What is the recommended dose of Fresh Frozen Plasma (FFP) for urgent warfarin reversal?

Fresh Frozen Plasma Dosage for Urgent Warfarin Reversal

For urgent warfarin reversal, the recommended dose of Fresh Frozen Plasma (FFP) is 10-15 mL/kg intravenously, although prothrombin complex concentrate (PCC) is preferred when available. 1

Primary Reversal Strategies for Warfarin-Induced Coagulopathy

First-Line Therapy (Preferred)

• Prothrombin Complex Concentrate (PCC):
  • 4-factor PCC is strongly preferred over FFP due to:
    • More rapid INR correction (within minutes vs. hours) 1
    • Lower volume requirements (reducing risk of fluid overload) 1
    • Higher efficacy in achieving target INR 1
  • Dosing based on weight and INR:

    INR Level	PCC Dose
    2 to <4	25 units/kg
    4 to 6	35 units/kg
    >6	50 units/kg

  • Always administer with vitamin K 10 mg IV 1

Second-Line Therapy (When PCC Unavailable)

• Fresh Frozen Plasma (FFP):
  • Dose: 10-15 mL/kg IV 1
  • Approximate volume per bag: 300 mL 1
  • Always administer with vitamin K 10 mg IV 1

Practical Considerations for FFP Administration

Timing and Monitoring

• Check INR 15-60 minutes after administration 1
• Serial INR monitoring every 6-8 hours for 24-48 hours 1
• If repeat INR remains ≥1.4 within 24-48 hours after initial FFP, consider additional FFP 1

Administration Logistics

• FFP requires thawing (10-20 minutes depending on method) 1
• Once thawed, FFP must be used within 24 hours if stored at 4°C 1
• Once removed from refrigeration, use within 30 minutes 1

Blood Type Considerations

• FFP should be the same blood group as the patient 1
• If blood group is unknown, group AB FFP is preferred 1

Limitations and Pitfalls of FFP for Warfarin Reversal

Clinical Limitations

• Slower INR correction compared to PCC 1
• May not achieve complete reversal of coagulopathy 3
• Particularly ineffective at normalizing Factor IX levels 3
• Risk of volume overload (12.8% with FFP vs. 4.9% with PCC) 1
• Requires cross-matching and thawing, delaying administration 1

Potential Complications

• Transfusion reactions (allergic and infectious) 1
• Risk of transfusion-related acute lung injury (TRALI) 1
• Fluid overload, particularly concerning in elderly patients or those with cardiac/renal dysfunction 1

Special Considerations

Intracranial Hemorrhage

• For warfarin-associated intracranial hemorrhage, PCC should be strongly preferred over FFP due to:
  • Faster INR reversal (65 vs. 256 minutes) 1
  • Lower rate of hematoma expansion (17.2% vs. 44.2%) 1
  • Critical importance of rapid reversal to limit neurological damage 1

Elderly Patients

• Elderly patients may be more susceptible to volume overload with FFP 1
• Consider reduced dosing (closer to 10 mL/kg) in frail elderly patients with cardiac or renal concerns

Monitoring Effectiveness

• Target INR ≤1.4 for most urgent reversal scenarios 1
• If INR remains elevated after initial FFP dose, additional FFP may be required 1

Despite the widespread use of FFP for warfarin reversal, evidence clearly demonstrates that PCC provides faster, more complete reversal with fewer complications. FFP should only be used when PCC is unavailable, and in such cases, the recommended dose is 10-15 mL/kg IV along with vitamin K 10 mg IV.