Approach to management of cryoprecipitate inventory during pandemic-related shortages

ABSTRACT

Background: A surprising and disturbing feature of blood shortages in the United States during the COVID-19 pandemic is that they include Cryoprecipitate, a component that was not historically affected by seasonal shortages. Our blood suppliers provide Cryoprecipitate primarily as 5-unit pools. A few individual whole blood-derived units of Cryoprecipitate are also provided for use for infants and young children. The adult dose of Cryoprecipitate, standardized many years ago, has been two pools (10 units). In an average-sized adult, this dose is expected to increase plasma fibrinogen by 50-100 mg/dl. Over the 10-year period 2011- 2020, the number of single units transfused at our 1000 bed tertiary care hospital remained small and relatively stable, but the number of transfused pools increased approximately 60%, from a monthly average of 322-522. During the pandemic, Cryoprecipitate usage at our hospital remained high, possibly because high-use surgeries, such as urgent cardiovascular and liver transplant procedures, were not restricted. In the face of donor- and manufacturing-related shortages, our blood bank has been challenged to maintain an adequate inventory to support these services. Aims: To develop and implement a plan for ensuring sufficient availability of Cryoprecipitate units to meet our patients' needs. Methods: As with other blood components, the shortage of Cryoprecipitate was initially managed through prospective review and modification (if appropriate) of orders by the Transfusion Medicine resident physician, and regular communications with the blood suppliers regarding inventory requirements. Additional steps for Cryoprecipitate were re-evaluating the standard dose of Cryoprecipitate, and exploring alternatives to the use of Cryoprecipitate pools. Results: Quality control data from our blood suppliers provided evidence that the fibrinogen content of Cryoprecipitate currently averages 524 mg per unit, more than twice the value of 250 mg per unit that is generally used for dosing calculations. These data justified halving the standard adult dose to 1 pool. An explanatory document was distributed to the clinical services, with comparisons of plasma fibrinogen increments expected with two pools versus one pool. An update to the electronic ordering system is in process, to change the default Cryoprecipitate order for adults from two pools to one pool. We increased the stock of single Cryoprecipitate units, whenever these were available, to build a buffer for adult use in case of ongoing shortage. We collaborated with the hospital pharmacy to maintain a reserve of purified fibrinogen concentrate, and develop a dosing and administration protocol for off-label use of this product. So far, there has not been an occasion to use either alternative. The efforts above have been supplemented with frequent, structured communication with the clinical services and hospital leaders regarding inventory levels of blood components, and the measures taken and requested to safeguard this precious resource. Summary/Conclusions: Meeting the challenge of extreme and prolonged blood shortages requires a multi-pronged approach that may include questioning assumptions, considering alternatives, and improving inter-disciplinary communications.