Fresh frozen plasma in burn resuscitation

Overview

Fresh frozen plasma (FFP) is gaining attention as a colloid adjunct in burn resuscitation, distinct from albumin in that it provides coagulation factors, fibrinogen, and other plasma proteins in addition to oncotic pressure. The rationale for FFP use in burns extends beyond simple volume expansion: severe burn injury produces a burn-induced coagulopathy and endotheliopathy that may be specifically addressed by plasma-inclusive resuscitation ^[2][4]. Whether FFP is superior to albumin as a colloid in burns remains an open question, but early observational data suggest FFP is safe and effective at reducing crystalloid requirements ^[1][3].

Burn-Induced Coagulopathy

Severe burns produce a complex coagulation disturbance that evolves over the first weeks after injury. Zhang et al. studied coagulation parameters in 104 patients with third-degree burns of 30% TBSA or greater and found that coagulation dysfunction was most prominent at 1 week, presenting as hypercoagulability ^[4]. Non-survivors had significantly higher INR and APTT and lower fibrinogen and platelet counts compared with survivors. On the day of death, 9 of 12 non-survivors had disseminated intravascular coagulation ^[4]. Large burn size, massive fluid resuscitation, inhalation injury, and sepsis all contributed to coagulation dysfunction ^[4].

Huzar et al. found that 60% of severely burned patients were hypercoagulable on admission by rapid thromboelastography (rTEG), while 24% were hypocoagulable ^[5]. Hypocoagulable patients had increased resuscitation and transfusion requirements. An activated clotting time of 128 or greater on admission rTEG predicted a 5-fold increased likelihood of supra-normal resuscitation (exceeding 5 mL/kg/%TBSA) ^[5].

Clinical Evidence for FFP in Burn Resuscitation

The central question is whether adding FFP to crystalloid resuscitation improves endpoints without introducing complications. Current evidence addresses two domains: resuscitation efficacy and coagulation safety.

Efficacy

Whether a standardized FFP infusion can improve resuscitation endpoints was tested by Wiktor et al. in a small single-center study of 53 patients with burns greater than 20% TBSA ^[1]. A fixed, non-titratable 8-hour FFP infusion (0.5 mL/kg/%TBSA) was added to a nursing-driven crystalloid protocol. Median input/output ratio improved from 0.8 at FFP initiation to 0.4 at 3 hours post-FFP (P < 0.001), and median urine output improved from 0.19 to 0.52 mL/kg/hr (P < 0.001). No complications related to resuscitation (abdominal compartment syndrome, ARDS, or transfusion reactions) occurred ^[1]. The protocol's value is in providing a standardized, reproducible framework for testing colloid optimization during burn resuscitation ^[1].

Safety: coagulation profile

A key concern with plasma-inclusive resuscitation is whether FFP shifts burn patients toward a prothrombotic state. Two prospective studies address this directly. Soo Ping Chow et al. characterized the endothelial, coagulation, and inflammatory profile of 33 burn patients before and after the first unit of FFP and found that while 8 biomarkers showed small but statistically significant reductions (factor VIII, fibrinogen, protein C, TFPI, TNF-alpha receptor 1, and others), post-unit concentrations either remained within or moved closer to expected reference ranges ^[2]. Separately, Mathew et al. analyzed viscoelastic assays in 35 patients receiving plasma-inclusive resuscitation and found no prothrombotic or lytic changes relative to baseline, with no transfusion reactions or thrombotic events observed ^[3]. Taken together, these data indicate that FFP does not produce clinically significant prothrombotic or inflammatory perturbations in burn patients ^[2][3].

Clinical Guidance

Evidence for FFP in burn resuscitation remains limited to small, single-center observational studies. FFP should not yet be considered a routine component of burn resuscitation. The following guidance reflects the best available data and should be applied within institutional protocols.

When to consider FFP: Burns greater than 20% TBSA with evidence of coagulopathy on admission, such as a hypocoagulable profile on rTEG or elevated INR ^[1][5]. Patients who are hypocoagulable on admission are at higher risk for supra-normal resuscitation volumes and may benefit most from early plasma supplementation ^[5].

Dose: The only prospectively tested protocol is 0.5 mL/kg/%TBSA delivered as a fixed, non-titratable infusion over 8 hours, added to standard crystalloid resuscitation ^[1]. No dose-finding studies exist.

Where evidence is too thin: No randomized controlled trial has compared FFP-inclusive to crystalloid-only or albumin-inclusive resuscitation. Effects on ventilator days, ICU length of stay, and mortality are unknown. FFP should be used only within institutional protocols that include prospective data collection, not as ad hoc rescue therapy outside a structured framework.

FFP versus Albumin

Whether FFP is superior to albumin as the colloid of choice in burn resuscitation is the current frontier question ^[6]. FFP provides coagulation factors and addresses endotheliopathy, which albumin does not. However, FFP carries risks of transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and alloimmunization. FFP also requires thawing time and has blood-type matching requirements, making it less rapidly available than albumin. Head-to-head comparison data in the burn population are extremely limited ^[6].

Controversies and Evidence Gaps

The optimal timing, dose, and duration of FFP administration during burn resuscitation are undefined. Wiktor et al. used a fixed non-titratable dose (0.5 mL/kg/%TBSA over 8 hours), while other centers use FFP as rescue therapy ^[1]. No randomized controlled trial has compared FFP-inclusive to crystalloid-only or albumin-inclusive resuscitation in burns. The effects of FFP on long-term outcomes (ventilator days, ICU length of stay, mortality) are unknown from the current evidence base. Whether burn-induced coagulopathy requires active treatment with FFP or is adequately managed by supportive care and crystalloid resuscitation alone is an unresolved question ^[4].

References

[1] Wiktor AJ et al. "Safety and Efficacy of an Early Low-Dose Fresh Frozen Plasma Infusion in Burn Resuscitation." J Burn Care Res 2025. PMID: 41466517 [2] Soo Ping Chow AM et al. "Characterization of the Endothelial, Coagulofibrinolytic, and Inflammatory Profile in Burn Patients after Resuscitation with Fresh Frozen Plasma." J Burn Care Res 2025;46(6):1194-1200. PMID: 40402034 [3] Mathew SK et al. "Plasma Inclusive Resuscitation Is Not Associated With Coagulation Profile Changes in Burn Patients." J Surg Res 2024;303:233-240. PMID: 39378792 [4] Zhang TN et al. "Coagulation dysfunction of severe burn patients: A potential cause of death." Burns 2022;49(3):678-687. PMID: 35623933 [5] Huzar TF et al. "Admission Rapid Thrombelastography (rTEG) Values Predict Resuscitation Volumes and Patient Outcomes After Thermal Injury." J Burn Care Res 2018;39(3):345-352. PMID: 28570309 [6] Cartotto R et al. "Burn State of the Science: Fluid Resuscitation." J Burn Care Res 2017;38(3):e735-e751. PMID: 28328669