Abstract
BackgroundAfter cardiac surgery with cardiopulmonary bypass (CPB), acquired coagulopathy often leads to post-CPB bleeding. Though multifactorial in origin, this coagulopathy is often aggravated by deficient fibrinogen levels.ObjectiveTo assess whether laboratory and thrombelastometric testing on CPB can predict plasma fibrinogen immediately after CPB weaning.Patients / MethodsThis prospective study in 110 patients undergoing major cardiovascular surgery at risk of post-CPB bleeding compares fibrinogen level (Clauss method) and function (fibrin-specific thrombelastometry) in order to study the predictability of their course early after termination of CPB. Linear regression analysis and receiver operating characteristics were used to determine correlations and predictive accuracy.ResultsQuantitative estimation of post-CPB Clauss fibrinogen from on-CPB fibrinogen was feasible with small bias (+0.19 g/l), but with poor precision and a percentage of error >30%. A clinically useful alternative approach was developed by using on-CPB A10 to predict a Clauss fibrinogen range of interest instead of a discrete level. An on-CPB A10 ≤10 mm identified patients with a post-CPB Clauss fibrinogen of ≤1.5 g/l with a sensitivity of 0.99 and a positive predictive value of 0.60; it also identified those without a post-CPB Clauss fibrinogen <2.0 g/l with a specificity of 0.83.ConclusionsWhen measured on CPB prior to weaning, a FIBTEM A10 ≤10 mm is an early alert for post-CPB fibrinogen levels below or within the substitution range (1.5–2.0 g/l) recommended in case of post-CPB coagulopathic bleeding. This helps to minimize the delay to data-based hemostatic management after weaning from CPB.
Highlights
A clinically useful alternative approach was developed by using on-cardiopulmonary bypass (CPB) at 10 min (A10) to predict a Clauss fibrinogen range of interest instead of a discrete level
An on-CPB A10 10 mm identified patients with a post-CPB Clauss fibrinogen of 1.5 g/l with a sensitivity of 0.99 and a positive predictive value of 0.60; it identified those without a post-CPB Clauss fibrinogen
When measured on CPB prior to weaning, a FIBTEM A10 10 mm is an early alert for postCPB fibrinogen levels below or within the substitution range (1.5–2.0 g/l) recommended in case of post-CPB coagulopathic bleeding
Summary
Platelet aggregation and hemostatic clot formation are strongly associated with the presence of fibrinogen, a soluble glycoprotein upregulated in a variety of inflammatory conditions.[1,2,3] Recently, fibrinogen gained renewed clinical interest after a number of studies demonstrated the inverse relationship between fibrinogen levels, perioperative blood loss and exposure to allogeneic blood transfusion.[1,2,3,4,5,6,7,8,9] In cardiac surgery with cardiopulmonary bypass (CPB), major post-CPB bleeding is not infrequent since CPB-associated conditions (e.g., hemodilution, hypothermia, platelet dysfunction and fibrinolysis) impair fibrinogen levels, function and clot stability This multifactorial acquired coagulopathy increases bleeding, allogeneic blood product exposure, morbidity and mortality.[5,10,11,12,13,14,15] Current European guidelines recommend fibrinogen substitution as a first-line therapy in case of significant bleeding accompanied by low levels of plasma fibrinogen.[16,17]. This coagulopathy is often aggravated by deficient fibrinogen levels
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