Authors: Amy Babb, MD AND Amanpreet Kalsi, MBBS, FRCA - Monroe Carell Jr. Children's Hospital at Vanderbilt -Vanderbilt University Medical Center
A 4 day-old with d-transposition of the great arteries (d-TGA) presents for arterial switch operation. After separation from cardiopulmonary bypass (CPB) and protamine administration, hemostasis has not been achieved. Viscoelastic testing reveals a fibrinogen deficiency. Which of the following best describes a key characteristic of fibrinogen concentrate?
EXPLANATION
Fibrinogen replacement is commonly needed in pediatric cardiac surgery to restore clot strength and stability after CPB. Both cryoprecipitate and fibrinogen concentrate are available options to correct hypofibrinogenemia and improve coagulation. Fibrinogen concentrate has been shown to be noninferior with a similar safety profile compared to cryoprecipitate.1,2
Fibrinogen concentrate (ie: RiaSTAP®; CSL Behring, Marburg Germany or Fibryga®; Octapharma AG, Lachen, Switzerland) delivers a purified, virally inactivated, lyophilized fibrinogen product stored at room temperature. It rapidly reconstitutes with sterile water and does not require thawing time.3,4 Each bottle provides a known amount of fibrinogen (approximately 1 gram) allowing a precise, weight-based dosing strategy for fibrinogen correction. Both products provide specific dosing calculations in the package inserts.3,5
The following fibrinogen replacement formula may be used to calculate required dosing for children less than 12 years old (Fibryga)5,
[(Target fibrinogen level – Measured fibrinogen level)/1.4] x pt weight (kg) = Dose (mg)
An empiric dose of 50-70mg/kg may be used when a measured fibrinogen level is not available5.
Cryoprecipate is a plasma-derived human blood component. It must be thawed prior to administration and used or discarded within 4-6 hours. In addition to fibrinogen, cryoprecipitate contains factors VIII and XIII, von Willebrand factor and fibronectin, potentially providing broader hemostatic effects, but with unknown and variable amounts of each coagulation component per unit, with potential for alloimmunization.3,4
In the scenario described above, both fibrinogen concentrate and cryoprecipitate may be used to replete fibrinogen levels. ABO matching and storage as a frozen component are characteristics of cryoprecipitate. On the other hand, fibrinogen concentrate is a purified lyophilized product that has been virally inactivated, thus making this statement the correct answer.
REFERENCES
1. Downey LA, Andrews J, Hedlin H, et al. Fibrinogen Concentrate as an Alternative to Cryoprecipitate in a Postcardiopulmonary Transfusion Algorithm in Infants Undergoing Cardiac Surgery: A Prospective Randomized Controlled Trial. Anesth Analg. 2020;130(3):740-751. doi:10.1213/ANE.0000000000004384
2. Downey LA, Moiseiwitsch N, Nellenbach K, Xiang Y, Brown AC, Guzzetta NA. Effect of In Vivo Administration of Fibrinogen Concentrate Versus Cryoprecipitate on Ex Vivo Clot Degradation in Neonates Undergoing Cardiac Surgery. Anesth Analg. 2025;141(2):240-251. doi:10.1213/ANE.0000000000007123
3. Huisman EJ, Crighton GL. Pediatric Fibrinogen PART I-Pitfalls in Fibrinogen Evaluation and Use of Fibrinogen Replacement Products in Children. Front Pediatr. 2021;9:617500. Published 2021 Apr 21. doi:10.3389/fped.2021.617500
4. Crighton GL, Huisman EJ. Pediatric Fibrinogen PART II-Overview of Indications for Fibrinogen Use in Critically Ill Children.Front Pediatr. 2021;9:647680. Published 2021 Apr 21. doi:10.3389/fped.2021.647680
5. FIBRYGA. FDA Package Insert. Octapharma USA, Inc. Revised 06/2025