Cryoprecipate Is Overused, an Unnecessary Expense

San Diego, CA—Only 30% of cryoprecipitate was used in accordance with established guidelines in a tertiary care center, in a study presented at ASH 2011 by researchers from Beth Israel Medical Center, Newark, NJ. "Hence, it seems that opportunities may exist for lower cryo usage," said Manpreet K. Sandhu, MD, of the hematology/ oncology department at Beth Israel. The literature has suggested that blood products, including cryoprecipitate, are overused. Their appropriate indications, and cryo constituent, according to the American Association of Blood Banks, are:

• Hypofibrinogenemia or dysfibrinogenemia: fibrinogen
• Factor XIII deficiency: factor XIII
• Bleeding associated with hemophilia A, or von Willebrand disease: factor VIII or von Willebrand factor
• Uremic bleeding: factor VIII and von Willebrand factor. Dr Sandhu and colleagues conducted a retrospective audit from January to May 2011, examining medical records and laboratory data of all patients who received cryo. The number of units transfused per patient, as well as the hospital service requesting the transfusion, were noted. The indication for cryo in each case was evaluated as appropriate or inappropriate, according to the guidelines.

Sixty-two patients received 71 pooled cryo transfusions, for a total of 691 units. Of the 71 transfusions, 61 in 52 patients (585 units) were evaluable. The mean number of units per transfusion was 9.7. The hematology/oncology department was the second-highest user of cryo (30%), whereas cardiothoracic surgery was used the most (62%); the remainder was used by pediatrics (4%) and obstetrics/gynecology (4%). All transfusions were given in the setting of bleeding, the most common reason being postoperative bleeding (34%), without a clear indication and predominantly ordered by cardiothoracic surgery (82%). In 8 patients, 81 units (14%) were transfused to correct uremic bleeding, all ordered by hematology/oncology.

"Most use was by surgeons. They had a patient on the table, bleeding, and they should have determined whether the patient truly needed this. Cryo is indicated only if the patient has low fibrinogen. Surgical hemostatis and reversal of anticoagulation (65% and 4%, respectively, of the use of cryo) are not indications," Dr Sandhu said. Overall, only 30% of cryo units were transfused appropriately as per guidelines, 53% for hypofibrinogenemia and 47% for uremic bleeding. "The highest incidence of cryo transfusions for appropriate indications was in the hem/onc department (75%)," he said. The total cost of inappropriate transfusions was $28,838 (calculated at $58 per unit), the investigators determined. "It is important to use cryo judiciously, in order to decrease the risks associated with transfusions, such as transmission of infectious agents, as well as save the cost of unnecessarily transfused blood products," Dr Sandhu concluded.—CH