Our meta-analysis indicated a significant but weak-to-moderate correlation between pre- and postoperative fibrinogen levels and postoperative blood loss in cardiac surgery. This moderate association calls for appropriate clinical studies on whether fibrinogen supplementation will decrease postoperative blood loss.
BackgroundProlonged or excessive blood loss is a common complication after cardiac surgery. Blood remnants and clots, remaining in the pericardial space in spite of chest tube drainage, induce high fibrinolytic activity that may contribute to bleeding complications. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. In this pilot study, the safety and feasibility of CPPF were evaluated and the effect on blood loss and other related complications was investigated.MethodsBetween November 2011 and April 2012 twenty-one adult patients undergoing surgery for congenital heart disease (CHD) received CPPF from sternal closure up to 12 h postoperative. With an inflow Redivac drain that was inserted through one of the chest tube incision holes, an irrigation solution (NaCl 0.9% at 38 °C) was delivered to the pericardial cavity using a volume controlled flushing system. Safety aspects, feasibility issues and complications were registered. The mean actual blood loss in the CPPF group was compared to the mean of a retrospective group (n = 126).ResultsCPPF was successfully completed in 20 (95.2%) patients, and no method related complications were observed. Feasibility was good in this experimental setting. Patients receiving CPPF showed a 30% (P = 0.038) decrease in mean actual blood loss 12 h postoperatively.ConclusionsCPPF after cardiac surgery was found to be safe and feasible in this experimental setting. The clinically relevant effect on blood loss needs to be confirmed in a randomized clinical trial.
Fibrinogen as precursor of fibrin plays an essential role in clot formation. There are three main mechanisms associated with a reduction in fibrinogen concentration during cardiac surgery: hemodilution, consumption, and degradation. Moreover, early fibrinogen degradation products (FgDPs) can interfere with normal fibrin formation of intact fibrinogen. The aim of this study was to determine the relative contributions of hemodilution, consumption, and degradation to fibrinogen loss in cardiac surgery and to evaluate the effects fibrinogen degradation products on blood clot formation in vitro. First, fibrin and fibrinogen concentrations, their degradation products, hematocrit, and albumin concentrations were compared in 10 patients before and after isolated coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass. Second, ex-vivo fibrinogen supplementation experiments were performed. Finally, the effects of purified FgDPs on clotting time and clot firmness were established in vitro in whole blood by ROTEM. Fibrinogen plasma concentration decreased 30% during surgery. This drop appears to be mainly caused by hemodilution, as both hematocrit and albumin levels decreased and no relevant increase in D-dimer levels and FgDPs was observed. Furthermore, the coagulation profile normalized after addition of purified fibrinogen. Early FgDPs demonstrated a significant impact on in-vitro whole blood clotting. Although early FgDPs have a pronounced effect on blood clot formation in vitro and therefore may induce or enhance in vivo coagulopathy, the drop of fibrinogen concentration seen after CABG surgery (using tranexamic acid) is primarily caused by hemodilution.
There is no clinically relevant effect on blood loss indicating an optimal stop day for ASA alone or in combination with Clo. Last use on Day -2 resulted in the reduction of percentage of patients receiving platelet transfusions, especially in the ASA+Clo group.
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