What is the recommended dose of Fresh Frozen Plasma (FFP)?

Recommended Dose of Fresh Frozen Plasma (FFP)

The recommended therapeutic dose of FFP is 15 ml/kg body weight to achieve adequate hemostatic effect, with a minimum target of 30% plasma factor concentration. 1, 2

Standard Dosing Guidelines

• Initial dose: 15 ml/kg is the most widely recommended therapeutic dose across major guidelines 1, 2
• Alternative dosing range: 10-15 ml/kg is acceptable, with further doses dependent on coagulation monitoring and ongoing blood product administration 1, 3
• For warfarin reversal specifically: 5-8 ml/kg is typically sufficient when prothrombin complex concentrate (PCC) is unavailable 2

Clinical Context for FFP Administration

FFP should be administered in the following scenarios:

• Massive hemorrhage with documented coagulopathy (PT/APTT >1.5 times normal or INR >1.5-2.0) 1, 2
• Active bleeding with INR >1.5 or equivalent point-of-care testing 1, 2, 3
• Trauma and obstetric hemorrhage requiring coagulation factor replacement 1, 2, 3
• Acute disseminated intravascular coagulation (DIC) with bleeding 1, 3

Important Dosing Considerations

Volume and Content

• Each unit of FFP contains approximately 250-300 ml 3
• Four units of FFP provide approximately 2 g of fibrinogen (compared to 4 g in two pools of cryoprecipitate) 1, 3

Dose-Response Relationship

• Doses below 10 ml/kg are generally inadequate for correcting coagulopathy 4
• Research demonstrates that correction of INR occurs in only 36% of patients receiving a median dose of 10 ml/kg, compared to successful correction with 17 ml/kg 4
• The hemostatic effect appears maximal at FFP:RBC ratios of 1:2, with no additional benefit from higher ratios (≥1:1) 5

Critical Pitfalls to Avoid

Prophylactic Use Without Bleeding

• Do not transfuse FFP prophylactically in non-bleeding ICU patients with mild-moderate coagulopathy before invasive procedures 1, 3
• Prophylactic FFP for INR ≤1.5 in stable patients does not confer hemostatic benefit and unnecessarily exposes patients to transfusion risks 6

Inadequate Dosing

• Administering less than the recommended 15 ml/kg often fails to achieve therapeutic effect 4
• Further doses should be guided by repeat coagulation monitoring rather than arbitrary fixed volumes 1

Transfusion-Related Risks

FFP carries significant risks that justify restricting use to appropriate indications:

• Transfusion-related acute lung injury (TRALI) - FFP is one of the most frequently implicated products 1, 3
• Acute lung injury occurs more frequently in transfused patients (18% vs 4%) 4
• Circulatory overload, particularly with large volumes 1, 3
• ABO incompatibility if not properly matched 1, 3

Practical Administration Details

• FFP must be ABO-compatible with the patient; use group AB if blood type unknown 1, 2, 3
• Can be thawed using dry oven (10 min), microwave (2-3 min), or water bath (20 min) 1, 3
• Once thawed, use within 24 hours if stored at 4°C (recently extended to 5 days for trauma-associated major hemorrhage) 1, 3
• Must be used within 30 minutes once removed from refrigeration 1, 3

When to Consider Alternatives

• Prothrombin complex concentrate (PCC) is preferred over FFP for urgent warfarin reversal 1, 2, 3
• Cryoprecipitate is more effective when fibrinogen is specifically low (<80-100 mg/dL) 2, 3
• Recombinant Factor VIIa may be considered when traditional options are exhausted 2