When should Fresh Frozen Plasma (FFP) be administered to patients?

Fresh Frozen Plasma (FFP) Administration Guidelines

Fresh frozen plasma should only be administered in specific clinical scenarios including major hemorrhage with coagulopathy, active bleeding with INR >1.5, acute DIC with bleeding, immediate warfarin reversal when PCC is unavailable, and thrombotic thrombocytopenic purpura. 1

Primary Indications for FFP

Definite Indications:

• Major hemorrhage with coagulopathy:

  • Trauma and obstetric hemorrhage requiring coagulation factor replacement 1
  • Early administration (15 ml/kg) recommended when massive hemorrhage is anticipated 1
  • Should be part of a balanced transfusion strategy in severe trauma (1:1:1 or 1:2 ratio of FFP:RBC:platelets) 1

• Active bleeding with abnormal coagulation:

  • For patients actively bleeding with INR >1.5 or equivalent point-of-care testing 1
  • Recommended dose: 15 ml/kg 1

• Acute disseminated intravascular coagulation (DIC) with bleeding 1, 2

• Immediate reversal of warfarin-induced hemorrhage when prothrombin complex concentrate (PCC) is not available (PCC is first-line therapy) 1

• Thrombotic thrombocytopenic purpura (TTP) - preferably using pathogen-inactivated FFP with plasmapheresis 1, 2

• Replacement of coagulation factors when specific factor concentrates are unavailable 1, 2

Conditional Uses (Only with Active Bleeding):

• Liver disease with significant coagulopathy - not for isolated abnormal PT/APTT 1
• Cardiopulmonary bypass surgery with coagulopathy 2
• Heparin resistance - dose 10-15 ml/kg 3

Inappropriate Uses of FFP

FFP should NOT be used for:

• Routine circulatory volume replacement 1, 2
• Mild-moderate coagulation abnormalities in non-bleeding patients 1
• Prophylactic correction of INR <1.5 in non-bleeding patients 4, 5
• Routine use in cirrhosis/liver disease without significant coagulopathy 1, 6
• Nutritional support or immunodeficiency states 2
• Formula replacement in plasma exchange procedures 2

Dosing and Administration

• Standard dose: 15 ml/kg body weight 1
• Timing: Thawed FFP can be used for up to 24 hours when stored at 4°C (extended to 5 days for trauma-associated major hemorrhage) 1
• Administration: Once out of refrigeration, must be used within 30 minutes 1
• Blood group compatibility: Should be the same group as the patient; if unknown, group AB FFP is preferred 1

Monitoring and Efficacy Assessment

• For established coagulopathy, more than 15 ml/kg may be required 1
• Fibrinogen should be maintained >1.5 g/L during major hemorrhage (>2 g/L in obstetric hemorrhage) 1
• Consider cryoprecipitate for isolated hypofibrinogenemia (more concentrated source of fibrinogen) 1
• Target platelet count >75 × 10⁹/L in massive hemorrhage (>100 × 10⁹/L in traumatic brain injury) 1

Important Caveats

• FFP transfusion for mild coagulation abnormalities (INR 1.1-1.85) fails to normalize PT in 99% of patients 4
• Observational data suggests potential harm with FFP transfusion in certain scenarios like acute variceal hemorrhage 6
• In critically ill patients, a careful risk/benefit assessment should be made prior to FFP transfusion due to limited evidence of benefit and known transfusion risks 5
• FFP contains approximately 2g of fibrinogen per 4 units, compared to 4g in two pools of cryoprecipitate 1

Special Considerations

• For patients born after 1996 in the UK, FFP is sourced from outside the UK and undergoes viral inactivation to reduce variant Creutzfeldt-Jakob disease risk 1
• Male-only plasma is preferred when available to reduce transfusion-related acute lung injury (TRALI) risk 1