What are the indications for administering fresh frozen plasma (FFP)?

Indications for Fresh Frozen Plasma (FFP) Administration

Definitive Indications for FFP Use

FFP should be administered to patients who are actively bleeding with INR >1.5 (or PT >1.5 times normal, or aPTT >2 times normal) at a therapeutic dose of 15 ml/kg body weight, which translates to approximately 3-4 units (1,050 ml) for a 70 kg patient. 1

Primary Clinical Scenarios Requiring FFP

Major Hemorrhage and Massive Transfusion:

• FFP is indicated for replacement of coagulation factors during major hemorrhage, particularly in trauma and obstetric bleeding 2, 1
• In massive transfusion protocols, maintain a 1:1 ratio of red blood cells to FFP until coagulation results become available 1
• This represents the most common and evidence-based indication for FFP use 2

Acute Disseminated Intravascular Coagulation (DIC):

• FFP is indicated for acute DIC with active bleeding, as it replaces multiple consumed coagulation factors simultaneously 2, 1

Warfarin Reversal:

• FFP is indicated for immediate reversal of warfarin-induced hemorrhage when prothrombin complex concentrate (PCC) is not available 2, 1
• Important caveat: PCC is the first-choice agent for warfarin reversal; FFP is second-line 2
• Lower doses of 5-8 ml/kg FFP are usually sufficient for warfarin reversal 1

Thrombotic Thrombocytopenic Purpura (TTP):

• FFP is indicated for TTP, usually administered via plasmapheresis, preferably using pathogen-inactivated FFP 2, 1

Specific Factor Deficiencies:

• FFP is indicated for replacement of coagulation factors when specific factor concentrates are not available, though this is uncommon in modern practice 2, 1

Critical Contraindications and Inappropriate Uses

FFP should NOT be used in the following situations:

Prophylactic Correction in Non-Bleeding Patients:

• There is very limited role for FFP in management of mild-moderate coagulation abnormalities in non-bleeding critically ill patients before invasive procedures 2
• Prophylactic correction of laboratory values in non-bleeding patients exposes patients to unnecessary transfusion risks without preventing bleeding 1

Cirrhosis/Liver Disease:

• FFP is not recommended for routine use in patients with cirrhosis/liver disease unless significant coagulopathy with active bleeding is identified 2
• Isolated PT or aPTT abnormalities do not reflect "balanced hemostasis" in liver disease 1
• FFP fails to correct PT in non-bleeding patients with mild abnormalities and may increase portal pressure 1

Volume Replacement:

• FFP should not be used simply as routine circulatory volume replacement or for hypovolemia 2, 3, 4

Other Inappropriate Uses:

• Nutritional support or protein-losing states 3, 4
• Treatment of immunodeficiency states 3, 4
• Plasma exchange procedures (use crystalloids or synthetic colloids instead) 3, 4

Essential Administration Guidelines

ABO Compatibility:

• FFP should be the same blood group as the patient 2
• If blood group is unknown, use group AB FFP (contains no anti-A or anti-B antibodies) 2, 1

Dosing Thresholds:

• The therapeutic dose is 15 ml/kg to achieve minimum 30% concentration of plasma factors 2, 1
• Doses below 10 ml/kg are unlikely to achieve the 30% factor concentration threshold needed for hemostasis 1

Timing and Storage:

• Once thawed and stored at 4°C, FFP can be used for up to 24 hours 1
• Once removed from refrigeration, FFP must be used within 30 minutes 1

Important Clinical Pitfalls to Avoid

Fibrinogen Deficiency:

• FFP has relatively low fibrinogen content—four units contain only approximately 2 g fibrinogen 2
• Cryoprecipitate is preferred over FFP for hypofibrinogenemia (fibrinogen <1.5 g/L, or <2 g/L in obstetrics) 1
• Each pool of cryoprecipitate (5 units) contains at least 2 g fibrinogen, making it more efficient than FFP 2

Transfusion-Related Complications:

• Transfusion-related acute lung injury (TRALI) is the most serious complication 1
• Other risks include transfusion-associated circulatory overload (TACO), ABO incompatibility reactions, allergic reactions, and infectious disease transmission 1
• Male-only plasma implementation has reduced TRALI incidence 1

Inadequate Dosing:

• Prophylactic FFP in non-bleeding patients with coagulopathy does not prevent bleeding and increases transfusion-related complications 1
• Insufficient doses fail to achieve therapeutic factor levels and unnecessarily expose patients to transfusion risks 1