Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes

Abstract

Summary. Background: Low fibrinogen levels are known to occur in trauma. However, the extent of fibrinogen depletion during trauma hemorrhage, the response to replacement therapy and association with patient outcomes remain unclear. Objectives: The study aims were to: characterize admission fibrinogen level and correlate it with factors associated with injury; describe the time course of fibrinogen depletion and response to replacement therapy; determine the correlation of fibrinogen level with rotational thromboelastography (ROTEM) parameters; evaluate the effect of fibrinogen supplementation ex vivo; and establish the association between fibrinogen level and clinical outcomes. Methods: This was a prospective cohort study of 517 patients. Blood samples were drawn on admission and after admistration of every 4 units of packed red blood cells. Fibrinogen levels were determined with the Clauss method, and global hemostatic competence was assessed with thromboelastometry. The effect of fibrinogen supplementation was assessed in a subgroup of coagulopathic patients. Results: Low admission fibrinogen level was independently associated with injury severity score (P < 0.01), shock (P < 0.001), and prehospital fluid volume (P < 0.001). Fibrinogen supplementation during transfusion maintained but did not augment fibrinogen levels. Administration of cryoprecipitate was associated with improved survival. ROTEM parameters correlated with fibrinogen level, and ex vivo fibrinogen administration reversed coagulopathic ROTEM parameters. Fibrinogen level was an independent predictor of mortality at 24 h and 28 days (P < 0.001). Conclusions: Fibrinogen level is decreased in injured patients on admission and is associated with poor outcomes. ROTEM is a rapid means of assessing hypofibrinogenemia. Earlier administration of specific fibrinogen replacement may improve outcomes, and prospective controlled trials are urgently needed.

Relationship between initial fibrinogen level with coagulopathy and mortality in multiple trauma patients

“…Therefore, other variables may play a role that could affect the relationship between fibrinogen and mortality. 9 There was no significant association between initial fibrinogen level with the occurrence of mortality in this study, it may be because the study subjects were mostly patients with a diagnosis of head trauma, so although head trauma could be severe, tissue damage however were not so extensive and blood loss was not significant enough to provoke a substantial fibrinolysis. With these explanations, further research may be needed to focus on the role of fibrinogen in head trauma.…”

“…Plasma fibrinogen reached the lowest value at the earlier phase than other coagulation factor parameters and low fibrinogen value is one of the signs of deficiency of clotting factors primary in the case of trauma with major bleeding. [9][10][11][12][13][14][15] Management of bleeding due to trauma requires the existence of a rapid identification TIC so that it can become the basis for replacement therapy.…”

“…A study reports in 2013 that mortality increases significantly in multiple trauma patients with ISS ≥ 15 accompanied by low initial fibrinogen value. 9,19 This research was expected to reveal a relationship between the level of fibrinogen with the coagulopathy and to see the relationship between initial fibrinogen with occurrence of multiple trauma patient mortality.…”

Point-of-Care Coagulation Management in Intensive Care Medicine

“…Additionally, trauma-associated coagulopathy is the consequence of a low admission fi brinogen level, which is independently associated with injury severity score, shock, and mortality at 24 h and 28 days after trauma. In a prospective cohort study of 517 trauma patients, thromboelastography enabled rapid detection of hypofi brinogenemia, and early administration of fi brinogen was related with improved survival [23]. Using rapid thromboelastography, Holcomb et al re cently succeeded in identifying patients with an increased risk of fi brinolysis and erythrocyte, plasma and platelet transfusions out of 1,974 major trauma patients [24].…”

Early administration of fibrinogen concentrates improves the short‐term outcomes of severe pelvic fracture patients

“…An increasing number of studies have reported the limited efficacy of fresh frozen plasma in treating severe hypofibrinogenemia 5. The fibrinogen level at admission is reported to be an independent predictor of mortality for trauma patients,6 and another study suggested that fibrinogen supplementation improves outcomes for traumatic hemorrhage 7…”