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Coccolini F, Shander A, Ceresoli M, Moore E, Tian B, Parini D, Sartelli M, Sakakushev B, Doklestich K, Abu-Zidan F, Horer T, Shelat V, Hardcastle T, Bignami E, Kirkpatrick A, Weber D, Kryvoruchko I, Leppaniemi A, Tan E, Kessel B, Isik A, Cremonini C, Forfori F, Ghiadoni L, Chiarugi M, Ball C, Ottolino P, Hecker A, Mariani D, Melai E, Malbrain M, Agostini V, Podda M, Picetti E, Kluger Y, Rizoli S, Litvin A, Maier R, Beka SG, De Simone B, Bala M, Perez AM, Ordonez C, Bodnaruk Z, Cui Y, Calatayud AP, de Angelis N, Amico F, Pikoulis E, Damaskos D, Coimbra R, Chirica M, Biffl WL, Catena F. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper. World J Emerg Surg 2024; 19:26. [PMID: 39010099 PMCID: PMC11251377 DOI: 10.1186/s13017-024-00554-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy.
| | - Aryeh Shander
- Anesthesiology and Critical Care, Rutgers University, Newark, NJ, USA
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Monza University Hospital, Monza, Italy
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | - Brian Tian
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
| | - Dario Parini
- General Surgery Department, Rovigo Hospital, Rovigo, Italy
| | | | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Medical University, Plovdiv, Bulgaria
| | - Krstina Doklestich
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Fikri Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Tal Horer
- Vascular and Trauma Surgery, Orebro Hospital, Orebro, Sweden
| | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Timothy Hardcastle
- Department of Trauma and Burns, Inkosi Albert Luthuli Central Hospital and Department of Surgical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Elena Bignami
- Anesthesia Department, Parma University Hospital, Parma, Italy
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, AB, Canada
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Igor Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Melahiti Hospital, Helsinki, Finland
| | - Edward Tan
- Emergency Surgery Department, Radboud Medical Centre, Nijmegen, The Netherlands
| | - Boris Kessel
- Hillel Yaffe Medical Center, Rappaport Medical School, Haifa, Israel
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, Kadikoy, Istanbul, Turkey
| | - Camilla Cremonini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | | | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Pablo Ottolino
- Unidad de Trauma y Urgencias, Hospital Dr. Sótero del Río, Santiago de Chile, Chile
| | - Andreas Hecker
- Department of General, Thoracic and Transplant Surgery, University Hospital of Giessen, Giessen, Germany
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Italy
| | - Ettore Melai
- ICU Department, Pisa University Hospital, Pisa, Italy
| | - Manu Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Vanessa Agostini
- Medicina Trasfusionale, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Yoram Kluger
- General, Emergency and Trauma Surgery Department, Rambam Medical Centre, Tel Aviv, Israel
| | | | - Andrey Litvin
- Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus
| | - Ron Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Belinda De Simone
- Department of Digestive and Emergency Surgery, Infermi Hospital, Rimini, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Aleix Martinez Perez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Zenon Bodnaruk
- Hospital Information Services for Jehovah's Witnesses, Tuxedo Park, NY, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Nicola de Angelis
- General Surgery Department, Ferrara University Hospital, Ferrara, Italy
| | - Francesco Amico
- Discipline of Surgery, The University of Newcastle, Newcastle, Australia
| | - Emmanouil Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Raul Coimbra
- General Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA, USA
| | - Mircea Chirica
- General Surgery Department, Grenoble University Hospital, Grenoble, France
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
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Lau MPXL, Low CJW, Ling RR, Liu NSH, Tan CS, Ti LK, Kofidis T, MacLaren G, Ramanathan K. Preoperative anemia and anemia treatment in cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2024; 71:127-142. [PMID: 37932652 DOI: 10.1007/s12630-023-02620-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/07/2023] [Accepted: 07/23/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE We aimed to conduct a systematic review and meta-analysis to assess the effects of anemia and anemia severity on patient outcomes in cardiac surgery and determine whether preoperative treatments confer postoperative benefit. SOURCE We searched four international databases for observational and randomized studies published until 1 October 2022. Study quality was assessed via Newcastle-Ottawa scores and the Cochrane Risk-of-Bias 2 tool and certainty of evidence was rated with the Grading of Recommendations, Assessment, Development and Evaluations approach. We conducted random-effects meta-analyses for our primary outcome of mortality, for secondary outcomes including length of stay (LOS) in the hospital and intensive care unit, and for postsurgical complications. As part of a secondary analysis, we analyzed short-term preoperative anemia treatments and conducted trial sequential analysis of randomized trials to assess the efficacy of these treatment programs. PRINCIPAL FINDINGS We included 35 studies (159,025 patients) in our primary meta-analysis. Preoperative anemia was associated with increased mortality (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.2 to 2.9; P < 0.001, high certainty). Study-level meta-regression revealed lower hemoglobin levels and studies with lower proportions of male patients to be associated with increased risk of mortality. Preoperative anemia was also associated with an increase in LOS and postsurgical complications. Our secondary analysis (seven studies, 1,012 patients) revealed short-term preoperative anemia treatments did not significantly reduce mortality (OR, 1.1; 95% CI, 0.65 to 1.9; P = 0.69). Trial sequential analysis suggested that there was insufficient evidence to conclude if treatment programs yield any benefit or harm. CONCLUSIONS Preoperative anemia is associated with mortality and morbidity after cardiac surgery. More research is warranted to test the efficacy of current anemia treatment programs. STUDY REGISTRATION PROSPERO (CRD42022319431); first submitted 17 April 2023.
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Affiliation(s)
- Michele P X L Lau
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Christopher J W Low
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Nigel S H Liu
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Chuen Seng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore, Singapore
| | - Theo Kofidis
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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Guo RJ, Smith T, Zamar D, Trudeau JD, Shih AW. Potential for prolongation of fibrinogen concentrates post-reconstitution. Transfus Apher Sci 2023:103657. [PMID: 36804189 DOI: 10.1016/j.transci.2023.103657] [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: 08/09/2022] [Revised: 10/04/2022] [Accepted: 02/13/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Reconstituted fibrinogen concentrate is considered stable for 8-24 h based on product monographs. Given the long half-life of fibrinogen in vivo (3-4 days), we hypothesized that reconstituted sterile fibrinogen protein would remain stable longer than 8-24 h. Extending the expiry date for reconstituted fibrinogen concentrate could decrease wastage and facilitate reconstitution in advance to minimize turnaround times. We performed a pilot study to define the stability of reconstituted fibrinogen concentrates over time. MATERIALS AND METHODS Reconstituted Fibryga® (Octapharma AG) from 64 vials was stored in the temperature-controlled refrigerator (4 °C) for up to 7 days with functional fibrinogen concentration measured serially using the automated Clauss method. The samples were frozen, then thawed and diluted with pooled normal plasma in order for them to be batch tested. RESULTS Reconstituted fibrinogen samples stored in the refrigerator showed no significant reduction in functional fibrinogen concentration for the entire 7-day study period (p = 0.63). Duration of initial freezing had no detrimental effect on functional fibrinogen levels (p = 0.23). CONCLUSION Fibryga® can be stored at 2-8 °C post-reconstitution for up to one week with no loss in functional fibrinogen activity based on Clauss fibrinogen assay. Further studies with other fibrinogen concentrate formulations and clinical in vivo studies may be warranted.
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Affiliation(s)
- Robert J Guo
- Department of Pathology and Laboratory Medicine, University of British Columbia, Rm. G227-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, Vancouver General Hospital, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada.
| | - Tyler Smith
- Department of Pathology and Laboratory Medicine, University of British Columbia, Rm. G227-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, Vancouver General Hospital, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada
| | - David Zamar
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Jacqueline D Trudeau
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada; Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Rm. 11228-2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada; Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Rm. G227-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, Vancouver General Hospital, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada
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4
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Lee JH. Prevention and management of difficult hemostasis in acute type A aortic dissection repair. Asian Cardiovasc Thorac Ann 2023; 31:15-19. [PMID: 35040355 DOI: 10.1177/02184923221074409] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Postoperative bleeding after surgery for acute aortic dissection is one of the most common complications and has an important influence on mortality and morbidity. Therefore, various methods have been introduced to prevent or manage postoperative bleeding. In this article, we investigated the causes of bleeding after surgery for acute aortic dissection, and introduce appropriate transfusion or pharmacologic treatment, topical hemostatic agents, and local compressive maneuver to manage it.
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Affiliation(s)
- Jae Hang Lee
- Department of Thoracic and Cardiovascular Surgery, 65462Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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5
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Byeon GJ, Yoon JU, Kim HJ, Choi EJ, Kim EJ, Park S, Park SJ, Heo W, Kim HY. The influence of circulating fibrinogen level on postoperative blood loss and blood transfusion in pediatric cardiac surgery: a retrospective observational study. Transl Pediatr 2022; 11:514-525. [PMID: 35558986 PMCID: PMC9085943 DOI: 10.21037/tp-21-236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/13/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pediatric patients are at high risk of massive bleeding after cardiac surgery under cardiopulmonary bypass (CPB). Fibrinogen is essential for coagulation; however, pediatric patients with congenital heart disease (CHD) present abnormal fibrinogen function. The pre- and post-operative fibrinogen level may affect the bleeding and transfusion amount in patients undergoing cardiac surgery. However, the relationship between plasma fibrinogen levels and the bleeding and transfusion amount in pediatric cardiac surgery remains unclear. This study aimed to assess the association of pre-CPB fibrinogen levels (PreFib) and post-CPB fibrinogen levels (PostFib) with postoperative bleeding and transfusion volume in pediatric cardiac surgery. METHODS We reviewed the medical records of 375 newborns and infants who underwent cardiac surgery under CPB for CHD. The primary endpoint was the correlation of the PreFib and PostFib values, as well as their difference (FibGap), with the bleeding and transfusion amount within 24 postoperative hours. RESULTS There was no correlation of the PreFib, PostFib, and FibGap values with the bleeding and transfusion amounts at postoperative 24 hours. However, patients with PreFib and PostFib values of <150 and <100 mg/dL, respectively, showed a significantly higher frequency of postoperative platelet (PLT) transfusion. In patients with complex CHD, PreFib showed a weak negative correlation with the bleeding amount at postoperative 24 hours and the number of PLT-transfused patients. CONCLUSIONS Our findings suggest that in pediatric patients with CHD who cannot undergo point-of-care (POC) tests, those presenting PreFib and PostFib values of <150 and <100 mg/dL, respectively, have a significantly higher frequency of postoperative PLT transfusion.
