What are the composition and indications for Cryoprecipitate (Cryo) and Fresh Frozen Plasma (FFP) based on Thromboelastography (TEG) or Rotational Thromboelastometry (ROTEM) results?

Composition and Indications for Cryoprecipitate and Fresh Frozen Plasma Based on TEG/ROTEM Results

Viscoelastic testing (TEG or ROTEM) should guide the administration of cryoprecipitate when fibrinogen levels are below 1.5 g/L in actively bleeding patients, while FFP should be administered when there is evidence of coagulation factor deficiency with INR >2.0 or when fibrinogen-specific products are unavailable. 1, 2

Composition of Blood Products

Cryoprecipitate

• Contains concentrated fibrinogen (approximately 250 mg per unit), factor VIII, von Willebrand factor, factor XIII, and fibronectin 2
• Available as single units (20-40 ml) or pooled bags of five units (100-200 ml) 2
• Each single unit contains 400-450 mg of fibrinogen, with pools of five units containing at least 2 g 2
• Fibrinogen concentration in cryoprecipitate typically ranges between 15-17 g/L 2

Fresh Frozen Plasma (FFP)

• Contains all soluble coagulation factors including labile factors V and VIII 2
• Relatively low fibrinogen concentration (2.5-3.0 g/L, sometimes as low as 0.9-2.0 g/L) 2
• Standard volume is approximately 300 ml per bag 2
• Four units of FFP contain approximately 2 g of fibrinogen (compared to 4 g in two pools of cryoprecipitate) 2

Indications Based on TEG/ROTEM Results

Cryoprecipitate Indications

• Functional fibrinogen deficit on thromboelastometry (maximum clot firmness <7 mm on FIBTEM correlates with fibrinogen level of approximately 2 g/L) 1
• When fibrinogen concentration is <1.5 g/L (or <2 g/L in obstetric hemorrhage) with active bleeding 2
• As adjunct therapy in massive transfusion protocols when fibrinogen levels cannot be measured in a timely fashion 2
• Initial dose should be 50 mg/kg (approximately 15-20 units in a 70-kg adult) 2, 1

Fresh Frozen Plasma Indications

• When TEG/ROTEM shows prolonged clotting time (R time in TEG or CT in ROTEM) suggesting coagulation factor deficiency 2
• For correction of excessive microvascular bleeding with INR >2.0 in the absence of heparin 2
• For correction of coagulation factor deficiency in patients receiving massive transfusion (>1 blood volume) when PT/INR cannot be obtained quickly 2
• Recommended therapeutic dose is 15 ml/kg 2
• Not indicated if PT/INR and aPTT are normal or solely for volume replacement 2

TEG/ROTEM-Guided Transfusion Algorithm

Fibrinogen Deficiency (FIBTEM/TEG Functional Fibrinogen)

• If maximum clot firmness (MCF) <7 mm on FIBTEM or functional fibrinogen amplitude <10 mm on TEG: administer cryoprecipitate 1, 3
• Initial dose: two pools of cryoprecipitate (10 units) or 3-4 g fibrinogen concentrate 2, 1
• Repeat doses should be guided by laboratory assessment of fibrinogen levels or viscoelastic testing 2

Factor Deficiency (EXTEM/TEG-R)

• If clotting time (CT) >80 seconds on EXTEM or R time >10 minutes on TEG: administer FFP 2, 3
• Initial dose: 15 ml/kg 2
• Target INR <1.5 or normalization of CT/R time 2

Platelet Dysfunction (EXTEM/TEG-MA)

• If maximum clot firmness (MCF) <45 mm on EXTEM with normal FIBTEM or maximum amplitude (MA) <45 mm on TEG with normal functional fibrinogen: consider platelet transfusion 2, 3
• Maintain platelet count >50 × 10⁹/L in general bleeding or >100 × 10⁹/L in traumatic brain injury 2

Clinical Considerations and Pitfalls

Important Considerations

• Fibrinogen is often the first coagulation factor to reach critically low levels during massive blood loss 1
• ROTEM-guided transfusion has been shown to reduce blood loss and unnecessary FFP transfusion in major surgeries 3
• Cryoprecipitate should be ABO compatible when possible 2
• In trauma patients, maintaining fibrinogen >1.5 g/L is recommended 2
• In obstetric hemorrhage, fibrinogen should be maintained >2 g/L 2

Common Pitfalls

• Relying solely on conventional coagulation tests (PT/INR, aPTT) which are poor predictors of bleeding in critically ill patients 2
• Using FFP for fibrinogen replacement is inefficient due to its low fibrinogen concentration 2
• Delayed administration of cryoprecipitate due to thawing time (consider having pre-thawed product available for emergency situations) 4
• Failure to recognize hypofibrinogenemia as a major contributor to ongoing coagulopathy in major surgeries 3
• Inconsistent fibrinogen content in cryoprecipitate units (can vary between preparations) 5

Alternatives to Consider

• Fibrinogen concentrate (20 g/L when reconstituted) may be used instead of cryoprecipitate with advantages of standardized dosing, viral inactivation, and no need for cross-matching 2
• Antifibrinolytic agents (tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/hour infusion) should be considered as adjunctive therapy in bleeding patients 2