Fresh Frozen Plasma Dosing for Coagulopathy Correction
Recommended Dose
The standard dose of fresh frozen plasma (FFP) for correcting coagulopathy is 10-15 ml/kg body weight, which typically translates to 2-4 units (500-1000 ml) for an average 70 kg adult. 1, 2
Dose-Specific Recommendations by Clinical Indication
Active Bleeding with Coagulopathy
- Administer 10-15 ml/kg FFP when PT >1.5 times normal, INR >2.0, or aPTT >2 times normal in the presence of microvascular bleeding 1, 2
- This dose achieves the minimum 30% plasma factor concentration required for hemostasis 1, 2
- Higher doses (median 11.1 ml/kg) are typically given when bleeding is the indication, compared to prophylactic use 3
Urgent Warfarin Reversal
- Lower doses of 5-8 ml/kg FFP are usually sufficient for urgent reversal of warfarin anticoagulation 1, 2
- This represents approximately 1-2 units for most adults 2
- Time to administration is critical: every 30-minute delay decreases the odds of INR reversal within 24 hours by 20% 4
Massive Transfusion
- Administer 10-15 ml/kg FFP when patients have received more than one blood volume (approximately 70 ml/kg) and coagulation tests cannot be obtained timely 1
- This applies particularly in trauma and obstetric hemorrhage 2, 5
Critical Dosing Principles
Minimum Effective Dose
- Doses below 10 ml/kg are unlikely to achieve therapeutic benefit as they fail to reach the 30% factor concentration threshold needed for hemostasis 2
- In one study, 53.8% of patients received subtherapeutic doses <10 ml/kg 6
Dose-Response Relationship
- The change in INR after one unit of FFP can be estimated by: ΔINR = 0.57 × PreINR - 0.72 7
- On average, one unit of FFP corrects the R time by approximately 5 minutes on thromboelastography, though significant individual variation exists 8
- Higher pretransfusion INR values require proportionally higher FFP doses (ranging from median 8.9 ml/kg at INR ≤1.5 to 15.7 ml/kg at INR >3) 3
When NOT to Transfuse FFP
FFP is contraindicated or not indicated in the following situations:
- Normal coagulation parameters (PT, INR, and aPTT are normal) 1
- Prophylactic use in non-bleeding patients with mild-moderate coagulopathy before invasive procedures 2
- Volume expansion or albumin replacement 1, 2
- Cirrhotic patients without active bleeding, as FFP can significantly increase portal pressure 2
Monitoring and Reassessment
- Recheck coagulation parameters after FFP administration to determine need for additional doses 2
- Posttransfusion INR corrections are consistently small unless pretransfusion INR was >2.5 3
- Greater INR corrections occur when FFP is administered during active bleeding compared to prophylactic use 3
Common Pitfalls to Avoid
Inadequate Dosing
- Avoid doses <10 ml/kg as they are ineffective at correcting coagulopathy 2
- In practice, 31% of FFP treatments are given to patients without PT prolongation, and 41% to patients without bleeding and only mild INR elevation (<2.5) 3
Delayed Administration
- Minimize time to FFP administration in warfarin-related emergencies, as shorter time to first dose (90 minutes vs. 210 minutes) significantly improves INR reversal rates 4
Inappropriate Indications
- Do not use FFP prophylactically in non-bleeding ICU patients with mild coagulopathy, as this does not prevent bleeding and increases transfusion-related complications 2
Transfusion-Related Risks
FFP carries significant risks that must be weighed against benefits:
- Transfusion-related acute lung injury (TRALI) - the leading cause of transfusion-related mortality 1, 2
- Circulatory overload 2
- ABO incompatibility 2
- Infectious disease transmission 2
- Allergic reactions 1, 2
Alternative Therapies
When available, consider alternatives that may be more effective: