TATM 2003;5(3):363-367

Fresh Frozen Plasma:

Clinical Guidelines and Use

SUMMARY

Fresh frozen plasma (FFP) is the liquid portion of one unit of human blood that

contains the labile and stable components of the coagulation, fibrinolytic and

complement systems, as well as the proteins that maintain oncotic pressure and
S YLVAIN B ÉLISLE , MD , FRCPC ,
AND J EAN -F RANÇOIS H ARDY, MD , FRCPC modulate immunity.The clinician must remember that a unit of single-donor allogeneic

DEPARTMENT OF ANESTHESIOLOGY plasma is a heterogeneous solution of proteins. Infusion of FFP normalizes abnormal
UNIVERSITY OF MONTREAL tests efficaciously in patients with hereditary coagulopathies. However, its benefit
MONTREAL, QUEBEC, CANADA
in the treatment of excessive bleeding remains unclear and variable. In clinical

practice, indication to transfuse FFP is based on a double threshold: a combination

of abnormal coagulation tests plus excessive bleedings. FFP is not the first-line

option in the prevention of hemorrhage and in emergency reversal of oral

anticoagulation for life-threatening complications.

• Fresh frozen plasma

• Indications
• Guidelines

Transfusion Alternatives in Transfusion Medicine 363 ) VOLUME 5 NUMBER 3 AUGUST 2003

