• To revise the principles of transfusion, see Principles of transfusion and Consent for transfusion guidelines
• Single donor FFP from male UK volunteer whole blood donors
• 1 unit mean volume = 275 mL
• mean Factor VIII 0.83 - specification >0.7
• Stored in controlled freezer at <-25°C for <36 months
• Once requested, prophylactic FFP will be thawed at 37°C taking <20 min
• once thawed, stored in blood fridge at 4-6°C for <72 hr

Pre-thawed FFP

• Available for major haemorrhage (MHP activation)
• 5-day shelf life

Pathogen - inactivated FFP

• Use in patients born after 1^st January 1996 to reduce the risk of transmission of vCJD
• inactivates encapsulated viruses and bacteria

Solvent detergent plasma (Octoplas LG^®)

• Standardised volume 200 mL
• <1520 donors per batch
• Mean Factor VIII 0.8 (specification >0.5), mean fibrinogen 2.6 (1.5-4.0)
• Stored in controlled freezer at <-18°C for <4 yrs
• shelf life 5 days post thaw

Methylene-blue treated FFP (MB-FFP)

• Non-UK sourced
• Single-donor (43 mL)
• Reduced fibrinogen and Factor VIII activity

• Evidence supporting FFP use is sparse
• prophylactic plasma transfusion appears to be associated with increased patient morbidity
• PT/APTT ratios reflect coagulation function in vitro, not what actually happens in the body
• measure clotting - not the natural inhibitors; protein C, protein S, antithrombin

Major Haemorrhage

• Immediately in major haemorrhage until bleeding is under control
• at least 1:2 ratio FFP:RBC
• aim for 1:1 in 'code red' trauma and vascular surgery except in obstetrics

Non-haemorrhage indications

• Discuss need for FFP with haematologist before ordering

Clinically significant bleeding

• Clinically significant bleeding (WHO grade ≥2) associated with coagulopathy (APTT ratio/INR>1.5) in the absence of major haemorrhage

Pre-procedural prophylactic plasma use

• Pre-procedural prophylactic plasma use is dependent on the cause of the abnormal clotting results, PT/APTT ratio and the bleeding risk of the procedure
• consider if PT ratio/INR>1.5 prior to an invasive procedure with risk of clinically significant bleeding
• Not routinely indicated in chronic liver disease (CLD) with INR ≤2.0 pre-procedure
• remember patients with CLD and prolonged INRs may still be hypercoagulable
• see Coagulopathy in Acute liver failure with encephalopathy guideline

Other possible indications

• Replacement of single coagulation factor deficiencies, where a specific or combined factor concentrate is unavailable e.g. factor V deficiency
• Thrombotic thrombocytopenic purpura (TTP) in conjunction with plasma exchange
• use SD-FFP/Octoplas LG^®
• Acute disseminated intravascular coagulation (DIC) in the presence of bleeding and abnormal coagulation results
• FFP is not indicated to reverse warfarin
• unless prothrombin complex concentrate (PCC) is contraindicated/unavailable

Fresh frozen plasma (FFP)

• Dose in units [or mL if BMI < 18.5 kg/m² in low weight patients or those at high risk of transfusion associated circulatory overload (TACO)]
• prescribe on fluid prescription of the drug chart
• Adult treatment dose of FFP is 12-15 mL/kg = 4-6 units
• Octaplas treatment dose 12-15 mL/kg dosed in mL (200 mL per unit)
• Assess every patient for risk of TACO and manage appropriately e.g. rate, diuretics, frequency of observations

• Transfuse as soon as possible after thawing using a standard blood giving set with a 170-200 micron filter
• Routinely administer each unit FFP/SD-FFP over 20-30 min
• 'stat' if MHP
• If delay is unavoidable, store at controlled temperature (4-6°C) or complete within 4 hr of thawing if stored at ambient temperature

Monitor

• Monitor patients closely for fluid overload (TACO) and allergic reactions including transfusion related acute lung injury (TRALI)
• Any blood component connected to the patient's IV access is regarded as 'transfused' for traceability purposes even if the unit was subsequently (partially) wasted
• Assess frequently during transfusion as high risk of fluid overload

• Therapeutic doses of plasma (15 mL/kg) typically raise clotting factor levels by 20%
• Plasma is unlikely to correct INR to below 1.8
• After each treatment dose, assess and document
• bleeding severity score in principles of transfusion guideline
• laboratory parameters [PT/APTT and Clauss fibrinogen]
• near patient thromboelastography (TEG, ROTEM) where available and relevant
• adverse events; especially signs/symptoms of respiratory distress (e.g. TACO, TRALI) and allergic reactions