An e-network member was wondering what transfusion services required in terms of a pre-transfusion sample, when dispensing FFP, cryoprecipitate and platelets. The background for this question was that the member's institution did not require a current sample for administration of FFP, cryoprecipitate or platelets so long as a historical blood type was on file for the patient. This policy was in place before the e-network member arrived at their current position in a hospital transfusion service. "If a patient had a reaction to a unit of FFP, cryoprecipitate or platelets, the blood bank lab would not always have a pretransfusion sample to examine". Apparently the AABB Standards do not require that a pretransfusion sample must available for a hemolysis comparison in the event of a suspected transfusion reaction.

To which the following replies were received:

1. Presumably, any patient who requires FFP, cryoprecipitated AHF, or platelets has a suspected or documented defect in hemostasis. Such a person is at increased risk of bleeding and, therefore, a valid blood sample should be submitted to the hospital's transfusion service. If there's a gap in Standards, it should be filled in with a medical policy.

Editor's note: While it is always sound medical policy to fill a gap in Standards, reply #1 actually represented a minority opinion in this discussion. My own reply would also be considered a minority opinion. In my own practice at USC, an occasional patient will require FFP or cryoprecipitate transfusion, yet not have an immediate need for an RBC transfusion. In order to deal with such a reality in a practical manner, the LAC+USC Medical Center will dispense FFP, cryoprecipitate and/or platelets based on the historical ABO/Rh type of the patient without obtaining a new specimen, provided the patient has been ABO/Rh typed using at least TWO different specimens, and providing the most recent of those ABO/Rh typings was within the previous 12 months. If there is no current specimen and the patient has not been typed at least twice with the most recent ABO/Rh typing occurring within the past 12 months, a new specimen will be tested for ABO/Rh before a platelet or plasma product will be dispensed. For example, if a patient had been ABO/Rh typed on 7/25/99 and again on 7/31/99, a request for FFP on 8/2/00 would require that a new specimen be tested for ABO/Rh, before FFP would be dispensed. The new specimen would be necessary because the most recent testing of the patient for ABO/Rh was more than 12 months ago.

The remainder of the replies reflected the majority opinion ...

2. As long as we have a historical type on the patient prior to transfusion of plasma products, we do not require a pre-transfusion specimen to be collected.

3. If we have a historical type for the patient, we do not require a current sample. If we do not have a type on the patient we will ask for a sample before issuing the products. If the product is ordered on an emergency and we have no type for the patient, we have substitution guidelines.

4. We do not require a current sample for transfusion of FFP, cryoprecipitate, or Platelets. We use historical ABO/Rh. On the rare occasion when a patient has had a reaction to FFP, cryoprecipitate or platelets, there has always been a pre-transfusion sample from chemistry or a clot in the lab because the patient had been crossmatched for RBC transfusion.

5. We require only a historical type for patients to receive plasma products and platelets.

6. If we have a historical record on the patient we issue FFP, platelets and cryoprecipitate. We only require a specimen if there is a discrepancy or no historical record.

ADDENDA Dec. 13, 2000 (The minority fights back.)

7. As a minimum, platelets should not be issued without the ability to respond promptly with a fully-qualified red cell transfusion. If the medical director of the blood bank is enforcing an up-to-date trigger for prophylactic platelet transfusions and a conservative threshold for platelet transfusions for thrombocytopenic bleeding, that blood bank should be prepared to issue red cells without waiting for a specimen to be collected. FFP, cryo and platelets are used to correct abnormal hemostasis and a valid order is an alert that the patient is at increased risk of serious bleeding. A policy that ignores that alert increases the risk of morbidity from delayed treatment of a bleeding complication. Potentially, that's a more serious clinical event than the shortened RBC survival that would result from all of the efforts made in blood banks to detect and identify every weak IgG alloantibody. I see this as an "out of sight, out of mind" assessment of risk. Such a policy also compromises the serologic work up of a transfusion reaction, since there would be no baseline pre-transfusion sample.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator