What are the complications associated with Fresh Frozen Plasma (FFP)?

Complications of Fresh Frozen Plasma (FFP)

Fresh frozen plasma administration is associated with significant complications including transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), allergic reactions, and infectious disease transmission, and should be avoided in patients without substantial bleeding. 1

Major Complications

Pulmonary Complications

• Transfusion-Related Acute Lung Injury (TRALI)

  • Most serious complication of FFP transfusion 1
  • FFP and platelet concentrates are most frequently implicated blood products in TRALI 1
  • Risk reduced by using male-only plasma (implemented in UK since 2003) 1
  • Characterized by acute respiratory distress following transfusion

• Transfusion-Associated Circulatory Overload (TACO)

  • Risk increases with volume and rate of transfusion
  • Particularly common when >3 units of FFP are administered (28.3% vs 7.6% with ≤3 units) 2
  • Presents with respiratory distress, tachypnea, and pulmonary edema
  • Nearly 20% of patients receiving FFP for warfarin reversal develop pulmonary complications 2

Immunologic Reactions

• Allergic and Anaphylactic Reactions

  • Range from mild urticaria to severe anaphylaxis
  • More common with FFP than other blood components 3
  • Can occur despite ABO compatibility

• Febrile Non-Hemolytic Transfusion Reactions

  • Less common than with cellular components but still occur 3

Infectious Complications

• Transmission of infectious diseases
  • Including viral (hepatitis, HIV), bacterial, and prion diseases 1
  • Risk reduced with pathogen-inactivated plasma
  • Special consideration for variant Creutzfeldt-Jakob disease (vCJD) 1

Other Complications

• Citrate Toxicity

  • Causes hypocalcemia due to citrate binding calcium
  • Risk increases with rapid transfusion and liver dysfunction
  • Metabolism may be dramatically impaired by hypoperfusion, hypothermia, and hepatic insufficiency 1

• Hemolytic Transfusion Reactions

  • Due to ABO incompatibility or other antibodies present in plasma 3

• Multiple Organ Failure

  • Increased incidence of post-injury multiple organ failure 1
  • Risk increases with volume of plasma transfused

Risk Factors for Complications

• Volume of FFP transfused

  • 3 units significantly increases risk of pulmonary complications (OR 2.49) 2

  • Complication rate increases with volume of plasma 1

• Patient Factors

  • Pre-existing cardiac or pulmonary disease (for TACO)
  • Liver dysfunction (for citrate toxicity)
  • Previous transfusion history (for alloimmunization)

Prevention Strategies

1. Appropriate Patient Selection

   • Avoid FFP in patients without substantial bleeding 1
   • Do not use for routine volume replacement 1
   • Do not use for prophylactic correction of mild-moderate coagulation abnormalities in non-bleeding patients 4

2. Dosing Considerations

   • Standard dose is 10-15 ml/kg 1
   • Consider lower volumes in patients at risk for TACO

3. Product Selection

   • Use pathogen-inactivated plasma when available
   • Consider male-only plasma to reduce TRALI risk 1
   • For patients born after 1996 (UK), use FFP sourced outside UK with viral inactivation 1

4. Administration Practices

   • Ensure ABO compatibility
   • Administer at appropriate rate
   • Monitor for signs of adverse reactions during transfusion

Monitoring During Administration

• Vital signs before, during, and after transfusion
• Watch for respiratory distress, hypotension, fever, or rash
• Monitor calcium levels during massive transfusion
• Be prepared to treat reactions promptly

Alternative Approaches

• Consider prothrombin complex concentrates (PCCs) for warfarin reversal 1
• Use specific factor concentrates when available
• Consider fibrinogen concentrate or cryoprecipitate for hypofibrinogenemia

By understanding and anticipating these complications, clinicians can minimize risks while appropriately utilizing FFP in situations where benefits outweigh risks.