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Indications for Plasma Transfusion S Y LVA I N B É L I S L E et al.
It was during the 19th century that the liquid part of blood was first
designated as plasma, the Greek word for modeling. Allogeneic plasma is
now considered the source of many circulating proteins, particularly
coagulation factors. Fresh frozen plasma (FFP) is the liquid portion of one
unit of human blood that has been centrifuged, separated and frozen solid
at -18°C (or colder) within six hours of collection. It contains the labile and
stable components of the coagulation, fibrinolytic and complement systems,
as well as the proteins that maintain oncotic pressure and modulate immunity.
The clinician must remember that a unit of single-donor allogeneic plasma
is a heterogeneous solution of proteins.1 The normal concentration of
coagulation factors ranges from 0.5 to 1.5 U/mL. However, a significant
number of units may present as an isolated factor deficiency, particularly
factors VII and IX.1 The variable mean content of coagulation factors is
influenced by individual variations, the ABO blood group, and conditions
during the preparation and storage of plasma. Viral inactivation even further
decreases the concentration of components in the plasma. For example, it
decreases the concentration of factor VIII and protein S, respectively, by 20%
and 50%, and the concentration of α2-antiplasmin by as much as 75% of
its initial concentration. Under such conditions, the clinician should not
expect a homogeneous response to the transfusion of plasma.
The use of FFP has increased dramatically in recent years. Its
administration is based on two assumptions: an inadequate concentration
of coagulation factors will increase the risk of an adverse outcome; and (2)
replenishment with allogeneic plasma can correct, decrease or prevent these
risks. Does the recent scientific literature validate this rationale and the
increasing use of FFP in clinical medicine? Do clinicians need to reconsider
transfusion practice guidelines? This paper will review the guidelines for
the use of fresh frozen plasma based on the level of evidence in the literature
on the indications and benefits of plasma transfusion.
Practice Guidelines
Standard transfusion practice has traditionally been based on a consensus
of expert opinions. The most rigorous practice guidelines were formulated
by the American Society of Anesthesiologists (ASA) in 19962 and the
Canadian Medical Association (CMA) in 1997.3 The American task force
reviewed the literature published until mid-1994 in order to develop
evidence-based guidelines on the proper indications for perioperative
administration of allogeneic blood products (ABP). The Canadian guidelines
were based on a systematic review of the literature published between
January 1966 and July 1996 and an assessment of the level of evidence.
The bibliographic search included articles on the transfusion of red blood
cells and plasma in both adults and children.
The American and Canadian experts make six recommendations each.
These recommendations are summarized in Table 1. The CMA bases its
guidelines and recommendations on a double transfusion threshold where
clinical appreciation of bleeding is an essential element needing
consideration in the transfusion of plasma. Based on this double threshold,
excessive bleeding unrelated to hypothermia, anemia, acidosis,
hypocalcemia or a surgically treatable source must be active and an
abnormal hemostatic profile must be identified.
Transfusion Alternatives in Transfusion Medicine 364 ) VOLUME 5 NUMBER 3 AUGUST 2003
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Since 1997, new published studies continue to refine our standards of
good transfusion practice. Indications for the use of FFP are confined to
the following conditions.
Replacement of Isolated Factor Deficiencies
FFP is indicated for the replacement of isolated factor deficiencies (II,
V, VII, IX, X, and XI) only when specific component therapy is neither
available nor appropriate. In fact, only factor V, protein S and plasminogen
are not available as a purified concentrate. Plasma should be used only
when bleeding has occurred or is reasonably expected to occur from surgery
or other invasive procedures. Under such conditions, the transfusion of
allogeneic plasma is effective to increase the concentration of one factor
above 0.5 U/mL.4 Furthermore, requirements for FFP (dosage, frequency
and length of administration) vary with the specific factor being replaced.
Reversal of Warfarin Effect
Anti-vitamin K drug use is becoming increasingly more prevalent. Major
hemorrhagic complications occur at a rate of 2.7 per 100 treatments a year.
Even in patients assigned to less intense therapy (international normalized
ratio [INR] 2.0 to 3.0), the annual incidence of major bleeding averaged
1.3%.5 These complications increase significantly with age and are
associated with an escalating INR. An INR > 4.0 carries an absolute risk
of intracranial hemorrhage of 2% per year with a mortality rate of 76%.
Prompt, effective and reliable normalization of the anticoagulant effect
produced by these drugs is the primary goal of the treatment.
Traditionally, in anticoagulated patients with active bleeding or requiring
emergency surgical or invasive procedures, FFP has been used to achieve
immediate hemostasis. The American Society of Anesthesiology
recommends a dose of 5 to 8 mL/kg. Guidelines from the Canadian Medical
Association make no recommendation regarding the volume of FFP to be
administered considering the lack of systematic assessments of this therapy.
A number of trials with limited numbers of patients compare FFP to other
treatment options. In contrast with FFP, the reversal of anticoagulation with
prothrombin complex concentrates (PCC) is faster (within 5 hours) and
more effective, but is of short duration. FFP has an intermediate effectiveness
(fewer patients achieve an INR < 1.5) and its action is delayed (within 7 to
8 hours). In two recent studies designed to compare the efficacy of allogeneic
plasma with PCC (reported in factor IX unit) and factor VII concentrate, the
transfusion of 4 units of allogeneic plasma (5-8 mL/kg) was insufficient to
reach the lower limit of 0.2 U/mL for vitamin K-dependent factors (II, VII,
IX, X) and to normalize the INR.1,6 Even after the infusion of a mean volume
of FFP of more than 2.7 liters, more than 8 hours were needed to observe
the correction of the INR (≤ 1.3).6 PCC antagonized the INR more rapidly
and completely than plasma. Moreover, in comparison with FFP-treated
patients presenting intracerebral hemorrhage, the administration of PCC has
been associated with less deterioration on the Reaction Level Scale. However,
this higher efficacy also entails some risk. Thrombosis and DIC have been
associated with this product, particularly in liver disease. Recombinant
activated factor VII (rFVIIa) is able to normalize experimentally prolonged
INR in healthy volunteers.7 For many clinicians, FFP is, therefore, no longer
the first choice of treatment for the immediate reversal of effects of warfarin.

