Can we administer one unit of Packed Red Blood Cells (PRBC) and Fresh Frozen Plasma (FFP) to a patient simultaneously?

Can PRBC and FFP Be Administered Together?

Yes, packed red blood cells (PRBC) and fresh frozen plasma (FFP) can and should be administered together in patients with major hemorrhage, using a balanced ratio approach of 1:1 to 1:1.5 (FFP:PRBC) to reduce mortality. 1

Clinical Context and Rationale

The simultaneous administration of PRBC and FFP is not only safe but represents the current standard of care in massive transfusion protocols, particularly for trauma patients with active bleeding. This approach evolved from military experience and has been validated in civilian trauma settings. 1

Recommended Transfusion Ratios

For patients requiring massive transfusion (>10 units PRBC in 24 hours):

• Target FFP:PRBC ratio of 1:1 to 1:1.5 to achieve optimal mortality reduction 1
• FFP should be administered within the first 6 hours of resuscitation 1
• This balanced ratio prevents early death from hemorrhage and reduces 24-hour mortality 1

The evidence strongly supports that:

• A 1:1.5 FFP:PRBC ratio at 6 hours independently reduces mortality at 6,12, and 24 hours 1
• Patients receiving FFP:PRBC ratios of 1:4 or lower have three-fold higher mortality compared to those receiving 1:1 ratios 1
• High ratios do not increase risk of multiorgan failure, nosocomial infection, or acute respiratory distress syndrome 1

Practical Administration Guidelines

Dosing Parameters

• FFP dose: 10-15 ml/kg is the standard recommended dose 1
• Administration timing: FFP and PRBC can be given simultaneously through separate IV lines 1
• Monitoring: Use coagulation studies to guide further doses, though in active bleeding, transfusion should be guided by hemodynamic response 1

Technical Considerations

• Both products require a 170-200 μm filter giving set 1
• FFP must be ABO compatible when possible 1
• Pre-thawed FFP can be stored at 4°C for up to 5 days in trauma patients, allowing for immediate availability 1
• Transfusion should be completed within 4 hours once started 1

Important Clinical Caveats

When NOT to Use High Ratios

For patients receiving <10 units PRBC (non-massive transfusion):

• High FFP:PRBC ratios may cause increased morbidity 2
• These patients had decreased ICU-free days and ventilator-free days with high ratios 2
• Rapidly terminate balanced transfusion protocols when it becomes clear massive transfusion is not required 2

Specific Indications for FFP

FFP is indicated for: 1

• Major hemorrhage (primary indication)
• Disseminated intravascular coagulation with active bleeding
• Warfarin reversal with active bleeding (only if prothrombin complex concentrate unavailable)
• Thrombotic thrombocytopenic purpura as exchange fluid

FFP is NOT indicated for: 1

• Prophylactic correction of abnormal coagulation tests in stable, non-bleeding patients
• Volume replacement alone
• Routine use before low-risk procedures in critically ill patients

Risks to Monitor

While administering PRBC and FFP together, be vigilant for: 1

• Transfusion-related acute lung injury (TRALI) - FFP is frequently implicated 1
• Circulatory overload
• ABO incompatibility reactions
• Allergic reactions
• Hypothermia (though high FFP:PRBC ratios reduce mortality even with hypothermia) 1

Algorithm for Decision-Making

1. Identify massive transfusion: Patient requires or will likely require >10 units PRBC in 24 hours
2. Initiate balanced transfusion: Start FFP:PRBC at 1:1 to 1:1.5 ratio immediately
3. Continue for first 6 hours: Maintain high ratio during critical early resuscitation period 1
4. Reassess at intervals: If transfusion requirements decrease below massive transfusion threshold, reduce FFP administration to avoid unnecessary morbidity 2
5. Guide by coagulation tests: Once available, use PT/APTT and fibrinogen levels to adjust further doses 1