Impact of Low Fibrinogen Levels in the Puzzle of Traumainduced Coagulopathy: Is This the Missing Link?

Abstract

ABSTRACT Background Patients with severe tissue injury and tissue hypoperfusion can present with low fibrinogen levels and signs of hyperfibrinolysis. The role of damage control resuscitation (DCR) in addressing the hyperfibrinolytic aspect of trauma induced coagulopathy (TIC) is unknown. We hypothesize a survival advantage when DCR is used in TIC patients with severe tissue injury and low fibrinogen levels. Materials and methods This is a 2 years prospective observational study of TIC patients who received DCR. TIC was defined as initial base deficit = –6 in combination with ISS = 12. Low fibrinogen was considered when serum level <200 mg/dl. Patients were stratified into those with an injury severity score (ISS) <20, and those with an ISS = 20. Variables analyzed between groups included: initial serum fibrinogen, INR, base deficit, intraoperative FFP: PRBC ratio and mortality. Results Of 67 patients with TIC, 29 (43.2%) had ISS < 20, and 38 (56.7%) an ISS ≥ 20. Mean ISS was 13.9 vs 32.8 (p < 0.0001) for the ISS < 20 group vs the ISS ≥ 20 group respectively. Mean initial fibrinogen levels for the ISS < 20 group vs the ISS ≥ 20 group was 357.4 mg/dl vs 148.5 mg/dl (p = 0.0007). Intraoperative DCR with FFP: PRBC for the ISS < 20 group vs the ISS ≥ 20 group showed no statistical difference: 1 to 1.12 vs 1 to 1.3 (p = 0.12). Overall mortality after controlling for DCR in the ISS < 20 group was 29 and 73% in the ISS ≥ 20 group (p = 0.0007). In a stepwise logistic regression, low fibrinogen levels was associated with mortality, p = 0.01; OR 1.01 (1.23-11.55) with area under the receiver operating characteristic curve of 0.701. The correlation coefficient for ISS vs initial fibrinogen level was –0.5635 (p = 0.0001). Conclusion Overall mortality was significantly increased in patients who had an ISS . 20 with low fibrinogen level despite effective DCR. Given the correlated decrease in fibrinogen levels in patients with severe tissue injury, further investigation regarding potential benefits of antifibrinolytic agents in DCR needs further validation. How to cite this article Duchesne JC, Guidry C, Park TS, Simms E, Hoffman JRH, Bock JM, Wascom J, Barbeau J, Meade P, McSwain NE Jr. Impact of Low Fibrinogen Levels in the Puzzle of Trauma-induced Coagulopathy: Is This the Missing Link? Panam J Trauma Critical Care Emerg Surg 2013;2(2): 74-79.