What are the indications for fresh frozen plasma (FFP) transfusion in patients with dengue?

Indications for Fresh Frozen Plasma Transfusion in Dengue

Fresh frozen plasma (FFP) should NOT be routinely used in dengue fever, even with thrombocytopenia or coagulopathy, unless there is active significant bleeding accompanied by documented coagulation abnormalities (PT >1.5 times normal, INR >2.0, or aPTT >2 times normal). 1, 2

Primary Indications for FFP in Dengue

FFP transfusion is appropriate only in the following specific circumstances:

• Active bleeding with coagulopathy: FFP is indicated when there is excessive microvascular bleeding AND documented PT >1.5 times normal, INR >2.0, or aPTT >2 times normal 1, 2
• Massive hemorrhage in dengue hemorrhagic fever: FFP may be used for significant ongoing bleeding with coagulation factor deficiency 2
• Disseminated intravascular coagulation (DIC): FFP is indicated when laboratory evidence shows prolonged PT/aPTT beyond dilution, thrombocytopenia, and fibrinogen <1.0 g/L with active bleeding 2

When FFP Should NOT Be Used

The following are NOT indications for FFP in dengue patients:

• Isolated thrombocytopenia: FFP should not be used for thrombocytopenia alone without coagulopathy and bleeding 2
• Laboratory abnormalities without bleeding: FFP should not be used to correct coagulation test abnormalities in non-bleeding patients 3, 1, 2
• Volume expansion: FFP is not indicated as a plasma volume expander or for albumin replacement 1, 2
• Mild coagulation abnormalities: Transfusing FFP for INR ≤1.5 does not confer hemostatic benefit and unnecessarily exposes patients to transfusion risks 4, 5

Proper FFP Dosing When Indicated

When FFP is appropriately indicated:

• Standard dose: Administer 10-15 ml/kg body weight to achieve minimum 30% plasma factor concentration 1, 2
• Typical adult dose: This translates to approximately 2-4 units (500-1000 ml) for a 70 kg adult 2
• ABO compatibility: FFP must be ABO compatible with the recipient 1, 2

Clinical Decision Algorithm

Step 1: Assess for active bleeding

• If no active bleeding → FFP is NOT indicated regardless of laboratory values 3, 1

Step 2: If active bleeding present, check coagulation parameters

• Obtain PT/INR and aPTT before FFP administration whenever possible 1

Step 3: Evaluate coagulation results

• If PT >1.5 times normal, INR >2.0, or aPTT >2 times normal → FFP is indicated 1, 2
• If coagulation parameters are less abnormal → FFP is NOT indicated 3, 5

Step 4: Consider alternative therapies

• For isolated hypofibrinogenemia (<1.0 g/L) with bleeding, cryoprecipitate or fibrinogen concentrate is more effective than FFP 3, 2

Common Pitfalls to Avoid

• Using FFP as volume expander: Crystalloids or colloids should be used for volume resuscitation, not FFP 1, 2
• Transfusing for isolated thrombocytopenia: Platelet transfusion, not FFP, is appropriate for severe thrombocytopenia with bleeding risk 6
• Inadequate dosing: Doses below 10 ml/kg are unlikely to achieve therapeutic effect 1, 2
• Prophylactic use: FFP transfusion to prevent bleeding in non-bleeding patients with mild coagulopathy increases complications without benefit 3, 5
• Failing to check coagulation parameters: Coagulation tests should guide FFP use whenever possible 1

Evidence Quality Considerations

While one small randomized trial showed FFP increased platelet counts at 12 hours in dengue patients with thrombocytopenia, this effect was not sustained and does not justify routine FFP use 7. The guideline consensus strongly emphasizes that FFP should be reserved for active bleeding with documented coagulopathy, not for laboratory abnormalities alone 3, 1, 2.