In disseminated intravascular coagulation with low fibrinogen, should I give cryoprecipitate or fresh frozen plasma?

Management of DIC with Low Fibrinogen: Cryoprecipitate vs FFP

In DIC with low fibrinogen, give cryoprecipitate as the primary treatment when fibrinogen is <1.0 g/L, as it delivers concentrated fibrinogen far more efficiently than FFP (4g fibrinogen in 2 pools of cryoprecipitate versus only 2g in 4 units of FFP). 1

Why Cryoprecipitate is Superior for Hypofibrinogenemia in DIC

Fibrinogen Concentration Advantage

• Cryoprecipitate contains 400-450 mg fibrinogen per single unit, with pooled units (5 units) providing at least 2g of fibrinogen 1, 2
• Two pools of cryoprecipitate deliver approximately 4g of fibrinogen compared to only 2g from four units of FFP 1
• This makes cryoprecipitate the most efficient product for correcting isolated hypofibrinogenemia 2

Specific Guideline Recommendations for DIC

• The Association of Anaesthetists (2016) explicitly recommends cryoprecipitate for DIC with fibrinogen <1.0 g/L 1
• The British Committee for Standards in Haematology states that severe hypofibrinogenemia (<1 g/L) persisting despite FFP should be treated with cryoprecipitate or fibrinogen concentrate 3
• European trauma guidelines recommend cryoprecipitate or fibrinogen concentrate when fibrinogen is <1 g/L with significant bleeding 1

Practical Dosing Algorithm

For Cryoprecipitate

• Give 2 pools (10 units total) as the standard adult dose 1, 2
• This provides approximately 4g of fibrinogen, sufficient to raise levels from critically low to therapeutic range 1
• Transfuse using a standard blood giving set with 170-200 μm filter 1, 2
• Target fibrinogen >1.5 g/L during major hemorrhage (>2 g/L in obstetric hemorrhage) 1, 2

When to Use FFP Instead

• FFP is indicated for DIC with bleeding when there is global coagulation factor deficiency (PT >1.5x normal or INR >2.0, aPTT >2x normal) 1
• FFP provides all soluble coagulation factors including labile factors V and VIII, not just fibrinogen 1
• Dose: 15 ml/kg (approximately 1000-1050 ml for 70kg adult, or 3-4 units) to achieve minimum 30% plasma factor concentration 1, 4

Clinical Decision Algorithm

Step 1: Check fibrinogen level and coagulation studies

• If fibrinogen <1.0 g/L → Give cryoprecipitate first 1, 3
• If PT/INR and aPTT also significantly prolonged → Add FFP for global factor replacement 1, 3

Step 2: Assess bleeding severity

• Active bleeding with isolated hypofibrinogenemia → Cryoprecipitate alone may suffice 1
• Active bleeding with global coagulopathy → Combine FFP (for factors) + cryoprecipitate (for concentrated fibrinogen) 3, 5

Step 3: Monitor and repeat dosing

• Recheck fibrinogen after initial cryoprecipitate dose 1
• Repeat coagulation studies to guide additional FFP or cryoprecipitate 3

Critical Pitfalls to Avoid

Volume Overload with FFP

• FFP requires large volumes (300 ml per unit) to deliver adequate fibrinogen, creating risk of transfusion-associated circulatory overload (TACO) in frail or cardiac patients 4, 6
• Cryoprecipitate delivers the same fibrinogen in much smaller volume (100-200 ml per pool) 1

Delayed Treatment

• Cryoprecipitate requires thawing (can be kept at ambient temperature for 4 hours once thawed) 1
• Order early when DIC is suspected to avoid delays 1
• Some centers use fibrinogen concentrate as alternative (no thawing required, 30-60 mg/kg dose) 1

Using FFP Alone for Hypofibrinogenemia

• FFP is inefficient for isolated fibrinogen replacement - you would need excessive volumes to correct severe hypofibrinogenemia 4
• This exposes patients to unnecessary volume load and transfusion risks 4

Nuances in the Evidence

The guidelines consistently prioritize cryoprecipitate for targeted fibrinogen replacement in DIC 1, 3, while FFP serves as the product for global coagulation factor deficiency 1, 5. Older research from 1976 demonstrated successful use of cryoprecipitate in severe DIC 7, and this practice has been validated in modern guidelines 1, 3. The British Committee emphasizes that FFP should not be given based on laboratory tests alone without bleeding 3, reinforcing that both products require clinical context (active bleeding or high bleeding risk) for appropriate use.