What are the indications for Fresh Frozen Plasma (FFP) administration?

Indications for Fresh Frozen Plasma (FFP) Administration

FFP should be administered primarily in patients with active bleeding accompanied by documented coagulopathy (INR >1.5 or equivalent point-of-care testing), during major hemorrhage requiring massive transfusion, or for urgent warfarin reversal when prothrombin complex concentrate is unavailable. 1

Primary Indications for FFP Use

Active Bleeding with Coagulopathy

• Administer FFP when patients are actively bleeding AND have INR >1.5 (or PT >1.5 times normal, or aPTT >2 times normal) 1, 2
• The therapeutic dose is 15 ml/kg body weight to achieve minimum 30% concentration of plasma factors 1, 2
• This typically translates to approximately 1,050 ml (3-4 units) for a 70 kg patient 2

Major Hemorrhage Scenarios

• Replacement of coagulation factors during major hemorrhage, particularly in trauma and obstetric bleeding 1
• In massive transfusion protocols, maintain a 1:1 ratio of red blood cells to FFP until coagulation results become available 2
• Thawed FFP stored at 4°C can now be used for up to 5 days specifically for trauma-associated major hemorrhage 1

Acute Disseminated Intravascular Coagulation (DIC)

• FFP is indicated for acute DIC with active bleeding 1
• This represents replacement of multiple consumed coagulation factors simultaneously 1

Urgent Warfarin Reversal

• FFP is indicated for immediate reversal of warfarin-induced hemorrhage when prothrombin complex concentrate (PCC) is not available 1
• PCC remains the first-choice agent for warfarin reversal 1
• Lower doses of 5-8 ml/kg FFP are usually sufficient for warfarin reversal (approximately 1-2 units for most adults) 2

Thrombotic Thrombocytopenic Purpura (TTP)

• FFP is indicated for TTP, usually administered via plasmapheresis, preferably using pathogen-inactivated FFP 1

Specific Factor Deficiencies

• FFP is indicated for replacement of coagulation factors when specific factor concentrates are not available 1
• This is an uncommon indication in modern practice 1

Critical Contraindications and Inappropriate Uses

Do NOT Use FFP For:

• Routine correction of mild-moderate coagulation abnormalities in non-bleeding critically ill patients before invasive procedures 1
• Routine use in patients with cirrhosis/liver disease unless significant coagulopathy with active bleeding is present 1, 3
• Isolated PT or aPTT abnormalities do not reflect "balanced hemostasis" in liver disease 1, 3
• FFP fails to correct PT in non-bleeding patients with mild abnormalities and may increase portal pressure 2, 3, 4
• Volume replacement or circulatory support - FFP is not indicated for hypovolemia 1, 5
• Nutritional support, albumin replacement, or protein-losing states 6
• Prophylactic correction of laboratory values in non-bleeding patients - this exposes patients to unnecessary transfusion risks 3, 7

Important Clinical Considerations

Blood Group Compatibility

• FFP should be ABO-compatible with the patient 1
• If blood group is unknown, use group AB FFP (contains no anti-A or anti-B antibodies) 1, 2
• For group O FFP given to non-group O children, ensure it is high-titre negative 1

Preparation and Storage

• FFP can be thawed using dry oven (10 minutes), microwave (2-3 minutes), or water bath (20 minutes) 1, 2
• Once thawed and stored at 4°C, FFP can be used for up to 24 hours 1, 2
• Once removed from refrigeration, FFP must be used within 30 minutes 1, 2
• Never refreeze thawed FFP 1

Transfusion-Related Risks

• Transfusion-related acute lung injury (TRALI) - the most serious complication 1, 3, 7
• Male-only plasma implementation has reduced TRALI incidence 1
• Transfusion-associated circulatory overload (TACO) 2, 3
• ABO incompatibility reactions 2
• Allergic reactions 2, 3
• Infectious disease transmission 2, 3

Common Clinical Pitfalls

Avoid These Mistakes:

• Do not transfuse FFP solely to "normalize" laboratory values - this practice persists despite lack of evidence and exposes patients to unnecessary risks 3, 8
• Studies show only 12.5% of patients with chronic liver disease achieve PT correction with standard FFP doses (2-4 units) 4
• Doses below 10 ml/kg are unlikely to achieve the 30% factor concentration threshold needed for hemostasis 2
• Prophylactic FFP in non-bleeding patients with coagulopathy does not prevent bleeding and increases transfusion-related complications 2

Alternative Agents to Consider:

• Cryoprecipitate is preferred over FFP for hypofibrinogenemia (fibrinogen <1.5 g/L, or <2 g/L in obstetrics) 1, 2
• Two pools of cryoprecipitate contain approximately 4 g fibrinogen versus only 2 g in four units of FFP 1
• Prothrombin complex concentrate (PCC) is preferred over FFP for urgent warfarin reversal 1, 2, 5
• Fibrinogen concentrate may be used as an alternative when fibrinogen is <80-100 mg/dL with bleeding 3