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Affiliation(s)
- Gyeong-Jo Byeon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Ji-Uk Yoon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Hye-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Eun-Ji Choi
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Yangsan, Korea
| | - Eun-Jung Kim
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Yangsan, Korea.,Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Korea
| | - Seyeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon Ji Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Wonjae Heo
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hee Young Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Abstract
Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.
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Chang KW, Owen S, Gaspar M, Laffan M, Arachchillage DRJ. Outcome of Major Hemorrhage at a Major Cardiothoracic Center in Patients with Activated Major Hemorrhage Protocol versus Nonactivated Protocol. Semin Thromb Hemost 2021; 47:74-83. [PMID: 33525040 DOI: 10.1055/s-0040-1718869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This study aimed to determine the impact of major hemorrhage (MH) protocol (MHP) activation on blood administration and patient outcome at a UK major cardiothoracic center. MH was defined in patients (> 16 years) as those who received > 5 units of red blood cells (RBCs) in < 4 hours, or > 10 units in 24 hours. Data were collected retrospectively from patient electronic records and hospital transfusion databases recording issue of blood products from January 2016 to December 2018. Of 134 patients with MH, 24 had activated MHP and 110 did not have activated MHP. Groups were similar for age, sex, baseline hemoglobin, platelet count, coagulation screen, and renal function with no difference in the baseline clinical characteristics. The total number of red cell units (median and [IQR]) transfused was no different in the patients with activated (7.5 [5-11.75]) versus nonactivated (9 [6-12]) MHP (p = 0.35). Patients in the nonactivated MHP group received significantly higher number of platelet units (median: 3 vs. 2, p = 0.014), plasma (median: 4.5 vs. 1.5, p = 0.0007), and cryoprecipitate (median: 2 vs. 1, p = 0.008). However, activation of MHP was associated with higher mortality at 24 hours compared with patients with nonactivation of MHP (33.3 vs. 10.9%, p = 0.005) and 30 days (58.3 vs. 30.9%, p = 0.01). The total RBC and platelet (but not fresh frozen plasma [FFP]) units received were higher in deceased patients than in survivors. Increased mortality was associated with a higher RBC:FFP ratio. Only 26% of patients received tranexamic acid and these patients had higher mortality at 30 days but not at 24 hours. Deceased patients at 30 days had higher levels of fibrinogen than those who survived (median: 2.4 vs. 1.8, p = 0.01). Patients with activated MHP had significantly higher mortality at both 24 hours and 30 days despite lack of difference in the baseline characteristics of the patients with activated MHP versus nonactivated MHP groups. The increased mortality associated with a higher RBC:FFP ratio suggests dilutional coagulopathy may contribute to mortality, but higher fibrinogen at baseline was not protective.
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Affiliation(s)
- Kathryn W Chang
- Department of Haematology, Imperial College London, London, United Kingdom
| | - Steve Owen
- Department of Haematology, Royal Brompton Hospital, London, United Kingdom
| | - Michaela Gaspar
- Department of Haematology, Royal Brompton Hospital, London, United Kingdom
| | - Mike Laffan
- Department of Haematology, Imperial College London, London, United Kingdom
| | - Deepa R J Arachchillage
- Department of Haematology, Imperial College London, London, United Kingdom.,Department of Haematology, Royal Brompton Hospital, London, United Kingdom
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Ng KT, Yap JLL, Kwok PE. The effect of fibrinogen concentrate on postoperative blood loss: A systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2020; 63:109782. [DOI: 10.1016/j.jclinane.2020.109782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/01/2020] [Accepted: 03/07/2020] [Indexed: 12/29/2022]
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9
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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Javaherforoosh Zadeh F, Janatmakan F, Soltanzadeh M, Zamankhani M. Investigating the Effect of Fibrinogen Injection on Bleeding in Coronary Artery Bypass Surgery: A Clinical Trial. Anesth Pain Med 2019; 9:e92165. [PMID: 31754609 PMCID: PMC6825327 DOI: 10.5812/aapm.92165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/08/2019] [Accepted: 08/02/2019] [Indexed: 11/16/2022] Open
Abstract
Background Prevention and optimal treatment of postoperative bleeding are of great clinical importance in various types of surgeries including coronary artery bypass graft (CABG). Reducing the amount of bleeding will reduce the complications subsequent to blood transfusion. The positive effects of coagulation factors, especially fibrinogen, after cardiovascular bypass could have beneficial effects due to reduced bleeding and less need for blood transfusion. However, different studies have reported controversial findings. Objectives The present study aimed to evaluate the effect of prophylactic administration of fibrinogen on blood loss in patients undergoing CABG surgery to achieve more accurate clinical outcomes. Methods This was a double-blind randomized clinical trial conducted on 36 patients hospitalized in Ahvaz Imam Khomeini Hospital for coronary artery bypass graft. Patients were randomized to receive either fibrinogen concentrate (n = 18) or placebo (n = 18). Hemoglobin, hematocrit, international normalized ratio, prothrombin time, partial thromboplastin time, and fibrinogen were checked preoperatively. The transfusion of allogeneic blood components and the volume of blood loss were recorded and compared between the groups. Results Prophylactic fibrinogen injection reduced the need for blood transfusion, blood products, and postoperative hypotension in the fibrinogen group when compared to the control group (P ≤ 0.005). There was a significant difference between the two groups in terms of the amount of bleeding during operation (P ≤ 0.005). Conclusions Fibrinogen plays a key role in preventing and stopping the bleeding. Accordingly, fibrinogen decreases bleeding and the need for paced cell in patients in CABG. Given the adverse outcomes of bleeding and coagulopathy in patients undergoing surgery, we conclude that the use of fibrinogen could be beneficial as a prophylactic in hemorrhagic surgery.
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Affiliation(s)
- Fatemeh Javaherforoosh Zadeh
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding Author: Associate Professor of Anesthesia, Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Farahzad Janatmakan
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mansoor Soltanzadeh
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Zamankhani
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Javaherforoosh Zadeh F, Janatmakan F, Shafaee Tonekaboni M, Soltanzadeh M. The Effect of Fibrinogen on Blood Loss After Lumbar Surgery: A Double-Blind Randomized Clinical Trial. Anesth Pain Med 2019; 9:e91199. [PMID: 31497522 PMCID: PMC6712358 DOI: 10.5812/aapm.91199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/22/2019] [Accepted: 04/26/2019] [Indexed: 12/16/2022] Open
Abstract
Background Spinal surgeries often have a high risk of hemorrhage during and after surgery, thus most patients require blood transfusions and blood products. Fibrinogen is used in different forms to control hemorrhage. Objectives The present study aimed to evaluate the outcomes of prophylactic fibrinogen administration in reducing hemorrhage after lumbar surgery. Methods This was a randomized clinical trial conducted on 30 patients undergoing lumbar surgery. The levels of fibrinogen, as well as hemoglobin (HB), hematocrit (HCT), prothrombin time (PT), partial thromboplastin time (PTT), and INR, were assessed preoperatively as the baseline values. The patients were divided into two groups: intervention (N = 15) and control (N = 15) groups. The intervention group received 1 g fibrinogen dissolved in 50 cc distilled water with surgical incision and the control group received 50 cc distilled water with the surgical incision. At the end of the operation, the volume of hemorrhage transfused blood products (fresh frozen plasma, packed cell, and platelet) was measured. In addition, at 0, 6, and 24 hours after the end of surgery and transfer to recovery, serum levels of fibrinogen, HB, HCT, INR, PT, PTT, and hemovac drain volume were measured. Results The hemorrhage during and after the operation in the control group was significantly higher than that of the intervention group (P < 0.05). There were no significant differences between hemoglobin and serum level of fibrinogen before and after surgery between the two groups. The postoperative hypotension showed no significant difference between the two groups. Conclusions The findings showed the effectiveness of fibrinogen in reducing acute hemorrhage. Considering the adverse consequences of hemorrhage and coagulopathy in patients undergoing surgery, using fibrinogen as prophylaxis is recommended in surgeries with high risks of hemorrhage.
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Affiliation(s)
- Fatemeh Javaherforoosh Zadeh
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding Author: Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Farahzad Janatmakan
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Shafaee Tonekaboni
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mansoor Soltanzadeh
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
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13
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Akbari E, Safari S, Hatamabadi H. The effect of fibrinogen concentrate and fresh frozen plasma on the outcome of patients with acute traumatic coagulopathy: A quasi-experimental study. Am J Emerg Med 2018; 36:1947-1950. [DOI: 10.1016/j.ajem.2018.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/16/2018] [Accepted: 02/21/2018] [Indexed: 10/18/2022] Open
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14
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Erdoes G, Dietrich W, Stucki MP, Merz TM, Angelillo-Scherrer A, Nagler M, Carrel T, Eberle B. Short-term recovery pattern of plasma fibrinogen after cardiac surgery: A prospective observational study. PLoS One 2018; 13:e0201647. [PMID: 30075017 PMCID: PMC6075772 DOI: 10.1371/journal.pone.0201647] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 07/19/2018] [Indexed: 11/18/2022] Open
Abstract
Low plasma fibrinogen level is common after cardiopulmonary bypass (CPB). Current substitution practice with fibrinogen concentrate generally follows a single measurement and cut-off values from the literature, whereas early postoperative endogenous fibrinogen kinetics is incompletely described and widely disregarded. The aim of this study was to determine the short-term recovery pattern of plasma fibrinogen after CPB weaning. Our hypothesis was that in the absence of surgical bleeding, CPB-induced hypofibrinogenemia would resolve spontaneously and predictably within a few hours. In a prospective, observational study of 26 patients undergoing conventional CPB (cCPB) or minimally invasive extracorporeal circulation (MiECC), Clauss fibrinogen level (C-FIB) was determined at 10 closely spaced time points after protamine administration. Primary endpoint was the time to recovery of post-CPB fibrinogen levels to ≥1.5 g/L. C-FIB reached its nadir after protamine administration corresponding to 62 ± 5% (mean ± SD) of the baseline level after cCPB and 68 ± 7% after MiECC (p = 0.027 vs. cCPB). C-FIB recovered spontaneously at a nearly constant rate of approximately 0.08 g/L per hour. In all patients, C-FIB was ≥1.5 g/L at 4 hours and ≥2.0 g/L at 13 hours after CPB weaning. Following cardiac surgery with CPB and in the absence of surgical bleeding, spontaneous recovery of normal endogenous fibrinogen levels can be expected at a rate of 0.08 g/L per hour. Administration of fibrinogen concentrate triggered solely by a single-point measurement of low plasma fibrinogen some time after CPB is not justified.
