Fresh Frozen Plasma

FFP is prepared at the time that blood is obtained from a donor. It contains all the plasma proteins, particularly factors V and VIII, which gradually decline during the storage of blood. The use of FFP carries with it certain inherent risks that are observed with the use of essentially any blood product. The major risk is transmission of infectious diseases, such as hepatitis B, hepatitis C, and AIDS. Other risks include sensitization to foreign proteins.

Despite all the problems associated with FFP, its use increased 10-fold between 1974 and 1984, when consumption had reached almost 2 million units annually. This alarming increase caused the National Institutes of Health to conduct a Consensus Development Conference on Fresh Frozen Plasma in September 1984, of which I was a member.^[62] More recently, the ASA Task Force 2 recommended the administration of FFP with the following guidelines:

1. For urgent reversal of warfarin therapy
2. For correction of known coagulation factor deficiencies for which specific correlates are unavailable
3. For correction of microvascular bleeding in the presence of increased (>1.5 times normal) prothrombin time or partial thromboplastin time

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4. For correction of microvascular bleeding secondary to coagulation factor deficiency in patients transfused with more than one blood volume and when prothrombin time and partial thromboplastin time cannot be obtained in a timely fashion
5. FFP should be given in doses calculated to achieve a minimum of 30% of plasma factor concentration (usually achieved with administration of 10 to 15 mL/kg of FFP), except for urgent reversal of warfarin anticoagulation, for which 5 to 8 mL/kg of FFP usually suffice. Four to five platelet concentrates, 1 unit of single-donor apheresis platelets, or 1 unit of whole blood provides a quantity of coagulation factors similar to that contained on 1 unit of FFP (except for decreased, but still hemostatic, concentrations of factors V and VIII in whole blood)
6. FFP is contraindicated for augmentation of plasma volume or albumin concentration.

The ASA Task Force 2 concluded that there was little scientific evidence to support the increasing use of FFP in clinical medicine. Although FFP is a reliable solution for intravascular volume replacement in cases of acute blood loss, alternative therapies are equally satisfactory and considerably safer. There is no documentation that FFP has a beneficial effect when used as part of transfusion management of patients with massive hemorrhage.

The practice of administering PRBCs and FFP to the same patient should be discouraged, because this adds to the cost and doubles the infection exposure. When conditions are appropriate, whole blood should be given.

The only indications for FFP administration the ASA Task Force 2 agreed on were the following:

1. Replacement of isolated factor deficiencies (as documented by laboratory evidence)
2. Reversal of warfarin effect
3. In cases of antithrombin III deficiency
4. Treatment of immunodeficiencies
5. Treatment of thrombotic thrombocytopenia purpura
6. Massive blood transfusion (rarely and only when factors V and VIII are less than 25% of normal)
7. Requirements for indications 1 and 6 are prothrombin and partial thromboplastin times at least 1.5 times longer than normal.

As of 2004, our policy at the University of California, San Francisco, is that in patients with clinical bleeding or oozing or those with an invasive procedure (e.g., percutaneous liver biopsy), the use of FFP is appropriate with a prothrombin time of 17 seconds or longer if the platelet count is more than 50,000 cells/mm³ and the blood fibrinogen concentration is more than 100 mg/dL. FFP may be indicated for dilutional coagulopathy in patients with a prothrombin time more than 17 seconds and in whom administration of more crystalloids is anticipated.