How to Transfuse FFP in Massive Transfusion
In massive transfusion scenarios, initiate FFP transfusion immediately using a 1:1:1 ratio of FFP:platelets:packed red blood cells, with an initial FFP dose of 15 ml/kg, and continue this high-ratio strategy until hemorrhage control is achieved. 1, 2
Immediate Protocol Activation
- Activate your hospital's massive hemorrhage protocol immediately when massive transfusion is anticipated or declared, ensuring clinical, laboratory, and logistic responses are mobilized simultaneously 3, 2
- Begin FFP transfusion early and empirically at 15 ml/kg if a senior clinician anticipates massive hemorrhage, rather than waiting for laboratory confirmation of coagulopathy 3, 2
- For a 70 kg patient, this translates to approximately 1,050 ml or 3-4 units of FFP as the initial bolus 4
Optimal Transfusion Ratios
The 1:1:1 ratio (FFP:platelets:PRBCs) is the most reasonable approach to initiate empiric transfusion when massive hemorrhage is suspected. 1, 2
- High-ratio transfusion strategies (at least 1:2 FFP:RBC, ideally approaching 1:1) reduce 24-hour mortality and death from exsanguination without increasing morbidity 1
- Military and civilian observational studies consistently demonstrate mortality benefits with ratios ranging from 1:1 to 1:2 FFP:RBC 1, 2
- The traditional approach of waiting for coagulopathy to develop before giving FFP (1:4 ratio) results in three-fold higher mortality compared to early high-ratio strategies 3
Practical Administration Details
Infuse FFP as rapidly as clinically tolerated in acute bleeding situations—the primary goal is rapid correction of coagulopathy, not adherence to a specific infusion rate 4
- FFP can be thawed using: dry oven (10 minutes), microwave (2-3 minutes), or water bath (20 minutes) 4
- Once thawed, FFP must be used within 30 minutes if removed from refrigeration, or within 24 hours if stored at 4°C 4
- Use group-specific blood without performing antibody screens, as patients will have minimal circulating antibodies; reserve O-negative blood only for immediate emergencies 3, 2
Monitoring and Adjustment Triggers
Established coagulopathy is defined as fibrinogen <1 g/L or PT/aPTT >1.5 times normal, which predicts microvascular bleeding and requires aggressive FFP replacement 3, 2
- Once established coagulopathy develops, more than 15 ml/kg of FFP will be required for correction 3
- Maintain a minimum target platelet count of 75 × 10⁹/L throughout the resuscitation 3, 2
- Recheck coagulation parameters after transfusion to determine need for additional doses 4
Critical Pitfalls to Avoid
Do not delay FFP administration waiting for laboratory results—by the time coagulopathy is documented, you are already behind 3, 2
- Avoid the outdated practice of transfusing 4-10 units of PRBCs before starting FFP, as this approach significantly increases mortality 3
- Be prepared to deactivate the 1:1:1 protocol once the patient stabilizes to avoid unnecessary blood product use 5
- Watch for transfusion-related acute lung injury (TRALI), as FFP and platelets are the most frequently implicated products in this serious complication 3, 4
Alternative Strategies for Fibrinogen Replacement
For isolated hypofibrinogenemia (<1 g/L), prioritize fibrinogen concentrate or cryoprecipitate over FFP, as FFP contains relatively low fibrinogen content (only ~2 g per 4 units) 3, 4
- Cryoprecipitate or fibrinogen concentrate achieves more rapid and effective fibrinogen replacement than FFP alone 3
- Point-of-care coagulation management with early calculated goal-directed therapy using fibrinogen concentrate can reduce FFP requirements by up to 90% 6
Post-Resuscitation Management
Commence standard venous thromboprophylaxis as soon as possible after hemostasis is secured, as patients develop a prothrombotic state following massive hemorrhage 3, 2