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Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | - Wulf Dietrich
- Institute for Research in Cardiac Anesthesia, Munich, Germany
| | - Monika Pia Stucki
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Michael Merz
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Nagler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thierry Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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Martini WZ, Guzman RD, Dubick MA. Stability of Fibrinogen Concentrate in Human Blood Samples: An In Vitro Study. Mil Med 2018; 183:183-188. [DOI: 10.1093/milmed/usx176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Indexed: 01/24/2023] Open
Affiliation(s)
- Wenjun Z Martini
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3650 Chambers Pass, Fort Sam Houston, TX 78234-6135
| | - Rodolfo de Guzman
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3650 Chambers Pass, Fort Sam Houston, TX 78234-6135
| | - Michael A Dubick
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3650 Chambers Pass, Fort Sam Houston, TX 78234-6135
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16
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Ichikawa J, Osada Y, Kodaka M, Nishiyama K, Komori M. Association Between Platelet Count and Postoperative Blood Loss in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass and Fresh Frozen Plasma Administration Guided by Thromboelastometry. Circ J 2018; 82:677-683. [DOI: 10.1253/circj.cj-17-0712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Junko Ichikawa
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Yoshiko Osada
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Mitsuharu Kodaka
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Keiko Nishiyama
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Makiko Komori
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
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17
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Négrier C, Ducloy-Bouthors AS, Piriou V, De Maistre E, Stieltjes N, Borel-Derlon A, Colson P, Picard J, Lambert T, Claeyssens S, Boileau S, Bertrand A, André MH, Fourrier F, Ozier Y, Sié P, Gruel Y, Tellier Z. Postauthorization safety study of Clottafact®
, a triply secured fibrinogen concentrate in acquired fibrinogen deficiency: a prospective observational study. Vox Sang 2017; 113:120-127. [DOI: 10.1111/vox.12624] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 09/26/2017] [Accepted: 11/14/2017] [Indexed: 01/02/2023]
Affiliation(s)
| | | | - V. Piriou
- South University Hospital; Lyon France
| | | | | | | | - P. Colson
- University Hospital; Montpellier France
| | - J. Picard
- University Hospital; Grenoble France
| | - T. Lambert
- Bicêtre Hospital; Kremlin Bicêtre France
| | | | | | - A. Bertrand
- Medical Affairs; LFB Biomédicaments; Les Ulis France
| | - M.-H. André
- Medical Affairs; LFB Biomédicaments; Les Ulis France
| | | | - Y. Ozier
- University Hospital; Brest France
| | - P. Sié
- Rangueil Hospital; Toulouse France
| | - Y. Gruel
- Trousseau Hospital; Tours France
| | - Z. Tellier
- Medical Affairs; LFB Biomédicaments; Les Ulis France
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18
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Jahangirifard A, Ahmadi ZH, Naghashzadeh F, Sharif-Kashani B, Rashid-Farokhi F, Afshar A, Yamini-Sharif R, Rezaei Y. Prophylactic Fibrinogen Decreases Postoperative Bleeding but Not Acute Kidney Injury in Patients Undergoing Heart Transplantation. Clin Appl Thromb Hemost 2017; 24:998-1004. [PMID: 29050500 PMCID: PMC6714712 DOI: 10.1177/1076029617731625] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present study is the premier clinical attempt to scrutinize the practicability of prophylactic fibrinogen infusion in patients undergoing heart transplantation (HT). A total of 67 consecutive patients who had undergone HT between January 2012 and December 2014 were assessed. After exclusion of some patients, 23 patients were given preoperative 2 g fibrinogen concentrate over a period of 15 minutes after the termination of cardiopulmonary bypass pump and complete reversal of heparin, and 30 patients were not given. Some laboratories were measured before general anesthesia and at 6 and 24 hours after surgery. In addition, major adverse events were also evaluated during hospitalization. The mean age of the patients was 39.5 ± 11.4 years, with a predominance of male sex (77.4%). All laboratories at baseline were comparable between groups. The length of hospital stay was longer in the control group compared to the fibrinogen group (20 [16-22] vs 16 [12-19] days; P = .005). There was a trend for patients in the fibrinogen group to have more acute kidney injury (AKI) after surgery (10% vs 30.4%) and less reoperation for bleeding (20% vs 8.7%). The amount of postoperative bleeding was significantly higher in the control group compared to the fibrinogen group (P < .001). The number of packed red blood cell transfused during 24 hours after surgery was significantly lower in the fibrinogen group (P < .001). The transfusion of fibrinogen in patients undergoing HT may be associated with reductions in postoperative bleeding, the number of packed red blood cells, and hospital length of stay; however, it may enhance postoperative AKI.
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Affiliation(s)
- Alireza Jahangirifard
- 1 Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zargham Hossein Ahmadi
- 2 Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farah Naghashzadeh
- 2 Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Babak Sharif-Kashani
- 3 Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farin Rashid-Farokhi
- 4 Telemedicine Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Afshar
- 2 Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reyhaneh Yamini-Sharif
- 1 Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- 5 Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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19
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Mahadeo KM, McArthur J, Adams RH, Radhi M, Angelo J, Jeyapalan A, Nicol K, Su L, Rabi H, Auletta JJ, Pai V, Duncan CN, Tamburro R, Dvorak CC, Bajwa RPS. Consensus Report by the Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplant Consortium Joint Working Committees on Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents: Part 2-Focus on Ascites, Fluid and Electrolytes, Renal, and Transfusion Issues. Biol Blood Marrow Transplant 2017; 23:2023-2033. [PMID: 28823876 DOI: 10.1016/j.bbmt.2017.08.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/10/2017] [Indexed: 01/19/2023]
Abstract
Even though hepatic veno-occlusive disease (VOD) is a potentially fatal complication of hematopoietic cell transplantation (HCT), there is paucity of research on the management of associated multiorgan dysfunction. To help provide standardized care for the management of these patients, the HCT Subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators and the Supportive Care Committee of the Pediatric Blood and Marrow Transplant Consortium, collaborated to develop evidence-based consensus guidelines. After conducting an extensive literature search, in part 2 of this series we discuss the management of fluids and electrolytes, renal dysfunction; ascites, pleural effusion, and transfusion and coagulopathy issues in patients with VOD. We consider the available evidence using the GRADE criteria.
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Affiliation(s)
- Kris M Mahadeo
- Pediatric Stem Cell Transplantation and Cellular Therapy, MD Anderson Children's Cancer Hospital Houston, The University of Texas, Houston, Texas
| | - Jennifer McArthur
- Department of Pediatric Critical Care Medicine, St Jude Children's Research Hospital Memphis, Memphis, Tennessee
| | - Roberta H Adams
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona; Hematology/Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Mohamed Radhi
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, Missouri
| | - Joseph Angelo
- Division of Nephrology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Asumthia Jeyapalan
- Division of Pediatric Critical Care Medicine, University of Miami- Miller School of Medicine, Miami, Florida
| | - Kathleen Nicol
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Leon Su
- Department of Pathology and Laboratory Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Hanna Rabi
- Division of Pediatric Hematology Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeffery J Auletta
- Division of Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio; Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Vinita Pai
- College of Pharmacy and Pharmacy Department, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Christine N Duncan
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert Tamburro
- Division of Pediatric Critical Care Medicine, Pennsylvania University, Penn State Hershey Children's Hospital, Hershey, PA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Rajinder P S Bajwa
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio.
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20
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Moyes AJ, Lamb RM, Ella-Tongwiis P, Pushkaran A, Ahmed I, Shergill I, Hughes SF. A pilot study evaluating changes to haematological and biochemical tests after Flexible Ureterorenoscopy for the treatment of kidney stones. PLoS One 2017; 12:e0179599. [PMID: 28683066 PMCID: PMC5499990 DOI: 10.1371/journal.pone.0179599] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 06/01/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Currently there is limited research documenting the changes in blood parameters, following Flexible Ureterorenoscopy. This study aims to determine whether there are any changes in haematology and biochemistry parameters, following Flexible Ureterorenoscopy for the treatment of kidney stones. METHODS 40 consecutive patients aged between 27-87 years (median 49 years) undergoing Flexible Ureterorenoscopy for the treatment of kidney stones were recruited (26 male, 14 female). Blood samples were collected from each patient at four time points: baseline (pre-operatively) followed by 30 minutes, 120 minutes and 240 minutes post-operatively. On these samples, routine haematological and biochemistry tests were carried out. In addition to the assessment of clinical parameters prospectively from the medical notes. RESULTS There was a significant decrease observed following Flexible Ureterorenoscopy in the following parameters: lymphocytes (p = 0.007), eosinophils (p = 0.001), basophils (p = 0.001), haemoglobin (p = 0.002), red blood cells (p = 0.001), platelet count (p = 0.001), fibrinogen concentration (p = 0.001), von Willebrand factor (p = 0.046), C reactive protein (p = 0.01), total protein (p = 0.001), albumin (p = 0.001), globulin (p = 0.001) and alkaline phosphatase (p = 0.001). In addition, there was a significant increase observed in the following parameters: white blood cells (p = 0.001), neutrophils (p = 0.001), activated partial thromboplastin time (p = 0.001), total bilirubin (p = 0.012), creatinine (p = 0.008), sodium (p = 0.002) and potassium (p = 0.001). Limiting factors for this study were the sample size, and restriction on the recruitment time points. CONCLUSIONS Significant changes were noted to occur in haematology and biochemistry parameters following Flexible Ureterorenoscopy. Some of the data presented in this study may represent the 'normal' post-operative response following FURS, as no major complications occurred, in the majority of our patients. This data on the 'normal response' will need to be validated but may ultimately aid clinicians in distinguishing patients at risk of complications, if reproduced in larger multi-centre studies.
