Prophylactic Use of Fibrinogen Concentrate on Postoperative Blood Fibrinogen Levels, Amount of Bleeding, and the Need for Blood Transfusion in Normofibrinogenemic Patients Undergoing Coronary Artery Bypass Graft Surgery
-
Khadijeh Ghavibonyeh
,
Ali Dabbagh
,
Alireza Jahangiri Fard
,
Ramin Baghaei
,
Kamal Fani
,
Marzieh Shahrabi
,
Mina Fani
Abstract
Background: Different studies investigated strategies to prevent perioperative bleeding in cardiac surgeries. The use of fibrinogen concentrate is one of these efforts. In this study, we will investigate the efficacy and proper dosage of fibrinogen concentrate as a prophylactic adjuvant for reducing postoperative bleeding in patients with normal blood fibrinogen under coronary artery bypass grafting (CABG) surgery.
Methods: Patients with preoperative normal plasma fibrinogen levels were randomly divided into two groups (15 patients in each). At the final stage of cardiac surgery and after reversal of heparin, the first group received 2gr of fibrinogen IV concentrate in 15 minutes, while the other group received the same volume of placebo. In each patient, postoperative haematocrit percentage, intraoperative and postoperative administered blood products, and postoperative drainage amount were collected.
Results: Although in the study group, the postoperative amount of plasma fibrinogen increased compared to preoperative and decreased in the control group, but this change was not statistically significant. Also there wasn’t any significant difference in terms of blood drainage and blood product consumption.
Conclusion: We did not find evidence of a significant difference in the change of fibrinogen blood level before and after the operation, the amount of drainage, and the consumption of blood products in the fibrinogen and placebo groups.
[1] Nuttall GA, Oliver WC, Santrach PJ, Bryant S, Dearani JA, Schaff HV, et al. Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology. 2001;94(5):773-81.
[2] Dyke C, Aronson S, Dietrich W, Hofmann A, Karkouti K, Levi M, et al. Universal definition of perioperative bleeding in adult cardiac surgery. J. Thorac. Cardiovasc. Surg. 2014;147(5):1458-63. e1.
[3] Menkis AH, Martin J, Cheng DC, Fitzgerald DC, Freedman JJ, Gao C, et al. Drug, devices, technologies, and techniques for blood management in minimally invasive and conventional cardiothoracic surgery a consensus statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011. Innovations. 2012;7(4):229-41.
[4] Hollis AL, Lowery AV, Pajoumand M, Pham SM, Slejko JF, Tanaka KA, et al. Impact on postoperative bleeding and cost of recombinant activated factor VII in patients undergoing heart transplantation. Ann Card Anaesth. 2016;19(3):418-24.
[5] Christensen MC, Krapf S, Kempel A, von Heymann C. Costs of excessive postoperative hemorrhage in cardiac surgery. J Thoracic Cardiovasc Surg. 2009;138(3):687-93.
[6] Christensen MC, Dziewior F, Kempel A, Von Heymann C. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth. 2012;26(1):46-51.
[7] Levi M, Cromheecke ME, de Jonge E, Prins MH, de Mol BJ, Briët E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet. 1999;354(9194):1940-7.
[8] Mengoli C, Franchini M, Marano G, Pupella S, Vaglio S, Marietta M, et al. The use of fibrinogen concentrate for the management of trauma-related bleeding: a systematic review and meta-analysis. Blood Transfus. 2017;15(4):318.
[9] Li J-Y, Gong J, Zhu F, Moodie J, Newitt A, Uruthiramoorthy L, et al. Fibrinogen concentrate in cardiovascular surgery: a meta-analysis of randomized controlled trials. Anesth Analg. 2018;127(3):612-21.
[10] Solomon C, Cadamuro J, Ziegler B, Schöchl H, Varvenne M, Sørensen B, et al. A comparison of fibrinogen measurement methods with fibrin clot elasticity assessed by thromboelastometry, before and after administration of fibrinogen concentrate in cardiac surgery patients. Transfusion. 2011;51(8):1695-706.
[11] Görlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, Rahe-Meyer N, Tanaka KA. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth. 2013;27(4):S20-S34.
[12] Miceli A, Ranucci M, Glauber M. Fibrinogen concentrate as first-line hemostatic treatment for the management of bleeding in complex cardiac surgery. J Thorac Cardiovasc Surg. 2016;151(2):383-4.
[13] Grottke O, Mallaiah S, Karkouti K, Saner F, Haas T, editors. Fibrinogen supplementation and its indications. Semin thromb hemost. 2020: Thieme Medical Publishers.
