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

Fresh Frozen Plasma (FFP) Transfusion Indications

FFP transfusion is indicated primarily for major hemorrhage with documented or presumed coagulopathy, with an initial dose of 10-15 ml/kg, and should be administered early in massive bleeding rather than waiting for laboratory confirmation. 1

Definitive Indications for FFP Transfusion

Major Hemorrhage and Coagulopathy

• Administer FFP in massive bleeding (>10 units RBC in 24 hours or >6 units in 6 hours) using high-ratio transfusion strategies of at least 1:2 FFP:RBC, ideally approaching 1:1 in trauma patients. 1
• FFP is indicated when PT >1.5 times normal, INR >2.0, or APTT >2 times normal in the presence of active microvascular bleeding. 1, 2
• In trauma with massive hemorrhage, maintain a 1:1:1 ratio of RBC:FFP:platelets until coagulation results become available. 3
• The standard therapeutic dose is 10-15 ml/kg (approximately 3-4 units or 750-1000 ml for a 70 kg adult). 1, 2

Critical pitfall: Doses below 10 ml/kg are unlikely to achieve the 30% factor concentration threshold needed for hemostasis and should be avoided. 2

Disseminated Intravascular Coagulation (DIC)

• FFP is indicated for acute DIC with evidence of active bleeding or high bleeding risk (e.g., planned surgery or invasive procedures). 1, 4

Warfarin Reversal

• FFP is indicated for urgent reversal of warfarin anticoagulation in the presence of active bleeding only when prothrombin complex concentrate (PCC) is not available. 1, 4
• When PCC is unavailable, use 5-8 ml/kg FFP for warfarin reversal (lower dose than for general coagulopathy). 2

Important caveat: PCC should be strongly preferred over FFP for warfarin reversal when available, as it provides faster and more complete reversal with lower volume. 4

Thrombotic Microangiopathies

• FFP is indicated as replacement fluid for therapeutic plasma exchange in thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). 1, 5

Hereditary Angioedema

• FFP contains C1-esterase inhibitor and is indicated for hereditary angioedema when specific therapies are unavailable. 1, 2

Conditional Indications (Use with Caution)

Specific Coagulation Factor Deficiencies

• FFP may be used for single coagulation factor deficiencies when specific factor concentrates are not available. 4, 5

Massive Transfusion Protocol

• After transfusion of one blood volume (approximately 70 ml/kg) with ongoing bleeding, administer FFP empirically when coagulation tests are unavailable. 3, 6
• In obstetric hemorrhage, withhold FFP until 4 units of RBC have been transfused unless early coagulopathy is documented, then maintain 1:1 ratio. 2

Absolute Contraindications and Inappropriate Uses

Do NOT Use FFP For:

• Prophylactic correction of abnormal coagulation tests (PT, APTT) prior to low-risk invasive procedures in critically ill, hemodynamically stable patients. 1
• Mild-to-moderate coagulation abnormalities (INR ≤1.5) in non-bleeding patients—this practice does not prevent bleeding and unnecessarily exposes patients to transfusion risks. 2, 7, 8
• Volume replacement or hypovolemia—use crystalloids or colloids instead. 1, 5
• Nutritional support, protein replacement, or albumin augmentation. 5
• Correction of coagulopathy in cirrhotic patients without active bleeding, as FFP can significantly increase portal pressure. 2
• Isolated thrombocytopenia without coagulopathy. 3

Critical evidence: A prospective audit demonstrated that FFP transfusion for mild coagulation abnormalities (INR 1.1-1.85) normalized PT-INR in only 0.8% of patients and failed to correct PT in 99% of patients. 8

Practical Administration Guidelines

Preparation and Timing

• FFP can be thawed using dry oven (10 minutes), microwave (2-3 minutes), or water bath (20 minutes). 2
• Once thawed, FFP must be used within 30 minutes if removed from refrigeration, or within 24 hours if stored at 4°C. 2
• Alert the blood bank immediately in anticipated massive hemorrhage to minimize delays—early FFP administration reduces mortality. 3

Infusion Rate

• In acute bleeding situations, infuse FFP as rapidly as clinically tolerated, prioritizing rapid correction of coagulopathy over adherence to a specific infusion rate. 2

Blood Type Compatibility

• FFP must be ABO-compatible with the patient's red blood cells; use AB plasma if blood type is unknown. 2, 4

Important Limitations and Alternatives

FFP Limitations

• FFP has relatively low fibrinogen content (four units contain only approximately 2 g fibrinogen), making it inefficient for isolated fibrinogen replacement. 1, 3
• Large volumes are required to correct established coagulopathy, which may be difficult to achieve rapidly. 3
• Abnormal standard coagulation tests (PT, APTT) are poor predictors of bleeding in critically ill, hemodynamically stable patients and do not reflect true hemostatic status in advanced liver disease. 1

Preferred Alternatives

• For hypofibrinogenemia (<1.0-1.5 g/L): Use cryoprecipitate or fibrinogen concentrate instead of FFP, as these are more effective and efficient. 1, 3
• For warfarin reversal in emergency situations: Use prothrombin complex concentrate (PCC) preferentially over FFP. 4
• For congenital coagulation factor deficiencies: Use specific factor concentrates when available. 5

Serious Risks and Monitoring

Major Complications

• Transfusion-related acute lung injury (TRALI)—the most serious complication, with FFP and platelets being the most frequently implicated products. 1, 3
• Transfusion-associated circulatory overload (TACO). 1, 3
• ABO incompatibility reactions. 1
• Transmission of infectious diseases (including prion diseases). 1
• Allergic reactions. 1
• Citrate toxicity with massive transfusion leading to hypocalcemia/hypomagnesemia. 2

Monitoring Requirements

• Measure hemoglobin and coagulation parameters before and after FFP transfusion to determine need for additional doses. 1, 2
• Monitor for signs of circulatory overload, TRALI, and metabolic derangements during massive transfusion. 2