Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study

Abstract

BackgroundBleeding diathesis after aortic valve operation and ascending aorta replacement (AV–AA) is managed with fresh-frozen plasma (FFP) and platelet concentrates. The aim was to compare haemostatic effects of conventional transfusion management and FIBTEM (thromboelastometry test)-guided fibrinogen concentrate administration.MethodsA blood products transfusion algorithm was developed using retrospective data from 42 elective patients (Group A). Two units of platelet concentrate were transfused after cardiopulmonary bypass, followed by 4 u of FFP if bleeding persisted, if platelet count was ≤100×103 µl−1 when removing the aortic clamp, and vice versa if platelet count was >100×103 µl−1. The trigger for each therapy step was ≥60 g blood absorbed from the mediastinal wound area by dry swabs in 5 min. Assignment to two prospective groups was neither randomized nor blinded; Group B (n=5) was treated according to the algorithm, Group C (n=10) received fibrinogen concentrate (Haemocomplettan® P/Riastap, CSL Behring, Marburg, Germany) before the algorithm-based therapy.ResultsA mean of 5.7 (0.7) g fibrinogen concentrate decreased blood loss to below the transfusion trigger level in all Group C patients. Group C had reduced transfusion [mean 0.7 (range 0–4) u vs 8.5 (5.3) in Group A and 8.2 (2.3) in Group B] and reduced postoperative bleeding [366 (199) ml vs 793 (560) in Group A and 716 (219) in Group B].ConclusionsIn this pilot study, FIBTEM-guided fibrinogen concentrate administration was associated with reduced transfusion requirements and 24 h postoperative bleeding in patients undergoing AV–AA.

Use of Prothrombin Complex Concentrates and Fibrinogen Concentrates in the Perioperative Setting: A Systematic Review

“…Although an improved Δ MCF was noted in the study by Lance and colleagues [11], this difference did not translate to a reduction in ABT utilization. Overall, thrombotic events were similar in both the intervention group and the comparator arm, with an overall low incidence rate [10][11][12][13][14][15].…”

“…Five prospective studies in this clinical grouping demonstrated reductions in ABT requirements [10,[12][13][14][15], of which 4 showed reduction in 24-hour chest tube drainage [10,[13][14][15] compared to the comparator arm (Table 5A). The study by Karlsson and colleagues [10] was assessed to have the lowest overall risk of methodological bias overall; the study reports that a prophylactic 2-g dose of FIBC given preoperatively in patients undergoing elective CABG surgery reduces chest tube drainage postoperatively (P b .01).…”

“…Overall, we identified 6 prospective [10][11][12][13][14][15] and 2 retrospective [16,17] studies in the cardiac surgery grouping. Of the 6 prospective studies, 3 were randomized and 3 were nonrandomized.…”

Haemostatic management of cardiac surgical haemorrhage

“…[5,9,17,18]. In an attempt to quantify the volume of bleeding when the chest is still open, the chest may be packed with swabs for exactly five minutes before weighing the swabs and subtracting their dry weight [19].…”

Coagulation Measurement and Optimisation in Cardiac Surgery

“…Options for replacing fibrinogen are fibrinogen concentrate reconstituted to 20g/L, Fresh Frozen Plasma containing 1.6-2g/L fibrinogen, or cryoprecipitate containing 17g/L. The traditional target of replacement of fibrinogen aimed for a level of 1g/L, but higher targets of 1.5-2g/L may be more appropriate in patients undergoing cardiac surgery (38). It remains to be established whether it is better to administer fibrinogen concentrate prophylactically, or to reserve treatment only for patients who are bleeding.…”