Fibrinogen concentrate administration attributes to significant reductions of blood loss and transfusion requirements in thoracic aneurysm repair

Journal of Cardiothoracic Surgery

Junki Takamatsu¹  Akihiko Usui³  Koji Yamamoto² 

[1] Aichi Red Cross Blood Center, Seto, Aichi, Japan;Department of Transfusion Medicine, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya 466-8560, Japan;Department of Thoracic Surgery, Nagoya University Hospital, Nagoya, Japan

关键词: Hypofibrinogenemia;    Dilutional coagulopathy;    Cardiopulmonary bypass;    Thoracic aortic aneurysm;    Massive hemorrhage;   

Others  :  823399
DOI  :  10.1186/1749-8090-9-90

 received in 2013-12-30, accepted in 2014-05-12,  发布年份 2014

【 摘 要 】

Background

Repair of thoracic aortic aneurysm (TAA) is often associated with massive hemorrhage aggravated by dilutional coagulopathy with severe hypofibrinogenemia. Although only fresh frozen plasma (FFP) is available for acquired hypofibrinogenemia in Japan, the hemostatic effect of FFP has not been enough for dilutional coagulopathy in TAA surgery. There are increasing reports suggesting that fibrinogen concentrate may be effective in controlling perioperative bleeding and reducing transfusion requirements.

Methods

We retrospectively analyzed the hemostatic effect of fibrinogen concentrate compared with FFP in total 49 cases of elective TAA surgery. In 25 patients, fibrinogen concentrate was administered when the fibrinogen level was below 150 mg/dL at the cardiopulmonary bypass (CPB) termination. The recovery of fibrinogen level, blood loss, and transfused units during surgery were compared between cases of this agent and FFP (n = 24).

Results

We observed rapid increases in plasma fibrinogen level and subsequent improvement in hemostasis by administration of fibrinogen concentrate after CPB termination. The average volume of total blood loss decreased by 64% and the average number of transfused units was reduced by 58% in cases of fibrinogen concentrate given, in comparison with cases of only FFP transfused for fibrinogen supplementation.

Conclusions

In patients showing severe hypofibrinogenemia during TAA surgery, timely administration of fibrinogen concentrate just after removal from CPB is effective for hemostasis, and therefore in reducing blood loss and transfused volumes.

