What dose of cryoprecipitate should be given to an adult with a fibrinogen level of 154 mg/dL to raise it above the hemostatic threshold?

Cryoprecipitate Dosing for Fibrinogen 154 mg/dL

Administer two pools (10 units) of cryoprecipitate immediately, which will provide approximately 4 grams of fibrinogen and is expected to raise the fibrinogen level by approximately 0.55 g/L (55 mg/dL), bringing the patient from 154 mg/dL to approximately 209 mg/dL, safely above the 150 mg/dL hemostatic threshold. 1, 2

Standard Dosing Protocol

• The standard adult dose is two pools of cryoprecipitate (10 units total), with each pool containing 5 units and at least 2 grams of fibrinogen. 1, 2
• Each single unit contains 400-450 mg of fibrinogen, so two pools provide approximately 4 grams total. 1, 2
• This dose should be administered as rapidly as possible through a standard blood giving set with a 170-200 μm filter. 1, 2

Expected Fibrinogen Increment

• Research data demonstrates that approximately 8-9 units of cryoprecipitate increases fibrinogen by 0.55 g/L (55 mg/dL), which translates to approximately 0.06 g/L per unit. 3
• For your patient at 154 mg/dL (1.54 g/L), two pools (10 units) should raise the level to approximately 2.1 g/L (210 mg/dL), comfortably above the 1.5 g/L threshold. 3
• The median increment following two pools of cryoprecipitate is 0.26 g/L in real-world practice, though this may be lower due to ongoing consumption or bleeding. 4

Alternative Higher-Dose Approach for Active Bleeding

• If the patient has active bleeding or major hemorrhage, consider the higher European trauma guideline dose of 50 mg/kg (approximately 15-20 units for a 70 kg adult), which provides 6-9 grams of fibrinogen. 2, 5, 6
• This higher dose is particularly appropriate for trauma, obstetric hemorrhage, or massive transfusion scenarios where fibrinogen consumption is ongoing. 2, 6

Target Fibrinogen Thresholds by Clinical Context

The target fibrinogen level depends on the clinical scenario:

• Major hemorrhage/trauma: maintain >1.5 g/L (150 mg/dL) 1, 2
• Obstetric hemorrhage: maintain >2.0 g/L (200 mg/dL) 1, 2
• DIC with bleeding: treat when <1.0 g/L (100 mg/dL) 1, 2
• Advanced liver disease: maintain >1.0 g/L (100 mg/dL) 1

Monitoring and Repeat Dosing

• Recheck fibrinogen levels after administration to confirm the target has been achieved. 2, 5
• If fibrinogen remains below target or viscoelastic testing (ROTEM/TEG) shows persistent functional deficit, administer additional pools. 2, 5
• Once thawed, cryoprecipitate must be used within 4 hours and cannot be refrigerated again. 1, 2

Critical Pitfalls to Avoid

• Do not assume the standard two-pool dose is sufficient in active bleeding—the CRYOSTAT-2 trial showed that even 3 pools (15 units, 6g fibrinogen) may not reduce mortality in unselected trauma patients, suggesting higher doses or targeted therapy may be needed. 7
• The fibrinogen concentration in cryoprecipitate varies significantly (dry vs. regular preparation affects content), so actual increments may differ from theoretical calculations. 8
• Monitor for volume overload, particularly in patients with cardiac or renal impairment, as two pools contain 200-400 mL of fluid. 2
• Fibrinogen is the first coagulation factor to fall critically during massive hemorrhage, so early administration is crucial before levels drop further. 6

Alternative: Fibrinogen Concentrate

• If available, fibrinogen concentrate (3-4 grams IV) offers advantages over cryoprecipitate including standardized dosing, viral inactivation, no need for thawing, and superior fibrinogen increment (0.44 g/L vs 0.26 g/L per equivalent dose). 2, 4
• The American College of Surgeons recommends 4 grams of fibrinogen concentrate to increase levels by approximately 110-120 mg/dL. 5