Four-Group Classification Based on Fibrinogen Level and Fibrin Polymerization Associated With Postoperative Bleeding in Cardiac Surgery

Essentials Near‐patient testing improves coagulopathy diagnosis in cardiac surgery patients with severe bleeding.We investigated how well pre‐emptive near‐patient testing predicted severe bleeding.Severe bleeding could be predicted using both near‐patient tests and patient clinical characteristics.Near‐patient test results gave little additional predictive value over clinical characteristics alone. BackgroundCoagulopathic bleeding is common after cardiac surgery and is associated with increased morbidity, mortality and healthcare costs. Implementation of blood management algorithms in which patients with severe bleeding undergo near‐patient coagulation testing results in less overall bleeding and transfusion. However, it is unknown whether there is additional value from pre‐emptive near‐patient testing to predict whether severe bleeding will occur.ObjectivesTo evaluate how well a comprehensive panel of 28 near‐patient platelet and viscoelastometry tests predict bleeding after cardiac surgery, compared to prediction using baseline clinical characteristics alone.MethodsSingle‐center, prospective cohort study in adults undergoing a range of cardiac surgery procedures. The primary outcome was clinical concern about bleeding (CCB), a composite of high blood loss (chest drain volume >600 mL within 6 hours), re‐operation for bleeding or administration of a pro‐haemostatic treatment directed by clinician judgement.ResultsIn 1833 patients recruited between March 2010 and August 2012, the median number of abnormal near‐patient test results was 5/28 per patient (range 0‐18). CCB occurred in 449/1833 patients (24.5%). The c‐statistic for a predictive model for CCB using only baseline clinical characteristics (baseline‐only model) was 0.72 (95% CI 0.69‐0.75). Addition of near‐patient test results to this model (baseline‐plus‐test model) improved the prediction of CCB (c‐statistic 0.75 [0.72‐0.77]), but increased the number of correctly classified patients by only 18 (0.98%).ConclusionsNear‐patient coagulation testing predicts bleeding in cardiac surgery patients, but offers little improvement in prediction compared to baseline clinical characteristics alone. trial registration: ISRNCTN 20778544 (http://www.isrctn.com/).

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“…Together, these suggest impaired clot formation and fibrinogen component of clot strength, both previously reported after cardiac surgery 41, 42…”

Section: Discussionsupporting

confidence: 57%

Near‐patient coagulation testing to predict bleeding after cardiac surgery: a cohort study

Mumford

Harris

Plummer

et al. 2017

Research and Practice in Thrombosis and Haemostasis

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“…In accordance with previous studies, these results clearly indicate the importance of preoperative coagulation assessment for maintaining normal coagulation function throughout the perioperative period of cardiac surgery. [22][23][24] FIBTEM-MCF reflects both plasma fibrinogen concentration and hematocrit values. 25,26 Despite significant reduction of hematocrit during cardiac surgery, FIBTEM-MCF significantly decreased during the period, and therefore, the observed FIBTEM-MCF values are considered to underestimate the fibrinogen defect.…”

Section: Importance Of Perioperative Assessments Of Coagulation Functionmentioning

confidence: 99%

Effects of Cardiac Surgery and Salvaged Blood Transfusion on Coagulation Function Assessed by Thromboelastometry

