FRESH FROZEN PLASMA

Franklin A. Bontempo, M.D., Associate Medical Director, Coagulation Services

INTRODUCTION

Fresh frozen plasma (FFP) is primarily indicated for patients with active or threatened bleeding who need short-term correction of coagulation factor deficiencies.  For the average adult, each unit raises clotting factor levels 2-3% so that more than two units are usually needed for replacement therapy.  FFP should not be used for volume replacement alone.

DESCRIPTION

Each unit of FFP contains 225 ml of plasma derived from a single whole blood unit and frozen at 18°C or colder in order to preserve the labile factors V and VIII at hemostatic levels.  FFP also contains a variety of stable proteins involved in the complement and fibrinolytic systems, in the maintenance of oncotic pressure, and in the modulation of immunity.  Units of FFP are labeled specifically for the ABO blood type of the donor from which they are prepared and are tested for the presence of syphilis, hepatitis B, hepatitis C, HTLV-I, HIV-1, and HIV-2.  This is identical to the procedure used for red blood cells and platelets.

indications

The major indication for FFP is as replacement therapy for documented single or multiple coagulation factor deficiencies.  Documentation may be by direct measurement of clotting factor levels or by prolongation of the prothrombin time (PT) or activated partial thromboplastin time (PTT).  Other indications are for thrombotic thrombocytopenic purpura (TTP) and during massive blood transfusion (>1 blood volume within 24 hours).

FFP may be used for patients with Coumadin overdose, hereditary antithrombin III deficiency, or hereditary protein C deficiency.  However, prothrombin complex or antithrombin III concentrates may be the therapy of choice depending on their availability and the specific clinical situation.  The use of FFP for the treatment of selected immunodeficiencies has been replaced by the newer intravenous immunoglobulin preparations.

Other uses of FFP are to be discouraged.  In particular, FFP should not be used for volume expansion or as a source of nutritional supplementation.  The prophylactic use of FFP for expected massive transfusion or following cardiac bypass has not reduced transfusion requirements unless the patients have abnormal coagulation tests beforehand.

RIsks

Allergic reactions occur in 1% of patients receiving FFP.  These usually consist of pruritus or hives and respond to antihistamines; however, rare fatal anaphylactic reactions have been reported.  Most reactions are related to a specific donor unit and do not preclude further FFP use.

The risks of viral transmission of FFP are similar to that for red cells and platelets.  However, there is probably no risk of transmission of CMV or HTLV-1 since these viruses require cellular vectors for transmission.

Circulatory overload occurs in many patients receiving large amounts of FFP due to its high volume and may limit its use in patients with cardiac disease.

Dosing

The dose for FFP for coagulopathies should be determined by the amount required to adequately replace deficient clotting factor levels or to correct the PT and APTT.  One unit of FFP raises clotting factor levels by an average of only 2-3%.  Because of this, the average adult will require at least 3-4 units of FFP as replacement therapy.  This will raise levels of each clotting factor level into the hemostatic range, which is 20-40% of normal depending on the clotting factor or factors involved.

administration

As with any blood product, infusion of FFP requires a standard blood administration set.  If the patient’s circulatory status permits, FFP may be rapidly infused over 20-30 minutes.  Depending on the blood type of the donor, FFP may contain A or B antibodies.  Therefore, type specific or type compatible plasma is required.  Thawing of FFP requires 30 minutes or more and it must be administered within six hours.

FUTURE PROSPECTS

The safety of FFP may soon be enhanced by the adaptation of new preparation techniques to prevent virus transmission.  A new product that uses this process, solvent-detergent plasma, is currently in clinical trials.  A future TMU will deal with this product in detail.

Copies of the Transfusion Medicine Update can be obtained by contacting Deborah Small at (412) 209-7320 or
by e-mail:  dsmall@itxm.org.