This section will briefly review clinical indications for the use of Fresh Frozen Plasma (FFP). The discussion is not meant to be definitive or all inclusive. Readers are encouraged to read the references and resources in Further Reading.
Before reviewing clinical uses, the preparation and composition of FFP will be briefly outlined.
This table includes some of the types of plasma components that are available. Note: Names, production details, and specifications may vary in different countries.
|Type of component||Plasma separated from a single donor unit of whole blood|
|Fresh Frozen Plasma||
|Fresh Frozen Plasma Apheresis||
FFP is prepared by separating plasma from whole blood donations followed by rapid freezing to preserve coagulation factors, as shown here:
- Preparation of plasma components such as FFP (Canadian Blood Services)
In particular circumstances Frozen Plasma and Cryosupernatant Plasma can often effectively substitute for FFP. See these resources for a discussion of the appropriate use of FFP versus other types of plasma:
- CBBS e-Network Forum
Indications for using FFP are briefly outlined in the two resources below:
1. American Association of Blood Banks (as reported in Cap Today )
- Bleeding or planned invasive or surgical procedure and any one or more of the following:
- PT greater than 1.5 times the midpoint of the reference range or > 17 secs
- APTT greater than 1.5 times the top of the reference range or > 49 secs
- Documented deficiency of factors II, V, VII, X, or XI
- Massive transfusion (>10 RBC units acutely and PT/APTT not yet available)
- Disseminated intravascular coagulation
- Thrombotic thrombocytopenic purpura
- Hemolytic uremic syndrome.
2. Blood Easy Course (see Online resources)
- Emergency reversal of warfarin therapy in a patient undergoing an emergency operative procedure or with potentially life-threatening bleeding
- Active bleeding/major surgery with PT/PTT more than 1.5 times normal
- Microvascular bleeding or massive transfusion AND patient's clinical status precludes waiting 3045 minutes for PT/PTT results
- Patients with liver disease-related coagulopathy for certain invasive procedures (percutaneous liver biopsy, paracentesis, thoracentesis) and INR >2.0
For in-depth discussion of the uses of FFP, see these resources and other papers under Further Reading:
- BCSH Guidelines:Guidelines for the use of Fresh Frozen Plasma, Cryoprecipitate and Cryosupernatant Br J Haematol 2004; 126, 11-28.
- CMA Expert Working Group. Guidelines for red blood cell and plasma transfusion for adults and children. CMAJ 1997;156 (11 suppl)
- Shulman IA, AuBuchon JP, Gernsheimer T. Composition and use of plasma components - presentation and speaker notes (AABB members only) (May 15, 2006)
The patient's relevant laboratory results and diagnosis were provided earlier. FFP is reported to be commonly over-used or used inappropriately:
Luk C, Eckert KM,Barr RM,Chin-Yee IH. Prospective audit of the use of fresh-frozen plasma, based on Canadian Medical Association transfusion guidelines. CMAJ 2002 Jun 11; 166(12): 153940.
It is beyond the scope of this case (and the author's expertise) to assess whether HL's FFP transfusions were clinically warranted, but HL's results meet at least one criterion outlined above:
- HL's PT = 20 secs
- PT greater than 1.5 times the midpoint of the reference range or > 17 secs (AABB as reported in CAP Today)
However, using formulae to decide when to transfuse is controversial.
There is also the general issue that the patient was transfused in the evening, a time when nursing staff levels are traditionally lower. The 2003 SHOT Report from the UK reported:
Errors in the collection and administration of blood components (n=232)
There were 232 errors in collection and administration of blood components in 187 cases.
In 36% of reported cases the primary error occurred at this stage of the transfusion process.
Of the 176 cases in which the time of the transfusion was reported, 65/176 (37%) took place between 8pm and 8am. It is
of note that of the 33/176 (19%) transfusions started between midnight and 8am, 16/33 were stated to be "routine".
Since HL was presumably transfused to correct his coagulopathy prior to surgery, could transfusion have waited until prior to surgery the next day?
- Determining clinical indications for FFP is complex and requires clinical judgement (i.e., assessment of several factors, including the patient's medical condition, clinical findings, coagulation test results, planned surgical procedures, etc.), and review of current guidelines for FFP use.
- As with all transfusions, the benefits of transfusion for an individual patient must be assessed against the risks.
- Many studies and guidelines for use of FFP exist but, for numerous reasons, prescribing physicians do not necessarily refer to them.
- Most practice guidelines for using FFP are not supported by evidence from randomized trials. In particular, there is little evidence for the effectiveness of the prophylactic use of FFP.
- Transfusing patients at night when staffing is lower should be done only when clinically required.
- Part 1: Clinical uses of FFP <--You are here
- Part 2. Compatibility requirements for plasma
- Part 3.Administering blood products
- Part 4: Investigating adverse events
- Part 5. Reporting adverse events
Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion. 2006 Aug;46(8):1279-85.
Atkinson S. An audit of fresh frozen plasma transfusion use in the Royal Hospitals Trust (RGHT) (poster P12). Transfus Med 2006 Oct;16(s1):30.
BCSH Guidelines: Guidelines for the use of Fresh Frozen Plasma, Cryoprecipitate and Cryosupernatant Br J Haematol 2004; 126, 11-28.
CMA Expert Working Group. Guidelines for red blood cell and plasma transfusion for adults and children. CMAJ 1997;156(11 suppl)
CAP Today (Q & A): When is the use of fresh frozen plasma in surgical procedures justified? (Feb. 2005)
Gajic O, Dzik WH, Toy P. Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm? Crit Care Med. 2006 May;34(5 Suppl):S170-3.
Holland LL, Brooks JP. Toward rational fresh frozen plasma transfusion: The effect of plasma transfusion on coagulation test results. Am J Clin Pathol. 2006 Jul;126(1):133-9.
Holland LL, Foster TM, Marlar RA, Brooks JP. Fresh frozen plasma is ineffective for correcting minimally elevated international normalized ratios. Transfusion 2005 Jul;45(7):1234-5.
Luk C, Eckert KM,Barr RM,Chin-Yee IH. Prospective audit of the use of fresh-frozen plasma, based on Canadian Medical Association transfusion guidelines. CMAJ 2002 Jun 11; 166(12): 1539-40.
Stanworth SJ, Brunskill SJ, Hyde CJ, McClelland DB, Murphy MF. Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol. 2004 Jul;126(1):139-52.
Wallis JP, Dzik S. Is fresh frozen plasma overtransfused in the United States? Transfusion. 2004 Nov;44(11):1674-5.
Bloody Easy Online Course (Sunnybrook & Women's College HSC, Toronto, Ontario, Canada)
Canadian Blood Services: Preparation of plasma components such as FFP
CBBS e-network forum
- Restrictions to the use of thawed plasma versus FFP
- Experience in the use of THAWED PLASMA
- Criteria for selection of plasma products when performing therapeutic plasma exchange for TTP patients
- What INR thresholds are being used for prophylactic and therapeutic use of FFP?
Shulman IA, AuBuchon JP, Gernsheimer T. Composition and use of plasma components - presentation and speaker notes (AABB members only) (May15, 2006)