PB1066 - Fibrinogen repletion for perioperative bleeding management: clinical use of cryoprecipitate, fibrinogen concentrate, and target levels used in clinical practice in the United States

Background: Fibrinogen is a critical factor in treating perioperative bleeding. Cryoprecipitate, a pooled multi-donor product, is routinely used in the United States (US) but has limited availability and a 4-hour shelf life, causing substantial wastage. Fibrinogen concentrates (FCs) are important alternatives and are the mainstay repletion therapy in other countries.

Aims: Identify current practice/knowledge gaps to improve fibrinogen repletion for major bleeding in a US perioperative setting.

Methods: A 22-question survey covering clinical practice relating to perioperative bleeding management was sent to members of the American Society of Anesthesiology. Invitations for participation, including the survey link, were e-mailed bi-weekly from 6/7/2023- 8/11/2023. Responses were collected using the Survey Monkey platform.

Results: Responses were received from 1014 anesthesiologists. Fibrinogen repletion was assessed based on viscoelastic testing (42.3%), central laboratory results (30.1%), or empiric replacement (27.6%), as indicated by the respondents. Target fibrinogen levels in bleeding patients were 200 mg/dL (35.1%), 150 mg/dL (25.8%), 100 mg/dL (9.6%), or unknown (18.9%), as shown in Figure 1. Sources for fibrinogen repletion were cryoprecipitate (65.9%), fresh frozen plasma (28.1%), or FCs (5.5%). FCs could be administered without approval (41.1%), following institutional protocol (10.6%), or after required approval (16.2%), but 32.1% did not have access to FCs. The projected patient populations that potentially favored FCs use instead of cryoprecipitate included cardiac surgery (42.6%), trauma (39.5%), postpartum hemorrhage (37.4%), liver transplantation (28.4%), and pediatric surgery (13.4%). Factors for deciding how to treat hypofibrinogenic patients included efficacy, time to receipt, access, thrombotic concerns, and cost, as shown in Figure 2.

Conclusion(s): Compared to cryoprecipitate, major concerns limiting FCs use include efficacy, cost, and access. Because most US hospital pharmacies store and dispense FCs, the lack of an acquired fibrinogen deficiency labeling likely limits clinician access. Nevertheless, with ongoing blood shortages, FCs provide an alternative fibrinogen repletion source for perioperative bleeding management.