Fresh Frozen Plasma (FFP) Collection, Preparation and Uses

• Samuel Good

Fresh Frozen Plasma

Introduction

Fresh Frozen Plasma (FFP) is the name for the liquid portion of human blood, which has been frozen and preserved. It is taken by blood donation and is stored until needed for blood transfusion.

FFP has been available since 1941 (Hoffman, et al, 1990), it was used initially as a volume expander (Erber, et al, 2006), but is now used for the “management and prevention of bleeding in coagulopathic patients” (Ho, et al, 2005).

The term FFP is confusing as the plasma cannot be frozen as well as fresh at the same time. What the term implies is that the plasma was frozen rapidly after it was taken and therefore can be considered fresh.

The plasma, from a transfusion aspect, contains essential components such as fibrinogen, albumin, globulin and coagulation factors. These allow for specific individual components to be transferred to a recipient who is in need.

The most efficient and effective way to make optimum use of blood which has been donated, is to separate it into its individual components. This process allows for a “wider availability of blood products” (Spence, et al, 2006) and also reduces the risk patients are exposed to “transfusion-related risks” (Erber, et al, 2006).

The use of FFP and its individual products has increased tenfold since its first introduction (Hoffman, et al, 1990). One reason for this may be the declining availability of whole blood because of the trend to use component therapy (Spence, et al, 2006).

Collection and Storage

When a donor gives a unit of whole blood, the blood is then separated into several components parts. These include; packed red blood cells (pRBC), platelets and FFP. If required the FFP can be further divided into cryoprecipitate and something called cryo-poor plasma. Cryo-poor plasma is rarely used as a therapeutic response (Lauzier, et al, 2007).

As mentioned previously, plasma is the non-cellular, liquid part of the blood. It is made up of; water, electrolytes and proteins. The proteins include the clotting factors and intrinsic coagulants (Murray, et al, 1995).

The plasma is separated from the blood after donation and then frozen. For the plasma to be considered ‘fresh’ it must be frozen “within eight hours of collection” (Murray, et al, 1995) and stored at a temperature of minus 18 degrees centigrade or lower. If this fails to happen, the product is known just as ‘frozen plasma’, which like cryo-poor plasma, is rarely used for therapeutic means. However, to maintain coagulation factors to optimum levels the plasma should be stored at minus 30 degrees centigrade (Lauzier, et al, 2007).

FFP can be prepared by separation from whole blood or via plasmapheresis. Plasmapheresis is the name given to a “broad range of procedures” where “extracorporeal separation of blood components” (Erber, et al, 2006) results in a plasma which is filtered.

Preparation

To summarise, FFP is collected in citrate-containing anticoagulant solution, frozen within 8 hours and stored at minus 30 degrees centigrade for up to a year.

Although every protection is taken to ensure sterility, it is quite possible for the donor to have an asymptomatic bacteraemia at the time of donation (Stanworth, et al, 2004). The bacteria will have its proliferation down-regulated by the plasma being frozen. However, FFP can still sometimes transmit infectious diseases. Therefore, screening and pathogen inactivation may be performed to reduce the risk.

FFP contains no RBC’s and also no WBC’s. As there are no WBC’s the plasma is referred to be as being leucodepleted. This is an indication as to why FFP can transmit said diseases. As mentioned pathogen inactivation can be performed and this is done by using either Methylene blue or a solvent/detergent process.

The Methylene Blue Technique

Methylene blue is a dye that has been shown to be very effective in the inactivation of pathogens. It binds to nucleic acids and, on illumination with white light, singlet oxygen is formed. This then destroys viral DNA and RNA, therefore viral replication cannot take place.

Solvent/Detergent Technique

This technique is used for the preparation of factors viii and ix as well as immunoglobulins. First, a solvent is added to the plasma which removes the lipid viral envelope. After this is complete, a detergent is added which inactivates the viral contents. The solvent and detergent are then removed by a physical separation technique, in which they are dissolved in oil. Column chromatography can then be used to isolate factors viii and ix.

