Fresh Frozen Plasma (FFP) Dosing for Anticoagulation Reversal and Bleeding Treatment
The recommended dosing of Fresh Frozen Plasma (FFP) for reversal of anticoagulation or treatment of bleeding is 10-15 mL/kg of body weight, with higher doses of at least 30 mL/kg required for severe bleeding or coagulopathy. 1, 2
General Dosing Guidelines
- Standard therapeutic dose for most clinical scenarios is 10-15 mL/kg 1, 2
- For urgent warfarin reversal, a lower dose of 5-8 mL/kg may be sufficient 1
- For severe or uncontrolled bleeding with coagulopathy, higher doses of at least 30 mL/kg are recommended 1
- Each unit of FFP contains approximately 250-300 mL of plasma 1, 2
Indications for FFP Administration
- Correction of excessive microvascular bleeding with PT >1.5 times normal, INR >2.0, or aPTT >2 times normal 1
- Correction of coagulopathy in patients transfused with more than one blood volume when coagulation tests cannot be obtained quickly 1
- Urgent reversal of warfarin therapy (though PCCs are preferred when available) 1
- Replacement of coagulation factors during major hemorrhage, particularly in trauma and obstetrics 1, 2
- Acute disseminated intravascular coagulation (DIC) with bleeding 1, 2
Specific Clinical Scenarios
Warfarin Reversal
- For warfarin reversal, PCCs are the first choice when available 1, 3, 4
- If PCCs are unavailable, FFP at 10-15 mL/kg should be administered with 5-10 mg IV vitamin K 1
- Time to treatment is critical - every 30 minutes of delay in FFP administration decreases odds of INR reversal by 20% 5
Massive Hemorrhage
- For prevention of dilutional coagulopathy in anticipated massive blood loss, early FFP administration is recommended 1
- In established haemostatic failure with widespread microvascular bleeding, at least 30 mL/kg of FFP is recommended 1
- Target maintaining fibrinogen levels >1 g/L and platelet count >75 × 10^9/L 1
Direct Oral Anticoagulants (DOACs)
- FFP has limited efficacy in reversing DOACs and should not be first-line therapy 6, 7
- For dabigatran reversal, idarucizumab is recommended 1, 7
- For factor Xa inhibitors (rivaroxaban, apixaban), andexanet alfa or PCCs are preferred over FFP 1, 7
Practical Administration Considerations
- FFP should be ABO-compatible with the recipient (group AB FFP if blood group is unknown) 1, 2
- FFP can be thawed using a dry oven (10 min), microwave (2-3 min), or water bath (20 min) 1
- Once thawed, FFP can be stored at 4°C for up to 24 hours 1
- Once removed from refrigeration, FFP must be used within 30 minutes 1
Monitoring and Efficacy Assessment
- Coagulation tests (PT/INR, aPTT) should be obtained before FFP administration when possible 1
- Repeat coagulation tests 15-60 minutes after administration to assess efficacy 1
- Serial monitoring every 6-8 hours for 24-48 hours is recommended in cases of severe bleeding 1
Limitations and Risks
- FFP administration carries risks including circulatory overload, ABO incompatibility, infectious disease transmission, allergic reactions, and transfusion-related acute lung injury (TRALI) 1, 2
- FFP may be insufficient to completely correct coagulopathy, particularly for factor IX deficiency 4
- FFP is not indicated for routine volume replacement or for correction of mild coagulation abnormalities in non-bleeding patients 1, 2