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

N Rahe-Meyer, M Pichlmaier, A Haverich, C Solomon, M Winterhalter, S Piepenbrock, K A Tanaka, N Rahe-Meyer, M Pichlmaier, A Haverich, C Solomon, M Winterhalter, S Piepenbrock, K A Tanaka

Abstract

Background: Bleeding 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.

Methods: A 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 < or =100 x 10(3) microl(-1) when removing the aortic clamp, and vice versa if platelet count was >100 x 10(3) microl(-1). The trigger for each therapy step was > or =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.

Results: A 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].

Conclusions: In this pilot study, FIBTEM-guided fibrinogen concentrate administration was associated with reduced transfusion requirements and 24 h postoperative bleeding in patients undergoing AV-AA.

Figures

Fig 1
Fig 1
Flow chart of transfusion algorithm. FFP, fresh-frozen plasma; PC, platelet concentrates; PLT, platelet count (×103 µl−1); u, unit.

References

    1. Nuttall GA, Oliver WC, Santrach PJ, et al. Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology. 2001;94:773–81. discussion 5A–6A.
    1. Levi M, Cromheecke ME, de Jonge E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet. 1999;354:1940–7.
    1. Sioris T, David TE, Ivanov J, Armstrong S, Feindel CM. Clinical outcomes after separate and composite replacement of the aortic valve and ascending aorta. J Thorac Cardiovasc Surg. 2004;128:260–5.
    1. Brandt M, Abdelkerim S, Clemm S, Boning A, Cremer J. Composite valve graft versus separate aortic valve and ascending aortic replacement. Cardiology. 2004;102:156–9.
    1. Casbard AC, Williamson LM, Murphy MF, Rege K, Johnson T. The role of prophylactic fresh frozen plasma in decreasing blood loss and correcting coagulopathy in cardiac surgery. A systematic review. Anaesthesia. 2004;59:550–8.
    1. Chowdhury P, Saayman AG, Paulus U, Findlay GP, Collins PW. Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol. 2004;125:69–73.
    1. Weinkove R, Rangarajan S. Fibrinogen concentrate for acquired hypofibrinogenaemic states. Transfus Med. 2008;18:151–7.
    1. Danes AF, Cuenca LG, Bueno SR, Mendarte Barrenechea L, Ronsano JB. Efficacy and tolerability of human fibrinogen concentrate administration to patients with acquired fibrinogen deficiency and active or in high-risk severe bleeding. Vox Sang. 2008;94:221–6.
    1. Haas T, Fries D, Velik-Salchner C, Oswald E, Innerhofer P. Fibrinogen in craniosynostosis surgery. Anesth Analg. 2008;106:725–31. table of contents.
    1. Mittermayr M, Streif W, Haas T, et al. Hemostatic changes after crystalloid or colloid fluid administration during major orthopedic surgery: the role of fibrinogen administration. Anesth Analg. 2007;105:905–17. table of contents.
    1. Heindl B, Delorenzo C, Spannagl M. High dose fibrinogen administration for acute therapy of coagulopathy during massive perioperative transfusion. Anaesthesist. 2005;54:787–90.
    1. Karlsson M, Ternstrom L, Hyllner M, Baghaei F, Nilsson S, Jeppsson A. Plasma fibrinogen level, bleeding, and transfusion after on-pump coronary artery bypass grafting surgery: a prospective observational study. Transfusion. 2008;48:2152–8.
    1. Blome M, Isgro F, Kiessling A, et al. Relationship between factor XIII activity, fibrinogen, haemostasis screening tests and postoperative bleeding in cardiopulmonary bypass surgery. Thromb Haemost. 2005;93:1101–7.
    1. Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-Cantos F, Ergin MA. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg. 1999;88:312–9.
    1. Despotis GJ, Santoro SA, Spitznagel E, et al. Prospective evaluation and clinical utility of on-site monitoring of coagulation in patients undergoing cardiac operation. J Thorac Cardiovasc Surg. 1994;107:271–9.
    1. Spalding GJ, Hartrumpf M, Sierig T, Oesberg N, Kirschke CG, Albes JM. Cost reduction of perioperative coagulation management in cardiac surgery: value of ‘bedside’ thrombelastography (ROTEM) Eur J Cardiothorac Surg. 2007;31:1052–7.
    1. Lang T, Toller W, Gutl M, et al. Different effects of abciximab and cytochalasin D on clot strength in thrombelastography. J Thromb Haemost. 2004;2:147–53.
    1. Johar RS, Smith RP. Assessing gravimetric estimation of intraoperative blood loss. J Gynecol Surg. 1993;9:151–4.
    1. Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5:266–73.
    1. Levy JH. Massive transfusion coagulopathy. Semin Hematol. 2006;43:S59–63.
    1. Velik-Salchner C, Haas T, Innerhofer P, et al. The effect of fibrinogen concentrate on thrombocytopenia. J Thromb Haemost. 2007;5:1019–25.
    1. Kestin AS, Valeri CR, Khuri SF, et al. The platelet function defect of cardiopulmonary bypass. Blood. 1993;82:107–17.
    1. Sniecinski RM, Chen EP, Tanaka KA. Reduced levels of fibrin (antithrombin I) and antithrombin III underlie coagulopathy following complex cardiac surgery. Blood Coagul Fibrinolysis. 2008;19:178–9.
    1. Elodi S, Varadi K. Optimization of conditions for the catalytic effect of the factor IXa–factor VIII complex: probable role of the complex in the amplification of blood coagulation. Thromb Res. 1979;15:617–29.
    1. Meh DA, Siebenlist KR, Mosesson MW. Identification and characterization of the thrombin binding sites on fibrin. J Biol Chem. 1996;271:23121–5.
    1. Khan H, Belsher J, Yilmaz M, et al. Fresh-frozen plasma and platelet transfusions are associated with development of acute lung injury in critically ill medical patients. Chest. 2007;131:1308–14.
    1. Spiess BD, Royston D, Levy JH, et al. Platelet transfusions during coronary artery bypass graft surgery are associated with serious adverse outcomes. Transfusion. 2004;44:1143–8.
    1. Ketchum L, Hess JR, Hiippala S. Indications for early fresh frozen plasma, cryoprecipitate, and platelet transfusion in trauma. J Trauma. 2006;60:S51–8.
    1. O'shaughnessy DF, Atterbury C, Bolton Maggs P, et al. Guidelines for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant. Br J Haematol. 2004;126:11–28.
    1. Diprose P, Herbertson MJ, O'shaughnessy D, Gill RS. Activated recombinant factor VII after cardiopulmonary bypass reduces allogeneic transfusion in complex non-coronary cardiac surgery: randomized double-blind placebo-controlled pilot study. Br J Anaesth. 2005;95:596–602.
    1. O’Connell KA, Wood JJ, Wise RP, Lozier JN, Braun MM. Thromboembolic adverse events after use of recombinant human coagulation factor VIIa. J Am Med Assoc. 2006;295:293–8.

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