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Affiliation(s)
- Alyson Jayne Moyes
- Department of Biological Sciences, University of Chester, Chester, United Kingdom
- North Wales & North West Urological Research Centre (NW2URC), Betsi Cadwaladr University Health Board (BCUHB) Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
- Department of Urology, BCUHB Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
- Department of Medical Sciences, Bangor University, Bangor, Wales, United Kingdom
| | - Rebecca May Lamb
- Department of Biological Sciences, University of Chester, Chester, United Kingdom
- North Wales & North West Urological Research Centre (NW2URC), Betsi Cadwaladr University Health Board (BCUHB) Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
- Department of Urology, BCUHB Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
| | - Peter Ella-Tongwiis
- Department of Biological Sciences, University of Chester, Chester, United Kingdom
- North Wales & North West Urological Research Centre (NW2URC), Betsi Cadwaladr University Health Board (BCUHB) Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
- Department of Urology, BCUHB Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
| | - Anish Pushkaran
- North Wales & North West Urological Research Centre (NW2URC), Betsi Cadwaladr University Health Board (BCUHB) Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
- Department of Urology, BCUHB Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
| | - Issam Ahmed
- North Wales & North West Urological Research Centre (NW2URC), Betsi Cadwaladr University Health Board (BCUHB) Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
- Department of Urology, BCUHB Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
| | - Iqbal Shergill
- North Wales & North West Urological Research Centre (NW2URC), Betsi Cadwaladr University Health Board (BCUHB) Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
- Department of Urology, BCUHB Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
| | - Stephen Fôn Hughes
- Department of Biological Sciences, University of Chester, Chester, United Kingdom
- North Wales & North West Urological Research Centre (NW2URC), Betsi Cadwaladr University Health Board (BCUHB) Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
- Department of Urology, BCUHB Wrexham Maelor Hospital, Wrexham, Wales, United Kingdom
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21
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Introduction of thromboelastometry-guided administration of fresh-frozen plasma is associated with decreased allogeneic blood transfusions and post-operative blood loss in cardiopulmonary-bypass surgery. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 16:244-252. [PMID: 28488956 DOI: 10.2450/2017.0265-16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/11/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cardiac surgery is frequently associated with excessive blood loss requiring multiple blood transfusions which are, in turn, associated with increased morbidity and mortality. We evaluated the effectiveness of rotational thromboelastometry (ROTEM®)-guided administration of fresh-frozen plasma (FFP) with regards to blood loss, transfusion requirements, and major post-operative complications. MATERIALS AND METHODS Coagulation management in 68 prospective patients undergoing cardiac surgery with cardiopulmonary bypass was based on a treatment algorithm guided by ROTEM® measurements. The primary end-point was blood loss at 24 hours after surgery. Secondary end-points were: (i) need for allogeneic blood products after cardiopulmonary bypass and 24 hours post-operatively, and (ii) post-operative complications until discharge. The results were compared with those of a retrospective, control group of 69 patients who received empirical coagulation management before implementation of the ROTEM®-guided algorithm. RESULTS Although patients with significantly lower haemoglobin levels received less packed red blood cells (PRBC) (840 vs 1,120 mL; p=0.031) and FFP (480 vs 720 mL; p=0.007) after introduction of the ROTEM® algorithm, the intra-operative blood loss and post-operative haemoglobin levels were similar in the ROTEM® and the retrospective control groups. In addition to significantly reduced blood loss and decreased requirements for PRBC (30.8 vs 62.3%; p<0.001) and FFP (25.0 vs 56.5%; p<0.001), the amounts of PRBC (315 vs 840 mL; p<0.001) and FFP (480 vs 840 mL; p=0.001) received during the first 24 hours after surgery were significantly reduced in the ROTEM® group, as was the duration of post-operative hospitalisation. DISCUSSION Compared with empirical treatment, timely ROTEM®-guided FFP administration during cardiac surgery can reduce not only overall blood product use and blood loss but also the duration of hospitalisation.
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22
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Kim CH, McBride DW, Raval R, Sherchan P, Hay KL, Gren ECK, Kelln W, Lekic T, Hayes WK, Bull BS, Applegate R, Tang J, Zhang JH. Crotalus atrox venom preconditioning increases plasma fibrinogen and reduces perioperative hemorrhage in a rat model of surgical brain injury. Sci Rep 2017; 7:40821. [PMID: 28102287 PMCID: PMC5244360 DOI: 10.1038/srep40821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 12/12/2016] [Indexed: 12/28/2022] Open
Abstract
Perioperative bleeding is a potentially devastating complication in neurosurgical patients, and plasma fibrinogen concentration has been identified as a potential modifiable risk factor for perioperative bleeding. The aim of this study was to evaluate preconditioning with Crotalus atrox venom (Cv-PC) as potential preventive therapy for reducing perioperative hemorrhage in the rodent model of surgical brain injury (SBI). C. atrox venom contains snake venom metalloproteinases that cleave fibrinogen into fibrin split products without inducing clotting. Separately, fibrinogen split products induce fibrinogen production, thereby elevating plasma fibrinogen levels. Thus, the hypothesis was that preconditioning with C. atrox venom will produce fibrinogen spilt products, thereby upregulating fibrinogen levels, ultimately improving perioperative hemostasis during SBI. We observed that Cv-PC SBI animals had significantly reduced intraoperative hemorrhage and postoperative hematoma volumes compared to those of vehicle preconditioned SBI animals. Cv-PC animals were also found to have higher levels of plasma fibrinogen at the time of surgery, with unchanged prothrombin time. Cv-PC studies with fractions of C. atrox venom suggest that snake venom metalloproteinases are largely responsible for the improved hemostasis by Cv-PC. Our findings indicate that Cv-PC increases plasma fibrinogen levels and may provide a promising therapy for reducing perioperative hemorrhage in elective surgeries.
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Affiliation(s)
- Cherine H Kim
- Department of Physiology &Pharmacology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Devin W McBride
- Department of Physiology &Pharmacology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Ronak Raval
- Department of Anesthesiology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Prativa Sherchan
- Department of Physiology &Pharmacology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Karen L Hay
- Department of Anesthesiology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Eric C K Gren
- Department of Earth and Biological Sciences, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Wayne Kelln
- Department of Earth and Biological Sciences, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Tim Lekic
- Department of Physiology &Pharmacology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA.,Department of Neurology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - William K Hayes
- Department of Earth and Biological Sciences, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Brian S Bull
- Department of Pathology and Human Anatomy, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Richard Applegate
- Department of Anesthesiology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - Jiping Tang
- Department of Physiology &Pharmacology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
| | - John H Zhang
- Department of Physiology &Pharmacology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA.,Department of Anesthesiology, Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA.,Department of Neurosurgery Loma Linda University School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA
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de Boer WJ, Visser C, Ganushchak YM. Preoperative hemoglobin level: the best predictor of transfusion of packed red cells. Perfusion 2016; 31:691-698. [DOI: 10.1177/0267659116657864] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Blood transfusions could have serious consequences for patients. A reduction in the transfusion rate could be accomplished by an optimized blood management. Clear guidelines and awareness among all employees at a single institution have resulted in a reduction in transfusion rates in recent years. Identification of the group of patients who still received a blood transfusion in recent years could result in a further reduction. This study enrolled 4022 patients undergoing cardiothoracic surgery between 2008 and 2013. Patients were divided into three groups: “no blood transfusion”, “transfusion of packed red cells only” and “any other combinations of blood transfusion”. In total, 16 variables were tested for their association with the administration of homologous blood. The variables associated with blood transfusion were included in a stepwise multinomial logistic regression analysis to find the variables with the strongest association. For the transfusion of packed red cells only and any other combinations of blood transfusion, the following predictors are found: gender, age, weight, type of surgery, reoperation, unstable angina pectoris, endocarditis, recent myocardial infarction, preoperative creatinine level, preoperative hemoglobin level and preoperative platelet count. The best predictor for the transfusion of packed red cells is preoperative hemoglobin level (4.1 to 7.8 mmol/l). For other blood products, the strongest association was found with type of surgery (aortic surgery, ventricular septal rupture and intracardiac tumour).
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Affiliation(s)
- Wiebe J. de Boer
- Department of Cardio-Thoracic Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Cornelis Visser
- Department of Cardio-Thoracic Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Yuri M. Ganushchak
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Höfer J, Fries D, Solomon C, Velik-Salchner C, Ausserer J. A Snapshot of Coagulopathy After Cardiopulmonary Bypass. Clin Appl Thromb Hemost 2016; 22:505-11. [DOI: 10.1177/1076029616651146] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cardiac surgery involving cardiopulmonary bypass (CPB) is often associated with important blood loss, allogeneic blood product usage, morbidity, and mortality. Coagulopathy during CPB is complex, and the current lack of uniformity for triggers and hemostatic agents has led to a wide variability in bleeding treatment. The aim of this review is to provide a simplified picture of the data available on patients’ coagulation status at the end of CPB in order to provide relevant information for the development of tailored transfusion algorithms. A nonsystematic literature review was carried out to identify changes in coagulation parameters during CPB. Both prothrombin time and activated partial thromboplastin time increased during CPB, by a median of 33.3% and 17.9%, respectively. However, there was marked variability across the published studies, indicating these tests may be unreliable for guiding hemostatic therapy. Some thrombin generation (TG) parameters were affected, as indicated by a median increase in TG lag time of 55.0%, a decrease in TG peak of 17.5%, and only a slight decrease in endogenous thrombin potential of 7%. The most affected parameters were fibrinogen levels and platelet count/function. Both plasma fibrinogen concentration and FIBTEM maximum clot firmness decreased during CPB (median change of 36.4% and 33.3%, respectively) as did platelet count (44.5%) and platelet component (34.2%). This review provides initial information regarding changes in coagulation parameters during CPB but highlights the variability in the reported results. Further studies are warranted to guide physicians on the parameters most appropriate to guide hemostatic therapy.
