What are the current guidelines for the use of blood products like Fresh Frozen Plasma (FFP), Cryoprecipitate (Cryo), and Prothrombin Complex Concentrate (PCC)?

Current Guidelines for Blood Products: FFP, Cryoprecipitate, and PCC

Fresh frozen plasma (FFP), cryoprecipitate, and prothrombin complex concentrates (PCCs) should only be administered for specific clinical indications with documented coagulopathy or active bleeding, as they carry significant risks and should not be used empirically. 1

Fresh Frozen Plasma (FFP)

Definite Indications:

• Replacement of coagulation factors during major hemorrhage, particularly trauma and obstetrics 1, 2
• Acute disseminated intravascular coagulation (DIC) with active bleeding 1, 2
• Patients who are actively bleeding with INR > 1.5 or equivalent point-of-care testing 1, 2
• Immediate reversal of warfarin-induced hemorrhage when PCC is not available (PCC is first choice) 1, 2
• Thrombotic thrombocytopenic purpura, usually with plasmapheresis 1
• Replacement of coagulation factors when specific factors are unavailable 1

Dosing and Administration:

• Recommended therapeutic dose: 15 ml/kg 1
• Should be ABO-compatible with the patient 1
• If blood group is unknown, group AB FFP is preferred 1
• Can be thawed using dry oven (10 min), microwave (2-3 min), or water bath (20 min) 1
• Once thawed, can be used for up to 24 hours if stored at 4°C (recently extended to 5 days for trauma-associated major hemorrhage) 1
• Must be used within 30 minutes once removed from refrigeration 1

Not Indicated For:

• Routine correction of mild-moderate coagulation abnormalities in non-bleeding patients 1
• Routine use in cirrhosis/liver disease without significant coagulopathy 1
• Routine circulatory volume replacement 1
• Hypovolemia 3
• Nutritional support 3

Cryoprecipitate

Indications:

• Hypofibrinogenemia due to major hemorrhage and massive transfusion 1
• When fibrinogen activity indicates fibrinolysis 1
• When fibrinogen concentration is < 80-100 mg/dl with excessive bleeding 1
• As adjunct in massively transfused patients when fibrinogen cannot be measured timely 1
• During major hemorrhage, maintain fibrinogen > 1.5 g/L (except in obstetric hemorrhage where > 2 g/L should be maintained) 1
• Combined liver and renal failure with bleeding 1
• Bleeding associated with thrombolytic therapy 1
• DIC with fibrinogen < 1.0 g/L 1
• Advanced liver disease, to maintain fibrinogen > 1.0 g/L 1
• Congenital fibrinogen deficiencies (in consultation with patient's hematologist) 1
• Von Willebrand disease when desmopressin or VWF/FVIII concentrate unavailable 1

Dosing and Administration:

• Adult dose is two pools 1
• Each single unit contains 400-450 mg fibrinogen; pools of five units contain at least 2g 1
• Transfuse using standard blood giving set with 170-200 μm filter 1
• Once thawed, can be kept at ambient temperature for 4 hours 1
• Rarely indicated if fibrinogen concentration is > 150 mg/dl in non-pregnant patients 1

Prothrombin Complex Concentrate (PCC)

Indications:

• First choice for urgent reversal of warfarin-induced hemorrhage 1, 2
• Preferred over FFP for vitamin K antagonist reversal due to faster correction and lower volume 2

Important Clinical Considerations

Monitoring and Assessment:

• Base transfusion decisions on clinical context and laboratory parameters 1
• FFP is more likely to correct INR if pre-transfusion INR is > 2.0 4
• Post-transfusion corrections of INR are consistently small unless pre-transfusion INR is > 2.5 4

Common Pitfalls to Avoid:

• Inappropriate use of FFP for fluid resuscitation (occurs in approximately 7% of orders) 5
• Using FFP to correct abnormal coagulation tests in non-bleeding patients 5
• "Formula" replacement without documented coagulopathy 3
• Administering cryoprecipitate when fibrinogen is > 150 mg/dl in non-pregnant patients 1
• Using FFP for minor or no bleeding (occurs in approximately 46% of orders) 5

Special Populations:

• In obstetric hemorrhage, maintain fibrinogen > 2 g/L 1
• In hematological malignancy, consult the clinical team before administering blood components 1
• For patients born after 1996, use pathogen-reduced plasma products when available 1

By following these evidence-based guidelines, clinicians can optimize the use of blood products while minimizing unnecessary transfusions and associated risks.