FFP Transfusion in Dengue Fever
Fresh frozen plasma (FFP) should NOT be routinely used in dengue fever, even in the presence of thrombocytopenia or coagulopathy, unless there is active significant bleeding with documented coagulation abnormalities (PT >1.5 times normal, INR >2.0, or aPTT >2 times normal). 1
When FFP IS Indicated in Dengue
FFP transfusion is appropriate only in the following specific circumstances:
Active bleeding with coagulopathy: FFP should be administered when there is excessive microvascular bleeding AND documented coagulation abnormalities with PT >1.5 times normal, INR >2.0, or aPTT >2 times normal 1, 2
Massive hemorrhage: In dengue hemorrhagic fever with significant ongoing bleeding and coagulation factor deficiency 2
Disseminated intravascular coagulation (DIC): When laboratory evidence shows prolonged PT/aPTT beyond dilution, thrombocytopenia, and fibrinogen <1.0 g/L with active bleeding 2
Proper FFP Dosing When Indicated
When FFP is warranted, appropriate dosing is critical:
- Standard dose: 10-15 ml/kg body weight to achieve minimum 30% plasma factor concentration 1, 3
- Typical volume: This translates to approximately 2-4 units (500-1000 ml) for a 70 kg adult 3
- ABO compatibility: FFP must be ABO compatible with the recipient 1, 3
When FFP Should NOT Be Used in Dengue
Critical contraindications and inappropriate uses:
Prophylactic correction of laboratory abnormalities: FFP should NOT be used to correct coagulation test abnormalities in non-bleeding patients 1, 2
Thrombocytopenia alone: FFP is not indicated for isolated thrombocytopenia without coagulopathy and bleeding 1
Volume expansion: FFP should never be used as a plasma volume expander or for albumin replacement 1, 3
Mild-moderate coagulopathy without bleeding: Correction of minor coagulation abnormalities in stable patients is not warranted 3
Evidence-Based Rationale
The recommendation against routine FFP use in dengue is supported by:
Limited efficacy data: A 2008 randomized controlled trial showed FFP (600 ml) produced only a transient platelet increase at 12 hours in dengue patients with platelets <40,000/mm³, with no sustained benefit at 24-48 hours 4
Potential harm: Retrospective data from 788 dengue patients with platelets <20,000/mm³ showed prophylactic platelet transfusion did not reduce bleeding but actually delayed platelet recovery (3 days vs 2 days to reach 50,000/mm³) and prolonged hospitalization (6 days vs 5 days) 5
Transfusion risks: FFP carries significant risks including transfusion-related acute lung injury (TRALI), circulatory overload, ABO incompatibility, and allergic reactions 3, 2
Clinical Decision Algorithm
Step 1: Assess for active bleeding beyond petechiae 1
Step 2: If bleeding present, obtain coagulation parameters (PT/INR, aPTT) 1, 2
Step 3: FFP indicated ONLY if:
Step 4: If FFP indicated, administer 10-15 ml/kg 1, 3
Step 5: Recheck coagulation parameters after transfusion 3
Common Pitfalls to Avoid
Using FFP for isolated thrombocytopenia: Thrombocytopenia in dengue is primarily due to decreased production and increased destruction, not coagulation factor deficiency 6
Prophylactic transfusion: A large randomized trial of 372 dengue patients showed prophylactic platelet transfusion did not prevent bleeding (21% vs 26%, p=0.16) but increased adverse events (5.8% absolute increase, p=0.0064) 7
Inadequate dosing: Doses below 10 ml/kg fail to achieve the 30% factor concentration threshold needed for hemostasis 3
Ignoring alternatives: For isolated hypofibrinogenemia (<1.0 g/L), cryoprecipitate or fibrinogen concentrate is more effective than FFP 2
Alternative Management Strategies
For dengue patients with thrombocytopenia and coagulopathy WITHOUT active bleeding:
- Supportive care: Bed rest, appropriate fluid therapy, and monitoring remain the cornerstone 7
- Platelet transfusion: Reserved only for platelet counts <10,000-20,000/mm³ with active bleeding or high bleeding risk 7
- Fibrinogen replacement: If fibrinogen <1.0 g/L with bleeding, cryoprecipitate is preferred over FFP 2