What dose of cryoprecipitate should be transfused?

Cryoprecipitate Dosing for Transfusion

The recommended initial dose of cryoprecipitate for significant bleeding is 50 mg/kg, which is approximately equivalent to 15-20 units in a 70 kg adult. 1

Indications for Cryoprecipitate Administration

Cryoprecipitate is indicated in the following clinical scenarios:

• When fibrinogen concentration is less than 1.5-2.0 g/L in the presence of significant bleeding 1
• When thromboelastometric signs show a functional fibrinogen deficit 1
• As an adjunct in massively transfused patients when fibrinogen concentrations cannot be measured in a timely fashion 1
• For patients with congenital fibrinogen deficiencies 1

Dosing Guidelines

Initial Dosing

• For adults with significant bleeding and hypofibrinogenemia: 50 mg/kg of cryoprecipitate (approximately 15-20 units in a 70 kg adult) 1
• For patients with plasma fibrinogen level <1 g/L: 3-4 g of fibrinogen concentrate or equivalent cryoprecipitate dose 2
• For management of symptomatic intracranial bleeding after alteplase: 10 units of cryoprecipitate infused over 10-30 minutes 2

Repeat Dosing

• Subsequent doses should be guided by laboratory assessment of fibrinogen levels or thromboelastometric monitoring 1, 2
• Target fibrinogen level should be above 1.5-2.0 g/L for effective hemostasis 2
• Additional fibrinogen should not be administered if plasma concentration is over 1.5 g/L 2

Monitoring Parameters

• Measure fibrinogen levels before and after administration to guide dosing 2
• Use either laboratory assessment of fibrinogen concentration or viscoelastic monitoring of functional fibrinogen 2
• In trauma patients, a maximum clot firmness of 7 mm on thromboelastometry correlates with a fibrinogen level of approximately 2 g/L 1

Clinical Considerations

• Fibrinogen is often the first coagulation factor to decrease critically during massive blood loss replacement 1
• During postpartum hemorrhage, fibrinogen plasma concentration <2 g/L has a positive predictive value of 100% for progression to severe bleeding 1
• Transfusion of cryoprecipitate is rarely indicated if fibrinogen concentration is greater than 150 mg/dL in non-pregnant patients 1

Recent Evidence on Empiric Cryoprecipitate Administration

• The CRYOSTAT-2 trial found that early empirical high-dose cryoprecipitate (3 pools, equivalent to 15 units or 6 g of fibrinogen) did not improve 28-day mortality in trauma patients with major hemorrhage compared to standard care 3, 4
• A US subanalysis of the CRYOSTAT-2 trial showed no benefit of empiric cryoprecipitate with respect to post-emergency department transfusions, complications, or mortality 5

Cost Considerations

• Fibrinogen concentrate is more expensive than cryoprecipitate, even after adjusting for cryoprecipitate wastage 6
• To be economically competitive with cryoprecipitate, fibrinogen concentrate would need to cost $414/g or demonstrate savings in ICU length of stay 6

Practical Application

For a 70 kg adult with significant bleeding and fibrinogen <1.5 g/L:

1. Administer 15-20 units of cryoprecipitate (approximately 50 mg/kg) 1
2. Infuse as rapidly as possible within clinical constraints 3
3. Measure post-transfusion fibrinogen levels 2
4. Administer additional doses as needed to maintain fibrinogen >1.5-2.0 g/L 2