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Gomes M, Ângelo-Dias M, Duarte GS, Dias SS, Serra SS, Lima J. Safety of Fibrinogen Concentrate in Non-Trauma and Non-Obstetric Adult Patients during Perioperative Care: Systematic Review and Meta-Analysis. J Clin Med 2024; 13:3482. [PMID: 38930009 PMCID: PMC11204778 DOI: 10.3390/jcm13123482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/27/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Low fibrinogen levels are associated with an increased risk of perioperative bleeding. However, there is an ongoing debate over the ideal treatment threshold, the benefits of prophylactic supplementation with fibrinogen concentrate, and the best source of fibrinogen. While fibrinogen concentrate supplementation is being widely used to treat bleeding related to acquired haemostatic deficiencies, there is a lack of evidence regarding its dosage, effectiveness, and safety. This systematic review provides an up-to-date summary of the relationship between fibrinogen concentrate supplementation and safety measures in the perioperative care of non-trauma, non-obstetric adult patients. Methods: A comprehensive online search was conducted on PubMed/Medline, EMBASE, Scopus, Web of Science, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. Results: This systematic review and meta-analysis encompasses ten studies involving 1391 patients. There was a decreased risk of total thromboembolic events in patients treated with fibrinogen compared to the control (OR 0.65, 95% CI 0.43 to 0.98, I2 = 0%). In addition, when fibrinogen was used prophylactically, it resulted in shorter ICU stays (MD -1.50, 95% CI -2.64 to -0.36), when set against its therapeutic use. A sensitivity analysis on cardiovascular surgery studies did not reveal any statistically significant difference. Conclusions: The use of fibrinogen concentrate in the perioperative care of non-trauma and non-obstetric adult patients may lead to potential benefits.
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Affiliation(s)
- Manuela Gomes
- Transfusion Medicine Department, Hemovida, Hospital da Luz Lisboa, Luz Saúde, 1500-650 Lisboa, Portugal;
| | - Miguel Ângelo-Dias
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
- Comprehensive Health Research Centre (CHRC), NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
| | - Gonçalo S. Duarte
- Clinical Pharmacology, Hospital da Luz Lisboa, Luz Saúde, 1500-650 Lisboa, Portugal;
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, 1649-004 Lisboa, Portugal
| | - Sara Simões Dias
- Comprehensive Health Research Centre (CHRC), NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
- ciTechCare—Centre for Innovative Care and Health Technology, Polytechnic of Leiria, 2411-901 Leiria, Portugal
| | - Sofia Silvério Serra
- Library, NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
| | - Jorge Lima
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
- Comprehensive Health Research Centre (CHRC), NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
- Department of Obstetrics and Gynecology, Hospital da Luz Lisboa, Luz Saúde, 1500-650 Lisboa, Portugal
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Lundbech M, Damsbo M, Krag AE, Hvas AM. Changes in Coagulation in Cancer Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Treatment (HIPEC)-A Systematic Review. Semin Thromb Hemost 2024; 50:474-488. [PMID: 36828005 DOI: 10.1055/s-0043-1764125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Venous thromboembolism and postoperative bleeding are complications of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this systematic review was to summarize current knowledge on the effect of cytoreductive surgery with HIPEC on coagulation and fibrinolysis within 10 days after surgery. Studies were identified in PubMed, Embase, and Web of Science on December 12, 2022. Data on biomarkers of coagulation and fibrinolysis measured preoperatively up to the 10th postoperative day were extracted. Among 15 included studies, 13 studies reported markers of primary hemostasis. Eleven studies found reduced platelet count following cytoreductive surgery with HIPEC and two studies reported reduced platelet function. Twelve studies reported impaired secondary hemostasis until postoperative day 10 indicated by prolonged international normalized ratio, prothrombin time, and activated partial thromboplastin time. Fibrinogen was decreased in three studies from preoperative to postoperative day 3 switching to increased levels until postoperative day 10. In accordance, three studies found reduced maximum amplitude and maximum clot firmness by thromboelastography/thromboelastometry (ROTEM/TEG) on the first postoperative day indicating impaired clot strength. Four studies demonstrated increased d-dimer, factor (F) VIII, and thrombin generation during the 10 postoperative days. Four studies investigated fibrinolysis by ROTEM/TEG and plasminogen activator inhibitor-1 (PAI-1) after cytoreductive surgery with HIPEC reporting contradictive results. In conclusion, a decrease in platelet count and subtle changes in secondary hemostasis were found following cytoreductive surgery with HIPEC. Data on the effect of cytoreductive surgery with HIPEC on fibrinolysis are sparse and this needs to be further investigated.