[14] Gielen C, Dekkers O, Stijnen T, Schoones J, Brand A, Klautz R, et al. The effects of pre-and postoperative fibrinogen levels on blood loss after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2014;18(3):292-8.
[15] Waldén K, Jeppsson A, Nasic S, Backlund E, Karlsson M. Low preoperative fibrinogen plasma concentration is associated with excessive bleeding after cardiac operations. Ann Thorac Surg. 2014;97(4):1199-206.
[16] 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 Cardiac Surgery: Including Mechanical and Biological Support for the Heart and Lungs. 2014;29(2):189-95.
[17] Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. Eur J Anaesthesiol| EJA. 2017;34(6):332-95.
[18] Sucker C, Zotz RB. The cell-based coagulation model. Perioperative hemostasis: coagulation for anesthesiologists: Springer; 2014. p. 3-11.
[19] Kattula S, Byrnes JR, Wolberg AS. Fibrinogen and fibrin in hemostasis and thrombosis. Arterioscler Thromb Vasc Biol. 2017;37(3):e13-e21.
[20] Momeni M, Carlier C, Baele P, Watremez C, Van Dyck M, Matta A, et al. Fibrinogen concentration significantly decreases after on-pump versus off-pump coronary artery bypass surgery: a systematic point-of-care ROTEM analysis. J Cardiothorac Vasc Anesth. 2013;27(1):5-11.
[21] Erdoes G, Dietrich W, Stucki MP, Merz TM, Angelillo-Scherrer A, Nagler M, et al. Short-term recovery pattern of plasma fibrinogen after cardiac surgery: a prospective observational study. PLoS One. 2018;13(8):e0201647.
[22] Hanna JM, Keenan JE, Wang H, Andersen ND, Gaca JG, Lombard FW, et al. Use of human fibrinogen concentrate during proximal aortic reconstruction with deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg. 2016;151(2):376-82.
[23] Raspé C, Besch M, Charitos EI, Flöther L, Bucher M, Rückert F, et al. Rotational thromboelastometry for assessing bleeding complications and factor XIII deficiency in cardiac surgery patients. Clin Appl Thromb/Hemost. 2018;24(9_suppl):136S-44S.
[24] Ikić V. Fibrinogen and Bleeding in Adult Cardiac Surgery: A Review of the Literature. Surgeries. 2021;2:409-36.
[25] Tanaka K, Esper S, Bolliger D. Perioperative factor concentrate therapy. Br J Anaesth. 2013;111(suppl_1):i35-i49.
[26] Perelman I, Saidenberg E, Tinmouth A, Fergusson D. Trends and outcomes in multicomponent blood transfusion: an 11‐year cohort study of a large multisite academic center. Transfusion. 2019;59(6):1971-87.
[27] Ternström L, Hyllner M, Backlund E, Schersten H, Jeppsson A. A structured blood conservation programme reduces transfusions and costs in cardiac surgery. Interact cardiovasc thorac surg. 2014;19(5):788-94.
[28] Mazer CD, Whitlock RP, Fergusson DA, Belley-Cote E, Connolly K, Khanykin B, et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Engl J Med. 2018;379(13):1224-33.
[29] Stone GW, Clayton TC, Mehran R, Dangas G, Parise H, Fahy M, et al. Impact of major bleeding and blood transfusions after cardiac surgery: analysis from the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial. Am Heart J. 2012;163(3):522-9.
[30] Ranucci M, Baryshnikova E, Castelvecchio S, Pelissero G, Surgical, Group COR. Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery. Ann Thorac Surg. 2013;96(2):478-85.
[31] Vivacqua A, Koch CG, Yousuf AM, Nowicki ER, Houghtaling PL, Blackstone EH, Sabik III JF. Morbidity of bleeding after cardiac surgery: is it blood transfusion, reoperation for bleeding, or both? Ann Thorac Surg. 2011;91(6):1780-90.
[32] Essa Y, Zeynalov N, Sandhaus T, Hofmann M, Lehmann T, Doenst T. Low fibrinogen is associated with increased bleeding-related re-exploration after cardiac surgery. Thorac Cardiovasc Surg. 2018;66(08):622-8.
[33] Nishi T, Mutsuga M, Akita T, Narita Y, Fujimoto K, Tokuda Y, et al. The incidence and risk factors of hypofibrinogenemia in cardiovascular surgery. Gen Thorac Cardiovasc Surg. 2020; 68(4):335-341.
