Cryoprecipitate transfusion: assessing appropriateness and dosing in trauma

Background: Originally developed for patients with congenital factor VIII deficiency, cryoprecipitate is currently largely used for acquired hypofibrinogenemia in the context of bleeding. However, scant evidence supports this indication and cryoprecipitate is commonly used outside guidelines. In trauma, the appropriate cryoprecipitate dose and its impact on plasma fibrinogen levels are unclear. Objectives: The aims were to evaluate (i) the appropriateness of cryoprecipitate transfusion in trauma and (ii) the plasma fibrinogen response to cryoprecipitate transfusion during massive transfusion in trauma. Methods: Retrospective review (January 1998-June 2008) of indications, dose and plasma fibrinogen response to cryoprecipitate transfusion at a large teaching hospital. A fibrinogen of <1.0 g L-1 within 2 and 6 h of transfusion was used for evaluating appropriateness. Results: Ten thousand five hundred and forty cryoprecipitate units were transfused in 1004 patients. Thirty-seven percent and 31% were used in cardiac surgery and trauma, respectively. In 394 events in trauma, 238 (60%) and 259 (66%) were considered appropriate using the 2- and 6-h cut-off criteria, respectively. In patients who did not receive plasma components 2 h prior to cryoprecipitate, a dose of 8.7 (+/-1.7) units caused a mean increase in fibrinogen levels of 0.55 (+/-0.24) g L-1, or 0.06 g L-1 per unit. Conclusions: In our hospital, where transfusion guidelines are overseen by transfusion medicine specialists and technologists, and policies for rapid blood component and laboratory turnaround times exist, it is possible to achieve high rates of appropriateness for cryoprecipitate transfusion in trauma. The current recommended dose causes a modest increase in fibrinogen levels (0.55 g L-1).