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Affiliation(s)
- Mikkel Lundbech
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matilde Damsbo
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Engel Krag
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
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Sarmiento IA, Guzmán MF, Chapochnick J, Meier J. Implementation of a Bleeding Management Algorithm in Liver Transplantation: A Pilot Study. Transfus Med Hemother 2024; 51:1-11. [PMID: 38314241 PMCID: PMC10836948 DOI: 10.1159/000530579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/03/2023] [Indexed: 02/06/2024] Open
Abstract
Objectives The aims of the study were to compare the consumption of blood products before and after the implementation of a bleeding management algorithm in patients undergoing liver transplantation and to determine the feasibility of a multicentre, randomized study. Background Liver transplantation remains the only curative therapy for patients with end-stage liver disease, but it carries a high risk of surgical bleeding. Materials and Methods Retrospective study of patients treated before (group 1) and after (group 2) implementation of a haemostatic algorithm guided by viscoelastic testing, including use of lyophilized coagulation factor concentrates (prothrombin complex and fibrinogen concentrates). Primary outcome was the number of units of blood products transfused in 24 h after surgery. Secondary outcomes included hospital stay, mortality, and cost. Results Data from 30 consecutive patients was analysed; 14 in group 1 and 16 in group 2. Baseline data were similar between groups. Median total blood product consumption 24 h after surgery was 33 U (IQR: 11-57) in group 1 and 1.5 (0-23.5) in group 2 (p = 0.028). Significantly fewer units of red blood cells, fresh frozen plasma, and cryoprecipitate were transfused in group 2 versus group 1. There was no significant difference in complications, hospital stay, or in-hospital mortality between groups. The cost of haemostatic therapy was non-significantly lower in group 2 versus group 1 (7,400 vs. 15,500 USD; p = 0.454). Conclusion The haemostatic management algorithm was associated with a significant reduction in blood product use during 24 h after liver transplantation. This study demonstrated the feasibility and provided a sample size calculation for a larger, randomized study.
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Affiliation(s)
| | - María F Guzmán
- Department of Anesthesiology, Universidad de los Andes, Santiago de Chile, Chile
| | | | - Jens Meier
- Department for Anesthesiology and Critical Care, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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Ayaganov D, Kuanyshbek A, Vakhrushev I, Li T. Prospective, Randomized Study of Fibrinogen Concentrate Versus Cryoprecipitate for Correcting Hypofibrinogenemia in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2024; 38:80-85. [PMID: 38016817 DOI: 10.1053/j.jvca.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE Cardiac surgery with cardiopulmonary bypass (CPB) is associated with hypofibrinogenemia and severe bleeding requiring transfusion. Guidelines recommend cryoprecipitate or fibrinogen concentrate (FC) for the treatment of acquired hypofibrinogenemia. This study compared cryoprecipitate and FC for the correction of acquired hypofibrinogenemia and the associated costs. DESIGN A single-center, prospective, randomized study evaluating patients with hypofibrinogenemia after cardiac surgery. The primary endpoint was direct treatment cost. Secondary endpoints included the change in fibrinogen level after FC and/or cryoprecipitate dosing. SETTING A single-center study in Astana, Kazakhstan. PARTICIPANTS Participants who underwent CPB from 2021 to 2022 and developed clinically significant bleeding and hypofibrinogenemia. INTERVENTIONS Patients were randomized to receive cryoprecipitate or FC. MEASUREMENTS AND MAIN RESULTS Eighty-eight adult patients with acquired hypofibrinogenemia (<2.0 g/L) after CPB were randomized to receive cryoprecipitate (N = 40) or FC (N = 48), with similar demographics between groups. Overall, mean ± SD 9.33 ± 0.94 units (range, 8-10) cryoprecipitate or 1.40 ± 0.49 g (1-2) FC was administered to the 2 groups. From before administration to 24 hours after, mean plasma fibrinogen increased by a mean ± SD of 125 ± 65 and 96 ± 65 mg/dL in the cryoprecipitate and FC groups, respectively. At 48 hours after administration, there was no significant difference in fibrinogen levels between groups. The mean direct cost of treatment with FC was significantly lower than with cryoprecipitate (p < 0.0001): $1,505.06 ± $152.40 and $631.75 ± $223.67 per patient for cryoprecipitate and FC, respectively. CONCLUSION Analysis of plasma fibrinogen concentration showed that cryoprecipitate and FC had comparable effectiveness. However, FC is advantageous over cryoprecipitate due to its ease of handling, lower cost, and high purity.