Disseminated Intravascular Coagulation (DIC)
Infusion of allogeneic plasma is recommended in patients with acute
disseminated intravascular coagulation who have active bleeding associated
with increased PT, INR or aPTT (activated partial thromboplastin time),
provided that the triggering condition can also be treated effectively.
Forty-one per cent (41%) of patients with brain injury develop an early
profile (1 to 4 hours) of DIC.8 The development of a laboratory
coagulopathy is significantly associated with a higher mortality rate in
adults8,9 and children.10 In non-survivors, severe brain edema, rather than
intracranial hemorrhagic complications, is the most frequent image seen
on cerebral axial tomography. Early prophylactic administration of plasma
cannot prevent the development of a coagulopathy in these patients.11
Plasma transfusion is not indicated in DIC without bleeding or in chronic
DIC. In decompensate DIC with bleeding, transfusion of FFP, along with
other blood components and especially rapid resolution of the initial trigger,
may be useful.
Massive Blood Transfusion/Microvascular Bleeding
Abnormal hemostasis can occur in association with massive transfusion.
In order of appearance, fibrinogen concentration < 0.5 g/L, clotting factor
levels < 20%, and platelet count < 50 x 109/L are the abnormal hemostatic
parameters associated with microvascular bleeding in massively transfused
patients.12,13 A significant decrease in clotting factor levels usually translates
into a prolonged PT and aPTT (> 1.8 times the normal).12
In 45 patients with acquired coagulation deficits (with active bleeding,
surgical prophylaxis, or warfarin overdose), the infusion of 8 mL/kg of FFP
was associated with an appropriate bleeding control in up to 27 % of cases.14
Interestingly, the active bleeding was contained more frequently than the
correction of the PT by three times. In the context of massive transfusion
(more than one blood volume), FFP should be administered if there is
microvascular bleeding associated with a significantly increased PT, INR or
aPTT (double threshold). If PT, INR or aPTT cannot be measured quickly,
allogeneic plasma may be transfused in an attempt to stop diffuse non-surgical
bleeding. FFP is ineffective in controlling persistent bleeding from a surgically
correctable cause or related to hypothermia, vascular hypertension, ionized
hypocalcemia, acidosis, anemia and no significant abnormalities of
coagulation tests. There is no evidence that the prophylactic administration
of FFP is effective or decreases transfusion requirements in massively
transfused patients who do not have documented coagulation defects.
Liver Disease
Liver disease impairs the hemostatic system by different mechanisms,
such as dysfunction of clotting and restriction factors, increasing fibrinolysis
and thrombocytopenia. Risks of excessive bleeding in patients with liver
disease include gastrointestinal hemorrhage, bleeding during routine
procedures (liver biopsy), or during major surgery. In patients with liver
disease, infusion of FFP is recommended when there is actual bleeding or
to prepare for surgery or liver biopsy when PT or INR are moderately
abnormal (INR > 2.0). The efficacy of allogeneic plasma to prevent excessive
bleeding during surgery or liver biopsy remains speculative, and
Transfusion Alternatives in Transfusion Medicine
Indications for Plasma Transfusion S Y LVA I N B É L I S L E et al.
prophylactic plasma transfusion is not indicated for percutaneous liver
biopsy, paracentesis and thoracentesis if the INR is ≤ 2.0.3 Other options
may be available in a near future if current investigations are conclusive.
Among them, rFVIIa induces a dose-dependent reduction of prolonged
PT in cirrhotic patients.15,16
Plasma Exchange Therapy
Indications for the use of FFP depend on the initial diagnosis. In Guillain-
Barré syndrome, for example, exchange with albumin as opposed to FFP
has been associated with a lower morbidity rate.17 In contrast, the
administration of FFP during plasma exchange improves outcome in
patients presenting with either thrombotic thrombocytopenic purpura
(TTP) or adult hemolytic-uremic syndrome (HUS).18 Plasma transfusion
is not, however, recommended in the classic form of pediatric HUS.
Cardiopulmonary Bypass/Cardiac Surgery
Abnormal coagulation test values are commonly used to justify the
administration of plasma in patients presenting with excessive bleeding
although spontaneous recovery of these parameters is observed over a few
hours. The reduction of plasma factor levels is too modest to be the sole
factor involved in most cases of excessive bleeding,19 and there is no proven
correlation between the various laboratory test abnormalities and patients
presenting with excessive bleeding or an anticipated blood loss. Furthermore,
although bleeders tend to receive more blood components, there is
surprisingly little effect on the coagulation factor levels measured.
Preventive use of plasma after cardiopulmonary bypass cannot reduce the
mediastinal drainage and increases exposure to allogeneic blood products.20,21
A recent study evaluates the benefit of allogeneic plasma (either FFP or
solvent/detergent plasma [SDP], volume infused of 8.5 mL/kg) in 67 patients
undergoing cardiac surgery and requiring massive transfusion.22 Effective control
of bleeding was defined as a reduction in blood loss of more than 50%. This
beneficial response was observed in approximately 40% of the cohort, without
significant difference between FFP and SDP. However, the treatment was totally
ineffective in about 25% of patients. The mortality rate was significantly higher
in the group of patients infused with FFP (FFP: 32% versus SDP: 11%,
p = 0.04). The positive impact of allogeneic plasma transfusion on the control
of the hemorrhage, therefore, remains variable, necessitating a balance between
the benefits of a spontaneous recovery and a potential risk of thrombosis.
Improper Use
There is no justification for the use of FFP as a volume expander or as a
nutritional source. Prophylactic transfusion of plasma before paracentesis
or thoracocentesis in patients with moderate coagulation abnormalities (PT
or PTT up to twice the midpoint normal value) secondary to liver disease
is not required. As already stated, FFP should not be used prophylactically
with massive blood transfusion since there is no documentation that it has
a beneficial effect when used as part of the transfusion management of
patients with massive hemorrhage. Nor should it be used prophylactically
after cardiopulmonary bypass.
365 ) VOLUME 5 NUMBER 3 AUGUST 2003
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Indications for Plasma Transfusion S Y LVA I N B É L I S L E et al.

