Overuse of Cryoprecipitate: A Chronic Condition,

Literature has revealed that there is considerable inappropriate use of blood products including cryoprecipitate (cryo). Appropriate indications for cryo use according to American Association of Blood Banks (AABB) guidelines include bleeding due to hypofibrinogenemia (fibrinogen level < 100mg/dl) or dysfibrinogenemia, factor XIII deficiency, bleeding associated with Hemophilia A or von Willebrand disease (when appropriate factor concentrates are not available) and uremic bleeding (DDAVP preferred). To determine appropriateness of use of cryo at Newark Beth Israel Medical Center, a review of cryo utilization was conducted at this tertiary care hospital.

A retrospective audit of cryo utilization was performed from January to May 2011. Medical records of all patients (pts) who received cryo during this time were reviewed for demographic information (age, sex, clinical diagnosis) and relevant laboratory data (PT, PTT, fibrinogen levels, serum creatinine). The number of units transfused per pt as well as the hospital service requesting the transfusion in each case was noted. The indication of cryo in each case was evaluated as appropriate or inappropriate, depending on AABB transfusion guidelines.

A total of 62 pts received 71 pooled cryo transfusions (total of 691 units). Out of the 71 transfusions, 61 in 52 pts (585 units) were evaluable with complete data. Mean age of these pts was 53 years (yrs) (range 0–83), with 42% being females. Mean number of units given per transfusion was 9.7(range 1–20). The majority of cryo use was by cardiothoracic (CT) surgery (360/585, 62%) followed by hematology/oncology (hem/onc) (177/585, 30%). The remainder was used by Pediatrics (Peds) (23/585, 4%) and Obstetrics/Gynecology (Ob/Gyn) (25/585, 4%). All the transfusions were given in the setting of bleeding. The most common reason for transfusion (201/585, 34%) was post-operative bleeding, without any clear indication based on guidelines, and predominantly ordered by CT surgery (165/201, 82%). 180/585 (31%) of the units were transfused intraoperatively with 160/180 (89%) of those transfusions occurring during cardio-thoracic procedure. In 8 pts, 81 cryo units (81/585, 14%) were transfused to correct uremic bleeding, and were all ordered by hem/onc. 12 pts received 93 units (93/585, 16%) for bleeding related to hypofibrinogenemia. 11/12 of these pts had disseminated intravascular coagulation (DIC), with 1/11 cases of DIC due to underlying malignancy, 9/11 due to sepsis and 1/11 due to acute fatty liver of pregnancy. Overall, 174/585 (30%) of cryo units were transfused appropriately as per AABB guidelines: 93/174(53%) for hypofibrinogenemia and 81/174 (47%) for uremic bleeding. The highest incidence of cryo transfusions for appropriate indications was in the hem/onc department (131/174, 75%). The total cost of inappropriate transfusions was $23,838 (411/585 units, calculated using $58 per unit). Of note, none of the cryo transfusions were used for bleeding Hemophilia A or von Willebrand disease pts since our medical center uses recombinant factor for those indications.

Cryo utilization varied by departments. CT surgery followed by hem/onc services are the principal users of cryo in our tertiary care hospital. As only 30% of cryo was used in accordance with established guidelines, the opportunities may exist for lower cryo usage. Further education of the medical community is warranted regarding the appropriate clinical indications for the use of cryo, in order to decrease the risks with transfusion (such as transmission of infectious agents) as well as to save the cost of unnecessarily transfused blood products.

No relevant conflicts of interest to declare.