Once any treatment that is required is complete, the FFP is ready for use. It is an accepted practice that FFP is thawed before use (Ho, et al, 2005). The required units of FFP are placed in a water bath set at 30 – 37 degrees centigrade for approximately 20 – 30 minutes.

Von Heyman, et al investigated the effects of 2 different thawing machines and running warm water of 43 degrees centigrade, on the activity of clotting factors, inhibitors and activation markers in FFP. They discovered no significant differences in the activity of coagulation markers over a 6 hour period post thawing. However, a major conclusion found was that, if FFP is immediately transfused after thawing, the product remained rich in clotting factors. Also, if the plasma is left, the activity of said clotting factors decline gradually and therefore FFP should only be maintained at room temperature for up to 4 hours.

If thawed FFP is not used within 24 hours it becomes a separate product known as ‘thawed plasma’ (Murray, et al, 1995). Most clotting factors are stable in thawed plasma, however some labile factors, such as v and viii are not. Their degradation actually accelerates whilst the plasma is in a liquid state (Lauzier, et al, 2007).

The only main advantage of having thawed plasma readily available, is that it can be transfused rapidly if a severely injured patient requires it.

FFP Blood Type Specific

It is widely accepted that O negative is the universal donor for pRBC’s, however for FFP this isn’t the case. A and B antigens of the blood are located on the red cells themselves. Type O individuals are devoid of these proteins on their red blood cells.

Plasma does not contain RBC’s, but it contains antibodies to the corresponding absent protein. An example of this is:

• Type A individual has Anti-B antibodies in their blood.
• Type O plasma has both Anti-A and Anti-B antibodies and is incompatible with about 55 percent of the population.
• An individual with type AB blood has neither Anti-A nor Anti-B antibodies.
• This makes the AB plasma ideal for universal use when the blood type of the patient is unknown.
• The Rh status is irrelevant because any plasma with Anti-D is destroyed at the manufacturing stage.

The major problem with blood type AB is that the percentage of the population which has it is only 4 percent. Therefore it is better to use FFP which is blood type compatible, which will be determined at the blood bank.

Usage

There are very few actual specific needs for the use of FFP (Spence, et al, 2006). Usually FFP is used to treat “deficiencies of coagulation proteins where specific factor concentrates are unavailable” (Hoffman, et al, 1990).

Coagulation deficiencies can occur in a variety of different clinical situations. These include massive blood loss, surgery, and infection or acquired multiple coagulation factor deficiencies.

Examples of FFP usage:

• Replacement of isolated factor deficiencies
• Reversal of Warfarin effects
• Massive blood transfusion
• Antithrombin III deficiency
• Treatment of immunodeficiency
• Treatment of thrombotic thrombocytopenic purpura
• Treatment of Disseminated intravascular coagulation

Replacement of isolated factor deficiency

FFP can be used to heat deficiencies of factors II, V, VII, IX, X and XI. It is only chosen as a treatment when no specific component therapy is available. Certain factors require a different haemostatic level, for example; severe factor X deficiency only requires a factor level of about 10 percent. Therefore FFP has a range of success when treating factor deficiencies.

Reversal of Warfarin effect

If a patient is being treated with Warfarin, they have been shown to be deficient in “functional vitamin K dependent coagulation factors II, VII, IX and X” (Spence, et al, 2006). Usually vitamin K will be administered, however anticoagulated patients will be actively bleeding, and therefore FFP can be used.

Massive blood transfusion

The use of FFP as a treatment on massive blood transfusion has increased over the decades. Massive bleeding is defined as “the loss of one blood volume within 24 hours” or as “50 percent blood loss within 3 hours” or a “bleeding rate of 150 ml/minute” (Lauzier, et al, 2007). It is indicated for use in patients who have documented blood clotting abnormalities after large blood loss and who are in need of urgent treatment. This is due to the fact that in most emergency situations it is unacceptable to wait hours for lab results to be returned.