population or condition does not account for this large variation. Medical
Dose
management and other institutional factors must, therefore, be considered
as independent risk factors for plasma transfusion. Financial cost, too, is
Normal plasma volume is 30 to 40 mL/kg. In theory, plasma should be
a strong modulator of the use of FFP.
given in doses calculated to achieve a minimum of 30% the normal plasma
Even more disquieting is the lack of adherence to the guidelines on the
factor concentration (10 to15 mL/kg). In cases of urgent reversal of warfarin
use of allogeneic plasma. The majority of clinicians would agree with the
anticoagulation, 5 to 8 mL/kg may be inadequate in many patients.
recommendations and guidelines. Yet bedside adherence to these guidelines
These recommended dosages are not derived from systematic
is poor, in part because of the difficulty in translating a synthetic algorithm
assessments of therapy. Ongoing clinical and laboratory evaluations are
and a fear of complications. Many authors have, in fact, observed an
necessary to measure the response and to determine subsequent action.
extrapolation of these guidelines resulting in a high rate of transfusion. Indeed,
of all allogeneic blood products, the transfusion of plasma continues to show
the highest rate of inappropriate use. Reported inappropriateness rates for
Variability of Transfusion Practice transfusion episodes range from 18% to 96%,26-29 with the rate being twice
that observed for red blood cell transfusions in one particular study.30
The use of FFP is controlled locally and varies not only from country
Better compliance is paramount and can be improved by institutional
to country but also from one institution to the next. Institutional exposure
measures, such as the creation of education programs, the implementation
to plasma is reported to range from 0% to as high as 97% in primary
of audit practices, and the introduction of an algorithm based on a double
elective coronary artery bypass surgery.23-25 The diversity of the patient
threshold (excessive bleeding plus abnormal
Table 1. coagulation). Plasma transfusion diagnostic algorithms
reduce unwarranted plasma requests by 64%,
Guidelines on the Indications for Plasma Transfusion mediastinal drainage by 52%, the relative risk of surgical
American Society
of Anesthesiologists 2
Canadian Medical Association Level of evidence
3
re-exploration for hemorrhage by 74%, and exposure
For known factor deficiencies for Plasma should be used only when Expert opinion to allogeneic plasma by 83%.31-34
which specific concentrates are bleeding has occurred or is
unavailable reasonably expected to occur
from surgery or other invasive
procedures
For urgent reversal of warfarin
therapy
When serious bleeding has
occurred or is expected in
Expert opinion
Conclusion
patients with vitamin K
deficiency Allogeneic plasma is a heterogeneous biological
For bleeding in patients with liver Weak (no randomized controlled
disease or to prepare for surgery study available) product. The perception of the efficacy of FFP is
or liver biopsy when PT or INR generally overestimated. Infusion of FFP normalizes
are sufficiently abnormal
abnormal tests efficaciously in patients with hereditary
Prophylactic use is not indicated coagulopathies. Its benefit in the treatment of excessive
if the INR is ≤ 2.0
For correction of microvascular Massive transfusion if there is Weak (no randomized controlled
bleeding remains unclear and variable. In clinical
bleeding with elevated PT or microvascular bleeding with study available) practice, FFP is recommended in situations of excessive
aPTT (> 1.5 times normal) significant increased PT, INR bleeding and abnormal coagulation tests (double
or aPTT
With transfusion of > one blood threshold). FFP is not the first-line option in the
volume and when PT and aPTT prevention of hemorrhage and in emergency reversal
cannot be obtained in a timely
fashion of oral anticoagulation for life-threatening complications.
For acute disseminated Weak (no randomized controlled The rate of inappropriate transfusion of FFP remains
intravascular coagulation with study available)
active bleeding associated with
high. Clinical practice must be based on the benefit, risk
increased PT, INR or aPTT, and efficiency of treatment, including cost. This assures an
provided that the triggering
condition can also be treated
optimal and efficient use of FFP. Also, this approach offers
effectively a framework for the evaluation of new therapeutic agents
Plasma should be used in the Strong (at least one randomized
(PCC, factor VII concentrates and rFVIIa). Indications for
treatment of TTP or adult HUS controlled study)
Dosage Expert opinion therapeutic plasma transfusion are decreasing rapidly as
Plasma should be given in doses These values are not derived from new alternatives will be proven beneficial. Through the
calculated to achieve a minimum systematic assessments of therapy
of 30% the normal plasma factor establishment of a transfusion committee to monitor the
concentration (10 to 15 mL/kg), No recommendation regarding use of blood products and the implementation of an
except for urgent reversal of volume of plasma to be
warfarin anticoagulation administered
appropriate plasma transfusion protocol and guidelines,
(5 to 8 mL/kg) hospitals can effectively reduce exposure to allogeneic
blood products and promote good clinical practice.

