When to transfuse Fresh Frozen Plasma (FFP) for low fibrinogen levels?

When to Transfuse FFP for Low Fibrinogen

Fresh Frozen Plasma (FFP) should not be used as first-line therapy for isolated low fibrinogen levels; instead, cryoprecipitate is indicated when fibrinogen concentration is less than 80-100 mg/dL in the presence of excessive microvascular bleeding. 1

Fibrinogen Replacement Algorithm

Assessment

• Measure fibrinogen level whenever possible before administering blood products
• Consider clinical context (active bleeding, planned procedure, etc.)

Treatment Decision Tree

For Low Fibrinogen with Active Bleeding:

1. Fibrinogen > 150 mg/dL:

   • Cryoprecipitate rarely indicated in non-pregnant patients 1
   • Consider other causes of bleeding

2. Fibrinogen 100-150 mg/dL:

   • Monitor closely
   • Consider cryoprecipitate only if excessive microvascular bleeding continues

3. Fibrinogen < 80-100 mg/dL with active bleeding:

   • Administer cryoprecipitate (first-line therapy) 1
   • FFP is not the preferred product for isolated fibrinogen replacement

4. Massive transfusion scenario:

   • When fibrinogen cannot be measured in a timely fashion:
     • Cryoprecipitate is indicated as an adjunct therapy 1
     • FFP may be used when transfused with more than one blood volume (~70 ml/kg) 1

Special Situations

Congenital Fibrinogen Deficiencies:

• Consult with patient's hematologist whenever possible 1
• Cryoprecipitate is indicated 1

Obstetric Patients:

• Higher fibrinogen threshold may be warranted 1

Rationale for Cryoprecipitate Over FFP

Cryoprecipitate is preferred over FFP for fibrinogen replacement because:

1. Higher concentration of fibrinogen per volume
2. Lower volume of administration required to achieve hemostatic fibrinogen levels
3. Reduced risk of volume overload compared to FFP

When FFP May Be Appropriate

FFP transfusion is indicated in the following scenarios:

1. Correction of excessive microvascular bleeding with INR > 2.0 (in absence of heparin) 1
2. Massive transfusion (>70 ml/kg) with coagulation factor deficiency when PT/INR/aPTT cannot be obtained promptly 1
3. Urgent warfarin reversal when PCCs unavailable 1
4. Known coagulation factor deficiencies without specific concentrates 1

Important Caveats

• FFP contains fibrinogen but at lower concentrations than cryoprecipitate
• Transfused platelets and fibrinogen may have very short lifespans in patients with vigorous coagulation activation 1
• Fibrinogen concentrate may be superior to FFP for treating dilutional coagulopathy 2, 3
• FFP is not indicated solely for augmentation of plasma volume or albumin concentration 1

Dosing Guidelines

• FFP: 10-15 ml/kg to achieve minimum 30% plasma factor concentration 1
• Cryoprecipitate: Typically 1 unit per 7-10 kg body weight

By following this algorithm, you can optimize patient outcomes by selecting the most appropriate blood product for fibrinogen replacement while minimizing unnecessary transfusions and associated risks.