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Affiliation(s)
- Judith Höfer
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Dietmar Fries
- Department of Surgical and General Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Cristina Solomon
- Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria
- CSL Behring, Marburg, Germany
| | - Corinna Velik-Salchner
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Julia Ausserer
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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Okerberg CK, Williams LA, Kilgore ML, Kim CH, Marques MB, Schwartz J, Pham HP. Cryoprecipitate AHF vs. fibrinogen concentrates for fibrinogen replacement in acquired bleeding patients - an economic evaluation. Vox Sang 2016; 111:292-298. [DOI: 10.1111/vox.12417] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 04/20/2016] [Accepted: 04/24/2016] [Indexed: 11/29/2022]
Affiliation(s)
- C. K. Okerberg
- Department of Health Care Organization and Policy; University of Alabama at Birmingham; Birmingham AL USA
| | - L. A. Williams
- Department of Pathology; University of Alabama at Birmingham; Birmingham AL USA
| | - M. L. Kilgore
- Department of Health Care Organization and Policy; University of Alabama at Birmingham; Birmingham AL USA
| | - C. H. Kim
- Department of Clinical Pharmacy; University of Colorado Anschutz Medical Campus; Aurora CO USA
| | - M. B. Marques
- Department of Pathology; University of Alabama at Birmingham; Birmingham AL USA
| | - J. Schwartz
- Department of Pathology and Cell Biology; Columbia University Medical Center and the New York-Presbyterian Hospital; New York NY USA
| | - H. P. Pham
- Department of Pathology; University of Alabama at Birmingham; Birmingham AL USA
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Erdoes G, Gerster G, Colucci G, Kaiser H, Alberio L, Eberle B. Prediction of Post-Weaning Fibrinogen Status during Cardiopulmonary Bypass: An Observational Study in 110 Patients. PLoS One 2015; 10:e0126692. [PMID: 26011420 PMCID: PMC4444179 DOI: 10.1371/journal.pone.0126692] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
Background After cardiac surgery with cardiopulmonary bypass (CPB), acquired coagulopathy often leads to post-CPB bleeding. Though multifactorial in origin, this coagulopathy is often aggravated by deficient fibrinogen levels. Objective To assess whether laboratory and thrombelastometric testing on CPB can predict plasma fibrinogen immediately after CPB weaning. Patients / Methods This prospective study in 110 patients undergoing major cardiovascular surgery at risk of post-CPB bleeding compares fibrinogen level (Clauss method) and function (fibrin-specific thrombelastometry) in order to study the predictability of their course early after termination of CPB. Linear regression analysis and receiver operating characteristics were used to determine correlations and predictive accuracy. Results Quantitative estimation of post-CPB Clauss fibrinogen from on-CPB fibrinogen was feasible with small bias (+0.19 g/l), but with poor precision and a percentage of error >30%. A clinically useful alternative approach was developed by using on-CPB A10 to predict a Clauss fibrinogen range of interest instead of a discrete level. An on-CPB A10 ≤10 mm identified patients with a post-CPB Clauss fibrinogen of ≤1.5 g/l with a sensitivity of 0.99 and a positive predictive value of 0.60; it also identified those without a post-CPB Clauss fibrinogen <2.0 g/l with a specificity of 0.83. Conclusions When measured on CPB prior to weaning, a FIBTEM A10 ≤10 mm is an early alert for post-CPB fibrinogen levels below or within the substitution range (1.5–2.0 g/l) recommended in case of post-CPB coagulopathic bleeding. This helps to minimize the delay to data-based hemostatic management after weaning from CPB.
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Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
- * E-mail:
| | - Germaine Gerster
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | | | - Heiko Kaiser
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | - Lorenzo Alberio
- Hématologie non-maligne et Hémostase, Service et Laboratoire central d`Hématologie, University Hospital Lausanne, Lausanne, Switzerland
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
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RANUCCI M, JEPPSSON A, BARYSHNIKOVA E. Pre-operative fibrinogen supplementation in cardiac surgery patients: an evaluation of different trigger values. Acta Anaesthesiol Scand 2015; 59:427-33. [PMID: 25600583 DOI: 10.1111/aas.12469] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/17/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pre-operative fibrinogen levels are negatively associated with postoperative bleeding in cardiac surgery patients. The guidelines of the European Society of Anaesthesiology consider the possibility of a prophylactic pre-operative supplementation in patients with fibrinogen levels<`3.8 g/l. The present study is a reanalysis of published data aimed to define the diagnostic accuracy of different values of pre-operative fibrinogen levels in predicting severe post-operative bleeding. METHODS Data were retrieved for 2154 patients in four different studies. Severe bleeding (SB) was defined as a post-operative chest drain output>1 l/12 h. Diagnostic accuracy for prediction of SB was tested at three cutoff values of pre-operative fibrinogen (2.5 g/l, 3.0 g/l, and 3.8 g/l). RESULTS At all the three cutoff values, pre-operative fibrinogen levels had an excellent negative predictive value, ranging from 86% to 100%. Conversely, the positive predictive value was poor at all the cutoff levels: 12% (3.8 g/l), 14% (3.0 g/l), and 19% (2.5 g/l). Overall, the accuracy of pre-operative fibrinogen levels for the prediction of SB was poor. A strategy based on pre-operative fibrinogen supplementation would lead to inappropriate treatment in > 80% of the treated patients. Overall, a trigger value of 3.8 g/l would result in an inappropriate treatment in 52% of the patients, of 3.0 g/l in 20% of the patients, and of 2.5 g/l in 4% of the patients. CONCLUSION Correction of pre-operative fibrinogen levels below 3.8 g/l would lead to an excessive rate of inappropriate interventions. Values below 2.5 g/l could be considered.
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Affiliation(s)
- M. RANUCCI
- Department of Cardiothoracic Anesthesia and Intensive Care; IRCCS Policlinico San Donato; San Donato Milanese (Milan) Italy
| | - A. JEPPSSON
- Department of Molecular and Clinical Medicine; Institute of Medicine; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Cardiothoracic Surgery; Sahlgrenska University Hospital; Gothenburg Sweden
| | - E. BARYSHNIKOVA
- Department of Cardiothoracic Anesthesia and Intensive Care; IRCCS Policlinico San Donato; San Donato Milanese (Milan) Italy
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Abstract
Fibrinogen is a critical protein for hemostasis and clot formation. However, transfusion guidelines have variable recommendations for maintaining fibrinogen levels in bleeding patients. An increasing number of studies support the practice of fibrinogen replacement therapy for acquired coagulopathies, and additional studies are underway. Fibrinogen therapy can be administered with cryoprecipitate or fibrinogen concentrates, and clinical practice varies according to their availability and licensing status. Fibrinogen concentrate therapy has been studied in animal models and clinical trials and supports the critical role of fibrinogen repletion in bleeding patients. Point-of-care testing will have an important role in guiding fibrinogen replacement for hemostatic therapy in clinical settings such as cardiovascular surgery, postpartum hemorrhage, and trauma. Fibrinogen therapy is an important component of a multimodal strategy for the treatment of coagulopathic bleeding.
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Solomon C, Gröner A, Ye J, Pendrak I. Safety of fibrinogen concentrate: analysis of more than 27 years of pharmacovigilance data. Thromb Haemost 2014; 113:759-71. [PMID: 25502954 DOI: 10.1160/th14-06-0514] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/22/2014] [Indexed: 11/05/2022]
Abstract
Fibrinogen concentrate use as a haemostatic agent has been increasingly explored. This study evaluates spontaneous reports of potential adverse drug reactions (ADRs) that occurred during postmarketing pharmacovigilance of Haemocomplettan P/RiaSTAP, and reviews published safety data. This descriptive study analysed postmarketing safety reports recorded in the CSL Behring pharmacovigilance database from January 1986 to December 2013. A literature review of clinical studies published during the same period was performed. Commercial data indicated that 2,611,294 g of fibrinogen concentrate were distributed over the pharmacovigilance period, corresponding to 652,824 standard doses of 4 g each, across a range of clinical settings and indications. A total of 383 ADRs in 106 cases were reported (approximately 1 per 24,600 g or 6,200 standard doses). Events of special interest included possible hypersensitivity reactions in 20 cases (1 per 130,600 g or 32,600 doses), possible thromboembolic events in 28 cases (1 per 93,300 g or 23,300 doses), and suspected virus transmission in 21 cases (1 per 124,300 g or 31,000 doses). One virus transmission case could not be analysed due to insufficient data; for all other cases, a causal relationship was assessed as unlikely due to negative polymerase chain reaction tests and/or alternative explanations. The published literature revealed a similar safety profile. In conclusion, underreporting of ADRs is a known limitation of pharmacovigilance. However, the present assessment indicates that fibrinogen concentrate is administered across a range of indications, with few ADRs and a low thromboembolic event rate. Overall, fibrinogen concentrate showed a promising safety profile.
