Fresh frozen plasma as an adjunctive therapy in acute organophosphate poisoning: a systematic review and...

Organophosphate poisoning is a leading cause of pesticide-related morbidity and mortality globally, particularly in low- and middle-income countries. Standard treatment with atropine and oximes has well-recognized limitations, and fresh frozen plasma has been proposed as an adjunctive therapy through exogenous butyrylcholinesterase supplementation. However, its clinical efficacy remains uncertain. This systematic review and meta-analysis evaluate the efficacy and safety of fresh frozen plasma as an adjunctive therapy in acute organophosphate poisoning.

We conducted a systematic review and meta-analysis following PRISMA guidelines. We searched PubMed, Cochrane Library, Science Direct, Google Scholar, Europe PMC, Trip Database, LILACS, IMSEAR, and trial registries from inception to July 2025 for randomized controlled trials comparing adjunctive fresh frozen plasma with standard therapy alone in hospitalized patients with acute symptomatic organophosphate poisoning. Pairs of reviewers independently screened studies, extracted data, assessed risk of bias using the Cochrane RoB2 tool, and evaluated certainty of evidence using GRADE. The primary outcome was mortality. Secondary outcomes included length of hospital stay, need for mechanical ventilation, atropine requirements, and adverse events.

Seven randomized controlled trials (total n = 421) were included. Meta-analysis of six studies (n = 369) showed no statistically significant mortality reduction with fresh frozen plasma (risk ratio 0.58; 95% confidence interval 0.27-1.25; I² = 17%; very low certainty). Fresh frozen plasma was associated with a shorter hospital stay (mean difference -1.89 days; 95% confidence interval -3.68 to -0.11; I² = 77%; very low certainty) and a reduced need for mechanical ventilation (risk ratio 0.80; 95% confidence interval 0.66-0.96; I² = 9%; low certainty). Atropine requirement data were heterogeneously reported and not suitable for meta-analysis. Non-severe adverse events were infrequent, primarily urticaria (risk ratio 3.59; 95% confidence interval 0.60-21.44; low certainty).

The available evidence suggests that adjunctive fresh frozen plasma may reduce the need for mechanical ventilation and shorten hospital stay in acute organophosphate poisoning, but it did not demonstrate a significant mortality benefit. These findings are limited by the small number of trials, methodological heterogeneity, and a generally high risk of bias across studies.

Adjunctive fresh frozen plasma may offer modest benefits in reducing ventilator dependence and hospitalization duration in acute organophosphate poisoning, with a manageable safety profile. However, current evidence is of low to very low certainty and insufficient to support routine use. Larger, high-quality randomized controlled trials are needed to definitively establish its role in clinical management.