How is fibrinogen replacement managed in patients with Disseminated Intravascular Coagulation (DIC) and low fibrinogen levels?

Fibrinogen Replacement in Disseminated Intravascular Coagulation (DIC)

In patients with DIC and active bleeding, fibrinogen replacement should be administered when fibrinogen levels fall below 1.5 g/L, using either two pools of cryoprecipitate or fibrinogen concentrate. 1, 2

Monitoring and Assessment

• Regular monitoring of coagulation parameters including fibrinogen levels is essential in patients at risk for or with established DIC 1, 2
• A fibrinogen level below 1.0 g/L is highly suggestive of DIC, especially when accompanied by prolonged PT/APTT and thrombocytopenia 1
• The frequency of monitoring should be tailored to the clinical situation, ranging from daily to monthly depending on the severity and progression of DIC 1, 2
• A 30% or greater drop in platelet count may be diagnostic of subclinical DIC even in the absence of clinical manifestations 1

Fibrinogen Replacement Thresholds

• For patients with active bleeding: replace fibrinogen when levels fall below 1.5 g/L despite other supportive measures 1, 2
• For patients without active bleeding but at high risk (e.g., pre-procedure): consider replacement when fibrinogen is below 1.0 g/L 1, 3
• The primary goal of replacement is to maintain adequate hemostasis while addressing the underlying cause of DIC 2

Replacement Options

• Fresh frozen plasma (FFP): Administer 15-30 mL/kg in actively bleeding patients 1, 2

  • FFP alone can correct fibrinogen deficiency but large volumes may be required 1
  • Consider volume status when administering FFP; volume overload is a potential complication 1, 2

• Cryoprecipitate: Indicated when fibrinogen remains critically low (<1.5 g/L) despite FFP administration 1, 2

  • Typically administer two pools of cryoprecipitate 1, 2
  • Contains approximately one-third of the fibrinogen in the original plasma plus factor VIII 4

• Fibrinogen concentrate: Alternative to cryoprecipitate, especially when volume overload is a concern 1, 3

  • More concentrated source of fibrinogen than cryoprecipitate or FFP 3
  • May be preferred in patients with cardiac or renal insufficiency 2

Important Considerations

• The lifespan of transfused fibrinogen may be very short in DIC due to ongoing consumption 1, 5
• Avoid prophylactic transfusions based solely on laboratory values in non-bleeding patients 6
• Treatment of the underlying cause is the cornerstone of DIC management and should always be prioritized 1, 2
• In patients with liver failure, decreased fibrinogen production may compound consumption issues 1

Special Situations

• In cancer-associated DIC: Treatment of the underlying malignancy is fundamental 1, 2
• In acute promyelocytic leukemia (APL): Early commencement of induction therapy is crucial for DIC resolution 1, 2
• In DIC with predominant thrombosis: Consider anticoagulation with heparin in addition to fibrinogen replacement if needed 2, 7

Potential Pitfalls

• Avoid delaying fibrinogen replacement in actively bleeding patients with low levels 1, 2
• Remember that standard coagulation tests may not fully reflect the complex coagulopathy in DIC, especially in patients with liver disease 6
• Be aware that excessive fibrinogen replacement without addressing the underlying cause may potentially fuel the coagulation process 5
• Consider that patients with severe sepsis-associated DIC with both low antithrombin and low fibrinogen may benefit from combination therapy with anticoagulants in addition to fibrinogen replacement 8