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 Indications for Plasma Transfusion S Y LVA I N B É L I S L E et al.

K e y P o i n t s
1. A unit of single donor plasma is a heterogeneous solution of proteins and the clinicians should not expect a homogeneous response to the transfusion
of plasma.
2. FFP is indicated for the replacement of isolated factor deficiencies only when specific components therapy is neither available nor appropriate. Only
factor V, protein S and plasminogen are not available as a purified concentrate.
3. FFP is no longer the first choice of treatment for the immediate reversal of effects of warfarin.
4. Plasma transfusion is not indicated in DIC without bleeding or in chronic DIC. In decompensate DIC with bleeding, transfusion of FFP, along with other
blood components and especially rapid resolution of the initial trigger, may be useful.
5. In the context of massive transfusion, FFP should be administered if there is microvascular bleeding and a significantly increased PT, INR or aPTT (double
threshold). If PT, INR or aPTT cannot be measured quickly, allogeneic plasma may be transfused in an attempt to stop diffuse non-surgical bleeding.
6. In patients with liver disease, infusion of FFP is recommended when there is actual bleeding or to prepare for surgery of liver biopsy when PT or INR
are moderately abnormal (INR > 2)
7. FFP should not be used prophylactically after cardiopulmonary bypass.
8. Indications for therapeutic plasma are decreasing rapidly as new alternatives such as prothrombin complex concentrates, factor VII concentrates and
rFVIIa will be proven beneficial.
9. Of all allogeneic blood products, the transfusion of plasma continues to show the highest rate of inappropriate use. Reported inappropriateness rates for
transfusion episodes range from 18% to 96%.
10. The establishment of a transfusion committee to monitor the use of blood products and the implementation of appropriate protocols and guidelines
can effectively reduce exposure to allogeneic blood products and promote good clinical practice.

