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Published on: June 4, 2020
Fibrinogen and Prothrombin Complex Concentrate: The Importance of the Temporal Sequence-A Post-Hoc Analysis of Two
Marco Ranucci1, Tommaso Aloisio1, Umberto Di Dedda1
1Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico, Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy.
Insights
Fibrinogen (FC) supplementation after cardiac surgery significantly reduces coagulation time (CT) in EXTEM tests. This suggests prioritizing FC normalization before administering prothrombin complex concentrate (PCC) to manage bleeding risks.
Area of Science:
- Coagulation science
- Cardiovascular surgery
- Hemorrhage management
Background:
- Low soluble coagulation factors post-cardiac surgery can lead to bleeding, often treated with prothrombin complex concentrate (PCC).
- Current guidelines lack defined triggers for PCC administration, with ROTEM® EXTEM CT values varying widely in published algorithms.
- Fibrinogen (FC) supplementation has been observed to decrease EXTEM CT in cardiac surgery patients.
Purpose of the Study:
- To investigate if increasing fibrinogen availability accelerates thrombin generation and fibrin network formation.
- To determine if normalizing fibrinogen levels should be prioritized before considering PCC administration.
- To evaluate the impact of FC supplementation on EXTEM CT in cardiac surgery patients.
Main Methods:
- Retrospective analysis of data from two previous randomized controlled trials (RCTs).
- Inclusion of 85 patients who received FC supplementation post-cardiac surgery.
- Post-hoc analysis of FIBTEM maximum clot firmness (MCF) and EXTEM CT values before and after FC supplementation.
Main Results:
- A significant negative association was found between FIBTEM MCF and EXTEM CT.
- FC supplementation decreased EXTEM CT in patients with both low and normal FIBTEM MCF.
- Post-FC supplementation, 53% of patients had EXTEM CT >80s, 26% >90s, and 9% >100s.
Conclusions:
- FC supplementation effectively reduces EXTEM CT, confirming its impact on coagulation.
- A stepwise approach prioritizing FC normalization before PCC administration may reduce the need for PCC.
- This strategy supports optimizing fibrinogen levels to manage post-cardiac surgery bleeding.
Abstract:
Background/Objectives: A low level of soluble coagulation factors after cardiac surgery may cause excessive bleeding and trigger clinical correction using prothrombin complex concentrate (PCC). According to the current guidelines, the trigger values for PCC administration are not defined. In the published algorithms, when driven by ROTEM®, the triggers vary from 80 s to >100 s of coagulation time (CT) during an EXTEM test. Two randomized controlled trials on fibrinogen (FC) supplementation after cardiac surgery previously pointed out that the patients receiving FC supplementation had a significant decrease in their EXTEM CT. This study investigates the hypothesis that after increasing the availability of a substrate (fibrinogen), thrombin generation induces fibrin network formation faster, and that, before considering PCC administration, the normalization of fibrinogen levels should be sought. Methods: A retrospective study based on a post-hoc analysis of the data collected in two previous RCTs involving 85 patients, all of whom received FC supplementation. Results: The results of this post-hoc analysis demonstrate that there is a significant negative association between FIBTEM maximum clot firmness (MCF) and the EXTEM CTs before and after FC supplementation; FC supplementation decreases the EXTEM CTs both in patients with a low FIBTEM MCF and a normal FIBTEM MCF. After FC supplementation, 45 (53%) of the patients had an EXTEM CT of >80 s, 22 (26%) had an EXTEM CT of >90 s, and 8 (9%) had an EXTEM CT of >100 s. Conclusions: Our study confirms and quantifies the effects of reducing EXTEM CTs through FC supplementation. A stepwise strategy of factors correction with FC supplementation should be used before considering PCC administration as it might reduce the need for PCC.
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