When do we transfuse cryoprecipitate?

Abstract

Background The 2001 National Health and Medical Research Council/Australasian Society of Blood Transfusion Clinical Practice Guidelines for cryoprecipitate are being updated, and cryoprecipitate has been incorporated into new Patient Blood Management modules. Aims This clinical audit sought to clarify current cryoprecipitate use in Victoria, Tasmania and the Australian Capital Territory; assess adherence to guidelines; and gain insights into deviations from recommended practice. This information can be utilised in updating guidelines to make them more relevant, to identify areas for clinician education and to form a baseline of practice prior to release of the 2011 guidelines. Methods Participating institutions were invited to audit up to 30 consecutive episodes of cryoprecipitate transfusion over an 11‐month period in 2008. The audits were conducted using a standardised pro forma and involved review of patient records. These were collated electronically using algorithms to determine alignment versus non‐alignment with guidelines. Results Cryoprecipitate is used in a variety of situations with surgery accounting for the highest volume. Twenty‐six per cent (26%) of transfusions were aligned with 2001 guidelines rising to 61% with a modified fibrinogen trigger. Fibrinogen levels did not appear to dictate all clinical decisions regarding cryoprecipitate use perhaps owing to the acuity of many cases. Additional bleeding risk together with low fibrinogen levels (e.g. thrombocytopenic patients) may contribute to empiric cryoprecipitate use. Conclusions These results highlight discrepancies between guidelines and practice, providing rationale for the update of the guidelines that is currently underway. Cryoprecipitate has attendant risks, and it is appropriate that transfusion be restricted to situations with good evidence or sound principles to underpin use.

Fibrinogen recovery and changes in fibrin‐based clot firmness after cryoprecipitate administration in patients undergoing aortic surgery involving deep hypothermic circulatory arrest

“…Cryoprecipitate has a long history of use in many countries, including the United Kingdom, the United States, and Republic of Korea. In Australia, it has been reported that 22% of cryoprecipitate consumption is in the setting of cardiac surgery . However, there is little robust evidence of the efficacy of cryoprecipitate in increasing fibrinogen levels and few recommendations on appropriate transfusion amounts 6‐8.…”

A retrospective review of cryoprecipitate transfusion practice in Kuala Lumpur Hospital

“…[14] Similar transfusion audits conducted in other countries also suggested that cryoprecipitate is often found not aligned to published guideline. [6151617] Nonetheless, this study outlined the main contributor for the practice inappropriateness is the absence of pretransfusion fibrinogen level estimation.…”

“…When the fibrinogen-based transfusion trigger was increased to 1.5 g/L, the rate of appropriateness improved to 61%. [17] In postpartum bleeding cases, studies showed that fibrinogen level <2 g/L were strongly associated with high risk of severe bleeding, with a predictive value of 100%. [25]…”

Audit‐based measures of overuse of medical care in Australian hospital practice

“…For studies of management strategies (Table ), corresponding rates of overuse comprised: 14–74% of blood product infusions among patients with various conditions ( n = 3) 15–55% of older patients receiving at least one inappropriate medication ( n = 7) 34% of chronically prescribed medications of various classes among older patients ( n = 1) 99% of ondansetron prescriptions in patients with severe emesis ( n = 1) 63–90% of regular prescriptions for gastric acid suppressants in patients admitted to intensive care units ( n = 2) 34% of regular prescriptions of direct oral anticoagulants in patients with various conditions ( n = 1) 21% of antimicrobial prescriptions for patients with acute infections ( n = 1) 52% of prescriptions for inhaled corticosteroids in patients with mild chronic obstructive pulmonary disease ( n = 1) 55% of instances of high flow oxygen therapy administered to patients with chronic obstructive pulmonary disease ( n = 1) 33% of overnight admissions to medical assessment and planning unit for monitoring and evaluation relating to patients presenting to emergency department with undifferentiated chest pain and low coronary risk ( n = 1) 10–64% of end‐of‐life care admissions featuring the administration of futile interventions ( n = 3) …”