Prophylactic fibrinogen infusion reduces bleeding after coronary artery bypass surgery - A prospective randomised pilot study
Martin Karlsson 1; Lisa Ternström 1; Monica Hyllner 2; Fariba Baghaei 3; Agneta Flinck 4; Stanko Skrtic 5; Anders Jeppsson1
1 Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; 2 Department of Cardiothoracic Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden; 3 Department of Medicine/Haematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden; 4 Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden; 5 Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden
cardiac surgery, bleeding, fibrinogen
It has been suggested that preoperative fibrinogen plasma concentration is independently associated to postoperative blood loss after cardiac surgery. Theoretically, prophylactic infusion of fibrinogen concentrate may thus reduce postoperative bleeding, but this has not previously been investigated. Twenty elective coronary artery bypass graft (CABG) patients with preoperative plasma fibrinogen levels <3.8 g/l were included in a prospective randomised pilot study. Patients were randomised to receive an infusion of 2 g fibrinogen concentrate (FIB group) or no infusion before surgery (control group). Primary endpoint was safety with clinical adverse events and graft occlusion assessed by multi-slice computed tomography. Predefined secondary endpoints were postoperative blood loss, blood transfusions, haemoglobin levels 24 hours (h) after surgery, and global haemostasis assessed with thromboelastometry, 2 and 24 hours after surgery. Infusion of 2 g fibrinogen concentrate increased plasma levels of fibrinogen by 0.6 ± 0.2 g/l. There were no clinically detectable adverse events of fibrinogen infusion. Computed tomography revealed one subclinical vein graft occlusion in the FIB group. Fibrinogen concentrate infusion reduced postoperative blood loss by 32% (565 ± 150 vs. 830 ± 268 ml/12 h, p=0.010). Haemoglobin concentration was significantly higher 24 h after surgery in the FIB group (110 ± 12 vs. 98 ± 8 g/l, p=0.018). Prophylactic fibrinogen concentrate infusion did not influence global postoperative haemostasis as assessed by thromboelastometry. In conclusion, in this pilot study preoperative fibrinogen concentrate infusion reduced bleeding after CABG without evidence of postoperative hypercoagulability. Larger studies are necessary to ensure safety and confirm efficacy of prophylactic fibrinogen treatment in cardiac surgery.