Fresh Frozen Facts, Part III: Before You Order FFP, Ask Yourself…

This is the third installment in my four-part series on plasma. In Part I, we broke down the different types of plasma products — from FFP and PF24 to thawed and cryopoor plasma. In Part II, we focused on appropriate indications: when plasma actually helps, why it works, and how to assess response. Today, we’re talking about what plasma doesn’t do — and why so much of its use is misguided.

Fresh frozen plasma often gets ordered in moments of uncertainty. A mildly elevated INR before a procedure. A confusing coagulopathy in a bleeding patient. A nagging feeling that “we should do something.” And too often, that “something” is FFP.

But plasma isn’t harmless. It’s a blood component — with all the risks that come with transfusion: TRALI, TACO, allergic reactions, alloimmunization. It takes time to type, thaw, and deliver. And most importantly, it only works when there’s a factor deficiency, and even then, its effect is modest and unpredictable.

Let’s start with the INR, because it’s the most common reason people reach for plasma. When the INR creeps above 1.3 — 1.4 — maybe 1.6 — it starts to feel uncomfortable, especially if a procedure is coming up. But the truth is, an INR in this range does not predict bleeding, and FFP won’t reliably correct it. In fact, most units of FFP have an INR around 1.3–1.5 themselves. That means even if you transfuse 2 or 3 units, you’re not pushing the needle much — just adding volume and risk without meaningful change.

This is especially true in liver disease, where INR elevation doesn’t tell the full story. Patients with cirrhosis have decreased synthesis of both procoagulant and anticoagulant factors — including protein C, protein S, and antithrombin. The result is a rebalanced hemostatic system, one that may actually lean prothrombotic, not bleeding-prone. That’s why routine correction of INR before procedures in liver patients has fallen out of favor — particularly for paracentesis, central lines, and even some biopsies. The INR may look alarming, but it doesn’t reflect true bleeding risk in this context.

Another common misuse: using FFP as a volume expander. It isn’t. FFP is high-volume (about 200–250 mL per unit), but it comes with clotting proteins, antibodies, and potential for serious reactions. If your patient needs volume, give crystalloids. If they need oncotic support, give albumin. Plasma should never be used to “fill the tank” — especially in patients at risk of TACO or other volume-sensitive complications.

What To Use Instead

If FFP is off the table, what is appropriate? That depends on what you’re treating.

I. Prothrombin Complex Concentrates (PCCs)

• First-line for urgent warfarin reversal (e.g., in bleeding or before emergent surgery).

• Contains factors II, VII, IX, and X — more concentrated and faster-acting than plasma.

• Administered in small volumes, reducing risk of volume overload.

• Effectively lowers INR and restores coagulation within minutes.

• Often used in trauma, neurosurgical bleeds, or GI hemorrhage in anticoagulated patients.

  
  

II. Cryoprecipitate

• Contains fibrinogen, vWF, factor VIII, and factor XIII.

• Best option when fibrinogen is low (<100–150 mg/dL), especially in DIC, trauma, or obstetric hemorrhage.

• FFP contains some fibrinogen, but not enough to meaningfully raise levels in hypofibrinogenemia.

• Dose is typically 1 unit per 10 kg body weight.

  
  

III. Platelets

• Appropriate for bleeding due to thrombocytopenia or qualitative platelet defects.

• If platelet count is <50K and the patient is bleeding or undergoing surgery, platelets are your answer — not plasma.

• Also critical in DIC, bone marrow failure, and massive transfusion protocols.

  
  

IV. Vitamin K

• Often overlooked, but essential for non-urgent reversal of warfarin or correction of nutritional/coagulopathic deficiencies.

• Can be given orally or IV depending on urgency; IV acts faster but should be infused slowly to avoid rare anaphylactoid reactions.

• Especially helpful in malnourished patients, those with fat malabsorption, or prolonged NPO status.

• Prolonged antibiotic use — especially with broad-spectrum agents — can cause deficiency by disrupting gut flora that synthesize vitamin K₂ (menaquinone).

• Won’t stop bleeding immediately, but plays a critical role in restoring normal hemostasis over hours to days.

  
  

V. Factor Concentrates (Targeted Use Only)

• Recombinant or plasma-derived factor VIII, IX, XIII, and vWF concentrates exist for hereditary deficiencies or inhibitor-related bleeding.

• FEIBA (Factor Eight Inhibitor Bypassing Activity) is used in patients with hemophilia A and inhibitors — it contains activated clotting factors that bypass the need for factor VIII.

• These are expensive, potent agents — used under specialist guidance, not general coagulopathy.

  
  

Transfusion Isn’t a Substitute for a Plan

Before you reach for FFP, ask yourself:

• Do I know what I’m treating?

• Is there a documented or suspected factor deficiency?

• Is plasma the right product, or am I just trying to do something?

• How will I assess response?

  
  

If you don’t have clear answers, don’t transfuse.

Bottom Line:

FFP isn’t for mild coagulopathy. It’s not for pre-procedure reassurance. And it’s definitely not for volume. Transfusing “just in case” isn’t good medicine — it’s defensive, imprecise, and wasteful.

Plasma saves lives when used well. But that requires clarity, restraint, and a commitment to treating the patient — not the INR.

Next up: the pharmaceutical cousins of plasma — albumin, IVIG, and more.