Decision to support with HLA matched platelets depends on the degree of alloimmunization:
    • For cPRA <15%, random units are recommended
    • For cPRA >15%, HLA-matched platelets are ordered from the Blood Supplier 
    • Platelets may be available within 4-5 hours if matched products are available at the local facility. In most patients (especially, if cPRA is high), it takes up to 24 hours or more to procure matched products and/or identify matched donors for future collections. 

B. Platelet cross match test

  • Orders for ‘Platelet Crossmatch Test’ should be placed only after consulting with the lab medicine resident.  
  • Performed only in urgent cases (HLA antibody test is pending/positive)
  • Test is carried out by the American Red Cross Reference Lab, Oakland
  • Routine testing: performed at 1 pm and 7 pm, Mon-Fri
  • STAT testing: Weekends/Holidays (critical cases only)  
  • Samples should ideally be drawn and sent to blood bank by 10 AM, M-F
  • Availability of crossmatch compatible platelets:
    • As some patients are incompatible with all donors tested, compatible units may not be available after platelet crossmatch testing  
    • Depending on collection date and other pending tests, crossmatch compatible products may be available on the same day or be delayed until the next day 

Laboratory Medicine Consult Note

Please call the Blood Bank to initiate a consult. Placing orders for ‘Platelet Refractory Testing’ without calling the Blood Bank will not trigger a consult. The Lab Medicine resident will post a Laboratory Medicine Consult Note in APeX and discuss transfusion recommendations with the 1st call covering provider. We recommend that this information be shared and handed off to the rest of the clinical team/documented in the patient’s notes.  

Please ensure that immediate post-transfusion (10-60 min post-infusion) platelet counts are obtained for all patients receiving HLA-matched/cross matched platelets. Monitoring the response to matched transfusions helps the Transfusion Service flag platelet donors providing good increments and notify blood supplier to arrange for additional collections from such donors.

Providers can look up prior documented work up for platelet refractoriness by: 

  1. Searching APeX for ‘Laboratory medicine’ consult notes     
  2. Checking APeX for recent HLA Class I antibody results.


Thawed Fresh Frozen Plasma (FFP) (24-hour outdate) and thawed plasma (120-hour outdate) are stored at 1-6 C, and contain equivalent levels of hemostatic factors. In 2016, the UCSF Transfusion Committee reviewed the literature and practice at other tertiary-care centers and approved the use of thawed plasma for all patients. Neonates (< 4 months) will continue to be supported with thawed FFP.