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Affiliation(s)
- Dauren Ayaganov
- NJSC "National Research Cardiac Surgery Center", Astana, Kazakhstan
| | - Aidyn Kuanyshbek
- NJSC "National Research Cardiac Surgery Center", Astana, Kazakhstan
| | - Ivan Vakhrushev
- NJSC "National Research Cardiac Surgery Center", Astana, Kazakhstan
| | - Tatyana Li
- NJSC "National Research Cardiac Surgery Center", Astana, Kazakhstan.
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Douin DJ, Fernandez-Bustamante A. Early Fibrinogen Replacement to Treat the Endotheliopathy of Trauma: Novel Resuscitation Strategies in Severe Trauma. Anesthesiology 2023; 139:675-683. [PMID: 37815472 PMCID: PMC10575674 DOI: 10.1097/aln.0000000000004711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
The authors provide a comprehensive review of the endothelial glycocalyx, the components that may be targeted to improve clinical outcomes, and the next steps for evaluation in human subjects.
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Affiliation(s)
- David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado
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Stéphan F, Gutermann L, Bourget S, Djabarouti S, Berdugo J, Fardini Y, Clerson P, Hébert G, Belmokhtar C. Real-World Experience with a Human Fibrinogen Concentrate: Clinical Data from Adult and Pediatric Patients Requiring Fibrinogen for Bleeding Control and Prevention. J Clin Pharmacol 2023; 63:1186-1196. [PMID: 37293880 DOI: 10.1002/jcph.2291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Abstract
Human fibrinogen concentrate (Fibryga) received temporary approval for fibrinogen replacement therapy in France (2017), with subsequent full approval for congenital and acquired hypofibrinogenemia. We evaluated real-world use for on-demand treatment of bleeding and prophylaxis to enhance our knowledge on fibrinogen concentrate as an option for fibrinogen replacement. Data were retrospectively collected from adult and pediatric patients with fibrinogen deficiency. The primary end point was indication for fibrinogen concentrate use; the secondary end point was treatment success for on-demand treatment/perioperative prophylaxis. The study included 150 adult (median age, 62 years; range, 18-94 years) and 50 pediatric (median age, 3 years; range, 0.01-17 years) patients with acquired fibrinogen deficiency. Fibrinogen concentrate was administered to 47.3% for nonsurgical bleeding, 22.7% for surgical bleeding, and 30.0% for perioperative prophylaxis in adult patients, and to 4.0% for surgical bleeding and 96.0% for perioperative prophylaxis in pediatric patients. Cardiac surgeries accounted for 79.5%/75.0% perioperative prophylaxis and 82.4%/100.0% surgical bleeding cases in adult/pediatric patients, respectively. The mean ± standard deviation (SD, median) total fibrinogen doses were 3.06 ± 1.69 g (32.61 mg/kg), 2.09 ± 1.36 g (22.99 mg/kg), and 2.36 ± 1.25 g (29.67 mg/kg) for adult nonsurgical bleeding, surgical bleeding, and perioperative prophylaxis, respectively; doses of 0.75 ± 0.35 g (47.64 mg/kg) and 0.83 ± 0.62 g (55.56 mg/kg) were used for pediatric surgical bleeding and perioperative prophylaxis, respectively. Treatment success was 85.7%/97.1/93.3% in adults and 50.0%/87.5% in pediatrics for nonsurgical bleeding (adults only), surgical bleeding, and perioperative prophylaxis, respectively. Fibrinogen concentrate demonstrated favorable effectiveness and safety across the age groups. This study contributes to evidence supporting fibrinogen concentrate for bleeding control/prevention in real-world clinical practice, particularly for patients with acquired fibrinogen deficiency.
