Fibrinogen Supplementation in Bleeding Patients

Clinical Applications and Dosing

Fibryga contains a higher concentration of factor XIII (0.2 IU factor XIII per mg fibrinogen) compared to other fibrinogen concentrates, which may explain the increased maximum clot firmness observed with thromboelastometry 1
For every gram of fibrinogen concentrate administered, there is an expected 2-mm increase in the fibrin-based thromboelastometry assay (FIBTEM) 2, 3

In trauma patients, a Maximum Clot Firmness (MCF) of 7 mm on ROTEM is associated with a fibrinogen level of approximately 2 g/L 4, 5
Administration of fibrinogen concentrate has been associated with reduction in blood transfusion requirements in bleeding patients 2, 6

Fibrinogen is the first coagulation factor to critically decrease during massive blood loss, making early assessment and replacement crucial 4, 5
ROTEM-guided fibrinogen administration may be preferable to laboratory fibrinogen measurement, as it provides real-time assessment of functional fibrinogen contribution to clot formation 4, 7
The higher factor XIII content in Fibryga may provide additional benefit in improving clot firmness compared to other fibrinogen concentrates 1, 3

Laboratory methods to measure fibrinogen concentration may have methodological issues, particularly in the presence of artificial colloids like hydroxyethyl starch, which can cause the Clauss method to overestimate fibrinogen concentration 4, 7
Although thrombotic risk is a theoretical concern with fibrinogen administration, studies have shown that fibrinogen levels naturally rise to approximately 7 g/L after major surgery and trauma, and intra-operative fibrinogen administration does not appear to increase thrombotic risk 4, 7

Hypofibrinogenemia is the biomarker most predictive of severe postpartum hemorrhage and is often the first coagulation factor to critically decrease during massive blood loss, according to the American College of Obstetricians and Gynecologists 8
Fibrinogen supplementation is indicated when there are thromboelastometric signs of a functional fibrinogen deficit or plasma fibrinogen levels <1.5-2.0 g/L in the presence of significant bleeding, as recommended by the Society of Critical Care Medicine 9

In trauma patients, a Maximum Clot Firmness (MCF) of 7 mm on ROTEM correlates with a fibrinogen level of approximately 2 g/L, according to the Society of Critical Care Medicine 9

In pregnancy, fibrinogen levels <200 mg/dL are associated with severe postpartum hemorrhage, suggesting higher target levels may be needed in this population, as noted by the American College of Obstetricians and Gynecologists 8