Fresh frozen plasma (FFP) is a blood product that has been available since 1941 [1]. Initially used as a volume expander, it is currently indicated for the management and prevention of bleeding in coagulopathic patients [1-3]. The evidence on FFP transfusion is scant and of limited quality [4].Estimates state that 25 to 30% of all critical care patients receive FFP transfusions [5,6]. selleck chemical Enzastaurin Despite its commonality, only 37% of the physicians in a recent study correctly responded to basic questions about FFP, including the volume of one unit [7]. An audit on transfusion practices suggested that one-half of all FFP transfused to critical care patients is inappropriate [5].Massive haemorrhage is among the most challenging issues in critical care, affecting trauma patients, surgical patients, obstetric patients and gastrointestinal patients [3,8,9].

In trauma, a recent series of retrospective clinical studies suggests that early and aggressive use of FFP at a 1:1 ratio with red blood cells (RBC) improves survival in cases of massive haemorrhage [10-19]. Because bleeding is directly responsible for 40% of all trauma-related deaths, this strategy – also known as haemostatic damage control or formula-driven resuscitation – has received substantial attention worldwide. This early formula-driven haemostatic resuscitation proposes transfusion of FFP at a near 1:1 ratio with RBC, thus addressing coagulopathy from the beginning of the resuscitation and potentially reducing mortality. Nevertheless, this strategy requires immediate access to large volumes of thawed universal donor FFP, which is challenging to implement.

Despite conflict with existing guidelines, early formula-driven haemostatic resuscitation use is expanding and is gradually being used in nontraumatic bleedings in critical care [20]. Both the existing guidelines and early formula-driven haemostatic resuscitation are supported by limited evidence, generating controversies and challeng ing clinical decisions in critical care (Table (Table1).1). The objective of the present article is to review the evidence on FFP in the management of massive traumatic haemorrhage and to critically appraise early formula-driven haemostatic resuscitation, providing the reader with resources to develop an informed opinion on the current controversy.

Table 1Arguments for and against the adoption of early formula-driven haemostatic resuscitation in traumaPlasma basics’Fresh frozen plasma’ is a confusing term as plasma cannot be fresh and frozen GSK-3 at the same time. Fresh refers to timing from collection to freezing, and frozen refers to the long-term storage condition. FFP transfusion must be ABO compatible, with AB being the universal type, lacking anti-A and anti-B antibodies. Only 4% of the population is AB, resulting in chronic shortage of this blood type [21].