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Affiliation(s)
- Francois Stéphan
- Service de Réanimation Adultes, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
| | - Loriane Gutermann
- Service Pharmacie et Stérilisation, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
| | | | - Sarah Djabarouti
- Service Pharmacie, Groupe Hospitalier Sud, CHU de Bordeaux, Pessac, France
| | | | | | | | - Guillaume Hébert
- Service Pharmacie et Stérilisation, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
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7
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Roy A, Sargant N, Bell J, Stanford S, Solomon C, Kruzhkova I, Knaub S, Mohamed F. Comparison of coagulation parameters associated with fibrinogen concentrate and cryoprecipitate for treatment of bleeding in patients undergoing cytoreductive surgery for pseudomyxoma peritonei: Subanalysis from a randomized, controlled phase 2 study. Health Sci Rep 2023; 6:e1558. [PMID: 37766781 PMCID: PMC10521228 DOI: 10.1002/hsr2.1558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Background and Aims The FORMA-05 study compared the efficacy and safety of human fibrinogen concentrate (HFC) versus cryoprecipitate for hemostasis in bleeding patients undergoing cytoreductive surgery for pseudomyxoma peritonei (PMP). This subanalysis explores coagulation parameters in the FORMA-05 patients, with a focus on the seven patients who developed thromboembolic events (TEEs). Methods FORMA-05 was a prospective, randomized, controlled phase 2 study in which patients with predicted blood loss ≥2 L received HFC (4 g) or cryoprecipitate (two pools of five units), repeated as needed. Plasma fibrinogen, platelet count, factor (F) XIII, FVIII, von Willebrand Factor (VWF) antigen and ristocetin cofactor activity levels, EXTEM A20, FIBTEM A20, and endogenous thrombin potential (ETP) were measured perioperatively. Results Fibrinogen, platelet count, EXTEM and FIBTEM A20, FXIII, FVIII, VWF levels, and ETP were maintained throughout surgery in both the HFC group (N = 21) and the cryoprecipitate group (N = 23). Seven TEEs were observed in the cryoprecipitate group. The two patients developing deep vein thromboses (DVT) appeared to have a procoagulant status preoperatively, with distinctively higher fibrinogen level, FIBTEM A20, and platelet levels, all of which persisted perioperatively. The five patients developing pulmonary embolism (PE) had slightly higher VWF levels preoperatively, with a disproportionate increase intraoperatively (postcryoprecipitate administration) and postoperatively. Conclusions Patients treated with HFC versus cryoprecipitate showed broad overlaps in coagulation parameters. Patients with PE experienced a disproportionate VWF rise following cryoprecipitate administration, whereas patients developing DVT displayed a procoagulant status before and following surgery. Preoperative testing may allow these patients to be identified.
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Affiliation(s)
- Ashok Roy
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
| | - Nigel Sargant
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
| | - John Bell
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
| | - Sophia Stanford
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
| | | | | | | | - Faheez Mohamed
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
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8
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Stanford S, Roy A, Cecil T, Hegener O, Schulz P, Turaj A, Lim S, Arbuthnot E. Differences in coagulation-relevant parameters: Comparing cryoprecipitate and a human fibrinogen concentrate. PLoS One 2023; 18:e0290571. [PMID: 37647278 PMCID: PMC10468048 DOI: 10.1371/journal.pone.0290571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Variable fibrinogen content within cryoprecipitate makes accurate dosing challenging in patients with coagulopathic bleeding, in addition to pathogen transmission risks associated with its administration. Purified and standardized human fibrinogen concentrates (HFCs) represent reliable alternatives. Full cryoprecipitate characterization is required to inform selection of an appropriate fibrinogen source for supplementation therapy. METHODS Extended biochemical comparison of pooled cryoprecipitate and HFC (Fibryga, Octapharma) was performed using commercially available assays to determine levels of variability in cryoprecipitate and HFC. In addition to standard procoagulant factors, measurements included activities of platelet-derived microparticles (PMPs) and plasminogen, and levels of fibrin degradation products. RESULTS Cryoprecipitate contains lower fibrinogen levels than HFC (4.83 vs.19.73 g/L; p<0.001), translating to approximately half the amount of fibrinogen per standard cryoprecipitate dose (two pools, pre-pooled from five donations each) vs. HFC (2.14 vs. 3.95 g; p<0.001). Factor XIII (FXIII) levels were also lower in cryoprecipitate vs. HFC (192.17 vs. 328.33 IU/dL; p = 0.002). Levels of procoagulants in cryoprecipitate, such as von Willebrand Factor (VWF) and factor VIII (FVIII), were highly variable, as was PMP activity. A standard cryoprecipitate dose contains significantly higher levels of measured plasminogen and D-dimer fragments than a standard HFC dose. CONCLUSION The tested HFC is a more reliable fibrinogen and FXIII source for accurate dosing compared with cryoprecipitate. Cryoprecipitate appears considerably less predictable for bleeding management due to wide variation in pro- and anticoagulation factors, the presence of PMPs, and the potential to elevate VWF and FVIII to prothrombotic levels.