Son

Yamada

Tarao

et al. 2020

Journal of Cardiothoracic and Vascular Anesthesia

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Objectives: Coagulation function dynamically changes during cardiac surgery and is normalized after surgery. The authors investigated changes of coagulation function during cardiac surgery and after mimicked salvaged blood transfusion (SBT), and determined background risk factors for coagulation dysfunction by thromboelastmetry including maximum clot firmness of fibrinogen assay (FIBTEM-MCF: primary variable). Design: Prospective observational study with ex vivo laboratory experiment. Setting: University hospital. Participants: Consecutive 65 adult elective cardiac surgery patients being scheduled to use cell salvage technique. Interventions: Arterial blood sampling (preoperative: after anesthesia induction, and postoperative: after reversal of heparin), and ex vivo dilution of postoperative blood with salvaged blood (7.4%: 2.5 mL + 0.2 mL and 18.5%: 2.2 mL + 0.5 mL). Measurements and Main Results: Thromboelastometry was performed for the preoperative blood sample, and postoperative blood samples mixed with different amount of the salvaged blood. Preoperative FIBTEM-MCF significantly decreased after cardiac surgery (16.5 [95% confidence interval (15.4-17.6)] mm to 9.5 [8.4-10.6] mm, p < 0.0001). In vitro 7.4% and 18.5% salvaged blood addition dose-dependently reduced FIBTEM-MCF (9.1 [95% confidence interval (8.0-10.1)] mm, 7.9 [6.8-9.0] mm, respectively, p < 0.0001). Preoperative FIBTEM-MCF and changes of FIBTEM-MCF during cardiac surgery were independent risk factors for development of the FIBTEM-MCF 8 mm or less after in vitro salvaged blood addition. Furthermore, residual heparin within salvaged blood was indicated by significant increase of intrinsic assay-clotting time/ heparin assay-clotting time after 18.5% in vitro salvaged blood addition (p < 0.0001). Conclusions: Salvaged blood transfusion of more than 18.5% whole blood volume may impair coagulation function particularly in patients with lower FIBTEM-MCF before and after cardiac surgery.

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“…This has been illustrated in a previous study where patients with a fibrinogen level of 150 mg/dL or greater but impaired fibrin polymerization were at high risk of bleeding in cardiac surgery. [ 33 ]…”

Section: Discussionmentioning

confidence: 99%

A Low-dose human fibrinogen is not effective in decreasing postoperative bleeding and transfusion requirements during cardiac surgery in case of concomitant clinical bleeding and low FIBTEM values: A retrospective matched study

et al. 2018

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Background:Studies evaluating the hemostatic effects of fibrinogen administration in cardiac surgery are not conclusive.Aims:We investigated whether the use of a low-dose human fibrinogen in case of clinical bleeding after protamine administration and concomitant low FIBTEM values is effective in reducing postoperative bleeding. Secondary end-point was to investigate the consumption of allogeneic blood products.Setting and Design:This was a retrospective matched study conducted at university hospital.Materials and Methods:Among 2257 patients undergoing surgery with cardiopulmonary (CPB) bypass, 73 patients received a median dose of 1 g human fibrinogen (ROTEM-Fibri group). This group was matched with 73 patients who had not received human fibrinogen (control group) among 390 patients having undergone surgery at the moment FIBTEM analysis was unavailable.Statistical Analysis:Matching was performed for the type and the presence of redo surgery. McNemar and Wilcoxon paired tests were used to respectively compare the categorical and quantitative variables.Results:The CPB bypass time was significantly higher in the ROTEM-Fibri group (P = 0.006). This group showed significantly higher bleeding in the first 12 and 24 h postoperatively (P < 0.001) and required significantly more transfusion of blood products (P < 0.001) and surgical revision (P = 0.007) when compared with the control group. There was no significant difference in the number of thromboembolic complications.Conclusions:These results show that the administration of 1 g of fibrinogen based on low-FIBTEM values and clinical bleeding after protamine administration does not stop bleeding and the need for transfusion of allogeneic blood products.

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Four-Group Classification Based on Fibrinogen Level and Fibrin Polymerization Associated With Postoperative Bleeding in Cardiac Surgery

Cited by 20 publications

References 16 publications

Near‐patient coagulation testing to predict bleeding after cardiac surgery: a cohort study

Near‐patient coagulation testing to predict bleeding after cardiac surgery: a cohort study

Effects of Cardiac Surgery and Salvaged Blood Transfusion on Coagulation Function Assessed by Thromboelastometry

A Low-dose human fibrinogen is not effective in decreasing postoperative bleeding and transfusion requirements during cardiac surgery in case of concomitant clinical bleeding and low FIBTEM values: A retrospective matched study

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