What is FFP (Fresh Frozen Plasma)?

What is Fresh Frozen Plasma (FFP)?

Fresh frozen plasma is a blood product containing all soluble coagulation factors that must be frozen to -25°C or below within 8 hours of collection to preserve labile factors V and VIII, and is primarily indicated for treating active bleeding with documented coagulopathy or major hemorrhage protocols. 1

Product Characteristics

• FFP contains all factors of the soluble coagulation system, including the labile coagulation factors V and VIII that are preserved through rapid freezing. 2
• Each unit contains approximately 250-300 mL of plasma. 2, 3
• Four units of FFP contain only approximately 2 grams of fibrinogen, making it relatively inefficient for isolated fibrinogen replacement. 1, 3
• FFP must be ABO-compatible with the recipient; if blood group is unknown, use group AB FFP as it contains no anti-A or anti-B antibodies. 1, 2

Storage and Preparation

• FFP is stored frozen at -25°C or below and can be thawed using three methods: dry oven (10 minutes), microwave (2-3 minutes), or water bath (20 minutes at 37°C). 2
• Once thawed, FFP can be stored at 4°C for up to 24 hours for general use, with an extended 5-day storage period specifically for major hemorrhage associated with trauma. 2
• Once removed from refrigeration, FFP must be used within 30 minutes and should never be refrozen. 2

Definitive Indications for FFP

Major hemorrhage with documented or presumed 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, 3
• Use in major hemorrhage protocols, often in 1:1 or 1:1.5 ratio with red blood cells until coagulation results are available. 1, 4

Active bleeding with documented coagulopathy:

• FFP is indicated when PT >1.5 times normal or INR >2.0, or aPTT >2 times normal with active bleeding. 1, 4, 3
• The therapeutic dose is 10-15 mL/kg body weight to achieve minimum 30% concentration of plasma factors, which typically translates to 2-4 units (500-1000 mL) for an average 70 kg adult. 1, 3

Specific clinical scenarios:

• Disseminated intravascular coagulation (DIC) with evidence of bleeding or high risk of bleeding (e.g., planned surgery or invasive procedure). 1, 5
• Reversal of warfarin anticoagulation in the presence of active bleeding if prothrombin complex concentrates are not available. 1
• Replacement of single coagulation factor deficiencies when specific concentrates are unavailable. 1, 5
• Replacement fluid for apheresis in thrombotic thrombocytopenic purpura or hemolytic uremic syndrome. 1, 5

Absolute Contraindications and Inappropriate Uses

FFP is NOT indicated in the following situations:

• Prophylactic correction of abnormal coagulation tests prior to low-risk invasive procedures in critically ill, hemodynamically stable patients without active bleeding. 1, 4, 3
• If PT or INR and aPTT are normal. 1
• Solely for augmentation of plasma volume or albumin concentration—use crystalloids or colloids instead. 1, 6
• For correction of coagulation abnormalities in non-bleeding cirrhotic patients, as standard coagulation tests are poor predictors of bleeding in advanced liver disease and do not reflect the true hemostatic status. 1, 4
• Transfusion of FFP for INR ≤1.5 does not confer hemostatic benefit while unnecessarily exposing patients to transfusion risks. 7

Critical Evidence on Ineffectiveness

• FFP transfusion fails to correct PT in non-bleeding patients with mild abnormalities (PT 13.1-17 seconds, INR 1.1-1.85), resulting in normalization in only 0.8% of patients and partial correction in only 15% of patients. 8
• Prophylactic FFP in elective cardiac surgery is not recommended. 1

Administration Guidelines

• FFP should be infused as rapidly as clinically tolerated in acute bleeding situations, with the primary goal being rapid correction of coagulopathy rather than adhering to a specific infusion rate. 3
• Alert the blood bank immediately to facilitate timely preparation, as thawing takes 10-20 minutes depending on method. 2, 3
• Monitor coagulation parameters before and after FFP transfusion to determine need for additional doses. 1, 3

Serious Risks and Complications

Transfusion-related acute lung injury (TRALI):

• TRALI is the most serious complication of FFP transfusion, with FFP being one of the most frequently implicated products. 3, 6
• Male-only plasma is preferentially used in the UK to reduce TRALI risk. 2

Transfusion-associated circulatory overload (TACO):

• Almost 20% of patients receiving FFP for warfarin reversal developed pulmonary complications, primarily TACO, with risk highest after >3 units of FFP (34% versus 15.6% with ≤3 units). 9

Other complications:

• Allergic reactions and infectious disease transmission. 4, 6
• ABO incompatibility if not properly matched. 3
• Citrate toxicity with massive transfusion causing hypocalcemia/hypomagnesemia. 3

Alternatives to FFP

For hypofibrinogenemia (<1.0-1.5 g/L):

• Use cryoprecipitate or fibrinogen concentrate instead of FFP, as these are more effective and efficient for fibrinogen replacement. 1, 3
• Cryoprecipitate is indicated when fibrinogen level is <1.5 g/L (<2 g/L in obstetric hemorrhage) with clinically significant bleeding. 1

For warfarin reversal:

• Prothrombin complex concentrates (PCCs) should be preferred over FFP for urgent warfarin reversal when available, as they are more effective and carry lower volume-related risks. 1, 3, 6

Common Pitfalls to Avoid

• Do not transfuse FFP solely to "normalize" laboratory values in non-bleeding patients—this practice persists despite lack of evidence and exposes patients to unnecessary risks including TACO and TRALI. 1, 4, 8
• Do not assume elevated INR equals bleeding risk in liver disease patients—the hemostatic balance is complex and not captured by standard tests. 4
• Do not use inadequate doses below 10 mL/kg, as these are unlikely to achieve the 30% factor concentration threshold needed for hemostasis. 3
• Recognize that FFP has relatively low fibrinogen content and is inefficient for isolated fibrinogen deficiency—use cryoprecipitate or fibrinogen concentrate instead. 1, 3