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Affiliation(s)
- C Solomon
- Assoc. Prof. Cristina Solomon, MD, MBA, CSL Behring GmbH, Emil-von-Behring-Strasse 76, 35041 Marburg, Germany, Tel: +49 6421 39 5813, Fax: +49 6421 39 4146, E-mail:
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31
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Gill R. Practical management of major blood loss. Anaesthesia 2014; 70 Suppl 1:54-7, e19-20. [DOI: 10.1111/anae.12915] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2014] [Indexed: 12/22/2022]
Affiliation(s)
- R. Gill
- Shackleton Department of Anaesthesia; University Hospital Southampton; Southampton UK
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LUNDE J, STENSBALLE J, WIKKELSØ A, JOHANSEN M, AFSHARI A. Fibrinogen concentrate for bleeding--a systematic review. Acta Anaesthesiol Scand 2014; 58:1061-74. [PMID: 25059813 DOI: 10.1111/aas.12370] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2014] [Indexed: 12/19/2022]
Abstract
Fibrinogen concentrate as part of treatment protocols increasingly draws attention. Fibrinogen substitution in cases of hypofibrinogenaemia has the potential to reduce bleeding, transfusion requirement and subsequently reduce morbidity and mortality. A systematic search for randomised controlled trials (RCTs) and non-randomised studies investigating fibrinogen concentrate in bleeding patients was conducted up to November 2013. We included 30 studies of 3480 identified (7 RCTs and 23 non-randomised). Seven RCTs included a total of 268 patients (165 adults and 103 paediatric), and all were determined to be of high risk of bias and none reported a significant effect on mortality. Two RCTs found a significant reduction in bleeding and five RCTs found a significant reduction in transfusion requirements. The 23 non-randomised studies included a total of 2825 patients, but only 11 of 23 studies included a control group. Three out of 11 found a reduction in transfusion requirements while mortality was reduced in two and bleeding in one. In the available RCTs, which all have substantial shortcomings, we found a significant reduction in bleeding and transfusions requirements. However, data on mortality were lacking. Weak evidence from RCTs supports the use of fibrinogen concentrate in bleeding patients, primarily in elective cardiac surgery, but a general use of fibrinogen across all settings is only supported by non-randomised studies with serious methodological shortcomings. It seems pre-mature to conclude whether fibrinogen concentrate has a routine role in the management of bleeding and coagulopathic patients. More RCTs are urgently warranted.
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Affiliation(s)
- J. LUNDE
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. STENSBALLE
- Section for Transfusion Medicine; Capital Region Blood Bank; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesia; Centre of Head and Orthopedics; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. WIKKELSØ
- Department of Anaesthesia and Intensive Care Medicine; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
| | - M. JOHANSEN
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesiology; Department of Neuroanaesthesia and Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. AFSHARI
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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Predictors of hypofibrinogenemia in blunt trauma patients on admission. J Anesth 2014; 29:242-8. [PMID: 25112812 DOI: 10.1007/s00540-014-1895-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/22/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE Massive bleeding usually leads to critically low levels of clotting factors, including fibrinogen. Although reduced fibrinogen levels correlate with increased mortality, predictors of hypofibrinogenemia have remained poorly understood. We investigated whether findings available on admission can be used as predictors of hypofibrinogenemia. METHODS We retrospectively reviewed serum fibrinogen levels tested on arrival in 290 blunt trauma patients transported to a level I trauma center during a 3-year period. The primary outcome was prehospital predictors for hypofibrinogenemia. Covariates included age, sex, prehospital fluid therapy, prehospital anatomical and physiological scores, time from injury, base excess, and lactate on arrival. All variables with values of p < 0.10 in univariate analysis were included in a multivariate logistic regression model. The relationships between the variables and the 7-day mortality rate were evaluated in a Cox proportional hazards model. RESULTS Patient's age [odds ratio (OR): 0.97, p < 0.001], Triage Revised Trauma Score (T-RTS) (OR: 0.81, p = 0.003), and prehospital fluid therapy (OR: 2.54, p = 0.01) were detected as independent predictors for hypofibrinogenemia in multivariate logistic regression analysis. Serum fibrinogen level [hazard ratio (HR): 0.99, p = 0.01] and T-RTS (HR: 0.77, p < 0.01) were associated with the 7-day mortality rate. CONCLUSION T-RTS is considered to play an important role in predicting hypofibrinogenemia and 7-day mortality in blunt trauma patients.
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Jalali A, Ghiasi M, Aghaei A, Khaleghparast S, Ghanbari B, Bakhshandeh H. Can plasma fibrinogen levels predict bleeding after coronary artery bypass grafting? Res Cardiovasc Med 2014; 3:e19521. [PMID: 25478546 PMCID: PMC4253797 DOI: 10.5812/cardiovascmed.19521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/17/2014] [Accepted: 06/07/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Fibrinogen is the main biomarker for bleeding. To prevent excessive postoperative bleeding, it would be useful to identify high-risk patients before coronary artery bypass grafting (CABG). OBJECTIVES In order to predicating bleeding after CABG, we sought to determine whether preoperative fibrinogen concentration was associated with the amount of bleeding following CABG. PATIENTS AND METHODS A total of 144 patients (mean age = 61.50 ± 9.42 years; 65.7% men), undergoing elective and isolated CABG, were included in this case-series study. The same anesthesia technique and medicines were selected for all the patients. In the ICU, the patients were assessed in terms of bleeding at 12 and 24 hours post-operation, amount of contingent blood products received, and relevant tests. Statistical tests were subsequently conducted to analyze the correlation between preoperative fibrinogen concentration and the amount of post-CABG bleeding. RESULTS The mean ± standard deviation of bleeding at 12 and 24 hours post-operation was 285.37 ± 280.27 and 499.31 ± 355.57 mL, respectively. The results showed that postoperative bleeding was associated with different factors whereas pre-anesthesia fibrinogen was not correlated with bleeding at 12 (P = 0.856) and 24 hours (P = 0.936) post-operation. There were correlations between the extra-corporal circulation time and bleeding at 12 hours post-operation (ρ = 0.231, P = 0.007) and bleeding at 24 hours post-operation (ρ = 0.218, P = 0.013). CONCLUSIONS Preoperative assessment of plasma fibrinogen levels failed to predict post-CABG bleeding.
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Affiliation(s)
- Alireza Jalali
- Department of Cardiac Anesthesiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Mohammadsaeid Ghiasi
- Department of Cardiac Anesthesiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Aghdas Aghaei
- Department of Anesthesiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Shiva Khaleghparast
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Behrooz Ghanbari
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
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35
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The prothrombotic paradox of severe obesity after cardiac surgery under cardiopulmonary bypass. Thromb Res 2014; 134:346-53. [DOI: 10.1016/j.thromres.2014.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 05/27/2014] [Accepted: 06/05/2014] [Indexed: 11/21/2022]
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Plasma fibrinogen level on admission to the intensive care unit is a powerful predictor of postoperative bleeding after cardiac surgery with cardiopulmonary bypass. Thromb Res 2014; 134:360-8. [DOI: 10.1016/j.thromres.2014.05.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 04/23/2014] [Accepted: 05/07/2014] [Indexed: 11/22/2022]
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Collins PW, Solomon C, Sutor K, Crispin D, Hochleitner G, Rizoli S, Schöchl H, Schreiber M, Ranucci M. Theoretical modelling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate. Br J Anaesth 2014; 113:585-95. [PMID: 25064078 PMCID: PMC4166889 DOI: 10.1093/bja/aeu086] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background We aimed to create a theoretical tool to model the effect of three haemostatic agents containing fibrinogen (therapeutic plasma, cryoprecipitate, and fibrinogen concentrate) on the patient's plasma fibrinogen level. Methods A mathematical model was developed step-wise. The relationship between the amount of haemostatic agent and plasma fibrinogen level was plotted for each agent. A fibrinogen concentration simulator (FCSamount) was developed, where the amount of haemostatic agent was calculated from patient characteristics, agent characteristics, and target plasma fibrinogen level. Refinements were introduced so that (i) FCSamount would account for in vivo fibrinogen recovery, (ii) circulatory volume would not increase ad infinitum with increasing amounts, and (iii) red blood cells would be included in the simulation if haematocrit decreased below a certain level. A second FCS (FCSlevel) was created to calculate fibrinogen levels resulting from specified amounts of haemostatic agents. Results Fibrinogen concentration in haemostatic agents has a critical impact on their ability to increase patients' fibrinogen levels. If the target plasma fibrinogen level approaches the concentration of the fibrinogen source, the required amounts increase exponentially; it is impossible to achieve a target above the concentration of the fibrinogen source. Conclusions We successfully developed two theoretical tools answering the questions: ‘How much therapeutic plasma, cryoprecipitate, or fibrinogen concentrate would be needed to achieve a specified target fibrinogen level?’ and ‘What would be the resultant fibrinogen level for a specified amount of haemostatic agent?’ The current tools are not intended for clinical application, but they are potentially useful for educational purposes.
