What are the guidelines for Fresh Frozen Plasma (FFP) transfusion?

Fresh Frozen Plasma (FFP) Transfusion Guidelines

Primary Indications for FFP Transfusion

FFP should be administered primarily for major hemorrhage with documented coagulopathy (PT >1.5 times normal, INR >2.0, or aPTT >2 times normal) and for urgent warfarin reversal when prothrombin complex concentrate is unavailable. 1, 2

Definite Indications

• Major hemorrhage with coagulopathy: Administer FFP when PT >1.5 times normal, INR >2.0, or aPTT >2 times normal in actively bleeding patients 1, 2
• Balanced transfusion in massive hemorrhage: Use 1:1 or 1:1.5 FFP:RBC ratio until coagulation test results are available 1
• Urgent warfarin reversal: FFP is indicated for active bleeding when prothrombin complex concentrate is unavailable 1, 2
• Disseminated intravascular coagulation (DIC): Use in patients with evidence of bleeding or high bleeding risk (e.g., planned surgery) 1, 3
• Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome: FFP serves as replacement fluid for apheresis 1, 3
• Hereditary angioedema: FFP contains C1-esterase inhibitor 1
• Single coagulation factor deficiencies: Only when specific factor concentrates are unavailable 3

Conditional Uses (Only with Active Bleeding AND Coagulopathy)

• Massive transfusion: When >1 blood volume (~70 ml/kg) has been transfused with ongoing bleeding 2, 3
• Liver disease with active bleeding: Use cautiously as FFP can increase portal pressure 4, 3
• Cardiopulmonary bypass surgery: Only if bleeding with documented coagulopathy 1, 3

Situations Where FFP is NOT Indicated

Prophylactic FFP to correct abnormal coagulation tests in non-bleeding, hemodynamically stable critically ill patients is not recommended and does not prevent bleeding. 1, 4

• Volume replacement or hypovolemia: Use crystalloids or colloids instead 1, 3
• Prophylactic correction of mild-moderate coagulopathy: Abnormal PT/aPTT are poor predictors of bleeding in stable ICU patients 1, 4
• Elective cardiac surgery prophylaxis: Not recommended 1
• Liver disease without bleeding: May worsen portal hypertension 4
• Nutritional support or albumin replacement: No justification 3

Dosing Recommendations

The therapeutic dose of FFP is 15 ml/kg to achieve minimum 30% plasma factor concentration, which typically equals 3-4 units (1,050 ml) for a 70 kg adult. 2, 4

Standard Dosing

• Initial dose for coagulopathy with bleeding: 10-15 ml/kg (2-4 units for average adult) 2, 4
• Urgent warfarin reversal: Lower doses of 5-8 ml/kg (1-2 units) are usually sufficient 2, 4
• Doses below 10 ml/kg are unlikely to achieve hemostatic threshold and should be avoided 2

Important Dosing Considerations

• Recheck coagulation parameters after transfusion to determine need for additional doses 2
• Higher doses (8 ml/kg vs 4 ml/kg) show better correction of coagulopathy 2
• Each unit contains approximately 250-300 ml 4, 5
• Four units of FFP contain approximately 2 g fibrinogen 4

Administration Guidelines

FFP should be infused as rapidly as clinically tolerated in acute bleeding situations, with rapid correction of coagulopathy being the primary goal. 4

Practical Administration

• Thawing methods: Dry oven (10 minutes), microwave (2-3 minutes), or water bath (20 minutes at 37°C) 4, 5
• Once thawed: Must be used within 30 minutes if removed from refrigeration 4, 5
• Refrigerated storage: Thawed FFP stored at 4°C can be used for up to 24 hours (extended to 5 days for trauma-related major hemorrhage) 5
• Never refreeze thawed FFP 5

Blood Group Compatibility

• FFP should be ABO-compatible with the recipient 5
• If blood group unknown: Use group AB FFP as it contains no anti-A or anti-B antibodies 2, 5
• Verify patient identification against bag label before administration 5

Critical Safety Considerations and Complications

FFP carries significant risks including transfusion-related acute lung injury (TRALI), circulatory overload (TACO), ABO incompatibility, and infectious disease transmission. 2, 4

Major Complications to Monitor

• TRALI: Most serious complication; risk reduced with male-donor predominant plasma 1, 4
• Circulatory overload (TACO): Particularly in elderly patients and those with cardiac dysfunction 4
• Citrate toxicity: Monitor for hypocalcemia/hypomagnesemia with massive transfusion 4
• ABO incompatibility reactions 4
• Allergic reactions: Range from mild to severe 4

Alternatives to FFP

Prothrombin complex concentrate (PCC) should be preferred over FFP for urgent warfarin reversal, and fibrinogen concentrate or cryoprecipitate should be used for isolated hypofibrinogenemia. 1, 2

Specific Alternatives

• Prothrombin complex concentrate: Preferred for urgent warfarin reversal 2, 4
• Cryoprecipitate: More effective for hypofibrinogenemia (<80-100 mg/dl) with bleeding 2, 4
• Fibrinogen concentrate: Noninferior to cryoprecipitate in cardiac surgery bleeding with hypofibrinogenemia 1
• Recombinant factor VIIa: Last-resort option when traditional therapies exhausted 2

Common Pitfalls to Avoid

• Do not use FFP prophylactically before low-risk procedures in non-bleeding patients with abnormal coagulation tests 1, 4
• Do not rely on FFP alone for volume expansion 1, 3
• Avoid inadequate dosing (<10 ml/kg) which fails to achieve therapeutic factor levels 2
• Do not use FFP for "formula replacement" in massive transfusion without documented coagulopathy 3
• Recognize that normal PT/aPTT do not exclude bleeding risk, but abnormal values in stable patients are poor predictors of bleeding 1