When is fresh frozen plasma (FFP) recommended for patients?

When is Fresh Frozen Plasma (FFP) Recommended?

Fresh frozen plasma should be administered primarily for major hemorrhage (often in 1:1 or 1:1.5 ratio with red blood cells) and for patients with active bleeding accompanied by documented coagulopathy (INR >2.0 or PT >1.5 times normal), but should NOT be used prophylactically to correct abnormal laboratory values in non-bleeding patients. 1, 2

Primary Indications for FFP

Major Hemorrhage (Strongest Indication)

• FFP is the cornerstone of damage control resuscitation in massive bleeding, administered early in balanced ratios with red blood cells (1:1 or 1:1.5) until coagulation test results become available 1
• This approach addresses acute traumatic coagulopathy through rapid replacement of clotting factors 1
• FFP contains approximately 70% of normal levels of all clotting factors, making it an adequate source for replacement 1

Active Bleeding with Documented Coagulopathy

• Use FFP when there is active bleeding AND coagulopathy defined as:
  • INR >2.0, OR
  • PT >1.5 times normal, OR
  • APTT >2 times normal 2, 3
• The therapeutic dose is 15 ml/kg to achieve minimum 30% concentration of plasma factors 4, 2, 3

Other Established Indications

• Disseminated intravascular coagulation (DIC) with evidence of bleeding or high bleeding risk (e.g., planned surgery or invasive procedure) 1
• Reversal of warfarin anticoagulation in the presence of active bleeding when prothrombin complex concentrate is not available 1, 3
• Replacement fluid for apheresis in microangiopathies (thrombotic thrombocytopenic purpura, hemolytic uremic syndrome) 1
• Hereditary angioedema (FFP contains C1-esterase inhibitor) 1

When FFP Should NOT Be Used

Prophylactic Correction of Laboratory Values

• There is no good evidence to support prophylactic FFP to correct abnormal coagulation tests prior to low-risk invasive procedures in critically ill patients, although this practice unfortunately still occurs 1, 2
• Abnormal standard coagulation tests (PT, APTT) are poor predictors of bleeding in critically ill and hemodynamically stable patients 1, 2
• In patients with advanced liver disease, these tests do not reflect the true hemostatic status, as the coagulopathy represents a rebalanced hemostatic system, not simply a deficiency state 1, 2
• Transfusion of FFP for INR ≤1.5 does not confer hemostatic benefit while unnecessarily exposing patients to transfusion risks 5
• Research demonstrates that FFP transfusion for mild coagulation abnormalities (PT 13.1-17 seconds, INR 1.1-1.85) normalizes PT-INR in only 0.8% of patients and fails to correct PT in 99% of patients 6

Other Inappropriate Uses

• Prophylactic use in elective cardiac surgery is not recommended 1, 7
• Volume replacement - FFP should not be used solely for this purpose 1, 2
• Hypovolaemia management 8, 9
• Nutritional support or protein-losing states 8, 9
• Treatment of immunodeficiency states 8, 9

Critical Dosing and Administration Details

Dosing

• Standard therapeutic dose: 15 ml/kg to achieve minimum 30% concentration of plasma factors 4, 2, 3
• For warfarin reversal: 5-8 ml/kg is usually sufficient 3
• Approximate volume per bag is 300 ml 4

Blood Group Compatibility

• FFP should be ABO-compatible with the recipient 1, 4
• If blood group is unknown, use group AB FFP (universal donor plasma) as it contains no anti-A or anti-B antibodies 4, 3
• For group O FFP given to non-group O children, it must be high-titre (HT) negative 4

Storage and Handling

• FFP must be stored frozen at -25°C or below 4
• Once thawed, can be stored at 4°C for up to 24 hours for general use 4
• Extended 5-day storage at 4°C is permitted specifically for major hemorrhage associated with trauma 4
• Once removed from refrigeration, FFP must be used within 30 minutes 4, 3
• Never refreeze thawed FFP 4

Common Pitfalls to Avoid

The "Normalize the Labs" Trap

• Do not transfuse FFP solely to "normalize" laboratory values - this practice persists despite lack of evidence and exposes patients to unnecessary risks including TRALI, circulatory overload, infections, ARDS, and multiple organ failure 1, 2
• Elevated INR does not equal bleeding risk, particularly in liver disease where hemostatic balance is complex and not captured by standard tests 2

Procedure-Related Misconceptions

• Proceed with low-risk procedures without prophylactic FFP correction, as bleeding risk is not predicted by INR elevation alone 2
• Reserve FFP for high-risk procedures only when bleeding occurs or patient has additional bleeding risk factors 2

Risks of FFP Transfusion

• Transfusion-related acute lung injury (TRALI) - male-only plasma is preferentially used in the UK to reduce this risk 1, 4
• Post-injury multiple organ failure and ARDS 1
• Infections and circulatory overload 1
• ABO incompatibility reactions 1
• Transmission of infectious diseases including prion diseases 1
• Mild allergic reactions 1