Coagulated Cryoprecipitate in an Intravenous Line

Cryoprecipitate contains fibrinogen, factor VIII, factor XIII, von Willebrand factor, and fibronectin. Cryoprecipitate production involves cold thawing of plasma to create a supraphysiologic concentrate of these cold-insoluble factors. Up to 20% of cryoprecipitate units are discarded during production because of precipitation or clotting, and careful handling is required.

In the image, cryoprecipitate has been transfused through tubing containing lactated Ringer’s solution that had previously been used to transfuse platelets. Shortly after the transfusion was started, a coagulum formed in the filter (fig., panel A) and accumulated in the hand pump (fig., panel B). No coagulum appeared below the pump, and the patient had no signs or symptoms of embolus. Cryoprecipitate may cause obstruction in-line because of (1) residual precipitate that was missed during thawing, (2) reprecipitation due to cooling before transfusion, and (3) coagulation initiated by a prothrombotic milieu in the tubing, e.g., active thrombin from previously transfused products like platelets.¹  Transfusion through a line containing lactated Ringer’s solution is controversial: most organizations forbid it because calcium-containing solutions may reverse the citrate anticoagulant,²  although the U.S. Food and Drug Administration states only that 0.9% NaCl is the “preferred” diluent. Many studies have found no evidence of clinically significant coagulation or thrombotic potential when blood products are mixed with lactated Ringer’s solution, and some experts argue that transfusing any blood product through lactated Ringer’s solution is appropriate when time or IV access is limited.³  We now avoid administering cryoprecipitate after platelets in the same line. In any clinical circumstances, if coagulation occurs, the transfusion should be stopped immediately and the tubing should be replaced.