When is cryoprecipitate (cryoprecipitated antihemophilic factor) indicated for administration in trauma patients?

Indications for Cryoprecipitate Administration in Trauma

Cryoprecipitate should be administered in trauma patients when significant bleeding is accompanied by a plasma fibrinogen level of less than 1.5 g/L (or less than 2.0 g/L in obstetric hemorrhage). 1

Components and Dosing

Cryoprecipitate is a concentrated plasma product containing:

• Fibrinogen
• Factor VIII
• von Willebrand factor
• Factor XIII
• Fibronectin

The recommended dosing for trauma patients:

• Initial dose: 15-20 units (approximately 50 mg/kg) in a 70-kg adult 2
• Each single unit contains 400-450 mg of fibrinogen
• Pooled bags of five units contain at least 2 g of fibrinogen
• Standard adult dose is two pools 2
• Administer using a standard blood giving set with a 170-200 μm filter 2

Specific Indications in Trauma

Cryoprecipitate is indicated in the following trauma scenarios:

1. Major hemorrhage with hypofibrinogenemia:

   • When fibrinogen levels fall below 1.5 g/L during active bleeding 2, 1
   • During massive transfusion protocols when laboratory confirmation may be delayed 1

2. Disseminated intravascular coagulation (DIC):

   • When fibrinogen level is < 1.0 g/L 2
   • When DIC is accompanied by active bleeding 2

3. Combined trauma with liver and renal failure:

   • When accompanied by bleeding 2

4. Trauma with thrombolytic therapy complications:

   • When bleeding is associated with prior thrombolytic therapy 2

Target Fibrinogen Levels

• Maintain fibrinogen ≥ 1.5 g/L during major hemorrhage in trauma 2, 1
• For obstetric hemorrhage, maintain higher levels (≥ 2.0 g/L) 2, 1

Monitoring and Administration Timing

• Measure fibrinogen levels using the Clauss method or viscoelastic testing (ROTEM/TEG) if available 1
• Repeat doses should be guided by laboratory assessment of fibrinogen levels 2
• Early administration is critical - aim to deliver cryoprecipitate within 90 minutes of hospital admission in major trauma 3
• Consider empiric administration in massive hemorrhage protocols rather than waiting for laboratory confirmation 1

Cryoprecipitate vs. Fibrinogen Concentrate

Both options are available for fibrinogen replacement, with some differences:

Fibrinogen concentrate advantages:

• Faster to administer
• More predictable fibrinogen content
• Lower infection risk
• Smaller volume infusion 1
• Associated with reduced transfusion requirements compared to cryoprecipitate 4

Cryoprecipitate advantages:

• Contains additional coagulation factors (vWF, FXIII, fibronectin)
• Generally less expensive 1
• More widely available in many trauma centers

Safety Considerations

• Cryoprecipitate is a pooled blood product with associated transfusion risks
• Potential adverse effects include allergic reactions, anaphylaxis, and transfusion-related acute lung injury 2, 5
• Monitor for thrombotic complications, particularly in patients with risk factors 1
• In some European countries, cryoprecipitate has been withdrawn due to safety concerns and replaced with pathogen-inactivated fibrinogen concentrate 5

Important Clinical Considerations

• Fibrinogen is typically the first coagulation factor to fall to critically low levels during major hemorrhage 1
• Consider early administration of tranexamic acid alongside cryoprecipitate in trauma patients 2, 1
• Recent evidence from the CRYOSTAT-2 trial suggests that empirical high-dose cryoprecipitate (6g fibrinogen equivalent) did not improve 28-day mortality compared to standard care in trauma patients with major hemorrhage 6
• Artificial colloids like hydroxyethyl starch may cause overestimation of fibrinogen levels when using the Clauss method 1

By following these guidelines for cryoprecipitate administration in trauma, clinicians can optimize hemostatic resuscitation and potentially improve outcomes in patients with traumatic hemorrhage.