Prepare a guideline for your hospital on the indications for the use of FFP and Cryoprecipitate

INTRODUCTION

Appropriate use of blood and blood products is becoming an increasingly important clinical governance and public health issue. These guidelines are intended to help the clinician to decide when it is appropriate to transfuse one of those blood components and to minimise the risk of donor exposure.  If in doubt always discuss with the Haematology SpR or Consultant on call.

Allow 20-40 minutes for thawing (at 37ºC).

Thawed FFP is best used immediately but can be stored in the blood bank fridge at 4ºC and infused within 24 hours.  (If FFP is removed from storage it should returned to the blood bank fridge within 30 minutes.)

Thawed cryoprecipitate stored at room temperature must be infused within 4 hours of thawing.

INDICATIONS FOR THE USE OF FRESH FROZEN PLASMA (FFP)

The risks of transmitting infection are broadly similar to those of other blood components (although it is thought that the risks of CJD are higher with plasma containing products and the risk of bacterial contamination is lower from FFP than blood or platelets).

In addition there risks of allergic reactions and anaphylaxis (particularly if the patient has IgA deficiency) and transfusion related acute lung injury.

Consider Hepatitis A and B vaccination in patients likely to receive large volumes of FFP.

Dose 12-15ml/kg body weight (BW), equivalent to 3-4units for an adult.  Typical infusion rate 10-20ml/kg/hr (approximately 30 minutes per unit) 1 unit FFP = (250-300ml). 

Solvent detergent virally inactivated FFP = 200ml/pack

Methylene blue virally inactivated FFP = 50-75ml/pack should be given to children (<16?)

The RhD status of the FFP is unimportant and RhD positive FFP can be safely given to Rh negative recipients – even young women. The Blood Safety and Quality

Regulations still requires FFP to be labelled according to the RhD group of the donor, even though this is not a requirement of the Council of Europe.

Indications for FFP

1. Massive transfusion – FFP should be used to treat coagulation factor deficiency. Coagulation factor deficiency can be expected after rapid replacement of one blood volume within 6 hours but can occur after earlier particularly in the context of trauma, where coagulopathy of trauma can occur (e.g. lung contusions can result in marked depletion of factor VII). FFP can be used at initial dose of 15ml/kg BW aiming for prothrombin time (PT) and APTT < 1.5 of control. Coagulation tests should be monitored if following administration of blood products and may be necessary to give repeat doses of FFP. (NB if packed cells / platelets / FFP  are mixed in a 1:1 ratio in a beaker the hematocrit would be 29%, the platelet count 88K, and the plasma coagulation factor activity would be 65%).

2. Replacement of single coagulation factors, where a specific factor concentrate is unavailable (ideally virally inactivated FFP should be used) e.g. factor V deficiency. 
3. Thrombotic thrombocytopenic purpura (TTP) usually in conjunction with plasma exchange. Virally inactivated (FFP) is preferable. Daily plasma exchange should continue for a minimum of 2 days after remission.
4. Acute disseminated intravascular coagulation (DIC) only in the presence of bleeding and abnormal coagulation results. There is no evidence that prophylactic replacement regimes prevent or reduce transfusion requirements but FFP is often used to correct coagulopathy so that procedures can be performed. 
5. Liver disease to correct bleeding or as prophylaxis prior to surgery when the PT is > 1.5 of the control. For liver biopsy PT should be within 4 seconds of the control.
6. Immediate reversal of Warfarin effect in the presence of life-threatening bleeding.  FFP should not usually be used to reverse the effect of Warfarin unless PCC is not available.

INDICATIONS FOR THE USE OF CRYOPRECIPITATE

Generally used to replace fibrinogen - usually aim to keep >1 g/l.

Dose: A typical adult dose is two five-unit pools( equivalent to the historical dose of 10 single donor units) containing 3-6g fibrinogen in a volume of 200 to

500 ml. One such treatment administered to an adult would typically raise the plasma fibrinogen to by about 1g/l. Repeat based on fibrinogen level.

Typical infusion rate 10-20ml/kg/hr (or 30 to 60 minutes per 5 unit pool)

1. Hypofibrinogenaemia (fibrinogen level < 1.0g/l) secondary to massive transfusion, DIC, Liver failure. Early use of FFP may avoid the need for cryoprecipitate. Repeat fibrinogen level after the initial dose.
2. Inherited hypofibrinogenaemia. (Consider recombinant fibrinogen concentrate)
3. Bleeding associated with thrombolytic therapy causing hypofibrinogenaemia.

Further reading

http://asheducationbook.hematologylibrary.org/content/2007/1/187.full?sid=2cde8e11-8364-4de5-8514-bb0ebe65162e

http://asheducationbook.hematologylibrary.org/content/2010/1/465.full