  • All plasma orders are reviewed (except for neonates; see below). If patient's diagnosis and/or lab values do not meet guidelines, Blood Bank will contact the ordering provider.
  • All routine coagulation parameters should be checked before plasma is ordered. This includes complete blood count, platelet count, PT, INR, PTT, and fibrinogen.
  • The cause of abnormal results should be established and the underlying condition should be treated.
  • Risks related to transfusion of allogeneic blood products should be considered.
  • Prophylactic transfusions should be used sparingly.
    • Given the design of currently available assays for INR/PTT, mild to moderately abnormal coagulation results may not predict risk of bleeding. Coagulation factor activity of 30% or higher are adequate to maintain hemostasis.
    • There is no direct relationship between bleeding and mild abnormalities of coagulation tests. While orders for plasma are currently approved by the Blood Bank for 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 plasma infusions. Several large centers have changed their transfusion practices and avoid prophylactic plasma infusions to patients with INR < 2.0.
    • Transfusion of plasma may however be indicated for patients with severely abnormal INR and/or PTT results prior to a planned invasive procedure.
  • Before transfusing plasma, provider should be aware that:
    • Satisfactory hemostasis may be achieved even with coagulation factor levels at ≥30% of normal, and fibrinogen level is ≥100 mg/dL.
    • The decision to transfuse plasma should not be based solely on the patient's mildly abnormal INR and/or PTT. 
    • Dose of plasma is 10-15 mL/kg. Each unit contains approximately 250-300 mL of plasma.
    • Plasma is best administered within an hour of the procedure as maximal effect declines 2-4 hours after transfusion. 
  • Clinical indications for use of plasma
    • Single-factor deficiencies:
      • Replacement of single factor deficiencies (e.g. factor XI, XIII, AT, Protein C, Protein S, C1 esterase inhibitor, complement, etc.), when a specific fractionated product, concentrate or recombinant factor is unavailable or the clinician preference/judgment is to use plasma.
      • Patients with the rare, inherited Factor V deficiency disorder, will be supported with FFP at the request of ordering provider. Please notify Blood Bank.
    • Multiple-factor deficiencies: 
      • Massive transfusion and dilutional coagulopathy.
      • Transfusion support may be required in patients with DIC and active bleeding. 
    • Urgent reversal of warfarin effect:
      • Four-factor prothrombin complex concentrate (4-factor PCC; K-centra) is first-line therapy for urgent warfarin reversal. 
      • Plasma may be used in patients with life-threatening hemorrhage or when K-centra is contraindicated. 
    • Vitamin K deficiency:
      • Hospitalized patients have inadequate vitamin K intake leading to a prolonged INR/PTT.
      • Oral or intravenous vitamin K should be given. 
      • Coagulation factors usually return to hemostatic levels approximately 12 hours after vitamin K administration.
      • Plasma 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. 
    • Liver disease:
      • Although patients with liver disease often have coagulation abnormalities, spontaneous bleeding is uncommon. 
      • Routine use of plasma 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.
      • Studies have shown that the response to plasma infusions in these patients is unpredictable and plasma rarely corrects mild abnormalities in coagulation tests.
      • Continuous plasma infusion (plasma drip):
        • 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
        • PT should be measured every 6 hours. If the PT is >1.3 times normal, an initial bolus of 15 mL plasma/kg body weight should be administered, followed by a plasma 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 plasma should be given.
        • If the patient is not bleeding and no procedure is planned, plasma infusion should be adjusted as follows: 
          • PT >19 seconds: continue at same rate 
          • PT 16-19 seconds: decrease by 50% 
          • PT <16 seconds: stop infusion 
    • Therapeutic plasmapheresis:
      • Thrombotic thrombocytopenic purpura or catastrophic antiphospholipid syndrome
      • Cryoprecipitate may be indicated if plasma fibrinogen is < 100 mg/dL 
      • FFP only orders are approved for 'PLEX replacement AND coagulopathy/recent surgery/procedure' indication
    • ABO-mismatched solid organ transplantation: Please notify Blood Bank. Plasma units selected for routine transfusion or plasma exchange should be ABO compatible with both donor and recipient
    • Cardiopulmonary bypass/ECMO/ECLS:
      • Coagulopathy during CPB is multifactorial; platelet dysfunction, heparin and dilution, all play a role. 
      • Transfusion requirements during CPB should be guided by “near-patient” coagulation tests, like TEG/ROTEM, when available. 
    • Complications during tPA infusion:
      • Neurovascular Service guidelines for the use of intravenous tPA in acute stroke recommend plasma, cryoprecipitate and platelet transfusions in patients who develop acute neurological deterioration, significant bleeding, or other complications during tPA infusion. 
      • Plasma dose: 2 units, every 6 hours for 24 hours after tPA.
    • Neonates (All orders are preapproved, regardless of indication/coagulation test results. FFP is dispensed)
      • In addition to the indications listed above, neonates may require plasma transfusions for other indications, including, but not limited to conditions like:
        • Undiagnosed bleeding/clotting disorders, requiring empiric therapy
        • Hemorrhagic disease of the newborn:
          • High risk infants including those with liver disease, born premature or born to mothers on medications such as INH or anticonvulsants
          • Treatment of severe disease
        • Neonatal purpura fulminans (Protein C/Protein S/AT deficiency)
        • Antithrombin deficiency in pediatric cardiac surgery patients with post-operative chylous effusion.
        • Colloids for volume expansion in acidotic/hypotensive/unstable neonates
    • Neurosurgery
      • Neurosurgical (cranium/spine) procedures- pre-procedure or postoperatively: plasma infusions for mildly abnormal laboratory tests of coagulation are of questionable clinical benefit (e.g. mildly elevated PT/PTT or INR > 1.3).

Notes for BB Staff:

LMR approval is NOT required and PT/INR results need not meet guidelines for the following scenarios:

  • Plasma orders for patients with active bleeding/urgent need for product
  • PTT > 45 seconds (> 1.5 times the upper limit of the current reference range)
  • Plasmapheresis orders
  • Plasma orders for neonates


Based on availability, either conventional cryoprecipitate or an equivalent dose of pathogen-reduced cryoprecipitate will be dispensed by the Transfusion Service.

Each unit (~15-20 mL) contains approximately 150-250 mg of fibrinogen.

  • Adults: 8-10 units raise fibrinogen level by 50-100 mg/dL
  • Children: 1-2 units/10 kg raises fibrinogen level by 50-100 mg/dL
  • Infants: 1 unit is usually sufficient to achieve hemostasis


  • Patients with fibrinogen levels < 100 mg/dL who are bleeding or who are at high risk for bleeding
  • Higher thresholds (< 200 mg/dL) may be appropriate in unstable patients with rapid ongoing consumptive coagulopathy, for e.g. obstetric patients, hematology- oncology patients with active DIC, cardiac surgery patients or patients with bleeding complications following tPA infusion.
  • Orders for blood products, including cryoprecipitate, are pre-approved for all patients with active bleeding/urgent need for product, regardless of site of bleeding, patient care location or results of recent fibrinogen levels. BB tech should not call LMR for approval.
  • 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.


