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

Guidelines for Fresh Frozen Plasma (FFP) Infusion

Administer FFP at a dose of 15 ml/kg (approximately 3-4 units for a 70 kg adult) when PT/INR >1.5 times normal or aPTT >1.5-2 times normal with active bleeding, or when massive hemorrhage is anticipated by a senior clinician. 1

Primary Indications for FFP Administration

Definite Indications (Strong Evidence)

Active bleeding with documented coagulopathy is the cornerstone indication for FFP:

• PT >1.5 times normal, INR >1.4-2.0, or aPTT >1.5-2 times normal with microvascular bleeding 1
• Massive hemorrhage where coagulopathy is anticipated or established 1
• Acute disseminated intravascular coagulation (DIC) with active bleeding 2, 3

Urgent warfarin reversal in intracranial hemorrhage or life-threatening bleeding:

• For INR ≥1.4: administer vitamin K 10 mg IV plus 3- or 4-factor prothrombin complex concentrate (PCC), or FFP 10-15 mL/kg if PCC unavailable 1
• PCC is strongly preferred over FFP when available 1

Single coagulation factor deficiencies where specific factor concentrates are unavailable 2, 3

Conditional Indications (Require Active Bleeding + Coagulopathy)

FFP should only be given in these scenarios if both bleeding AND abnormal coagulation tests are present:

• Massive transfusion (>1 blood volume or ~70 mL/kg) 2, 3
• Liver disease with active bleeding 2, 3
• Cardiopulmonary bypass surgery with bleeding 2, 3

Dosing Guidelines

Standard Therapeutic Dose

15 mL/kg body weight is the recommended dose to achieve minimum 30% concentration of plasma factors needed for hemostasis 1, 4

• For a 70 kg adult: approximately 1,050 mL (3-4 units of 250-300 mL each) 4
• Doses below 10 mL/kg are unlikely to achieve therapeutic effect 4

Specific Clinical Scenarios

• Anticipated massive hemorrhage (prophylactic): 15 mL/kg 1
• Established coagulopathy: >15 mL/kg may be required 1
• Urgent warfarin reversal: 10-15 mL/kg (or 5-8 mL/kg if lower urgency) 1, 4
• Intracranial hemorrhage with INR ≥1.4: 10-15 mL/kg plus vitamin K 10 mg IV 1

Military-Style Massive Transfusion Protocol

1:1:1 ratio (RBC:FFP:platelets) is reserved for the most severely traumatized patients with ongoing massive hemorrhage 1

Administration Guidelines

Infusion Rate and Timing

Infuse FFP as rapidly as clinically tolerated in acute bleeding situations - the priority is rapid correction of coagulopathy, not adherence to a specific infusion rate 4

• Once removed from refrigeration, FFP must be used within 30 minutes 5, 4
• Alert blood bank immediately to facilitate timely preparation 4

Thawing Methods (Time Required)

• Dry oven: 10 minutes 5, 4
• Microwave: 2-3 minutes 5, 4
• Water bath at 37°C: 20 minutes 5

Storage Requirements

• Store frozen at -25°C or below 5
• Once thawed: store at 4°C for up to 24 hours (extended to 5 days for trauma-associated major hemorrhage) 5
• Never refreeze thawed FFP 5

Blood Group Compatibility

FFP must be ABO-compatible with the recipient 5, 4

• If blood group unknown: use group AB FFP (universal donor plasma - contains no anti-A or anti-B antibodies) 5, 6
• Group O FFP given to non-group O children must be high-titre negative 5

Monitoring and Follow-Up

Recheck coagulation parameters after FFP administration to determine need for additional doses 4

• For warfarin reversal: repeat INR 15-60 minutes after PCC administration, then serially every 6-8 hours for 24-48 hours 1
• If INR remains ≥1.4 within first 24-48 hours after initial PCC dosing, consider further correction with FFP 1

Critical Pitfalls to Avoid

Inappropriate Uses (No Justification)

Do NOT use FFP for:

• Hypovolemia or volume expansion 2, 3
• Prophylactic correction of mild coagulopathy (INR ≤1.5) in non-bleeding patients 4, 7
• Nutritional support or protein replacement 2, 3
• Plasma exchange procedures (use albumin or synthetic colloids instead) 2, 3
• Treatment of immunodeficiency states 2, 3
• Correction of coagulopathy in cirrhotic patients without bleeding (may increase portal pressure) 4

Dose-Response Considerations

Transfusing FFP for INR ≤1.5 does not confer hemostatic benefit and unnecessarily exposes patients to transfusion risks 7

• Only 0.8% of patients with mild coagulopathy (PT 13.1-17 seconds, INR 1.1-1.85) achieve normalization with FFP 8
• 99% of patients with mild abnormalities fail to correct PT with FFP transfusion 8

Alternative Therapies to Consider First

Fibrinogen replacement takes priority - hypofibrinogenemia is the most common factor deficiency in massive hemorrhage 4

• If fibrinogen <1.0-1.5 g/L: use fibrinogen concentrate or cryoprecipitate (10 units) rather than FFP 1, 4
• Cryoprecipitate is more effective for rapid fibrinogen replacement 1

For warfarin reversal: PCC is strongly preferred over FFP when available 1

Associated Risks

Significant transfusion-related complications include:

• Transfusion-related acute lung injury (TRALI) - use male-only plasma when possible to reduce risk 5, 4
• Transfusion-associated circulatory overload (TACO) 4, 6
• ABO incompatibility reactions 4, 6
• Infectious disease transmission 4, 6
• Citrate toxicity with massive transfusion (hypocalcemia/hypomagnesemia) 4
• Allergic reactions 6

Special Considerations

Platelet Management in Massive Hemorrhage

Maintain minimum platelet count of 75 × 10⁹/L in massive hemorrhage situations 1

Thromboprophylaxis

Commence standard venous thromboprophylaxis as soon as possible after hemostasis is secured - patients develop a prothrombotic state following massive hemorrhage 1

Hospital Protocol Requirements

Every hospital must have a major hemorrhage protocol that includes clinical, laboratory, and logistic responses, mobilized immediately when massive hemorrhage is declared 1