Dear Tomasz,

actually I think you need to ask your question more precisely. The treatment depends on the kind of coagulation disorder. For example, I think that hyperfibrinolysis is a severe coagulation disorder, which will not be treated efficiently by neither fibrinogen nor cryoprecipitate.

If you are thinking of a disorder due to loss or consumption of coagulation factors, I would rather use a combination of fresh frozen plasma, fibrinongen, platelets or else (FVIIa, tranexamic acid, pthrombin complex...) according to, for example, results of point of care diagnostics like Rotem or at least some tests like aPTT, PT, fibrinogen concentration or else...

Maybe you could be more detailed in asking your question?

Julian,

Thank you very much for your answer. I mentioned low plasma fibrinogen level due to major bleeding in major trauma patients and I changed my question accordingly.

Tomasz,

At Oslo University Hospital, we us Fibrinogen concentrate when a low fibrinogen concentration is detected. Also, in critical bleeding with long prehospital transportation times, significant amounts of crystalloid has been given, low Hgb, and high base deficit, we administer fibrinogen concentration without knowing the actual concentration. 

Dear Tomasz,

in that case I would prefer fibrinogen - especially as cryoprecipitate does not seem to be available in Germany any more. Cryoprecipitate includes fibrinogen, FVIII, von Willebrand factor, FXIII and fibronectin - and if you have the impression that fibrinogen is the only factor missing, I would choose fibrinogen. From my point of view, the "golden rule" of transfusion medicine applies: Always take as much as needed, but as little as possible, and as targeted as possible...

However, I could imagine that there is more behind your question: Are there different prices for fibrinogen concentrates and cryoprecipitate? Is cryoprecipitate cheaper than fibrinogen? I do not know that...

In polytrauma, we use tranexamic acid regardless of hyperfibrinolysis as it always helps reducing the number of units transfused. In case of isolated hypofibrinogenemia, fibrinogen (2 or 4 gr according to the extent of hypofibrinogenemia) would be my first choice. In case of global loss / consumption of coagulation factors, many clinicians use a rate of 1:2 or even 1:1 of RBCs and FFP (don´t forget platelets...). Sometimes, fibrinogen concentrate needs to given in addition.

However, in the end I am not favouring giving only fibrinogen, as some have proposed in the recent past. In my humble oppinion, a mixture of all blood products should be administered, always looking at the single case, by the help of point of care diagnostics and / or targeted diagnosis of hemostasis as needed.

Hi Tomasz,

Short answer:  Yes!

Longer answer:  I use cryo frequently in massive transfusion (we see a lot of trauma, and also less than occasional severe obstetric haemorrhage with delayed presentation).  My standard massive transfusion protocol involves the use of near-1:1:1 product administration.  From a practical perspective, my "first wave" of products I order is 4 units of packed red blood cells (PRBCs), 4 units of fresh frozen plasma (FFPs) and a pooled unit (6 random units) of platelets.  This is to support the rapid volume expansion that is required for patients who have had massive haemorrhage, while recognizing that some of the data suggests that early administration of platelets gives a survival benefit.  My next wave omits the FFPs in favour of cryoprecipitate, unless there is still a very large volume deficit.  Cryo is a much more effective source of fibrinogen at lower volume load.  FFP plays a more prominent role in TRALI, and has a fibrinogen (and other clotting factor) level similar to that of normal plasma, so giving FFP to a patient with already depleted coagulation factors is like adding weak tea to more weak tea and expecting to be left with strong tea.  Cryo is like a fresh teabag, if you follow my analogy.

I hope that is helpful.

Dear Dr Czarnik

My field is heart surgery. We use fibrinogen and sometime cryo due to major  operation like dissection of aorta or in patients under open heart surgery with prolong CPB time based on ROTEM. We can use cryo if we reserved preoperatively. But fibrinogen is available.

Dear Tomas Czarnik

  We use cryoprecipitate  in major surgery with poor control bleeding after rule out of surgical bleeding especially cardiac surgery with  prolonged bypass time  and multiple condition including: CRF patients who candidates for surgery, platelet dysfunction drugs consumption preoperatively and poor control bleeding in spite of transfusion of platelet,  especially  on pump  cardiac surgery because of platelet dysfunction,significant drainage in spite of  two round of FFP transfusion ( 15- 20 ml/Kg) and hypofibrinogenemia  documentation.  I think cryo is similar to cement for control of bleeding but thrombosis must be considered.

With thanks for your practical guestion

Dear Tomas,

In major obstetric bleeding like PPH (my speciality), many doctors add cryo when you are considering massive transfusion protocol and low fibrinogen level, but if you have FIBTEM in your institution you can guide your therapy according to this result. In Low and middle income country like ours, cryo is a better and feasible choice in any major bleeding. I hope this information could be useful...

Dear Tomas,

Yes we do use cryoprecipitate  in our major trauma patients and patients who require  massive transfusion . but fibrinogen concentrate in yet not available in our country

Yes, we analyse the coagulation profile with thrombelastograpy and if we have hypofibrinogenemia, we use haemocompletan, 1 g /botle 

Julian, Jostein, Ross, Nahid, Abdorasoul, Jose, Humaira and D. Pavelescu thank you all for very interesting answers.

I administer initially 2g of fibrinogen concentrate called Riastap in case of major trauma associated hypofibrinogenemia when its plasma level drops below 200mg/dL

Thank you once again.