What to do for a patient with hypofibrinogenemia after plasmapheresis (plasma exchange)?

From the Guidelines

For a patient with hypofibrinogenemia after plasmapheresis with a fibrinogen level of 94 mg/dL, the primary treatment is fibrinogen replacement through cryoprecipitate administration, with an initial dose of 3-4 g, equivalent to 15-20 single donor units of cryoprecipitate, as recommended by the European guideline on management of major bleeding and coagulopathy following trauma 1.

The patient's fibrinogen level is below the recommended threshold, indicating a need for supplementation to prevent bleeding complications. Cryoprecipitate is preferred due to its high fibrinogen content and is recommended for treatment of acquired hypofibrinogenemia, especially in cases of clinically significant bleeding or high bleeding risk 1.

Key considerations for treatment include:

• Administering an initial dose of 3-4 g of fibrinogen, which can be achieved with 15-20 single donor units of cryoprecipitate 1
• Monitoring fibrinogen levels before and after replacement therapy to ensure adequate correction
• Considering adjunctive therapies, such as tranexamic acid, in cases of severe bleeding with hypofibrinogenemia
• Prophylactic fibrinogen replacement or modified replacement fluids that include FFP for patients requiring regular plasmapheresis

It is essential to note that the patient's blood group should be matched with the donor blood group for FFP and cryoprecipitate transfusion, and ABO non-identical plasma is acceptable if it has 'low titre' anti-A or anti-B activity 1.

In this case, since the patient's fibrinogen level is 94 mg/dL, which is below the recommended threshold, cryoprecipitate administration with an initial dose of 3-4 g is the most appropriate treatment option, as it will help raise the fibrinogen level and reduce the risk of bleeding complications 1.

From the Research

Next Steps for Hypofibrinogenemia after Plasmapheresis

• The patient's fibrinogen level is 94 mg/dL, which is considered low, but not critically low according to some studies 2.
• Fibrinogen supplementation can be achieved using plasma or cryoprecipitate, but there are safety concerns associated with these allogeneic blood products 3.
• Fibrinogen concentrate provides a promising alternative to allogeneic blood products, allowing for a standardized dose of fibrinogen to be rapidly administered in a small volume, with a good safety profile and viral inactivation as standard 3.
• The decision to supplement fibrinogen should be based on individual patient risk factors, such as bleeding risk and anticoagulation therapy 4.
• Some studies suggest that a lower fibrinogen threshold does not lead to increased bleeding risk in patients receiving therapeutic plasma exchange, but this may depend on individual patient factors 2, 5.

Considerations for Fibrinogen Replacement

• Fibrinogen levels can be monitored using standard coagulation tests and ROTEM® tests 6.
• Replacement with fibrinogen concentrate or fresh frozen plasma (FFP) can help maintain fibrinogen levels > 1 g/L after plasmapheresis, but FFP replacement may be associated with a lower bleeding risk 6.
• The choice of replacement fluid should be based on individual patient needs and risk factors, as well as the availability of replacement fluids 4.

Bleeding Risk Assessment

• Bleeding risk should be assessed individually, taking into account patient factors such as anticoagulation therapy, bleeding history, and underlying medical conditions 2, 4.
• Point-of-care viscoelastic testing can be used to guide individualized dosing of fibrinogen concentrate and assess bleeding risk 3.