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Affiliation(s)
- Sophia Stanford
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Ashok Roy
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | - Tom Cecil
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
| | | | - Petra Schulz
- Octapharma Pharmazeutika Produktionsges.m.b.H., Vienna, Austria
| | - Anna Turaj
- Faculty of Medicine, Centre for Cancer Immunology, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
| | - Sean Lim
- Faculty of Medicine, Centre for Cancer Immunology, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
| | - Emily Arbuthnot
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
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9
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Shettar SS, Vandyck K, Tanaka KA. Coagulation Management in End-Stage Liver Disease. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Hensley NB, Mazzeffi MA. Pro-Con Debate: Fibrinogen Concentrate or Cryoprecipitate for Treatment of Acquired Hypofibrinogenemia in Cardiac Surgical Patients. Anesth Analg 2021; 133:19-28. [PMID: 34127586 DOI: 10.1213/ane.0000000000005513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.
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Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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Haas T, Callum J, Grottke O, Asmis LM, Cushing MM. Response to Wirtz et al: The impact of blood product ratio and procoagulant therapy on the development of thromboembolic events in severely injured hemorrhaging trauma patients. Transfusion 2021; 61:991-992. [PMID: 33719043 DOI: 10.1111/trf.16241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/07/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - Jeannie Callum
- Transfusion Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Oliver Grottke
- Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Lars M Asmis
- Center of Perioperative Hemostasis, Zurich, Switzerland
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
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12
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Dranichnikov P, Mahteme H, Cashin PH, Graf W. Coagulopathy and Venous Thromboembolic Events Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2021; 28:7772-7782. [PMID: 33839978 PMCID: PMC8519924 DOI: 10.1245/s10434-021-09941-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
Background Coagulopathy after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is recognized but few details have been studied. Objectives The aim of this study was to investigate changes in coagulation biomarkers and their predictive ability for venous thromboembolism (VTE). Methods Patients undergoing CRS and HIPEC at Uppsala University Hospital, Sweden, from 2004 to 2014 were included in a prospective study of coagulation biomarkers. Prothrombin time international normalized ratio (PT-INR), activated partial thromboplastin time (APTT), fibrinogen, antithrombin, D-dimer, and platelets were sampled on postoperative days 1, 2, 5, and 10. Logistic regression analysis was used to evaluate predictive capacity for coagulation-related complications. Results Overall, 380 patients were included (214 females, mean age 56 years); 38 patients had a history of thromboembolism and 57 were active smokers. Mean perioperative blood loss was 1228 mL and 231 (61%) received perioperative blood transfusions. PT-INR and APTT were elevated directly after surgery but returned to normal levels on postoperative day 5. Conversely, fibrinogen, platelet count, D-dimer, and antithrombin increased by postoperative day 5 and continued to increase up to day 10. There were 23 radiologically verified cases of VTE within 6 months. The multivariate analysis identified a completeness of cytoreduction score of 2–3 (p = 0.047) and day 2 D-dimer (p = 0.0082) as independent risk factors for postoperative VTE. Conclusion Significant postoperative changes in coagulation biomarkers occur with dynamic changes over 10 days postoperatively. The incidence of symptomatic VTE was low. Residual tumor at completion of surgery and elevated D-dimer on day 2 were independent risk factors for postoperative VTE.
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Affiliation(s)
- Paul Dranichnikov
- Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University, Uppsala, Sweden. .,Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University Hospital, Uppsala, Sweden.