Antithrombin III deficiency

FFP is sometimes used as a source of Antithrombin III in people who are deficient of this inhibitor. Especially if the patients are undergoing surgery or who use Heparin to treat thrombosis.

Treatment of Immunodeficiency

FFP has been used in children and adults with a humoral immunodeficiency as a source of immunoglobulin. It is also sometimes used for infants when parental nutrition is lacking, and they are suffering with severe protein losing enteropathy (Erber, et al, 2006).

Treatment of thrombotic thrombocytopenic purpura

The treatment recommended for this condition is a daily plasma exchange (Murray, et al, 1995). Prompt intervention is indicated if development of neurological abnormalities start to appear. This plasma exchange usually continues for at least 2 days after remission (Ho, et al, 2005).

Treatment of Disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is a syndrome where the control of the coagulation system becomes disturbed and out of control. This is usually due to pro-coagulants being dispersed into circulation (Stanworth, et al, 2004). Most of the time this happens secondary to a disease or disorder, such as cancer. In the presence of DIC, fibrinogen, platelets and coagulation factors V and VIII become rapidly depleted. FFP is given as treatment to prevent further problems or progression. Treatment usually involves a patient being infused with a single line of FFP and then coagulation tests performed to assess the clinical benefit (Stanworth, et al, 2004).

There are also some conditional uses where FFP can be used but is not the first choice treatment, such as liver disease and Paediatric use. If patients have an abnormal coagulation profile and are suffering from liver disease, they can be treated with FFP. There is varying success and treatment must be monitored by regular transfusion coagulation tests.

Clotting times of infants have been shown to be longer than that of adults (Murray, et al, 1995), and even longer in premature babies (O’Shaughnessy, et al, 2004). Vitamin K deficiency is the most common cause of neonatal bleeding (Murray, et al, 1995). FFP can be used to counter the effects if required. In the case of babies suffering from haemorrhagic disease of the newborn, FFP can be used as treatment. But only if the “chance of bleeding is greater than the risk of harmful reactions” to the treatment with FFP (Lauzier, et al, 2007).

Risks

As with any transfusion there is a risk of infection, the main risks identified include:

• Disease transmission
• Excessive intravascular volume
• Anaphylactoid reactions
• Alloimmunisation
• Transfusion related acute lung injury

The risks associated with viral infectivity of FFP are similar to that of whole blood and RBC’s. As mentioned earlier this risk can be countered by photochemically treating the plasma.

Allergic reactions that occur in response to FFP transfusion vary in severity from “hives to fatal non-cardiac pulmonary oedema” (Stanworth, et al, 2004). Transfusion relate acute lung injury (TRALI) is defined as a “new episode of acute lung injury within 6 hours of complicated therapy” (O’Shaughnessy, et al, 2004). It manifests as severe respiratory problems, including hypoxia and other symptoms linked to pulmonary oedema. Symptoms will usually subside 2 days after ceasing FFP treatment (Stanworth, et al, 2004).

Alloimmunisation can occur if Anti-Rh antibodies are formed after treatment with FFP. To counter this, plasma containing Anti-D antibodies should not be given to an RhD-positive recipient. There has also been reported incidences of post-transfusion Hepatitis, and depends on a number factors, including donor selection. Also with any intravenously transfused fluid, there is a chance of hypervolemia which could lead to cardiac failure, therefore administration of FFP should not be given in excessive doses.

Below is a suggested dosage breakdown:

Volume of 1 Unit Plasma: 200-250 mL 1 mL plasma contains 1 u coagulation factors 1 Unit contains 220 u coagulation factors Factor recovery with transfusion = 40% 1 Unit provides ~80 u coagulation factors 70 kg X .05 = plasma volume of 35 dL (3.5 L) 80 u = 2.3 u/dL = 2.3% (of normal 100 u/dL) 35 dL

In a 70 kg Patient: 1 Unit Plasma increases most factors ~2.5% 4 Units Plasma increase most factors ~10%

Figures taken from (http://reference.medscape.com/drug/ffp-octaplas-fresh-frozen-plasma-999499)

Conclusion

In conclusion, FFP can be used as an effective treatment for a number of different clinical issues. It also does not come without risk and therefore FFP should be collected, stored, prepared and used in an efficient and safe manner. Below I have summarised the administration of FFP.

