What to do if a patient has hypofibrinogenemia?

Management of Hypofibrinogenemia

For patients with hypofibrinogenemia and significant bleeding, treatment with fibrinogen concentrate (3-4g) or cryoprecipitate (15-20 units in a 70kg adult) is recommended when plasma fibrinogen levels fall below 1.5 g/L.

Diagnosis and Assessment

• Measure plasma fibrinogen levels using the Clauss method
• Consider viscoelastic testing (thromboelastometry/ROTEM) if available, particularly in trauma settings
• Normal plasma fibrinogen concentration ranges from 2 to 4 g/L
• Without supplementation, fibrinogen is the first coagulation factor to fall to critically low levels during major hemorrhage 1

Treatment Algorithm

For Active Bleeding with Hypofibrinogenemia:

1. If fibrinogen level < 1.5 g/L (or < 2.0 g/L in obstetric hemorrhage):

   • Administer fibrinogen concentrate 3-4g IV 2, 1
   • OR administer cryoprecipitate 15-20 units (approximately 50 mg/kg) 2

2. Monitor response:

   • Repeat fibrinogen level measurement after administration
   • Target fibrinogen level ≥ 1.5 g/L in most cases 1
   • Target fibrinogen level ≥ 2.0 g/L in obstetric hemorrhage 2

3. Repeat dosing as needed:

   • Guided by laboratory assessment of fibrinogen levels or viscoelastic monitoring 2
   • Continue monitoring during ongoing bleeding

For Non-Bleeding Patients with Hypofibrinogenemia:

• If fibrinogen < 1.0 g/L with planned invasive procedure:
  • Consider prophylactic fibrinogen replacement 2
  • Target level depends on bleeding risk of procedure

Specific Clinical Scenarios

Trauma Patients:

• Maintain fibrinogen ≥ 1.5 g/L 2
• Consider early administration of tranexamic acid 2
• Use viscoelastic testing if available to guide therapy 2

Obstetric Hemorrhage:

• Target higher fibrinogen levels (≥ 2.0 g/L) 2
• Early aggressive correction may improve outcomes 3

Disseminated Intravascular Coagulation (DIC):

• Treat underlying condition as cornerstone of management 4
• Replace fibrinogen if level < 1.0 g/L with persistent bleeding despite FFP 4
• Consider antifibrinolytic agents only in primary hyperfibrinolytic states 4

Advantages of Fibrinogen Concentrate vs. Cryoprecipitate

• Fibrinogen concentrate:

  • Faster to administer (no thawing required) 2
  • More predictable fibrinogen content 5
  • Lower infection risk (viral inactivation) 5
  • Smaller volume infusion 3

• Cryoprecipitate:

  • More widely available in some regions
  • Contains additional factors (vWF, FXIII, fibronectin) 2
  • Generally less expensive

Important Considerations

• Fibrinogen concentrate produces a greater increment in fibrinogen levels per unit administered compared to cryoprecipitate (0.44 g/L vs 0.26 g/L per standard dose) 5
• Artificial colloids like hydroxyethyl starch may cause overestimation of fibrinogen levels when using the Clauss method 2
• The European guideline recommends treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by plasma fibrinogen level < 1.5 g/L 2
• In massive hemorrhage, consider administering fibrinogen replacement early rather than waiting for laboratory confirmation of hypofibrinogenemia 2

Monitoring and Follow-up

• Repeat fibrinogen levels after replacement therapy
• Continue monitoring during active bleeding
• Assess clinical response (reduction in bleeding)
• Monitor for potential adverse effects (thrombotic complications, allergic reactions)

Remember that while fibrinogen replacement is crucial in managing hypofibrinogenemia, treating the underlying cause of fibrinogen depletion remains essential for successful management.