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Affiliation(s)
- P W Collins
- School of Medicine, Cardiff University and University Hospital of Wales, Cardiff, UK
| | - C Solomon
- CSL Behring, Marburg, Germany Department of Anesthesiology, Perioperative Medicine and General Intensive Care, Paracelsus Medical University, Salzburg, Austria
| | - K Sutor
- Meridian HealthComms, Cheshire, UK
| | | | | | - S Rizoli
- Department of Surgery and Critical Care Medicine, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - H Schöchl
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Salzburg, Austria Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - M Schreiber
- Trauma, Critical Care and Acute Care Surgery Division, Oregon Health and Science University, Portland, OR, USA
| | - M Ranucci
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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Kim NY, Shim JK, Song JW, Kim EK, Kwak YL. Impact of Preoperative Fibrinogen Concentration on Postoperative Outcome in Patients Who Received Dual Antiplatelet Therapy in Proximity to Off-Pump Coronary Bypass Surgery. Circ J 2014; 78:1661-6. [DOI: 10.1253/circj.cj-14-0161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Na Young Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine
| | - Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine
| | - Eui-Kyung Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine
- Severance Biomedical Science Institute, Yonsei University College of Medicine
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Pillai RC, Fraser JF, Ziegenfuss M, Bhaskar B. The Influence of Circulating Levels of Fibrinogen and Perioperative Coagulation Parameters on Predicting Postoperative Blood Loss in Cardiac Surgery:
A Prospective Observational Study. J Card Surg 2013; 29:189-95. [DOI: 10.1111/jocs.12255] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ravi C. Pillai
- John McCarthy Intensive Care Unit; The Prince Charles Hospital; Brisbane Australia
| | - John F. Fraser
- John McCarthy Intensive Care Unit; The Prince Charles Hospital; Brisbane Australia
- Critical Care Research Group; The Prince Charles Hospital; Brisbane Australia
| | - Marc Ziegenfuss
- John McCarthy Intensive Care Unit; The Prince Charles Hospital; Brisbane Australia
- Critical Care Research Group; The Prince Charles Hospital; Brisbane Australia
| | - Balu Bhaskar
- John McCarthy Intensive Care Unit; The Prince Charles Hospital; Brisbane Australia
- Critical Care Research Group; The Prince Charles Hospital; Brisbane Australia
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Gielen C, Dekkers O, Stijnen T, Schoones J, Brand A, Klautz R, Eikenboom J. The effects of pre- and postoperative fibrinogen levels on blood loss after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2013; 18:292-8. [PMID: 24316606 DOI: 10.1093/icvts/ivt506] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Fibrinogen concentrate is increasingly used in cardiac surgery when bleeding is anticipated or ongoing. Since randomized clinical studies to support this are lacking, it is relevant to know whether lower fibrinogen levels are associated with excessive bleeding. We performed a systematic review and meta-analysis to define the association between fibrinogen levels and blood loss after cardiac surgery. METHODS A database search (January 2013) was performed on publications assessing the association between pre- and postoperative fibrinogen levels and postoperative blood loss in adult patients undergoing cardiac surgery. Cohort studies and case-control studies were eligible for inclusion. The main outcome was the pooled correlation coefficient, calculated via Fisher's Z transformation scale, in a random-effects meta-analysis model stratified for the time point at which fibrinogen was measured. RESULTS A total of 20 studies were included. The pooled correlation coefficient of studies (n = 9) concerning preoperative fibrinogen levels and postoperative blood loss was -0.40 (95% confidence interval: -0.58, -0.18), pointing towards more blood loss in patients with lower preoperative fibrinogen levels. Among papers (n = 16) reporting on postoperative fibrinogen levels and postoperative blood loss, the pooled correlation coefficient was -0.23 (95% confidence interval: -0.29, -0.16). CONCLUSIONS Our meta-analysis indicated a significant but weak-to-moderate correlation between pre- and postoperative fibrinogen levels and postoperative blood loss in cardiac surgery. This moderate association calls for appropriate clinical studies on whether fibrinogen supplementation will decrease postoperative blood loss.
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Affiliation(s)
- Chantal Gielen
- Departments of Cardio-Thoracic Surgery and Thrombosis and Hemostasis, Leiden University Medical Center (LUMC), Leiden, Netherlands
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Levy JH, Welsby I, Goodnough LT. Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy. Transfusion 2013; 54:1389-405; quiz 1388. [DOI: 10.1111/trf.12431] [Citation(s) in RCA: 213] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/14/2013] [Accepted: 08/14/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Jerrold H. Levy
- Department of Anesthesiology; Duke University School of Medicine; Durham North Carolina
| | - Ian Welsby
- Department of Anesthesiology; Duke University School of Medicine; Durham North Carolina
| | - Lawrence T. Goodnough
- Department of Pathology; Stanford University School of Medicine, Stanford Medical Center; Palo Alto California
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Wikkelsø A, Lunde J, Johansen M, Stensballe J, Wetterslev J, Møller AM, Afshari A. Fibrinogen concentrate in bleeding patients. Cochrane Database Syst Rev 2013; 2013:CD008864. [PMID: 23986527 PMCID: PMC6517136 DOI: 10.1002/14651858.cd008864.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Hypofibrinogenaemia is associated with increased morbidity and mortality, but the optimal treatment level, the use of preemptive treatment and the preferred source of fibrinogen remain disputed. Fibrinogen concentrate is increasingly used and recommended for bleeding with acquired haemostatic deficiencies in several countries, but evidence is lacking regarding indications, dosing, efficacy and safety. OBJECTIVES We assessed the benefits and harms of fibrinogen concentrate compared with placebo or usual treatment for bleeding patients. SEARCH METHODS We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8); MEDLINE (1950 to 9 August 2013); EMBASE (1980 to 9 August 2013); International Web of Science (1964 to 9 August 2013); CINAHL (1980 to 9 August 2013); LILACS (1982 to 9 August 2013); and the Chinese Biomedical Literature Database (up to 10 November 2011), together with databases of ongoing trials. We contacted trial authors, authors of previous reviews and manufacturers in the field. SELECTION CRITERIA We included all randomized controlled trials (RCTs), irrespective of blinding or language, that compared fibrinogen concentrate with placebo/other treatment or no treatment in bleeding patients, excluding neonates and patients with hereditary bleeding disorders. DATA COLLECTION AND ANALYSIS Three review authors independently abstracted data; we resolved any disagreements by discussion. Our primary outcome measure was all-cause mortality. We performed subgroup and sensitivity analyses to assess the effects of fibrinogen concentrate in adults and children in terms of various clinical and physiological outcomes. We presented pooled estimates of the effects of intervention on dichotomous outcomes as risk ratios (RRs) and on continuous outcomes as mean differences, with 95% confidence intervals (CIs). We assessed the risk of bias through assessment of trial methodological components and the risk of random error through trial sequential analysis. MAIN RESULTS We included six RCTs with a total of 248 participants; none of the trials were determined to have overall low risk of bias. We found 12 ongoing trials, from which we were unable to retrieve any data. Only two trials provided data on mortality, and one was a zero event study; thus the meta-analysis showed no statistically significant effect on overall mortality (2.6% vs 9.5%, RR 0.28, 95% CI 0.03 to 2.33). Our analyses on blood transfusion data suggest a beneficial effect of fibrinogen concentrate in reducing the incidence of allogenic transfusions (RR 0.47, 95% CI 0.31 to 0.72) but show no effect on other predefined outcomes, including adverse events such as thrombotic episodes. AUTHORS' CONCLUSIONS In the six available RCTs of elective surgery, fibrinogen concentrate appears to reduce transfusion requirements, but the included trials are of low quality with high risk of bias and are underpowered to detect mortality, benefit or harm. Furthermore, data on mortality are lacking, heterogeneity is high and acute or severe bleeding in a non-elective surgical setting remains unexplored. Currently, weak evidence supports the use of fibrinogen concentrate in bleeding patients, as tested here in primarily elective cardiac surgery. More research is urgently needed.
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Affiliation(s)
- Anne Wikkelsø
- Hvidovre Hospital, University of CopenhagenDepartment of Anaesthesiology and Intensive Care MedicineKettegård Alle 30,HvidovreDenmark2650
| | - Jens Lunde
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
| | - Mathias Johansen
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
| | - Jakob Stensballe
- Copenhagen University Hospital, RigshospitaletDepartment of Anaesthesiology, Centre of Head and Orthopaedics & Section for Transfusion Medicine, Capital Region Blood BankBlegdamsvej 9CopenhagenDenmarkDK‐2100 KBH Ø
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of CopenhagenCochrane Anaesthesia, Critical and Emergency Care GroupHerlev RingvejHerlevDenmark2730
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre, Department of AnaesthesiologyCopenhagenDenmark
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Martini J, Maisch S, Pilshofer L, Streif W, Martini W, Fries D. Fibrinogen concentrate in dilutional coagulopathy: a dose study in pigs. Transfusion 2013; 54:149-57. [DOI: 10.1111/trf.12241] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 03/13/2013] [Accepted: 03/14/2013] [Indexed: 02/01/2023]
Affiliation(s)
- Judith Martini
- Clinical Department of Anesthesiology and General Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Clinical Department of General and Surgical Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Department of Paediatrics; Medical University Innsbruck; Innsbruck Austria
- US Army Institute of Surgical Research; Fort Sam Houston Texas
| | - Sonja Maisch
- Clinical Department of Anesthesiology and General Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Clinical Department of General and Surgical Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Department of Paediatrics; Medical University Innsbruck; Innsbruck Austria
- US Army Institute of Surgical Research; Fort Sam Houston Texas
| | - Lisa Pilshofer
- Clinical Department of Anesthesiology and General Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Clinical Department of General and Surgical Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Department of Paediatrics; Medical University Innsbruck; Innsbruck Austria
- US Army Institute of Surgical Research; Fort Sam Houston Texas
| | - Werner Streif
- Clinical Department of Anesthesiology and General Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Clinical Department of General and Surgical Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Department of Paediatrics; Medical University Innsbruck; Innsbruck Austria
- US Army Institute of Surgical Research; Fort Sam Houston Texas
| | - Wenjun Martini
- Clinical Department of Anesthesiology and General Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Clinical Department of General and Surgical Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Department of Paediatrics; Medical University Innsbruck; Innsbruck Austria
- US Army Institute of Surgical Research; Fort Sam Houston Texas
| | - Dietmar Fries
- Clinical Department of Anesthesiology and General Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Clinical Department of General and Surgical Intensive Care Medicine; Medical University Innsbruck; Innsbruck Austria
- Department of Paediatrics; Medical University Innsbruck; Innsbruck Austria
- US Army Institute of Surgical Research; Fort Sam Houston Texas
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Fibrinogen concentrate reduces intraoperative bleeding when used as first-line hemostatic therapy during major aortic replacement surgery: results from a randomized, placebo-controlled trial. J Thorac Cardiovasc Surg 2013; 145:S178-85. [PMID: 23410777 DOI: 10.1016/j.jtcvs.2012.12.083] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 12/19/2012] [Accepted: 12/28/2012] [Indexed: 12/15/2022]
Abstract
OBJECTIVES We assessed whether fibrinogen concentrate as targeted first-line hemostatic therapy was more effective than placebo or a standardized transfusion algorithm in controlling coagulopathic bleeding in patients undergoing major aortic surgery. METHODS In this single-center, prospective, double-blind study, adults undergoing elective thoracic or thoracoabdominal aortic replacement surgery involving cardiopulmonary bypass were randomized to intraoperative fibrinogen concentrate (n = 29) or placebo (n = 32). Study medication was given if patients had clinically relevant coagulopathic bleeding, measured by 5-minute bleeding mass, after cardiopulmonary bypass removal, protamine administration, and surgical hemostasis. Fibrinogen concentrate dosing was individualized using the thromboelastometric FIBTEM test. If bleeding continued, a standardized transfusion algorithm was followed. In the placebo group, all 32 patients received 1 transfusion cycle of fresh-frozen plasma/platelets, and 30 patients required a second transfusion cycle; none of these patients received any other procoagulant therapy. Change in bleeding rate after treatment was compared using t tests. RESULTS Mean change in bleeding rate after fibrinogen concentrate was -48.3 g/5 min, compared with 0.4 g/5 min after placebo (P < .001), -16.1 g/5 min after 1 transfusion cycle (fresh-frozen plasma or platelets; P = .003), and -28.0 g/5 min after 2 transfusion cycles (fresh-frozen plasma and platelets; P = .11). Reductions in bleeding rate were greater for patients with higher bleeding rates before treatment, especially with fibrinogen concentrate. CONCLUSIONS FIBTEM-guided intraoperative hemostatic therapy with fibrinogen concentrate is more effective than placebo in controlling coagulopathic bleeding during major aortic replacement surgery. Fibrinogen concentrate is also more effective than 1 cycle of fresh-frozen plasma/platelets and is more rapid than--and at least as effective as--2 cycles of fresh-frozen plasma/platelets.
