Fresh Frozen Plasma Transfusion

Canine FFP is canine WB that is separated from its cellular components and frozen within 8 hours of collection. FFP can be stored frozen for up to one year which then is relabeled as frozen plasma (FP). FFP contains all coagulation factors and plasma proteins found in circulating blood. FP contains most of the coagulation factors but loses the labile factors (FV, FVIII, von Willebrand factor) over time.

## USES

- FFP is indicated to correct coagulation factor deficiencies and or prophylactically to treat MWDs who are at risk of bleeding from clotting factor abnormalities.
- As compared to isotonic crystalloids, canine FFP provides the following added benefits as a resuscitation fluid:
  - Supports hemostatic resuscitation. Its ability to deliver coagulation factors and other plasma proteins (e.g. albumin, fibrinogen) while restoring intravascular volume minimizes the risk of invoking a dilutional coagulopathy.
  - Provides oncotic support by supplementing albumin in addition to restoring effective circulating volume.

## AVAILABILITY

- FFP comes in different sized units but 240 to 250 mL units are most appropriate for MWDs.
- FFP is obtainable from one of two methods:

1. Separation of Fresh Whole Blood (FWB):
   - Place a unit (450 to 500 mL) of FWB into a blood centrifuge and spin at 2000 x g for 10 minutes to separate the cellular components.
   - Express the plasma from the primary collection bag into a satellite bag and then seal.
   - Place plasma in freezer at -20°C to -80°C (-4°F to -112°F) within 8 hours of collection if it is intended to serve as FFP.
2. Plasmapheresis is an alternate way to obtain FFP; however, this process requires special training and equipment. Only trained personnel with the appropriate equipment should perform plasmapheresis.

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## HANDLING/ STORAGE

- FFP should be stored in a dedicated, appropriate freezer at -20 to -80oC. Perform daily temperature checks to ensure the freezer is secured and operating appropriately.
- If FFP is to be shipped it should be shipped with proper insulated packaging on dry ice to ensure the product remains frozen at the correct temperatures.

Note: Care should be taken when handling FFP as the plasma bag is not pliable and can crack at low temperatures. Consider placing in two large Ziploc® bags or similar packaging to avoid direct handling of the FFP bag.

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## DOSAGE AND ADMINISTRATION

- Typical dose of canine FFP is 10 to 20 mL/kg over 1- 4 hours (depending on the situation). This translates to approximately one to two 240 to 250 mL bags of FFP per MWD.
- FFP should NOT be used to try to increase plasma albumin levels as up to 40 to 50 mL/kg could be necessary to raise recipient’s albumin levels by 1.0 g/dL.
- MWDs that do not have ongoing hemorrhage or other substantial fluid losses, administration of FFP over 2-4 hours is appropriate.
- FFP must first be thawed before administration.
  - Optimally, thaw FFP in a commercial plasma thawer following manufacturer’s recommendations for thawing human plasma.
  - If no plasma thawer is available, remove FFP from the freezer and place in two Ziploc® bags. Submerge the FFP and outer Ziploc® bags in lukewarm tap water. A large MWD food bowl is often suitable for this purpose.
  - Ensure the water does not exceed 98.6°F (37°C); water temperatures exceeding 98.6°F (37°C) may cause protein denaturation. It is important that the thawing process does not occur too quickly by adding hot water as plasma proteins can be denatured if the process is rushed. Consider exchanging the water every 15 to 20 minutes or use a gentle continuous flow of water if necessary to keep the water bath warm. Expect 30-40 minutes to complete the thawing process using this technique.
- Once thawed, spike FFP bag with a blood administration set (which contains a 170 micron blood filter) or a regular fluid administration set. If no blood administration set is available, place a blood filter (Hemo-Nate® filter) in the transfusion line to reduce transfusion of clots or other impurities from the transfused product. Do not let the lack of a Hemo-Nate® (or similar blood filter) preclude the administration of FFP if it is clinically necessary.
  1. Connect the primed transfusion line to a 20 gauge or larger bore peripheral or central IV catheter or an IO catheter.
  2. Begin transfusion at 1 to 2 mL/kg/h over the first 15 minutes and monitor the MWD for signs of transfusion reaction. (See Table 10.) If there is no significant reaction, increase the rate of transfusion to 2 to 4 mL/kg/h for an additional 15 minutes. If no transfusion reactions are seen over the first 30 minutes, increase the transfusion rate to ensure the complete delivery of FFP within 2 to 4 hours.
- In emergent situations, consider blousing 1-3 units thawed FFP to MWDs similar to that indicated for MWDs that are rapidly losing blood form a major blood vessel laceration. Bolus the whole unit of FFP over 10 minutes by one of the following techniques:
  - Placing the FFP bag in a commercial IV pressure infuser system or manual squeezing of the FFP bag, OR
  - Using the 3-way stopcock and 60 mL syringe set-up described in the WB administration section above.

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## TRANSFUSION MONITORING AND REASSESSMENT

- Vigilant monitoring for transfusion reactions is required during non-emergent FFP transfusions (e.g. in absence of bolus FFP therapy). Types and signs associated with transfusion reactions are similar to those for WB transfusions. (See above section on transfusion reactions for WB.)
- Monitor core body temperature, pulse rate and quality, respiration (rate and effort) and blood pressure:
  - Every 5 minutes for the first 15 minutes of transfusion, then
  - Every 15 minutes for the first hour, then
  - Every 30-60 minutes thereafter until completion of the transfusion.
- The most common indications of a transfusion reaction are fever, facial edema, tachycardia, tachypnea, vomiting, hypotension and weakness.7
  - If any of these signs are encountered, reduce the transfusion rate by 50% and reassess the MWD. If clinical signs resolve, continue the transfusion.
  - If signs of transfusion reaction persist or worsen despite reducing the transfusion rate, halt the transfusion and seek consultation with the supporting 64F.
- Reassess the MWD upon completion of the transfusion. Assessment includes a physical examination with special attention to the cardiovascular, coagulation and perfusion parameters to include blood pressure assessment. If end points of resuscitation are not reached, consider administering an additional unit of FFP following the guidelines above.
- Continue hemorrhagic shock resuscitation with FDP or FFP until canine WB is available to administer.