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Published on: November 28, 2018
U-shaped relationship between pre-operative plasma fibrinogen levels and severe peri-operative bleeding in cardiac
Stefano Mion1, Benoît Duval, Thibaut Besnard
1From the Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, CHU Bordeaux (SM, BDu, TB, AR, AO), INSERM, UMR 1034, Biology of Cardiovascular Diseases, University Bordeaux, Bordeaux (SM, BDu, TB, AO), Monitoring Force Group, Maisons-Laffitte (BDa), Biological Haematology Department (CM), Department of Technical Engineering, CHU Bordeaux (OJ), Department of Cardiovascular Surgery, CHU Bordeaux, Bordeaux, France (LL) and Department of Anesthesia, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada (CZ).
Background:
An inverse linear relationship has been reported between pre-operative fibrinogen levels and postoperative blood loss in cardiac surgery. However, recently high pre-operative fibrinogen levels have also been reported to be associated with increased blood transfusion and re-operation.
Objective:
We tested the hypothesis that the relationship between pre-operative fibrinogen levels and severe peri-operative bleeding is not linear.
Design:
A large-scale (n = 3883) single-centre retrospective study.
Setting:
A tertiary care teaching hospital.
Patients:
We analysed data from our institutional database which includes all patients above 18 years who underwent on-pump cardiac surgery through a sternotomy between September 2010 and May 2014.
Main Outcome Measures:
Peri-operative severe bleeding adapted from the Universal Definition of Peri-operative Bleeding, class 3 or 4. The relationship between pre-operative fibrinogen levels and peri-operative severe bleeding was analysed by binary logistic regression. A cubic B-spline transformation was used to estimate the relationship between pre-operative fibrinogen level associated with excessive peri-operative bleeding.
Results:
Severe peri-operative bleeding was observed in 957 (24.6%) patients. An L-shaped relationship was observed between pre-operative fibrinogen levels and 24-h postoperative blood loss. The relationship between pre-operative fibrinogen levels and severe peri-operative bleeding (i.e. Universal Definition of Peri-operative Bleeding class 3 or 4) was U-shaped: the risk of severe peri-operative bleeding bottomed at 3.3 g l when the upward sloping curve started at 5.8 g l with a steeper increase above 8.2 g l.
Conclusion:
We reported a U-shaped relationship between severe peri-operative bleeding and pre-operative fibrinogen levels. While a low-level of fibrinogen appears to be associated with a high risk of bleeding, a high level does not necessarily protect the patient against such a risk and could even be a risk factor for peri-operative bleeding.
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