[34] Karlsson M, Ternström L, Hyllner M, Baghaei F, Nilsson S, Jeppsson A. Plasma fibrinogen level, bleeding, and transfusion after on‐pump coronary artery bypass grafting surgery: a prospective observational study. Transfusion. 2008;48(10):2152-8.
[35] Jahangirifard A, Ahmadi ZH, Naghashzadeh F, Sharif-Kashani B, Rashid-Farokhi F, Afshar A, et al. Prophylactic fibrinogen decreases postoperative bleeding but not acute kidney injury in patients undergoing heart transplantation. Clin Appl Thromb/Hemost. 2018;24(6):998-1004.
[2] Dyke C, Aronson S, Dietrich W, Hofmann A, Karkouti K, Levi M, et al. Universal definition of perioperative bleeding in adult cardiac surgery. J. Thorac. Cardiovasc. Surg. 2014;147(5):1458-63. e1.
[3] Menkis AH, Martin J, Cheng DC, Fitzgerald DC, Freedman JJ, Gao C, et al. Drug, devices, technologies, and techniques for blood management in minimally invasive and conventional cardiothoracic surgery a consensus statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011. Innovations. 2012;7(4):229-41.
[4] Hollis AL, Lowery AV, Pajoumand M, Pham SM, Slejko JF, Tanaka KA, et al. Impact on postoperative bleeding and cost of recombinant activated factor VII in patients undergoing heart transplantation. Ann Card Anaesth. 2016;19(3):418-24.
[5] Christensen MC, Krapf S, Kempel A, von Heymann C. Costs of excessive postoperative hemorrhage in cardiac surgery. J Thoracic Cardiovasc Surg. 2009;138(3):687-93.
[6] Christensen MC, Dziewior F, Kempel A, Von Heymann C. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth. 2012;26(1):46-51.
[7] Levi M, Cromheecke ME, de Jonge E, Prins MH, de Mol BJ, Briët E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet. 1999;354(9194):1940-7.
[8] Mengoli C, Franchini M, Marano G, Pupella S, Vaglio S, Marietta M, et al. The use of fibrinogen concentrate for the management of trauma-related bleeding: a systematic review and meta-analysis. Blood Transfus. 2017;15(4):318.
[9] Li J-Y, Gong J, Zhu F, Moodie J, Newitt A, Uruthiramoorthy L, et al. Fibrinogen concentrate in cardiovascular surgery: a meta-analysis of randomized controlled trials. Anesth Analg. 2018;127(3):612-21.
[10] Solomon C, Cadamuro J, Ziegler B, Schöchl H, Varvenne M, Sørensen B, et al. A comparison of fibrinogen measurement methods with fibrin clot elasticity assessed by thromboelastometry, before and after administration of fibrinogen concentrate in cardiac surgery patients. Transfusion. 2011;51(8):1695-706.
[11] Görlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, Rahe-Meyer N, Tanaka KA. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth. 2013;27(4):S20-S34.
[12] Miceli A, Ranucci M, Glauber M. Fibrinogen concentrate as first-line hemostatic treatment for the management of bleeding in complex cardiac surgery. J Thorac Cardiovasc Surg. 2016;151(2):383-4.
[13] Grottke O, Mallaiah S, Karkouti K, Saner F, Haas T, editors. Fibrinogen supplementation and its indications. Semin thromb hemost. 2020: Thieme Medical Publishers.
[14] Gielen C, Dekkers O, Stijnen T, Schoones J, Brand A, Klautz R, et al. The effects of pre-and postoperative fibrinogen levels on blood loss after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2014;18(3):292-8.
[15] Waldén K, Jeppsson A, Nasic S, Backlund E, Karlsson M. Low preoperative fibrinogen plasma concentration is associated with excessive bleeding after cardiac operations. Ann Thorac Surg. 2014;97(4):1199-206.
[16] 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 Cardiac Surgery: Including Mechanical and Biological Support for the Heart and Lungs. 2014;29(2):189-95.
[17] Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. Eur J Anaesthesiol| EJA. 2017;34(6):332-95.
[18] Sucker C, Zotz RB. The cell-based coagulation model. Perioperative hemostasis: coagulation for anesthesiologists: Springer; 2014. p. 3-11.
[19] Kattula S, Byrnes JR, Wolberg AS. Fibrinogen and fibrin in hemostasis and thrombosis. Arterioscler Thromb Vasc Biol. 2017;37(3):e13-e21.
