title: In vitro efficacy of RiaSTAP after rapid reconstitution.
abstract: BACKGROUND
  Fibrinogen is the first coagulation factor to reach critical levels during hemorrhage. Consequently, reestablishing normal fibrinogen levels is necessary to achieve adequate hemostasis. Fibrinogen is supplemented through administration of fresh frozen plasma, cryoprecipitate, or human fibrinogen concentrate, RiaSTAP. RiaSTAP is potentially the most advantageous fibrinogen replacement product because it offers the highest fibrinogen concentration, lowest volume, and most consistent dose. Unfortunately, RiaSTAP is limited by a protocol reconstitution time of 15 min. Conversely, physicians in emergency settings frequently resort to a forceful and rapid reconstitution, which causes foaming and possible protein loss and/or damage. This study aims to address the in vitro effectiveness of protocol-reconstituted RiaSTAP versus rapidly reconstituted RiaSTAP versus cryoprecipitate.
  
  
  METHODS
  Three fibrinogen treatments were prepared: protocol-reconstituted RiaSTAP, rapidly reconstituted RiaSTAP, and thawed cryoprecipitate. Each treatment was added in theoretical doses of 0-600 mg/dL to fibrinogen-depleted plasma (normal fibrinogen level is 150-450 mg/dL). Samples were generated in triplicate, and each sample was subjected to rapid thrombelastography and Clauss assays. The rapid thrombelastography assay measures the hemostatic potential of a blood and/or plasma sample. The maximum amplitude (MA) parameter indicates overall clot strength and is a reflection of fibrinogen efficacy. The Clauss assay measures the time to clot formation in response to a known concentration of thrombin, and the amount of functional fibrinogen is then determined from a standard curve.
  
  
  RESULTS
  For all fibrinogen treatments, increasing fibrinogen dose resulted in an increase in MA. There was no significant difference in MA between both RiaSTAP reconstitutions (slope of RiaSTAP [protocol], 10.85 mm/[100 mg/dL] and slope of RiaSTAP [rapid], 10.54 mm/[100 mg/dL]). However, both protocol-reconstituted RiaSTAP and rapidly reconstituted RiaSTAP have higher MA values than cryoprecipitate in doses of ≥100 mg/dL. Moreover, each replicate of cryoprecipitate showed a higher variance in fibrinogen efficacy (coefficient of variance [CV] = 44.7%) at a fibrinogen dose of 300 mg/dL. RiaSTAP, however, showed a lower variance in fibrinogen efficacy for both reconstitutions (RiaSTAP [protocol], CV = 3.3% and RiaSTAP [rapid], CV = 2.7%), indicating a consistent fibrinogen dose.
  
  
  CONCLUSIONS
  RiaSTAP (either reconstitution method) has greater hemostatic potential and less variability in fibrinogen concentration compared with cryoprecipitate. Rapidly reconstituted RiaSTAP does not compromise hemostatic potential and can be used to potentially facilitate hemostasis in rapidly bleeding patients.
authors.affiliation: Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas.
authors.forename: Jay V
authors.initials: JV
authors.lastname: Karri
authors.affiliation: Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas.
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Cardenas
authors.affiliation: Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas; Section for Transfusion Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Pär I
authors.initials: PI
authors.lastname: Johansson
authors.affiliation: Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas.
authors.forename: Nena
authors.initials: N
authors.lastname: Matijevic
authors.affiliation: Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas; Section for Transfusion Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.affiliation: Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas; Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas.
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.affiliation: Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas; Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas. Electronic address: John.Holcomb@uth.tmc.edu.
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
mesh_terms: D005169:Factor VIII; D005340:Fibrinogen / Q000737:chemistry / Q000627:therapeutic use*; D006487:Hemostasis; D006489:Hemostatic Techniques; D006801:Humans; D012995:Solubility
chemical_list: C026912:cryoprecipitate coagulum; D005169:Factor VIII; D005340:Fibrinogen
keywords: Cryoprecipitate; Fibrinogen; Resuscitation; RiaSTAP; Trauma