Fresh Frozen Facts, Part II: FFP Is Not a Vitamin

This is the second post in my four-part series on plasma products — what they are, when to use them, and why they’re so often misunderstood. In Part I, we broke down the differences between FFP, PF24, thawed plasma, and cryopoor plasma. Today, we’re turning to indications: the clinical scenarios where plasma actually helps, how it works in those settings, and what to consider when deciding whether it’s the right tool for the job.

Once upon a time, fresh frozen plasma (FFP) was the Swiss Army knife of coagulation management. Long before recombinant factors, PCCs, or viscoelastic testing, we had plasma — frozen within 8 hours of collection, rich in clotting factors, and theoretically capable of correcting just about anything.

And so we used it for everything.

For decades, FFP was infused for elevated INRs, thrombocytopenia, mild oozing, or even just a bad “feeling” in the OR. In the early days of trauma resuscitation, the concept of 1:1:1 transfusion (plasma:platelets:RBCs) emerged from military and civilian protocols aiming to mimic whole blood and prevent dilutional coagulopathy. But as tools and evidence evolved, we learned something critical: FFP only works when the problem is a true factor deficiency — and even then, it’s not always the best option.

Despite these advances, FFP still gets ordered reflexively. That elevated INR? Plasma. Platelets a little low? Plasma. Bleeding? Plasma — even when the root cause has nothing to do with factor levels.

Let’s move past that. Because FFP is not a vitamin. It’s a blood product with real risks, finite benefits, and a narrow set of appropriate indications.

Appropriate Indications for FFP (and Related Plasma Products)

I. Thrombotic Thrombocytopenic Purpura (TTP)

Plasma is essential, not optional, in this rare but life-threatening condition.

• Why it works: TTP is caused by a deficiency or inhibition of ADAMTS13, a protease that cleaves vWF multimers. FFP replenishes functional ADAMTS13 during plasma exchange.

• How it’s used: FFP is the standard replacement fluid for therapeutic plasma exchange (TPE), often given daily for 5–7 days or more.

• Alternatives: Cryopoor plasma can be used if vWF reduction is also desired, though it's not widely available.

• Measuring effectiveness: Monitor LDH, platelet count, and neurologic symptoms daily — improvement signals clinical response.

• Pearl: This is one of the few times plasma is curative, not just supportive.

  
  

II. Disseminated Intravascular Coagulation (DIC) with Active Bleeding

In DIC, widespread clotting consumes platelets and factors, leading to bleeding.

• Why it works: FFP replaces the consumed clotting factors — especially in patients with bleeding and prolonged PT/aPTT.

• When to use: Only in the setting of active bleeding or an upcoming invasive procedure; don’t transfuse based on labs alone.

• Dosing: Usually 10–15 mL/kg, guided by clinical status and factor levels.

• Measuring effectiveness: Watch for stabilization of bleeding and normalization of PT/aPTT — but correction may be partial or transient.

• Pearl: Platelets and cryoprecipitate may also be needed. FFP alone won’t fix low fibrinogen.

  
  

III. Liver Disease with Bleeding or High-Risk Procedure

The cirrhotic liver synthesizes most clotting factors — when it fails, so does hemostasis.

• Why it works: FFP provides a broad spectrum of factors, especially when PT/INR are prolonged and bleeding is present.

• Caution: Elevated INR in cirrhosis doesn’t always reflect bleeding risk; thromboelastography (TEG/ROTEM) may give better insight.

• When to use: For active bleeding or before high-risk interventions (e.g., liver biopsy, large paracentesis), if there's demonstrable coagulopathy.

• Measuring effectiveness: Clinical bleeding control matters more than INR correction; labs often lag behind or mislead.

• Pearl: Overtransfusion may worsen portal hypertension and increase the risk of TACO. Use intentionally.

  
  

IV. Massive Transfusion Protocols (MTPs)

Hemorrhagic shock can rapidly dilute clotting factors, even without baseline coagulopathy.

• Why it works: Plasma helps restore clotting capacity during large-volume resuscitation (typically >1 blood volume within 24h).

• When to use: In trauma, obstetric hemorrhage, or surgical bleeding with major blood loss.

• Typical ratios: 1:1:1 of plasma, platelets, and RBCs is often used, though this may vary based on institution and patient response.

• Measuring effectiveness: Clinical stabilization, viscoelastic testing (if available), fibrinogen >150–200 mg/dL, PT/aPTT trends.

• Pearl: MTP is about anticipation, not reaction. Plasma should be ready before the patient becomes coagulopathic.

  
  

V. Rare Factor Deficiencies (When Specific Factor Concentrates Aren’t Available)

FFP is still a fallback in rare cases.

• Examples: Factor V and other factors that lack commercial concentrates.

• Why it works: FFP provides small amounts of each factor, enough to bridge mild to moderate bleeding risk.

• When to use: During bleeding episodes or peri-procedurally in known deficiency patients.

• Dosing and response: Requires large volumes to achieve even modest factor increases; monitor with specific assays if available.

• Pearl: Always check whether recombinant or plasma-derived factor concentrates exist first — they’re safer and more effective.

  
  

VI. Cryopoor Plasma (Niche Use)

Rarely needed — but notable.

• What it is: The plasma that remains after cryoprecipitate is removed from FFP.

• Why it’s used: Occasionally used in refractory cases of TTP.

• Availability: May be restricted to certain centers; not a routine product.

• Pearl: Know that it exists — and when to call the blood bank about it.

  
  

One More Thing: FFP Changes Over Time

Once thawed, both FFP and plasma frozen within 24 hours (PF24) are stored at 1–6°C and relabeled thawed plasma after 24 hours. They’re typically good for 5 days, but labile factors like V and VIII degrade with time. That means thawed plasma may not be appropriate when you need high levels of those factors — such as in TTP or factor V deficiency — but it’s usually adequate for liver disease or DIC.

Final Thought: Know What You’re Treating

Before ordering FFP, ask:

• Is there a documented or strongly suspected factor deficiency?

• Is the patient bleeding or about to bleed?

• Will plasma meaningfully change the outcome?

• Do you have a way to measure effectiveness?

  
  

Transfusing FFP without an indication is like prescribing antibiotics for a viral sore throat — satisfying in the moment, but clinically empty. And it isn’t harmless.

FFP is powerful. But only when used with precision.

Coming up next: When not to order FFP — and what to use instead.