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.

  • Clinical indications for FFP
  • This case

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
  • Separated & frozen within 8 hrs of donation
  • Contains all clotting factors including at least 0.70 IU/mL of Factor VIII
Frozen Plasma
  • Separated more than 8 hours and up to 72 hrs after donation
  • Contains all coagulation factors but has reduced levels of factors VIII and V
Cryosupernatant Plasma
  • Prepared following cryoprecipitated AHF production
  • Contains all coagulation factors but has reduced levels of fibrinogen, factors VIII and V
Fresh Frozen Plasma Apheresis
  • Collected by apheresis and frozen within eight hrs of donation
  • Contains at least 0.70 IU/mL of Factors VIII, V, and other clotting factors

FFP is prepared by separating plasma from whole blood donations followed by rapid freezing to preserve coagulation factors.


Clinical Indications for FFP

In particular circumstances Frozen Plasma and Cryosupernatant Plasma can often effectively substitute for FFP. 

Indications for using FFP are briefly outlined in the two resources below:

1. American Association of Blood Banks

  1. 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
  2. Thrombotic thrombocytopenic purpura
  3. Hemolytic uremic syndrome.

2. Blood Easy Course

  1. Emergency reversal of warfarin therapy in a patient undergoing an emergency operative procedure or with potentially life-threatening bleeding
  2. Active bleeding/major surgery with PT/PTT more than 1.5 times normal
  3. Microvascular bleeding or massive transfusion AND patient's clinical status precludes waiting 30–45 minutes for PT/PTT results
  4. Patients with liver disease-related coagulopathy for certain invasive procedures (percutaneous liver biopsy, paracentesis, thoracentesis) and INR >2.0

This Case

The patient's relevant laboratory results and diagnosis were provided earlier. FFP is reported to be commonly over-used or used inappropriately:

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, 150/176 (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?

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Learning Points

  • 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.

Practical Notes

  • Transfusing patients at night when staffing is lower should be done only when clinically required.

More Discussion...

  • 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