Fresh Frozen Plasma (FFP) 

1. Definition

Fresh Frozen Plasma (FFP) is the cell-free liquid portion of whole blood, separated and frozen within a defined time after collection to preserve labile coagulation factors (V & VIII).

2. Preparation & Processing

Source

• Obtained from:
• Whole blood donation, or
• Plasmapheresis

Processing Steps

1. Whole blood centrifuged → plasma separated
2. Plasma frozen rapidly:
• Within 8 hours (US FDA)
• Within 6 hours (many European standards)

Why rapid freezing?

• Preserves labile clotting factors (V, VIII)
• Prevents degradation of natural anticoagulants (Protein C, S)

3. Storage & Shelf Life

Thawing occurs in a water bath at 30 °C to 37 °C over 20 to 30 minutes or in an FDA-cleared device in as little as 2 to 3 minutes. Once thawed, FFP should be administered immediately. Storage at 1 °C to 6 °C is required if not used right away.

⚠️ Once thawed → use within 24 hours(Once thawed, clotting factor activity declines gradually, particularly factor V and factor VIII. Due to the short half-life of factor VII, which ranges from 2 to 6 hours,)

4. Composition

FFP contains ALL plasma proteins in physiological concentrations:

Coagulation Factors

• Procoagulants: I (fibrinogen), II, V, VII, VIII, IX, X, XI, XII, XIII
• Natural anticoagulants:
• Protein C
• Protein S
• Antithrombin III

Other Components

• Albumin
• Immunoglobulins
• Complement proteins
• Electrolytes

5. Volume & Dosing

Standard Volume

• 200–250 mL per unit

Dose

📌 Rule of thumb:

• 1 unit FFP ↑ clotting factor levels by ~2–3%
• The administration of a single 250 mL unit is expected to increase the fibrinogen level by 5 to 10 mg/dL. 

6. ABO & Rh Compatibility

ABO

• MUST be ABO compatible
• Plasma compatibility is reverse of RBC

➡️ Universal plasma donor = AB plasma

Rh

• Rh matching NOT required (no RBCs)

7. Mechanism of Action

FFP:

• Replenishes deficient clotting factors
• Restores thrombin generation
• Corrects prolonged PT / INR / aPTT
• Provides antithrombin in DIC & massive transfusion

8. Indications 

A. Active Bleeding + Coagulopathy (MOST IMPORTANT)

FFP is indicated ONLY when there is bleeding or high bleeding risk

1. Massive Transfusion Protocol (MTP)

• PRBC : FFP : Platelets = 1 : 1 : 1
• Prevents dilutional coagulopathy

2. Trauma-induced coagulopathy

• Early balanced transfusion improves survival

B. Elevated INR with Bleeding

📌 Never give FFP just to “correct INR” without bleeding

C. Liver Disease

• Active bleeding or prior to high-risk procedures
• INR alone is NOT indication (rebalanced hemostasis concept)

D. Disseminated Intravascular Coagulation (DIC)

• Only if bleeding
• Along with:
• Treat cause
• Platelets if <50,000
• Cryoprecipitate if fibrinogen <100 mg/dL

E. Warfarin Reversal (when PCC unavailable)

⚠️ FFP is slower, larger volume, less effective than PCC

F. Thrombotic Thrombocytopenic Purpura (TTP)

• Therapeutic plasma exchange
• FFP replaces ADAMTS13 enzyme

➡️ FFP is LIFE-SAVING in TTP

G. Congenital Factor Deficiency (Rare)

• Factor V deficiency
• Factor XI deficiency
• When specific factor concentrate unavailable

9. Contraindications / NON-INDICATIONS 

❌ DO NOT USE FFP FOR:

10. Adverse Effects & Complications

A. Transfusion-Associated Circulatory Overload (TACO)

• Large volume
• Elderly, CHF, CKD

B. Transfusion-Related Acute Lung Injury (TRALI)

• Most common with plasma
• Anti-HLA / anti-neutrophil antibodies
• Acute hypoxemia, non-cardiogenic pulmonary edema

C. Allergic Reactions

• Urticaria → anaphylaxis

D. Infectious Risks

• HIV, HBV, HCV (very rare now)
• Bacterial contamination (rare)

E. Citrate Toxicity

• Hypocalcemia → hypotension, arrhythmias
• Common in massive transfusion

11. Monitoring After FFP

Clinical

• Bleeding control
• Hemodynamics
• Respiratory status (TRALI/TACO)

Laboratory

• PT / INR
• aPTT
• Fibrinogen
• Ionized calcium (during massive transfusion)

12. FFP vs Other Plasma Products