Reduction of Fresh Frozen Plasma Requirements by Perioperative Point-of-Care Coagulation Management with Early Calculated Goal-Directed Therapy

Abstract

Background: Massive bleeding and transfusion of packed red blood cells (PRBC), fresh frozen plasma (FFP) and platelets are associated with increased morbidity, mortality and costs. Patients and Methods: We analysed the transfusion requirements after implementation of point-of-care (POC) coagulation management algorithms based on early, calculated, goal-directed therapy with fibrinogen concentrate and prothrombin complex concentrate (PCC) in different perioperative settings (trauma surgery, visceral and transplant surgery (VTS), cardiovascular surgery (CVS) and general and surgical intensive care medicine) at 3 different hospitals (AUVA Trauma Centre Salzburg, University Hospital Innsbruck and University Hospital Essen) in 2 different countries (Austria and Germany). Results: In all institutions, the implementation of POC coagulation management algorithms was associated with a reduction in the transfusion requirements for FFP by about 90% (Salzburg 94%, Innsbruck 88% and Essen 93%). Furthermore, PRBC transfusion was reduced by 8.4–62%. The incidence of intraoperative massive transfusion (≧10 U PRBC) could be more than halved in VTS and CVS (2.56 vs. 0.88%; p < 0.0001 and 2.50 vs. 1.06%; p = 0.0007, respectively). Platelet transfusion could be reduced by 21–72%, except in CVS where it increased by 115% due to a 5-fold increase in patients with dual antiplatelet therapy (2.7 vs. 13.7%; p < 0.0001). Conclusions: The implementation of perioperative POC coagulation management algorithms based on early, calculated, goaldirected therapy with fibrinogen concentrate and PCC is associated with a reduction in the transfusion requirements for FFP, PRBC and platelets as well as with a reduced incidence of massive transfusion. Thus, the limited blood resources can be used more efficiently.

Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage

“…, a conventional level at which fibrinogen replacement therapy has been widely recommended [28,30,31]. Our algorithm allowed us to reassess the response to its administration promptly, and administer more fibrinogen rapidly if the FibTEM value still indicated abnormality.…”

Point-of-Care Coagulation Management in Intensive Care Medicine

“…POC-guided transfusion was associated with decreased transfusion of frozen plasma (12.8 ± 7 vs. 21.5 ± 1 2.7 units), but did not aff ect 3-year survival [16]. Analyzing more than 18, 000 thromboelastography measurements in the context of 642 patients with liver transplantation, the implementation of a POC coagu lation management based on early, calculated, goaldirected therapy with fi brinogen concentrate, prothrombin complex concentrate and antifi brinolytic therapy resulted in early detection of hyperfi brinolysis and consequently antifi brinolytic therapy [17], and a reduction in transfusion requirements for erythrocytes, fresh frozen plasma (FFP), and platelets as well as a reduced incidence of massive transfusion [18].…”

“…Th e level of fi brinogen typically falls below the lower reference range after 150 % blood volume loss, followed by a decrease in other coagulation factors to 25 % activity after 200 % blood loss [19]. FFP alone, if given in suffi cient quantity (> 15-20 ml/kg), will most likely correct fi brinogen and most coagulation factor defi ciencies, but large volumes may be required, which are further associated with infectious complica tions [20] and multiple organ failure [21] ; therefore goal-directed therap y with coagulation factor concentrates should be preferred [18] in patients outside the clinica l setting of 'massive transfusion' .…”

Goal-directed therapy in trauma induced coagulopathy and focus on traumatic brain injury

“…Se il target dell'aumento in MCF FIB è di 8 mm, è necessaria una dose di 50 mg/kg di concentrato di fibrinogeno: pertanto, in un paziente del peso di 80 kg, la dose necessaria di fibrinogeno è 4 g. Per ottenere lo stesso effetto utilizzando FFP, sono necessari circa 3 litri di plasma, che possono causare la diluizione di RBC e l'abbassamento dei livelli di emoglobina, con conseguente aumento del rischio di eventi avversi associati alla trasfusione e sovraccarico circolatorio associato alla trasfusione. Utilizzando questo algoritmo di gestione basato sul ROTEM® per la goal-directed therapy, diagnosi e terapia possono essere messe in atto in un breve lasso di tempo: in circa 30 minuti è possibile diagnosticare la coagulopatia, effet- Tabella I. Dosaggi di fibrinogeno utilizzati nello studio di Görlinger et al [19] tuare la terapia appropriata e controllare l' efficacia dell'intervento terapeutico. Questo lasso di tempo è decisamente breve, anche considerando che rappresenta circa la metà del tempo necessario per ottenere i risultati dei test di laboratorio standard.…”

“…Inoltre, con questo approccio la terapia coagulativa può essere completamente separata dalla terapia di reintegro dei volumi, e in alcuni casi questo può costituire un vantaggio. In Tabella I si riportano i dati relativi all'utilizzo di concentrato di fibrinogeno nella nostra esperienza; tali dati possono essere utili per calcolare adeguatamente la dose necessaria di concentrato di fibrinogeno (Tabella I) [19]. Il secondo caso, rappresentato in Figura 4, riguarda una situazione in cui la stabilità del coagulo è nell'area target, ma si registra nell'EXTEM test un prolungamento del tempo di coagulazione, evidenziando quindi un problema nella generazione di trombina.…”