R E F E R E N C E S

1. Makris M, Greaves M, Phillips WS, Kitchen S, Rosendaal
FR, Preston EF. Emergency oral anticoagulant reversal: the
relative efficacy of infusions of fresh frozen plasma and
clotting factor concentrate on correction of the
coagulopathy. Thromb Haemost 1997;77:477-80.
2. Practice Guidelines for blood component therapy: A
report by the American Society of Anesthesiologists Task
Force on Blood Component Therapy. Anesthesiology
1996;84:732-47.
3. Expert Working Group. Guidelines for red blood cell and
plasma transfusions for adults and children. CMAJ
1997;156(11 Suppl):S1-24.
4. Inbal A, Epstein O, Blickstein D, Kornbrot N, Brenner B,
Martinowitz U. Evaluation of solvent/detergent treated
plasma in the management of patients with hereditary and
acquired coagulation disorders. Blood Coagul Fibrinolysis
1993;4:599-604.
5. Levine MN, Raskob G, Landefeld S, Kearon C.
Hemorrhagic complications of anticoagulant treatment.
Chest 2001;119(1 Suppl):108S-121S.
6. Boulis NM, Bobek MP, Schmaier A, Hoff JT. Use of factor
IX complex in warfarin-related intracranial hemorrhage.
Neurosurgery 1999;45:1113-9.
7. Erhardtsen E, Nony P, Dechavanne M, Ffrench P, Boissel
JP, Hedner U. The effect of recombinant factor VIIa
(NovoSeven) in healthy volunteers receiving
acenocoumarol to an International Normalized Ratio
above 2.0. Blood Coagul Fibrinolysis 1998;9:741-8.
8. Hulka F, Mullins RJ, Frank EH. Blunt brain injury activates
the coagulation process. Arch Surg 1996;131:923-8.
9. Olson JD, Kaufman HH, Moake J, et al. The incidence and
significance of hemostatic abnormalities in patients with
head injuries. Neurosurgery 1989;24:825-32.
10. Chiaretti A, Pezzotti P, Mestrovic J, et al. The influence
of hemocoagulative disorders on the outcome of children
with head injury. Pediatr Neurosurg 2001;34:131-7.
11. Winter JP, Plummer D, Bottini A, Rockswold GR, Ray D.
Early fresh frozen plasma prophylaxis of abnormal
coagulation parameters in the severely head-injured
patient is not effective. Ann Emerg Med 1989;18:553-5.
12. Ciavarella D, Reed RL, Counts RB, et al. Clotting factor
levels and the risk of diffuse microvascular bleeding in
the massively transfused patient. Br J Haematol
1987;67:365-8.
13. Hiippala S. Replacement of massive blood loss. Vox Sang
1998;74 Suppl 2:399-407.
14. Lerner RG, Nelson J, Sorcia E, et al. Evaluation of
solvent/detergent-treated plasma in patients with a
prolonged prothrombin time. Vox Sang 2000;79:161-7.
15. Bernstein DE, Jeffers L, Erhardtsen E, et al.
Recombinant factor VIIa corrects prothrombin time in
cirrhotic patients: a preliminary study. Gastroenterology
1997;113:1930-7.
16. Jeffers L, Chalasani N, Balart L, Pyrsopoulos N,
Erhardtsen E. Safety and efficacy of recombinant factor
VIIa in patients with liver disease undergoing laparoscopic
liver biopsy. Gastroenterology 2002;123:118-26.
17. Raphael JC, Chevret S, Hughes RA, Annane D. Plasma
exchange for Guillain-Barre syndrome. Cochrane
Database Syst Rev 2001:CD001798.
18. Rock GA, Shumak KH, Buskard NA, et al. Comparison of
plasma exchange with plasma infusion in the treatment of
thrombotic thrombocytopenic purpura. Canadian
