Impact of fibrinogen concentrate alone or with prothrombin complex concentrate (+/− fresh frozen plasma) on plasma fibrinogen level and fibrin-based clot strength (FIBTEM) in major trauma: a retrospective study

Christoph J Schlimp,Herbert Schöchl,Marc Maegele,Wolfgang Voelckel,Kenji Inaba

doi:10.1186/1757-7241-21-74

Abstract

BackgroundLow plasma fibrinogen concentration is a predictor of poor outcome in major trauma patients. The role of fibrinogen concentrate for rapidly increasing fibrinogen plasma levels in severe trauma is not well defined.MethodsIn this retrospective study we included severe trauma patients treated with fibrinogen concentrate alone (FC group), fibrinogen concentrate with prothrombin complex concentrate (FC–PCC group) or fibrinogen concentrate with PCC and fresh frozen plasma (FC–PCC–FFP group). PCC was generally administered as the second step of intraoperative therapy, while FFP was only administered as a third step. All patients received ≥1 g fibrinogen concentrate within 24 hours. Plasma fibrinogen concentration and ROTEM parameters upon emergency room (ER) admission, intensive care unit (ICU) admission, and after 24 hours were analysed.ResultsAmong 157 patients fulfilling the inclusion criteria, 83% were male; mean age was 44 years and median injury severity score (ISS) was 29. Standard coagulation tests reflected increasing severity of coagulopathy with increasing complexity of haemostatic therapy (highest severity in the FC–PCC–FFP group; p < 0.0001). Total 24-hour fibrinogen concentrate dose also increased with complexity of haemostatic therapy. Plasma fibrinogen concentration was maintained, with no significant difference between ER admission and ICU admission in all patient groups. FIBTEM clot firmness at 10 minutes (CA10) was similarly maintained, albeit with a small increase in the FC–PCC group. Fibrinogen concentration and FIBTEM CA10 were within the normal range in all groups at 24 hours. The ratio of fibrinogen concentrate to red blood cells (g:U) ranged between 0.7:1.0 and 1.0:1.0.ConclusionFibrinogen concentrate therapy maintained fibrinogen concentration and FIBTEM CA10 during the initial phase of trauma care until ICU admission. After 24 hours, these parameters were comparable between the three groups and within the normal range for each of them. Further studies are warranted to investigate the effect of fibrinogen concentrate on clinical outcomes.

Highlights

Low plasma fibrinogen concentration is a predictor of poor outcome in major trauma patients
We retrospectively investigated major trauma patients presenting at the AUVA Trauma Centre, Salzburg who were treated with fibrinogen concentrate as first-line coagulation therapy
Patients are usually treated with a ROTEM guided algorithm, receiving fibrinogen concentrate and prothrombin complex concentrate (PCC) according to their actual needs

Summary

Introduction

Low plasma fibrinogen concentration is a predictor of poor outcome in major trauma patients. The role of fibrinogen concentrate for rapidly increasing fibrinogen plasma levels in severe trauma is not well defined. Recent data from military and civilian trauma centres revealed that early and high-volume fresh frozen plasma (FFP) transfusion is associated with a favourable survival rate [4,5]. Fibrinogen supplementation may compensate for dilutional coagulopathy or impaired haemostasis due to thrombocytopenia [8,9] Low plasma fibrinogen concentration is common among major trauma patients and associated with poor clinical outcomes [10,11,12,13]. Cryoprecipitate and purified human fibrinogen concentrate represent potential alternatives to plasma for maintaining or increasing the patient’s fibrinogen level, subject to these products’ availability. Several retrospective studies and case series have reported improved outcomes using fibrinogen concentrate in trauma [20,21,22,23,24,25,26]

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Conclusion