In a patient with laboratory evidence of disseminated intravascular coagulation but no active bleeding, should cryoprecipitate be given?

Do Not Transfuse Cryoprecipitate in DIC Without Active Bleeding

In patients with laboratory evidence of DIC but no active bleeding, cryoprecipitate should not be given. The most recent guidelines explicitly state that transfusion therapy in DIC should be reserved for patients with active bleeding, not based on laboratory abnormalities alone 1, 2.

Evidence-Based Rationale

Current Guideline Recommendations

The 2025 Association of Anaesthetists guidelines clarify that fresh frozen plasma (FFP) is indicated for "disseminated intravascular coagulation with evidence of bleeding or at high risk of bleeding (e.g., planned surgery or invasive procedure)" 1. This same principle applies to cryoprecipitate.

The 2016 AAGBI guidelines specify cryoprecipitate indications in DIC as "disseminated intravascular coagulation with fibrinogen < 1.0 g/L" 1, but this must be interpreted in the context of active bleeding, as the guidelines consistently emphasize that component therapy should not be driven by laboratory values alone in non-bleeding patients.

Specific Thresholds for Bleeding Patients

When DIC patients are actively bleeding, the transfusion algorithm is clear 2, 3:

• Maintain platelets >50 × 10⁹/L
• Administer FFP at 15-30 mL/kg for prolonged PT/aPTT
• Replace fibrinogen if <1.5 g/L persists despite FFP using two pools of cryoprecipitate or fibrinogen concentrate

Why Not Transfuse Without Bleeding?

Transfused blood products have extremely short survival in active DIC due to ongoing consumption and activation 2, 3. In non-bleeding patients, this creates a futile cycle of repeated transfusions that provide only transient laboratory correction without clinical benefit 3.

The 2025 guidelines explicitly warn: "There is no good evidence to support the use of prophylactic FFP to correct abnormal coagulation tests prior to low-risk invasive procedures in patients who are critically ill" 1. This principle extends to cryoprecipitate.

Clinical Decision Algorithm

Step 1: Assess for Active Bleeding

• If bleeding present → Proceed to Step 2
• If no bleeding → Do NOT transfuse; treat underlying cause 2, 3

Step 2: Check Fibrinogen Level (Only if Bleeding)

• If fibrinogen <1.5 g/L despite FFP → Give two pools of cryoprecipitate 2, 3
• If fibrinogen ≥1.5 g/L → Continue FFP support alone

Step 3: Identify DIC Phenotype

• Bleeding-predominant → Aggressive transfusion support 2
• Thrombosis-predominant → Consider therapeutic heparin despite abnormal labs 2, 3

Critical Pitfalls to Avoid

Do not transfuse based on laboratory abnormalities alone 2, 3, 4. Abnormal PT/aPTT in critically ill patients are poor predictors of bleeding and do not reflect true hemostatic status 1.

Do not assume prophylactic correction prevents bleeding. The British Committee for Standards in Haematology states: "Transfusion of platelets or plasma in patients with DIC should not primarily be based on laboratory results and should in general be reserved for patients who present with bleeding" 4.

Recognize the exception for high-risk procedures. If an invasive procedure is planned, the patient transitions to "high risk of bleeding" status, and prophylactic correction may be warranted 1, 2.

The Cornerstone: Treat the Underlying Cause

The fundamental intervention in DIC is treating the triggering condition—sepsis, malignancy, trauma, or obstetric complications 2, 3. Early chemotherapy in cancer-associated DIC, particularly acute promyelocytic leukemia, achieves excellent resolution of coagulopathy 2, 3, 5.

Supportive transfusion without addressing the underlying trigger results in continued consumption and futile repeated dosing 2, 3.