What is the difference between using fresh frozen plasma (FFP) and cryoprecipitate for a patient with coagulopathy, specifically in terms of volume replacement, warfarin reversal, and treatment of fibrinogen deficiency?

Fresh Frozen Plasma vs Cryoprecipitate: Key Differences and Clinical Applications

Direct Comparison

Cryoprecipitate is the superior choice for treating isolated fibrinogen deficiency, while FFP is indicated for multiple coagulation factor deficiencies in major hemorrhage. 1

Primary Indications

Cryoprecipitate:

• First-line therapy for acquired hypofibrinogenemia with fibrinogen <1.5 g/L (<2 g/L in obstetric hemorrhage) and clinically significant bleeding 1
• Fibrinogen <1 g/L with significant bleeding risk prior to procedures 1
• Bleeding associated with thrombolytic therapy 1
• More concentrated and efficient source of fibrinogen than FFP 1, 2

Fresh Frozen Plasma:

• Major hemorrhage requiring multiple coagulation factors, typically administered in 1:1 or 1:1.5 ratio with RBCs until coagulation results available 1
• Disseminated intravascular coagulation with active bleeding or high bleeding risk 1
• Warfarin reversal with active bleeding only when prothrombin complex concentrate is unavailable 1
• Replacement fluid for therapeutic apheresis in thrombotic thrombocytopenic purpura 1

Volume and Dosing Considerations

FFP has significant volume burden compared to cryoprecipitate:

• FFP standard dose: 10-15 ml/kg (approximately 700-1050 ml for 70 kg patient = 3-4 units) 2
• Each FFP unit contains 250-300 ml volume 2
• Four units of FFP contain only approximately 2 g of fibrinogen, making it inefficient for isolated fibrinogen replacement 2
• Cryoprecipitate delivers concentrated fibrinogen with minimal volume 1

Warfarin Reversal Context

FFP is inferior to prothrombin complex concentrate for warfarin reversal:

• FFP should only be used for warfarin reversal when prothrombin complex concentrate is unavailable 1
• Lower FFP doses (5-8 ml/kg) are sufficient for warfarin reversal compared to hemorrhage management 2
• Clotting factor concentrates achieve complete INR correction (median 1.3) while FFP fails to fully correct INR (mean 2.3, range 1.6-3.8) 3
• Factor IX levels remain inadequate after FFP (median 19 u/dl) versus concentrates (median 68.5 u/dl) 3

Critical Pitfalls to Avoid

Do not use FFP for volume replacement - this is explicitly contraindicated 1, 2

Do not use FFP to correct abnormal coagulation tests in non-bleeding, hemodynamically stable critically ill patients - abnormal PT/APTT are poor predictors of bleeding and do not reflect true hemostatic status, particularly in liver disease 1, 4

Do not use FFP prophylactically before low-risk procedures - there is no evidence supporting this practice 1

Do not use FFP when fibrinogen is the primary deficiency - cryoprecipitate or fibrinogen concentrate are more effective and efficient 1, 2

Blood Group Compatibility

Both products require ABO compatibility:

• Donor and recipient blood groups should match 1
• If blood group unknown, use ABO non-identical plasma with low titre anti-A or anti-B activity 1
• Group O components should only be given to group O recipients 1

Transfusion-Related Risks

FFP carries higher risk profile due to larger volumes:

• Transfusion-related acute lung injury (TRALI) - most serious complication 2, 4
• Transfusion-associated circulatory overload (TACO) 2, 4
• Febrile non-hemolytic reactions (1 in 14 per unit) 1
• Allergic reactions (1 in 50 per unit) 1
• ABO incompatibility 2
• Infectious disease transmission 2, 4

Platelets and FFP are the blood components most frequently implicated in transfusion reactions 1

Practical Administration

FFP preparation and storage:

• Thawing methods: dry oven (10 min), microwave (2-3 min), or water bath (20 min) 2
• Once thawed, use within 24 hours if stored at 4°C 2
• Must use within 30 minutes if removed from refrigeration 2

Cryoprecipitate:

• Standard concentrated fibrinogen source in UK 1
• Requires same blood group matching as FFP 1

Alternative Therapies

Fibrinogen concentrates (Haemocomplettan/RiaSTAP, Fibryga):

• Many European countries use as first-line therapy for fibrinogen replacement 1
• Pasteurized, lyophilized products from pooled donors 1
• Do not require cross-matching 1
• Recent large trial showed non-inferiority to cryoprecipitate in cardiac surgery bleeding with hypofibrinogenemia 1
• Limited UK licensure currently 1