Administration of fibrinogen concentrate for refractory bleeding in massively transfused, non-trauma patients with coagulopathy: a retrospective study with comparator group

Abstract

BackgroundThis retrospective, single centre study was conducted to investigate the efficacy of fibrinogen concentrate (FBNc) in decreasing blood requirements and reaching optimal fibrinogen level, in non-trauma, massively transfused, bleeding patients with coagulopathy.MethodsOver a 3-years period, all patients for whom a massive transfusion protocol was activated and had received ≥4 units of allogeneic blood components within a ≤4 h period, were included. Patients were classified according to whether they received FBNc or achieved an optimal fibrinogen level of ≥2 g/L within 24 h after FBNc administration.ResultsSeventy-one patients received 2 [2,4] g of FBNc (FBNc group) and 72 did not (comparator group). FBNc was administered after transfusing 5 [5,9] blood component units, 3 [2,6] hours after massive transfusion protocol activation. Linear regression analysis showed that SOFA (AOR 0.75 [95% CI:0.08-1.43]) and admission fibrinogen level (AOR -2.7 [95% CI:-4.68 – -0.78]), but not FBNc administration, were independently associated with total transfused units. There was a significant inverse relation between both admission and target fibrinogen levels, and total transfused components. Logistic regression showed a direct relationship between admission fibrinogen level and achieving a target level ≥2 g/L (AOR 3.29 [95% CI;1.95-5.56]). No thromboembolic events associated with FBNc were observed.ConclusionsIn massively transfused, non-trauma patients with coagulopathy and refractory bleeding, late administration of low FBNc dosage was not associated with decreased blood transfusion or increased post-infusion fibrinogen level. Given that both fibrinogen upon admission and target fibrinogen levels were associated with decreased blood transfusion, earlier administration and higher doses of FBNc could be needed.

Acquired hypofibrinogenemia: current perspectives

“…Also, there is evidence that late low-dose administration in the context of massive blood loss is probably not effective despite a correlation of blood loss to the lowest fibrinogen level observed. 30 Of note is also that there were no thromboembolic complications following fibrinogen replacement.…”

“…Two strategies are employed to produce a 10× more concentrated replacement treatment: 30 the production of cryoprecipitate by thawing fresh frozen plasma at 4°C rather than at room temperature and plasma fractionation to concentrate fibrinogen. Both products are by-products of the production of other plasma products such as a factor VIII/von Willebrand factor concentrate (cryoprecipitate) 31 and albumin (Cohn plasma fractionation).…”

Risk factor and outcome for intra-abdominal bleeding in patients with enterocutaneous fistula

“…So, the improvement of coagulation function in this sort of patient would prevent hemorrhage in a certain degree, which included the early use of cryoprecipitation for fibrinogen and thrombin. [26] …”

A national common massive transfusion protocol (MTP) is a feasible and advantageous option for centralized blood services and hospitals

“…Early fibrinogen replacement is critical in both trauma and non‐trauma‐related massive bleeding, low fibrinogen levels being associated with higher mortality in massive trauma bleeding .…”