[20] Momeni M, Carlier C, Baele P, Watremez C, Van Dyck M, Matta A, et al. Fibrinogen concentration significantly decreases after on-pump versus off-pump coronary artery bypass surgery: a systematic point-of-care ROTEM analysis. J Cardiothorac Vasc Anesth. 2013;27(1):5-11.
[21] Erdoes G, Dietrich W, Stucki MP, Merz TM, Angelillo-Scherrer A, Nagler M, et al. Short-term recovery pattern of plasma fibrinogen after cardiac surgery: a prospective observational study. PLoS One. 2018;13(8):e0201647.
[22] Hanna JM, Keenan JE, Wang H, Andersen ND, Gaca JG, Lombard FW, et al. Use of human fibrinogen concentrate during proximal aortic reconstruction with deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg. 2016;151(2):376-82.
[23] Raspé C, Besch M, Charitos EI, Flöther L, Bucher M, Rückert F, et al. Rotational thromboelastometry for assessing bleeding complications and factor XIII deficiency in cardiac surgery patients. Clin Appl Thromb/Hemost. 2018;24(9_suppl):136S-44S.
[24] Ikić V. Fibrinogen and Bleeding in Adult Cardiac Surgery: A Review of the Literature. Surgeries. 2021;2:409-36.
[25] Tanaka K, Esper S, Bolliger D. Perioperative factor concentrate therapy. Br J Anaesth. 2013;111(suppl_1):i35-i49.
[26] Perelman I, Saidenberg E, Tinmouth A, Fergusson D. Trends and outcomes in multicomponent blood transfusion: an 11‐year cohort study of a large multisite academic center. Transfusion. 2019;59(6):1971-87.
[27] Ternström L, Hyllner M, Backlund E, Schersten H, Jeppsson A. A structured blood conservation programme reduces transfusions and costs in cardiac surgery. Interact cardiovasc thorac surg. 2014;19(5):788-94.
[28] Mazer CD, Whitlock RP, Fergusson DA, Belley-Cote E, Connolly K, Khanykin B, et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Engl J Med. 2018;379(13):1224-33.
[29] Stone GW, Clayton TC, Mehran R, Dangas G, Parise H, Fahy M, et al. Impact of major bleeding and blood transfusions after cardiac surgery: analysis from the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial. Am Heart J. 2012;163(3):522-9.
[30] Ranucci M, Baryshnikova E, Castelvecchio S, Pelissero G, Surgical, Group COR. Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery. Ann Thorac Surg. 2013;96(2):478-85.
[31] Vivacqua A, Koch CG, Yousuf AM, Nowicki ER, Houghtaling PL, Blackstone EH, Sabik III JF. Morbidity of bleeding after cardiac surgery: is it blood transfusion, reoperation for bleeding, or both? Ann Thorac Surg. 2011;91(6):1780-90.
[32] Essa Y, Zeynalov N, Sandhaus T, Hofmann M, Lehmann T, Doenst T. Low fibrinogen is associated with increased bleeding-related re-exploration after cardiac surgery. Thorac Cardiovasc Surg. 2018;66(08):622-8.
[33] Nishi T, Mutsuga M, Akita T, Narita Y, Fujimoto K, Tokuda Y, et al. The incidence and risk factors of hypofibrinogenemia in cardiovascular surgery. Gen Thorac Cardiovasc Surg. 2020; 68(4):335-341.
[34] Karlsson M, Ternström L, Hyllner M, Baghaei F, Nilsson S, Jeppsson A. Plasma fibrinogen level, bleeding, and transfusion after on‐pump coronary artery bypass grafting surgery: a prospective observational study. Transfusion. 2008;48(10):2152-8.
[35] Jahangirifard A, Ahmadi ZH, Naghashzadeh F, Sharif-Kashani B, Rashid-Farokhi F, Afshar A, et al. Prophylactic fibrinogen decreases postoperative bleeding but not acute kidney injury in patients undergoing heart transplantation. Clin Appl Thromb/Hemost. 2018;24(6):998-1004.
| Files | ||
| Issue | Article in Press |
|
| Section | Research Article(s) | |
| Keywords | ||
| fibrinogen concentrate blood fibrinogen level coronary artery bypass graft surgery | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Ghavibonyeh K, Dabbagh A, Jahangiri Fard A, Baghaei R, Fani K, Shahrabi M, Fani M. Prophylactic Use of Fibrinogen Concentrate on Postoperative Blood Fibrinogen Levels, Amount of Bleeding, and the Need for Blood Transfusion in Normofibrinogenemic Patients Undergoing Coronary Artery Bypass Graft Surgery. Arch Anesth & Crit Care. 2025;.