【 授权许可】

   
2014 Yamamoto et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

【 参考文献 】

• [1]Aboulafia DM, Aboulafia ED: Aortic aneurysm-induced disseminated intravascular coagulation. Ann Vasc Surg 1996, 10:396-405.
• [2]Paparella D, Rotunno C, Guida P, Malvindi PG, Scrascia G, de Palo M, de Cillis E, Bortone AS, de Luca Tupputi Schinosa L: Hemostasis alterations in patients with acute aortic dissection. Ann Thorac Surg 2011, 91:1364-1369.
• [3]Chandler WL: Effects of hemodilution, blood loss, and consumption on hemostatic factor levels during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2005, 19:459-467.
• [4]Rahe-Meyer N, Pichlmaier M, Haverich A, Solomon C, Winterhalter M, Piepenbrock S, Tanaka KA: Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study. Br J Anaesth 2009, 102:785-792.
• [5]Levi M, Cromheecke ME, de Jonge E, Prins MH, de Mol BJ, Briët E, Büller HR: Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999, 354:1940-1947.
• [6]Hiippala ST, Myllyla GJ, Vahtera EM: Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 1995, 81:360-365.
• [7]Levi M, Fries D, Gombotz H, van der Linden P, Nascimento D, Callum JL, Belisle S, Rizoli S, Hardy J-F, Johansson PI, Samama CM, Grottke O, Rossaint R, Henny CP, Goslings JC, Theusinger OM, Spahn DR, Ganter MT, Hess JR, Dutton RP, Scalea TM, Levy JH, Spinella PC, Panzer S, Reesink HW: Prevention and treatment of coagulopathy in patients receiving massive transfusions. Vox Sang 2011, 101:154-174.
• [8]Yang L, Stanworth S, Hopewell S, Doree C, Murphy M: Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion 2012, 52:1673-1686.
• [9]Bornikova L, Peyvand F, Allen G, Bernstein J, Manco-Johnson MJ: Fibrinogen replacement therapy for congenital fibrinogen deficiency. J Thromb Haemost 2011, 9:1687-1704.
• [10]Fenger-Eriksen C, Lindberg-Larsen M, Christensen A, Ingerslev J, Sørensen B: Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth 2008, 101:769-773.
• [11]Weinkove R, Rangarajan S: Fibrinogen concentrate for acquired hypofibirinogenaemic states. Transfus Med Rev 2008, 18:151-157.
• [12]Bell SF, Rayment R, Collins PW, Collis RE: The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anesth 2010, 19:218-234.
• [13]Ahmed S, Harrity C, Johnson S, Varadkar S, McMorrow S, Fanning R, Flynn CM, O’Riordan JM, Byrne BM: The efficacy of fibrinogen concentrate compared with cryoprecipitate in major obstetric haemorrhage – an observational study. Transfus Med 2012, 22:344-349.
• [14]Fries D, Mortini W: Role of fibrinogen in trauma-induced coagulopathy. Br J Anaesth 2010, 105:116-121.
• [15]Rourke C, Curry N, Khan S, Taylor R, Raza I, Davenport R, Stanworth S, Brohi K: Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost 2012, 10:1342-1351.
• [16]Rahe-Meyer N, Solomon C, Winterhalter M, Piepenbrock S, Tanaka K, Haverich A, Pichlmaier M: Thromboelastmetry-guided administration of fibrinogen concentrate for the treatment of excessive intraoperative bleeding in thoracoabdominal aortic aneurysm surgery. J Thorac Cardiovas Surg 2009, 138:694-702.
• [17]Solomon C, Picklmaier U, Schoechl H, Hagl C, Raymondos K, Scheinichen D, Koppert W, Rahe-Meyer N: Recovery of fibrinogen after administration of fibrinogen concentrate to patients with severe bleeding after cardiopulmonary bypass surgery. Br J Anaesth 2010, 104:555-562.
• [18]Bolliger D, Görlinger K, Tanaka KA: Pathophysiology and treatment of coagulopathy in massive hemorrhage and hemodilution. Anesthesiology 2010, 113:1205-1219.
• [19]Chung JH, Gikakis N, Rao AK, Drake TA, Colman RW, Edmunds LH Jr: Pericardial blood activates the extrinsic coagulation pathway during clinical cardiopulmonary bypass. Circulation 1996, 93:2014-2018.
• [20]Weerwind PW, Lindhout T, Caberg NEH, de Jong DS: Thrombin generation during cardiopulmonary bypass: the possible role of retransfusion of blood aspirated from the surgical field. Thromb J 2003, 1:1-9.
• [21]Ide M, Bolliger D, Taketomi T, Tanaka KA: Lessons from the aprotinin saga: current perspective on antifibrinolytic therapy in cardiac surgery. J Anesth 2010, 24:96-106.
• [22]Levy JH, Szlam F, Tanaka KA, Sniecienski RM: Fibrinogen and hemostasis: a primary hemostatic target for the management of acquired bleeding. Anesth Analg 2012, 114:261-274.
• [23]Bolliger D, Szlam F, Molinaro RJ, Rahe-Meyer N, Levy JH, Tanaka KA: Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model. Br J Anaesth 2009, 102:793-799.
• [24]Lang T, Johanning K, Metzler H, Piepenbrock S, Solomon C, Rahe-Meyer N, Tanaka KA: The effects of fibrinogen levels on thromboelastometric variables in the presence of thrombocytopenia. Anesth Analg 2009, 108:751-758.
• [25]Kozek-Langenecker S, Sørensen B, Hess JR, Spahn DR: Clinical effectiveness of fresh frozen plasma compared with fibrinogen concentrate: a systematic review. Crit Care 2011, 15:R239. BioMed Central Full Text
• [26]Danes AF, Cuenca LG, Bueno SR, Barrenechea LM, Ronsano JBM: Efficacy and tolerability of human fibrinogen concentrate administration to patients with acquired fibrinogen deficiency and active or in high-risk severe bleeding. Vox Sang 2008, 94:221-226.
• [27]Warmuth M, Mad P, Wild C: Systematic review of the efficacy and safety of fibrinogen concentrate substitution in adults. Acta Anaesthesiol Scand 2012, 56:539-548.
• [28]Rahe-Meyer N, Solomon C, Hanke A, Schmidt DS, Knoerzer D, Hochleitner G, Sørensen B, Hagl C, Pichlmaier M: Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial. Anesthesiology 2013, 118:40-50.
• [29]Rahe-Meyer N, Hanke A, Schmidt DS, Hagl C, Pichlmaier M: 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-S185.