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In perspective
Fibrinogen replacement in trauma haemorrhage: essential but not empirical?
  1. Ross Davenport1,2,
  2. Nicola Curry3,4
  1. 1 Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
  2. 2 Royal London Major Trauma Centre, Barts Health NHS Trust, London, UK
  3. 3 Radcliffe Department of Medicine, Oxford University, Oxford, UK
  4. 4 Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  1. Correspondence to Dr Ross Davenport, Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; ross.davenport{at}qmul.ac.uk

https://doi.org/10.1136/emermed-2024-213925

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    The CRYOSTAT-2 randomised controlled trial (RCT), published in JAMA 1 in October 2023, is the largest transfusion trial to date in major trauma haemorrhage. In this international study across all major trauma centres in the UK and one Level 1 centre in the USA, 1604 bleeding trauma patients were enrolled to receive either standard of care resuscitation (STD), or the early empirical administration of a high dose (three pools) of cryoprecipitate (CRYO) in addition to standard of care. Cryoprecipitate is the standard source of fibrinogen in the UK and is fundamental to blood clotting while known to be rapidly depleted in bleeding trauma patients.2

    The primary outcome of all-cause mortality at 28 days was the same in both arms (26.1% vs 25.3%), with no difference in transfusion requirements or safety outcomes. Of concern, in prespecified subgroup analyses for the 36% of patients with penetrating trauma, 28-day mortality was significantly higher in CRYO versus STD groups (16.2% vs 10.0%; OR 1.74 (95% CI 1.20 to 2.51)). Cryoprecipitate has always been, and remains, a central component of major haemorrhage protocols (MHPs), and fibrinogen replacement is critical in trauma patients to preserve blood clotting. However, the potential signal of harm in some patients identified in CRYOSTAT-2 requires urgent further investigation.

    Over the last 15 years, we have developed and evolved MHPs which aim to maintain the ability of …

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    Footnotes

    • Handling editor Jason E Smith

    • X @rossdavenport

    • Contributors RD and NC coauthored the article.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests RD and NC were principal investigators for the CRYOSTAT-2 trial. RD reports receiving grants from Barts Charity and UK National Institute for Health and Care Research: Health Technology Assessment during the conduct of the study, and personal fees from Octapharma, personal fees and non-financial support from Werfen and grants from HemoSonics outside the submitted work. NC reports receiving grants from UK National Institute for Health and Care Research: Health Technology Assessment during the conduct of the study, and personal fees from Octapharma and LFB outside the submitted work.

    • Provenance and peer review Commissioned; internally peer reviewed.