| | - Haile Mahteme
- Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University, Uppsala, Sweden.,Department of Surgery and Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
| | - Peter H Cashin
- Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University, Uppsala, Sweden.,Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Wilhelm Graf
- Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University, Uppsala, Sweden.,Department of Surgical Sciences, Department of Colorectal Surgery, Uppsala University Hospital, Uppsala, Sweden
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13
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Chen W, Shen J, Zhang Y, Hu A, Liang J, Ma L, Yu X, Huang Y. A randomised controlled trial of fibrinogen concentrate during scoliosis surgery. Anaesthesia 2020; 75:1476-1481. [PMID: 32500569 DOI: 10.1111/anae.15124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 01/28/2023]
Abstract
Bleeding and blood transfusion are common after scoliosis surgery. Fibrinogen is essential for blood clot formation and depletes quickly during haemorrhage. We randomly allocated 102 children 12-18 years old having surgery for idiopathic scoliosis, 51 to intra-operative fibrinogen concentrate 30 mg.kg-1 (maximum 2 g) and 51 to saline placebo. Fibrinogen reduced peri-operative blood loss by a median (95%CI) volume of 155 (5-320) ml, from a median (IQR [range]) of 1035 (818-1420 [400-3030]) ml to 885 (755-1155 [270-2645]) ml, p = 0.04. Seven and four children received allogeneic red blood cell transfusion after fibrinogen and placebo, respectively, p = 0.34. There were no side-effects.
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Affiliation(s)
- W Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - J Shen
- Department of Orthopedics Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Y Zhang
- Medical Research Center, Peking Union Medical College Hospital, Beijing, China
| | - A Hu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - J Liang
- Department of Orthopedics Surgery, Peking Union Medical College Hospital, Beijing, China
| | - L Ma
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - X Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Y Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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14
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Grottke O, Callum J, Cushing MM, Haas T. The use of coagulation factor concentrates for perioperative bleeding management - a global perspective. Transfusion 2020; 60:663-666. [PMID: 32154943 DOI: 10.1111/trf.15749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine and Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
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15
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Roy A, Stanford S, Nunn S, Alves S, Sargant N, Rangarajan S, Smith EA, Bell J, Dayal S, Cecil T, Tzivanakis A, Kruzhkova I, Solomon C, Knaub S, Moran B, Mohamed F. Efficacy of fibrinogen concentrate in major abdominal surgery - A prospective, randomized, controlled study in cytoreductive surgery for pseudomyxoma peritonei. J Thromb Haemost 2020; 18:352-363. [PMID: 31654548 PMCID: PMC7027898 DOI: 10.1111/jth.14665] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/18/2019] [Accepted: 10/22/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei (PMP) is associated with excessive bleeding and acquired fibrinogen deficiency. Maintaining plasma fibrinogen may support hemostasis. OBJECTIVES To compare hemostatic efficacy and safety of human fibrinogen concentrate (HFC) vs cryoprecipitate as fibrinogen sources for bleeding patients with acquired fibrinogen deficiency undergoing PMP CRS. METHODS FORMA-05 was an off-label single-center, prospective, randomized, controlled phase 2 study. Patients undergoing PMP surgery with predicted intraoperative blood loss ≥2 L received human fibrinogen concentrate (HFC; 4 g) or cryoprecipitate (two pools of 5 units, containing approximately 4.0-4.6 g fibrinogen), repeated as needed. The primary endpoint was a composite of intraoperative and postoperative efficacy, graded using objective 4-point scales and adjudicated by an independent committee. RESULTS One hundred percent of patients receiving HFC (95% confidence interval: 83.9-100.0, n = 21) or cryoprecipitate (84.6-100.0, n = 22) achieved hemostatic success. HFC demonstrated noninferior efficacy (P = .0095; post hoc) and arrived in the operating room 46 minutes faster. There were significantly greater mean increases with HFC vs cryoprecipitate in plasma fibrinogen (0.78 vs 0.35 g/L; P < .0001) and FIBTEM A20 (3.33 vs 0.93 mm; P = .003). Factor XIII, factor VIII, and von Willebrand factor activity were maintained throughout surgery. Only red blood cells were transfused intraoperatively (median units: HFC group, 1.0; cryoprecipitate group, 0.5). Thromboembolic events were detected with cryoprecipitate only. Safety was otherwise comparable between groups. CONCLUSIONS Human fibrinogen concentrate was hemostatically efficacious in patients undergoing major abdominal PMP surgery, with a favorable safety profile. These results are relevant to other surgical settings where bleeding and acquired fibrinogen deficiency occur.
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Affiliation(s)
- Ashok Roy
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | | | - Sean Nunn
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Sue Alves
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Nigel Sargant
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Savita Rangarajan
- University Hospital Southampton NHS Foundation TrustUK
- KJ Somaiya AyurviharMumbaiIndia
| | | | - John Bell
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Sanjeev Dayal
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Tom Cecil
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | | | | | | | | | - Brendan Moran
- Basingstoke and North Hampshire HospitalBasingstokeUK
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