Complications during tPA infusion:

  • UCSF 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.
    • Cryoprecipitate dose: 20 units.
    • 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.

Red Blood Cells

RBC Transfusion 2023 AABB International Guidelines

AABB Choosing Wisely

Blood Substitutes

Washed RBCs

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

  • Infants (<1 year of age) with single-ventricle physiology.
    • Single ventricle defects include tricuspid atresia (TA), Ebstein's anomaly, hypoplastic left heart syndrome (HLHS), mitral valve atresia, double-inlet left ventricle (DILV), double-outlet right ventricle (DORV), cardiac heterotaxy defects, pulmonary atresia/intact ventricular septum, and any other anomaly deemed by peds CT as 'single-ventricle physiology'.
  • Infants (<1 year of age) during a 72 hour post-op period.
  • Infants and children up to 2 years of age undergoing (or listed for) heart transplant.
  • Pediatric cardiac patients with renal insufficiency or hyperkalemia.
  • 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.
  • Adult patients with uncontrolled hyperkalemia, typically prior to initiating dialysis.
  • IgA deficient patients at risk for an anaphylactic transfusion reaction (2 L saline wash is recommended).
  • Patients with a history of severe transfusion reactions, after a consultation with a Blood Bank Physician.
  • Patient with a diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH) when group specific red cells are not available for transfusion.


  1. For removal of potassium, 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.
  2. Washed RBCs are not required routinely for patients with renal failure while they are on CRRT, if the hyperkalemia is well controlled and potassium levels are normal. Exceptions may apply to high-risk patients with cardiac disease.


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. 

Administering Granulocytes

  • 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.
  • Routine premedication of the recipient is not recommended.
  • 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.
  • The granulocyte transfusion should be given daily or QOD during the period of neutropenia depending on donor availability.

Autologous and Directed Donations

Autologous and Directed Donations for UCSF patients should be coordinated directly through blood collection sites run by either the American Red Cross (ARC), Vitalant or Stanford Blood Center. Patients/donors may donate at any one of their sites.

Information and forms required for arranging donations at American Red Cross (ARC):

  • Prior to donation:
    • Please read instructions in ARC physicians guide: Physicians Guide.
    • The American Red Cross directed donation program is initiated with a written order from the treating physician.
    • The ordering physician must complete ALL sections of the American Red Cross Blood Services Special Collection Order and FAX (800-886-7024) to the Patient Services Department: Special Collection Order Form.
    • Once they receive the order, ARC will call the patient/family and start the scheduling process.
    • ARC has donor centers in San Jose, Newark, Oakland, Pleasant Hills, Turlock, Sonora, Modesto, and Stockton. Collection can also be scheduled in Southern California, and units shipped to UCSF.
    • There are additional fees associated with these special donations that may not be covered by insurance. ARC bills the hospital, then the hospital bills the patient/insurance. There are no upfront ARC charges to the patient or donors - there is no money exchanged between ARC and the patient/donors.
    • Donations from a husband to a wife in childbearing years are not allowed without approval by an ARC physician due to the risk of fetal-maternal blood group incompatibility that may affect future pregnancies.
  • All RBC/PLASMA donations must be completed at least 10 working days prior to the scheduled transfusion date.
  • All platelet donations should be scheduled at least 3 days prior to transfusion date
  • ARC NOR-CAL Contact Information
  • Additional information for donors: Click Here.

Information and forms required for arranging donations at Vitalant

  • The ordering physician must complete ALL section of the Vitalant Special Collections Form BS 365 and email to [email protected].
  • Additional fees associated with these special donations may not be covered by insurance
  • Vitalant Contact Information
    • Special Donations hours of operation are M-F, 7AM-3:30PM
    • Please call Special Donations Department at 1-800-215-6225, with questions
  • All RBC/PLASMA donations must be completed at least 10 working days prior to the scheduled transfusion date
  • All platelet donations should be scheduled at least 3 days prior to transfusion date

Information and forms required for arranging donations at Stanford Blood Center (SBC)

  • The ordering physician must complete ALL sections of the Stanford Blood Center Autologous blood donation order form (03-F66) or the Directed donation order form (03-F03)
  • Forms and additional information are available on the SBC website
  • Additional fees associated with these special donations may not be covered by insurance
  • SBC Contact Information
    • Special Donations Information, Appointments, and Questions
    • Monday-Friday, 8:00AM-5:00PM
    • Phone: 650-723-6667
    • [email protected]
  • All RBC/PLASMA donations must be completed at least 10 working days prior to the scheduled transfusion date
  • All platelet donations should be scheduled at least 3 days prior to transfusion date

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

Maximum Surgical Blood Order Schedule (MSBOS)