Should plasma or cryoprecipitate be given to a patient with coagulopathy?

Fibrinogen Replacement in Coagulopathy: Cryoprecipitate vs. Plasma

For patients with coagulopathy and active bleeding, cryoprecipitate should be administered when fibrinogen levels fall below 1.5 g/L (or below 2.0 g/L in obstetric hemorrhage), as it provides more concentrated fibrinogen than plasma and leads to better outcomes. 1, 2

Assessment of Fibrinogen Levels

• Use laboratory testing to determine fibrinogen levels:

  • Clauss fibrinogen assay (most accurate method)
  • Viscoelastic testing (ROTEM/TEG) if available, particularly useful in trauma settings
  • Target FIBTEM A5 or MCF parameters if using viscoelastic testing

• Critical thresholds requiring intervention:

  • Fibrinogen < 1.5 g/L in trauma and general bleeding
  • Fibrinogen < 2.0 g/L in obstetric hemorrhage
  • Viscoelastic signs of functional fibrinogen deficit

Treatment Algorithm

First-line Treatment:

1. Cryoprecipitate administration:

   • Initial dose: 15-20 single donor units (equivalent to 3-4g fibrinogen) 1
   • This provides approximately 400-450mg fibrinogen per unit
   • Administer using standard blood giving set with 170-200 μm filter 2

2. Alternative option - Fibrinogen concentrate:

   • Initial dose: 3-4g IV infusion 1, 3
   • Advantages over cryoprecipitate: faster administration, more predictable fibrinogen content, lower infection risk, smaller volume 2, 3
   • Non-inferior to cryoprecipitate in cardiac surgery patients with significant hemorrhage 3

Monitoring and Repeat Dosing:

• Repeat fibrinogen level measurement after initial replacement
• Continue monitoring during active bleeding
• Guide subsequent doses based on:
  • Laboratory fibrinogen levels
  • Viscoelastic testing results
  • Clinical response (reduction in bleeding)

Why Cryoprecipitate Over Plasma?

Cryoprecipitate is superior to plasma for fibrinogen replacement because:

1. Higher fibrinogen concentration:

   • Cryoprecipitate contains concentrated fibrinogen (approximately 15g/L)
   • FFP contains relatively low fibrinogen levels (approximately 2g/L) 1

2. Volume considerations:

   • FFP requires excessive volumes to achieve target fibrinogen levels
   • Mathematical modeling shows it's extremely difficult to achieve fibrinogen levels >1.8 g/L with FFP alone 1

3. Additional beneficial components:

   • Cryoprecipitate contains other important coagulation factors:
     • Factor VIII
     • von Willebrand factor
     • Factor XIII (important for clot stability)
     • Fibronectin 4, 5, 6

Clinical Considerations

• Timing: Early administration of fibrinogen replacement is crucial in massive hemorrhage 1, 2

• Combination therapy: Consider adding tranexamic acid alongside cryoprecipitate in trauma patients to inhibit fibrinolysis 2

• Goal-directed approach: Use viscoelastic testing when available to guide individualized coagulation therapy rather than fixed ratio protocols 1

• Platelet considerations: Maintain platelet count >50 × 10^9/L in general bleeding and >100 × 10^9/L in traumatic brain injury 1

Pitfalls to Avoid

1. Delayed administration: Fibrinogen is often the first coagulation factor to critically decrease during massive blood loss 1

2. Overreliance on plasma: FFP alone is impractical for increasing fibrinogen levels >1.5 g/L due to volume limitations 1

3. Fixed ratio protocols without monitoring: While 1:1:1 (RBC:FFP:platelets) protocols are used in severe trauma, goal-directed therapy guided by laboratory or viscoelastic testing is preferred for optimal outcomes 1

4. Ignoring fibrinogen levels: Low fibrinogen (<1.5 g/L) is strongly associated with increased mortality in major trauma patients 1

5. Artificial colloids interference: Hydroxyethyl starch may cause overestimation of fibrinogen levels when using the Clauss method 2

The evidence strongly supports using cryoprecipitate or fibrinogen concentrate over plasma for treating hypofibrinogenemia in coagulopathic patients, with the choice between these two products depending on local availability, cost considerations, and specific clinical scenarios.