How to correct low CFF on TEG?

Correcting Low Citrated Functional Fibrinogen (CFF) on Thromboelastography (TEG)

For patients with low Citrated Functional Fibrinogen (CFF) on TEG, administer cryoprecipitate or fibrinogen concentrate (30-60 mg/kg) to correct the deficiency, as these provide more targeted and effective fibrinogen replacement than fresh frozen plasma. 1

Understanding Low CFF on TEG

• TEG is a whole blood viscoelastic test that provides a global assessment of hemostatic function by measuring the viscoelastic changes associated with fibrin polymerization 2
• Low CFF on TEG indicates decreased functional fibrinogen levels, which impairs clot formation and strength 3
• Hypofibrinogenemia in TEG is typically identified by:
  • Reduced maximum amplitude (MA) on the functional fibrinogen channel
  • Weak clot formation
  • Potentially prolonged clotting time 3

Diagnostic Thresholds

• Severe hypofibrinogenemia: fibrinogen level <0.5 g/L
• Moderate hypofibrinogenemia: fibrinogen level between 0.5-0.9 g/L
• Mild hypofibrinogenemia: fibrinogen level between 1.0 g/L and lower limit of normal 1
• On TEG, a functional fibrinogen TEG MA <20 mm indicates significant fibrinogen deficiency requiring correction 3

Treatment Options

First-Line Therapy:

• Cryoprecipitate: Two pools of cryoprecipitate for adults with active bleeding and low CFF 3, 1

  • Contains concentrated fibrinogen and other coagulation factors
  • More effective than FFP for targeted fibrinogen replacement

• Fibrinogen Concentrate: 30-60 mg/kg for patients with low CFF 1

  • Advantages include rapid administration, no thawing required, pathogen-inactivated, and precise dosing
  • Provides more predictable fibrinogen levels than FFP

Alternative Option:

• Fresh Frozen Plasma (FFP): Should be avoided for hypofibrinogenemia correction if cryoprecipitate or fibrinogen concentrate are available 3
  • If used, requires high volumes (≥30 mL/kg) in severe cases 1
  • Less efficient for fibrinogen replacement as it contains only ~70% of normal levels of clotting factors 3

Monitoring Response

• Repeat TEG after administration of replacement therapy to ensure adequate correction 1
• Target fibrinogen level ≥1.5 g/L in most clinical scenarios 1
• For patients with liver disease, target fibrinogen levels may need to be higher (≥2.0 g/L) 3
• One unit of FFP typically corrects reaction time (R) by approximately 5 minutes, but response varies significantly between patients 4

Special Considerations in Liver Disease

• Patients with cirrhosis often have rebalanced hemostasis despite abnormal conventional coagulation tests 3
• TEG-guided blood product transfusion in cirrhosis patients has been shown to decrease transfusion requirements (16.7% vs. 100%) compared to standard care using INR and platelet count 3
• When correction is needed in cirrhosis patients, low-volume cryoprecipitate or four-factor prothrombin complex concentrate are preferred to high-volume FFP 3
• INR should not be used to gauge bleeding risk in patients with cirrhosis 3

Pitfalls to Avoid

• Delaying fibrinogen replacement in actively bleeding patients; early intervention is critical 1
• Using standard FFP doses (15 mL/kg) in massive hemorrhage, which are often inadequate 1
• Failing to treat underlying causes of acquired hypofibrinogenemia (e.g., DIC, liver disease) 1
• Not considering the risk of thrombosis when administering fibrinogen products, especially in patients with thrombotic history 1

Efficacy of TEG-Guided Therapy

• TEG-guided transfusion strategies have been shown to result in fewer blood transfusions compared to conventional coagulation test-guided strategies 3
• TEG-guided therapy allows for more targeted correction of specific coagulation defects rather than empiric transfusion 5
• In trauma patients, TEG-guided resuscitation has demonstrated lower mortality at 24 hours (5% vs. 13%) and 30 days (11% vs. 25%) compared to conventional testing 3