When to give cryoprecipitate for low fibrinogen?

When to Give Cryoprecipitate for Low Fibrinogen

Administer cryoprecipitate when fibrinogen levels fall below 80-100 mg/dL (0.8-1.0 g/L) in the presence of active, excessive bleeding that cannot be controlled by other hemostatic measures. 1

Primary Indications for Cryoprecipitate

Critical Fibrinogen Thresholds

• Give cryoprecipitate when fibrinogen is <80-100 mg/dL AND the patient has excessive bleeding that requires intervention 1

• Cryoprecipitate is rarely indicated if fibrinogen is >150 mg/dL in nonpregnant patients, as transfusion above this threshold does not improve outcomes 1

• In trauma patients with significant bleeding, treat when fibrinogen falls below 1.0 g/L (100 mg/dL), with an initial dose of 50 mg/kg cryoprecipitate (approximately 15-20 units in a 70-kg adult) 1

Specific Clinical Scenarios

Massive transfusion protocols:

• Administer cryoprecipitate as an adjunct when patients receive more than one blood volume and fibrinogen levels cannot be measured in a timely fashion 1
• Fibrinogen is often the first coagulation factor to reach critically low levels during massive blood loss 2

Obstetric hemorrhage:

• Cryoprecipitate may be indicated at higher fibrinogen concentrations in actively bleeding obstetric patients (maintain fibrinogen >2.0 g/L) 1, 2

Evidence of fibrinolysis:

• When laboratory testing indicates active fibrinolysis with low fibrinogen, cryoprecipitate is indicated 1

Congenital fibrinogen deficiencies:

• For patients with congenital afibrinogenemia or hypofibrinogenemia, decisions should be made in consultation with the patient's hematologist 1

Von Willebrand Disease Management

Type 1 and 2A:

• First-line treatment is desmopressin, followed by specific VWF/FVIII concentrate if available 1
• Give cryoprecipitate only if there is no response to desmopressin or if VWF/FVIII concentrate is unavailable 1

Types 2B, 2M, 2N, and 3:

• Specific VWF/FVIII concentrate is preferred 1
• Cryoprecipitate is indicated only if VWF/FVIII concentrate is not available 1

Dosing Guidelines

Standard adult dosing:

• Initial dose: 50 mg/kg of cryoprecipitate, equivalent to 15-20 units in a 70-kg adult 1, 2
• Each pool of cryoprecipitate contains approximately 2g of fibrinogen 3
• Typical adult dose is two pools of cryoprecipitate 3

Target fibrinogen levels:

• Aim to raise fibrinogen plasma level above 1.0 g/L for sufficient hemostasis 1
• In trauma, maintain fibrinogen >1.5 g/L 2
• In obstetric hemorrhage, maintain fibrinogen >2.0 g/L 2

Repeat dosing:

• Repeat doses should be guided by laboratory assessment of fibrinogen levels 1
• Monitor fibrinogen levels carefully to prevent both inadequate treatment and excessive levels that may increase thrombotic risk 3

Critical Pitfalls to Avoid

Do NOT transfuse cryoprecipitate based solely on laboratory values without active bleeding:

• In cirrhosis patients, low fibrinogen levels reflect disease severity rather than causation of bleeding 4
• The American College of Gastroenterology recommends against transfusing based solely on laboratory values without active bleeding in cirrhosis patients 4
• Recent evidence shows that cryoprecipitate transfusion for low fibrinogen in critically ill cirrhosis patients does not affect bleeding or survival outcomes 5

Do NOT use cryoprecipitate for:

• Volume expansion or albumin supplementation 1
• Prophylactic correction in cirrhosis patients before procedures, as fibrinogen levels do not reliably predict post-procedural bleeding risk 4

Consider fibrinogen concentrate as an alternative:

• Fibrinogen concentrate is preferred over cryoprecipitate when available because it has lower volume, standardized fibrinogen content, no need for cross-matching, and avoids unnecessary von Willebrand factor 4
• Fibrinogen concentrate (20 g/L when reconstituted) may be used instead of cryoprecipitate with advantages of standardized dosing and viral inactivation 2

Administration Considerations

Timing and preparation:

• Cryoprecipitate must be transfused using a standard blood giving set with a 170-200 μm filter 3
• Once thawed, cryoprecipitate must be used within 4 hours and should not be refrigerated again 3

Monitoring for adverse events:

• Common adverse reactions include anemia (14.3%), acute kidney injury (8.0%), and thrombocytopenia (5.5%) 3
• Volume overload can occur, particularly in patients with cardiac or renal impairment 3
• Allergic reactions and anaphylaxis are of particular concern 1

Adjunctive therapy:

• Consider antifibrinolytic agents (tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/hour infusion) as adjunctive therapy in bleeding patients 2