Apheresis Study Group. N Engl J Med 1991;325:393-7.
19. Bick RL. Alterations of hemostasis associated with
cardiopulmonary bypass: pathophysiology, prevention,
diagnosis, and management. Semin Thromb Hemost
1976;3:59-82.
20. Trimble AS, Osborn JJ, Kerth GW, Gerbode F. The
prophylactic use of fresh frozen plasma after
extracorporeal circulation. J Thorac Cardiovasc Surg
1964;48:314-6.
21. Kasper SM, Giesecke T, Limpers P, Sabatowski R,
Mehlhorn U, Diefenbach C. Failure of autologous fresh
frozen plasma to reduce blood loss and transfusion
requirements in coronary artery bypass surgery.
Anesthesiology 2001;95:81-6.
22. Haubelt H, Blome M, Kiessling AH. Effects of
solvent/detergent-treated plasma and fresh-frozen plasma
on haemostasis and fibrinolysis in complex coagulopathy
following open-heart surgery. Vox Sang 2002;82:9-14.
23. Goodnough LT, Johnston MF, Toy PT. The variability of
transfusion practice in coronary artery bypass surgery.
Transfusion Medicine Academic Award Group. JAMA
1991;265(1):86-90.
24. Stover EP, Siegel LC, Parks R, et al. Variability in
transfusion practice for coronary artery bypass surgery
persists despite national consensus guidelines: a 24-
institution study. Institutions of the Multicenter Study of
Perioperative Ischemia Research Group. Anesthesiology
1998;88:327-33.
25. Kytola L, Nuutinen L, Myllyla G. Transfusion policies in
coronary artery bypass—a nationwide survey in Finland.
Acta Anaesthesiol Scand 1998;42:178-83.
26. Venema D, Schut M, van Oers MH. [Lack of adherence to
the guidelines on the use of fresh frozen plasma]. Ned
Tijdschr Geneeskd 1998;142:1999-2002.
27. Thomson A, Contreras M, Knowles S. Blood component
treatment: a retrospective audit in five major London
hospitals. J Clin Pathol 1991;44:734-7.
28. Beloeil H, Brosseau M, Benhamou D. [Transfusion of
fresh frozen plasma (FFP): audit of prescriptions]. Ann Fr
Anesth Reanim 2001;20:686-92.
29. Pita-Ramirez L, Cabrera Carbajal BE, Ortega Zavala C.
[Reasons for fresh frozen plasma transfusion in a general
hospital]. Rev Invest Clin 1999;51:89-92.
30. Metz J, McGrath KM, Copperchini ML, et al.
Appropriateness of transfusions of red cells, platelets and
fresh frozen plasma. An audit in a tertiary care teaching
hospital. Med J Aust 1995;162:572-3, 576-7.
31. Spiess BD, Gillies BS, Chandler W, Verrier E. Changes in
transfusion therapy and reexploration rate after institution
of a blood management program in cardiac surgical
patients. J Cardiothorac Vasc Anesth 1995;9:168-73.
32. Despotis GJ, Grishaber JE, Goodnough LT. The effect of
an intraoperative treatment algorithm on physicians'
transfusion practice in cardiac surgery. Transfusion
1994;34:290-6.
33. Nuttall GA, Oliver WC, Santrach PJ, et al. Efficacy of a
simple intraoperative transfusion algorithm for
nonerythrocyte component utilization after
cardiopulmonary bypass. Anesthesiology 2001;94:773-81.
34. Marconi M, Almini D, Pizzi MN, et al. Quality assurance
of clinical transfusion practice by implementation of the
privilege of blood prescription and computerized
prospective audit of blood requests. Transfus Med
1996;6:11-9.

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