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Ranucci M. Fibrinogen Supplementation in Cardiac Surgery: Where Are We Now and Where Are We Going? J Cardiothorac Vasc Anesth 2013. [DOI: 10.1053/j.jvca.2012.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Görlinger K, Bergmann L, Dirkmann D. Coagulation management in patients undergoing mechanical circulatory support. Best Pract Res Clin Anaesthesiol 2013; 26:179-98. [PMID: 22910089 DOI: 10.1016/j.bpa.2012.04.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 03/25/2012] [Accepted: 04/20/2012] [Indexed: 12/28/2022]
Abstract
The incidence of bleeding and thrombo-embolic complications in patients undergoing mechanical circulatory support therapy remains high and is associated with bad outcomes and increased costs. The need for anticoagulation and anti-platelet therapy varies widely between different pulsatile and non-pulsatile ventricular-assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) systems. Therefore, a unique anticoagulation protocol cannot be recommended. Notably, most thrombo-embolic complications occur despite values of conventional coagulation tests being within the targeted range. This is due to the fact that conventional coagulation tests such as international normalised ratio (INR), activated partial thromboplastin time (aPTT) and platelet count cannot detect hyper- or hypofibrinolysis, hypercoagulability due to tissue factor expression on circulating cells or increased clot firmness, and platelet aggregation as well as response to anti-platelet drugs. By contrast, point-of-care (POC) whole blood viscoelastic tests (thromboelastometry/-graphy) and platelet function tests (impedance or turbidimetric aggregometry) reflect in detail the haemostatic status of patients undergoing mechanical circulatory support therapy and the efficacy of their anticoagulation and antiaggregation therapy. Therefore, monitoring of haemostasis using POC thromboelastometry/-graphy and platelet function analysis is recommended during mechanical circulatory support therapy to reduce the risk of bleeding and thrombo-embolic complications. Notably, these haemostatic tests should be performed repeatedly during mechanical circulatory support therapy since thrombin generation, clot firmness and platelet response may change significantly over time with a high inter- and intra-individual variability. Furthermore, coagulation management can be hampered in non-pulsatile VADs by acquired von Willebrand syndrome, and in general by acquired factor XIII deficiency as well as by heparin-induced thrombocytopenia. In addition, POC testing can be used in bleeding patients to guide calculated goal-directed therapy with allogeneic blood products, haemostatic drugs and coagulation factor concentrates to optimise the haemostasis and to minimise transfusion requirements, transfusion-associated adverse events and to avoid thrombo-embolic complications, as well. However, coagulation management in patients undergoing mechanical circulatory support therapy is somehow like navigating between Scylla and Charybdis, and development of protocols based on POC testing seems to be beneficial.
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Affiliation(s)
- Klaus Görlinger
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinkum Essen, Universität Duisburg-Essen, Hufelandstrasse 55, D-45122 Essen, Germany.
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Wikkelsoe AJ, Afshari A, Stensballe J, Langhoff-Roos J, Albrechtsen C, Ekelund K, Hanke G, Sharif HF, Mitchell AU, Svare J, Troelstrup A, Pedersen LM, Lauenborg J, Madsen MG, Bødker B, Møller AM. The FIB-PPH trial: fibrinogen concentrate as initial treatment for postpartum haemorrhage: study protocol for a randomised controlled trial. Trials 2012; 13:110. [PMID: 22805300 PMCID: PMC3434105 DOI: 10.1186/1745-6215-13-110] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 07/17/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality worldwide. In Denmark 2% of parturients receive blood transfusion. During the course of bleeding fibrinogen (coagulation factor I) may be depleted and fall to critically low levels, impairing haemostasis and thus worsening the ongoing bleeding. A plasma level of fibrinogen below 2 g/L in the early phase of postpartum haemorrhage is associated with subsequent development of severe haemorrhage. Use of fibrinogen concentrate allows high-dose substitution without the need for blood type crossmatch. So far no publications of randomised controlled trials involving acutely bleeding patients in the obstetrical setting have been published. This trial aims to investigate if early treatment with fibrinogen concentrate reduces the need for blood transfusion in women suffering severe PPH. METHODS/DESIGN In this randomised placebo-controlled double-blind multicentre trial, parturients with primary PPH are eligible following vaginal delivery in case of: manual removal of placenta (blood loss ≥ 500 ml) or manual exploration of the uterus after the birth of placenta (blood loss ≥ 1000 ml). Caesarean sections are also eligible in case of perioperative blood loss ≥ 1000 ml. The exclusion criteria are known inherited haemostatic deficiencies, prepartum treatment with antithrombotics, pre-pregnancy weight <45 kg or refusal to receive blood transfusion. Following informed consent, patients are randomly allocated to either early treatment with 2 g fibrinogen concentrate or 100 ml isotonic saline (placebo). Haemostatic monitoring with standard laboratory coagulation tests and thromboelastography (TEG, functional fibrinogen and Rapid TEG) is performed during the initial 24 hours.Primary outcome is the need for blood transfusion. To investigate a 33% reduction in the need for blood transfusion, a total of 245 patients will be included. Four university-affiliated public tertiary care hospitals will include patients during a two-year period. Adverse events including thrombosis are assessed in accordance with International Conference on Harmonisation (ICH) good clinical practice (GCP). DISCUSSION A widespread belief in the benefits of early fibrinogen substitution in cases of PPH has led to increased off-label use. The FIB-PPH trial is investigator-initiated and aims to provide an evidence-based platform for the recommendations of the early use of fibrinogen concentrate in PPH. TRIAL REGISTRATION ClincialTrials.gov NCT01359878.
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Affiliation(s)
- Anne Juul Wikkelsoe
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Herlev Ringvej 75, DK-2730, Herlev, Denmark.
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Mitterlechner T, Innerhofer P, Streif W, Lödl M, Danninger T, Klima G, Hansson K, Fries D. Prothrombin complex concentrate and recombinant prothrombin alone or in combination with recombinant factor X and FVIIa in dilutional coagulopathy: a porcine model. J Thromb Haemost 2011; 9:729-37. [PMID: 21255250 DOI: 10.1111/j.1538-7836.2011.04211.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND This study was conducted to assess whether newly developed recombinant clotting factor concentrates enable the reversal of dilutional coagulopathy. METHODS In 50 anesthetized pigs, ~60% of the blood volume was withdrawn and replaced with hydroxyethyl starch. Pigs were randomized to receive either 200 mg kg(-1) fibrinogen (n = 10), fibrinogen and 35 IU kg(-1) prothrombin complex concentrate (PCC) (n = 10), fibrinogen and 4 mg kg(-1) recombinant human factor II (rhFII) concentrate (n = 10), fibrinogen and a three-factor combination (3F) of 4 mg kg(-1) rhFII, 0.006 mg kg(-1) recombinant human FVIIa and 0.32 mg kg(-1) recombinant human FX (n = 10), or saline (n = 10). Thereafter, a standardized liver laceration was performed to induce uncontrolled hemorrhage. Survival time and blood loss were determined, and standard coagulation tests and thrombelastometry were performed. RESULTS Fibrinogen combined with rhFII or PCC improved survival. Blood loss was significantly decreased in all groups as compared with the animals receiving saline. Clotting time was significantly shortened in the animals treated with fibrinogen and PCC, as well as in those treated with fibrinogen and 3F. One animal died after administration of fibrinogen and PCC. CONCLUSION Following hemodilution, a combination of fibrinogen and PCC, rhFII or 3F enhances coagulation and final clot strength. Mortality was reduced statistically significantly only in the animals treated with fibrinogen and rhFII or PCC, whereas administration of the combination of fibrinogen and PCC caused a fatal thromboembolic complication. The combination of fibrinogen and rhFII might be effective in reversing dilutional coagulopathy and may reduce blood loss in cases of dilutional coagulopathy.
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Affiliation(s)
- T Mitterlechner
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
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Cui Y, Hei F, Long C, Feng Z, Zhao J, Yan F, Wang Y, Liu J. Perioperative Monitoring of Thromboelastograph on Blood Protection and Recovery for Severely Cyanotic Patients Undergoing Complex Cardiac Surgery. Artif Organs 2010; 34:955-60. [DOI: 10.1111/j.1525-1594.2010.01148.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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