• FFP (Fresh Frozen Plasma) Volume: 240-300ml (mean 273ml)
• Storage: designated temperature controlled freezer. Core temperature -30 o C
• Shelf life: 24 months (frozen)
• Must be ABO compatible, but Rh is not necessary to be considered for transfusion and no anti D prophylaxis is required if Rh-D negative patients receive Rh-D positive FFP.
• Prior to the transfusion FFP must be thawed under controlled conditions using specifically designed equipment. Thawing usually takes approximately 15-30 minutes
• Once thawed, FFP must not be re-frozen and should be transfused as quickly as possible. Post-thaw storage results in a decline in the quality of coagulation factors.
• If stored at 4 degrees centigrade post thawing (in a designated temperature controlled refrigerator), the transfusion must be completed within 24 hours of thawing.
• Pooled solvent-detergent treated plasma is also commercially available
• Dose: typically 10-15ml/kg. This dose may need to be exceeded in massive haemorrhage depending on the clinical situation and its monitoring (BCSH 2004)
• Typical infusion rate 10-20ml/kg/hr (approximately 30 minutes per unit)
• Rapid infusion may be appropriate when given to replace coagulation factors during major haemorrhage. There is anecdotal evidence that acute reactions may be more common with faster administration rates.

(http://reference.medscape.com/drug/ffp-octaplas-fresh-frozen-plasma-999499)

REFERENCES

Erber WN, Perry DJ: Plasma and plasma products in the treatment of massive hemorrhage. Best Pract Res Clin Haematol 2006, 19:97-112

Hewson JR, Neame PB, Kumar N, Ayrton A, Gregor P, Davis C, Shragge BW. Coagulopathy related to dilution and hypotension during massive transfusion. Crit Care Med. 1985;13(5):387-391.

Ho AM, Karmakar MK, Dion PW. Are we giving enough coagulation factors during major trauma resuscitation? Am J Surg. 2005;190(3):479-484.

Hoffman M, Jenner P. Variability in fibrinogen and Von Willebrand factor content of cryoprecipitate. Brief Sci Rep. 1990;93(5):694-697.

Lauzier F, Cook D, Griffith L, Upton J, Crowther M: Fresh frozen plasma transfusion in critically ill patients. Crit Care Med 2007, 35:1655-1659.

Leslie SD, Toy PT. Laboratory hemostatic abnormalities in massively transfused patients given red blood cells and crystalloid. Am J Clin Pathol. 1991;96(6):770-773.

Murray DJ, Olson J, Strauss R, Tinker JH. Coagulation changes during packed red cell replacement of major blood loss. Anesthesiology. 1988;69(6):839-845

Murray DJ, Pennell BJ, Weinstein SL, Olson JD.Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding. Anesth Analg. 1995;80(2):336-342.

O’Shaughnessy DF, Atterbury C, Bolton Maggs P, Murphy M, Thomas D, Yates S, Williamson LM, British Committee for Standards in Haematology, Blood Transfusion Task Force: Guidelines for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant. Br J Haematol 2004, 126:11-28.

Spence RK: Clinical use of plasma and plasma fractions. Best Pract Res Clin Haematol 2006, 19:83-96.

Stanworth SJ, Brunskill SJ, Hyde CJ, McClelland DB, Murphy MF: Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol 2004, 126:139-152

Tieu BH, Holcomb JB, Schreiber MA. Coagulopathy:its pathophysiology and treatment in the injured patient. World J Surg. 2007;31(5):1055-1065

http://en.wikipedia.org/wiki/Fresh_frozen_plasma

http://www.psbc.org/therapy/ffp.htm

http://reference.medscape.com/drug/ffp-octaplas-fresh-frozen-plasma-999499

http://ccforum.com/content/14/1/202