FFP is isolated from whole blood and frozen within 8 h of donation to prevent inactivation of labile coagulation factors. FFP may be stored frozen for up to 1 year. Thawing of FFP is usually accomplished by soaking in a 37 °C water bath for 30–45 min. Once thawed, FFP can be refrigerated for a maximum of 24 h. FFP contains physiologic concentrations of coagulation factors, complement, albumin and globulins. Each unit of FFP raises plasma levels of each clotting factor by approximately 2–3 %. In addition to being used in massive transfusions, FFP is used to correct coagulopathies associated with liver disease, warfarin, or isolated factor deficiencies. ABO-compatibility is ideal, but not mandatory as it is for pRBC transfusion.

Platelets are isolated from donor whole blood and suspended in approximately 50 mL of plasma. Individual platelet units can be stored for up to 5 days at room temperature. Platelets are typically pooled from multiple donors prior to administration, and must be used within 4 h of pooling. The usual number of units pooled is 6, and can be expected to raise the platelet count by 30,000–60,000 × 10⁹/L in an average sized adult. ABO and Rh compatibility, although desirable, is not necessary for transfusion. However, transfusion of Rh-positive platelets may sensitize an Rh-negative individual due to small concentrations of red cells present in platelet units. The life span of transfused platelets is between 1 and 7 days in the absence of active bleeding or immune mediated destruction. Guidelines for transfusion of platelets are not hard and fast, and continue to change. Patients with platelet counts less than 5 × 10⁹/L are at increased risk for significant hemorrhage and most guidelines propose prophylactic platelet transfusions for counts less than 10 × 10⁹/L. Platelet transfusions are of little benefit, and may be harmful, in cases of thrombocytopenia due to immunologic processes such as TTP and ITP. If given quickly or through an in line warmer, platelet activation and histamine release can occur leading to hypotension.

Cryoprecipitate (cryo) is produced by centrifuging frozen FFP that has been thawed to 6 °C and re-suspending the precipitated proteins in 15 mL of supernatant plasma. Similarly to platelets, several units are pooled prior to dosing, and are a concentrated source of factors VIII, XIII, von Willebrand factor, fibronectin, and fibrinogen. The advantage of cryo over FFP is the ability to deliver specific proteins with less total volume. Cryo was historically used for the treatment of inherited coagulopathies such as hemophilia A, Factor XIII deficiency and von Willebrand’s disease. Isolated factor concentrates are now used for these diseases and Cryo is now most often administered to replenish fibrinogen. No specific guidelines exist regarding the administration of cryo, but the usual dose for treatment of hypofibrinogenemia is 10 units to start, then 6–10 units every 8 h as necessary to keep fibrinogen above 100 mg/dL. As with platelets, ABO and Rh compatibility is not required for administration.

Complications arising from produc t transfusion can be classified as either immune mediated or infectious. Immune mediated reactions can be further classified as hemolytic and non-hemolytic. Hemolytic reactions are most commonly due to ABO blood incompatibility with an approximate frequency of 1:38,000 transfusions. These reactions are often severe and can result DIC, shock and death. Fatal hemolytic transfusion reactions occur in about 1 in 100,000 transfusions. Non-hemolytic transfusion reactions include febrile reactions, anaphylactic reactions, and transfusion related acute lung injury. Transfusion related acute lung injury (TRALI) occurs in about 1 in 5000 transfusions and is thought to be caused by damage to alveolar capillaries from transfused anti-leukocyte or anti-HLA antibodies. TRALI manifests as acute hypoxia and non-cardiogenic pulmonary edema within 6 h of blood product transfusion. Treatment is supportive, and TRALI typically resolves spontaneously within 4 days.

Transfusion associated infections may be viral, parasitic or bacterial. The rise of HIV in the 1980s and 1990s led to more stringent donor criteria and increasingly sensitive screening tests. Rates of transmission for HIV and Hepatitis C are approximately 1:2,000,000 and rates of transmission for hepatitis B are about 1:200,000. Bacterial contamination of blood products is far more common, and is the second leading cause of transfusion-associated mortality. Gram- negative and Gram-positive bacteria can contaminate blood products and cause sepsis in recipients. The prevalence of bacterial contamination varies by blood product, ranging from 1:2000 for platelets to 1:7000 for pRBCs. Transmission of parasites such as malaria, toxoplasmosis and Chagas’ disease has been reported, but is extremely rare.

Resuscitative fluids should be thought of as medications; they have specific indications and dosages. Appropriate resuscitation involves understanding the composition of both the resuscitative fluids and the perioperative fluid losses. Most balanced resuscitations consist of multiple types of crystalloid, colloid, and blood products. Much research continues to be done on the ideal composition of resuscitative fluids, and the field will likely continue to evolve quickly in the years to come.