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Higher fibrinogen concentrations for reduction of transfusion requirements during major paediatric surgery: A
T Haas1, N Spielmann2, T Restin3
1Department of Anaesthesia, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland thorsten.haas@kispi.uzh.ch.
Insights
Prophylactic fibrinogen concentrate administration significantly reduced red blood cell (RBC) transfusions in pediatric craniosynostosis surgery by targeting higher fibrinogen levels. This early substitution strategy effectively decreased blood loss and transfusion needs.
Area of Science:
- Anesthesiology
- Pediatric Surgery
- Hematology
Background:
- Perioperative coagulopathy in pediatric surgery is often linked to hypofibrinogenemia.
- Fibrinogen concentrate administration aims to maintain adequate fibrinogen levels.
- This study investigates the impact of early fibrinogen substitution on transfusion requirements.
Purpose of the Study:
- To evaluate if maintaining higher intraoperative fibrinogen concentrations reduces red blood cell (RBC) transfusion volumes.
- To assess the efficacy of prophylactic fibrinogen concentrate administration in pediatric patients undergoing major surgery.
Main Methods:
- A prospective, randomized clinical trial involving pediatric patients (6 months–17 years) undergoing craniosynostosis and scoliosis surgery.
- Patients received fibrinogen concentrate based on two trigger levels: ROTEM FIBTEM maximum clot firmness (MCF) <8 mm (conventional) or <13 mm (early substitution).
- The primary outcome measured was the total volume of RBCs transfused within 24 hours post-surgery.
Main Results:
- In craniosynostosis surgery, the early substitution group (<13 mm MCF) received significantly fewer RBCs (median 28 ml/kg) compared to the conventional group (<8 mm MCF; median 56 ml/kg).
- Calculated blood loss decreased significantly in the early substitution group for craniosynostosis surgery (median 90% of estimated total blood volume vs. 160%).
- No significant differences in RBC transfusion volumes or blood loss were observed in the scoliosis surgery population. No adverse events were reported.
Conclusions:
- Intraoperative fibrinogen concentrate administration targeting a FIBTEM MCF of <13 mm effectively reduces bleeding and transfusion requirements in craniosynostosis surgery.
- The early substitution strategy did not show significant benefits in scoliosis surgery patients.
- Prophylactic fibrinogen concentrate is a safe and effective method to manage coagulopathy and reduce transfusions in specific pediatric surgical settings.
Background:
Hypofibrinogenaemia is one of the main reasons for development of perioperative coagulopathy during major paediatric surgery. The aim of this study was to assess whether prophylactic maintenance of higher fibrinogen concentrations through administration of fibrinogen concentrate would decrease the volume of transfused red blood cell (RBCs).
Methods:
In this prospective, randomised, clinical trial, patients aged 6 months to 17 yr undergoing craniosynostosis and scoliosis surgery received fibrinogen concentrate (30 mg kg(-1)) at two predefined intraoperative fibrinogen concentrations [ROTEM(®) FIBTEM maximum clot firmness (MCF) of <8 mm (conventional) or <13 mm (early substitution)]. Total volume of transfused RBCs was recorded over 24 h after start of surgery.
Results:
Thirty children who underwent craniosynostosis surgery and 19 children who underwent scoliosis surgery were treated per protocol. During craniosynostosis surgery, children in the early substitution group received significantly less RBCs (median, 28 ml kg(-1); IQR, 21 to 50 ml kg(-1)) compared with the conventional fibrinogen trigger of <8 mm (median, 56 ml kg(-1); IQR, 28 to 62 ml kg(-1)) (P=0.03). Calculated blood loss as per cent of estimated total blood volume decreased from a median of 160% (IQR, 110-190%) to a median of 90% (IQR, 78-110%) (P=0.017). No significant changes were observed in the scoliosis surgery population. No bleeding events requiring surgical intervention, postoperative transfusions of RBCs, or treatment-related adverse events were observed.
Conclusions:
Intraoperative administration of fibrinogen concentrate using a FIBTEM MCF trigger level of <13 mm can be successfully used to significantly decrease bleeding, and transfusion requirements in the setting of craniosynostosis surgery, but not scoliosis.
Clinical Trial Registry Number:
ClinicalTrials.gov NCT01487837.
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