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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 1/2016

Open Access 01-12-2016 | Original research

Fibrinogen levels in trauma patients during the first seven days after fibrinogen concentrate therapy: a retrospective study

Authors: Christoph J. Schlimp, Martin Ponschab, Wolfgang Voelckel, Benjamin Treichl, Marc Maegele, Herbert Schöchl

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2016

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Abstract

Background

Fibrinogen concentrate (FC) is increasingly used as first line therapy in bleeding trauma patients. It remains unproven whether FC application increases post-traumatic plasma fibrinogen concentration (FIB) in injured patients, possibly constituting a prothrombotic risk. Thus, we investigated the evolution of FIB following trauma in patients with or without FC therapy.

Methods

At the AUVA Trauma Centre, Salzburg, we performed a retrospective study of patients admitted to the emergency room and whose FIB levels were documented thereafter up to day 7 post-trauma. Patients were categorized into those with (treatment group) or without (control group) FC therapy during the first 24 h after hospital admission. A subgroup analysis was carried out to investigate the influence of the amount of FC given.

Results

The study enrolled 435 patients: treatment group, n = 242 (56 %); control group, n = 193 (44 %), with median Injury Severity Score of 34 vs. 22 (P < 0.001) and massive transfusion rate of 18.4 % vs. 0.2 % (P < 0.001). In the treatment group (median FC dose 6 g), FIB was lower on admission and up to day 2 compared with the control group. In patients receiving high (≥10 g) doses of FC, FIB was lower up to day 5 as compared to controls. At other timepoints, FIB did not differ significantly between the groups. In the treatment vs. the control group, other coagulation parameters such as prothrombin time index and platelet count were consistently lower, while activated partial thromboplastin time was consistently prolonged at most timepoints. Inflammatory parameters such as C-reactive protein, interleukin-6 and procalcitonin were generally lower in controls.

Discussion

The rise of FIB levels from day 2 onwards in our study can be attributed to an upregulated fibrinogen synthesis in the liver, occurring in both study groups as part of the acute phase response after tissue injury.

Conclusions

The treatment of severe trauma patients with FC during bleeding management in the first 24 h after hospital admission does not lead to higher FIB levels post-trauma beyond that occurring naturally due to the acute phase response.
Literature
1.
Schlimp CJ, Schochl H. The role of fibrinogen in trauma-induced coagulopathy. Hamostaseologie. 2014;34:29–39.CrossRefPubMed
2.
Schlimp CJ, Voelckel W, Inaba K, Maegele M, Ponschab M, Schöchl H. Estimation of plasma fibrinogen levels based on hemoglobin, base excess and ISS upon emergency room admission. Crit Care. 2013;17:R137.CrossRefPubMedPubMedCentral
3.
Rourke C, Curry N, Khan S, Taylor R, Raza I, Davenport R, et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost. 2012;10:1342–51.CrossRefPubMed
4.
Hiippala ST, Myllyla GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg. 1995;81:360–5.PubMed
5.
Schöchl H, Cotton B, Inaba K, Nienaber U, Fischer H, Voelckel W, et al. FIBTEM provides early prediction of massive transfusion in trauma. Crit Care. 2011;15:R265.CrossRefPubMedPubMedCentral
6.
Tauber H, Innerhofer P, Breitkopf R, Westermann I, Beer R, El Attal R, et al. Prevalence and impact of abnormal ROTEM (R) assays in severe blunt trauma: results of the ‘Diagnosis and Treatment of Trauma-Induced Coagulopathy (DIA-TRE-TIC) study’. Br J Anaesth. 2011;107:378–87.CrossRefPubMed
7.
Karlsson M, Ternstrom L, Hyllner M, Baghaei F, Flinck A, Skrtic S, et al. Prophylactic fibrinogen infusion reduces bleeding after coronary artery bypass surgery. A prospective randomised pilot study. Thromb Haemost. 2009;102:137–44.PubMed
8.
Rahe-Meyer N, Hanke A, Schmidt DS, Hagl C, Pichlmaier M. Fibrinogen concentrate reduces intraoperative bleeding when used as first-line hemostatic therapy during major aortic replacement surgery: results from a randomized, placebo-controlled trial. J Thorac Cardiovasc Surg. 2013;145:S178–85.CrossRefPubMed
9.
Charbit B, Mandelbrot L, Samain E, Baron G, Haddaoui B, Keita H, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5:266–73.CrossRefPubMed
10.
Chambers LA, Chow SJ, Shaffer LE. Frequency and characteristics of coagulopathy in trauma patients treated with a low-or high-plasma-content massive transfusion protocol. Am J Clin Pathol. 2011;136:364–70.CrossRefPubMed
11.
Inaba K, Karamanos E, Lustenberger T, Schochl H, Shulman I, Nelson J, et al. Impact of fibrinogen levels on outcomes after acute injury in patients requiring a massive transfusion. J Am Coll Surg. 2013;216:290–7.CrossRefPubMed
12.
Danes AF, Cuenca LG, Bueno SR, Mendarte Barrenechea L, Ronsano JB. Efficacy and tolerability of human fibrinogen concentrate administration to patients with acquired fibrinogen deficiency and active or in high-risk severe bleeding. Vox Sang. 2008;94:221–6.CrossRefPubMed
13.
Stinger HK, Spinella PC, Perkins JG, Grathwohl KW, Salinas J, Martini WZ, et al. The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital. J Trauma. 2008;64:S79–85.CrossRefPubMed
14.
Schöchl H, Forster L, Woidke R, Solomon C, Voelckel W. Use of rotation thromboelastometry (ROTEM) to achieve successful treatment of polytrauma with fibrinogen concentrate and prothrombin complex concentrate. Anaesthesia. 2010;65:199–203.CrossRefPubMed
15.
Schöchl H, Nienaber U, Maegele M, Hochleitner G, Primavesi F, Steitz B, et al. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care. 2011;15:R83.CrossRefPubMedPubMedCentral
16.
Ziegler B, Schimke C, Marchet P, Stogermuller B, Schochl H, Solomon C. Severe pediatric blunt trauma--successful ROTEM-guided hemostatic therapy with fibrinogen concentrate and no administration of fresh frozen plasma or platelets. Clin Appl Thromb Hemost. 2013;19:453–9.CrossRefPubMed
17.
Kozek-Langenecker SA, Afshari A, Albaladejo P, Santullano CA, De Robertis E, Filipescu DC, et al. Management of severe perioperative bleeding: Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013;30:270–382.CrossRefPubMed
18.
Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17:R76.CrossRefPubMedPubMedCentral
19.
Schöchl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care. 2010;14:R55.CrossRefPubMedPubMedCentral
20.
Innerhofer P, Westermann I, Tauber H, Breitkopf R, Fries D, Kastenberger T, et al. The exclusive use of coagulation factor concentrates enables reversal of coagulopathy and decreases transfusion rates in patients with major blunt trauma. Injury. 2013;44:209–16.CrossRefPubMed
21.
Theusinger OM, Madjdpour C, Spahn DR. Resuscitation and transfusion management in trauma patients: emerging concepts. Curr Opin Crit Care. 2012;18:661–70.CrossRefPubMed
22.
van Hylckama VA, Rosendaal FR. High levels of fibrinogen are associated with the risk of deep venous thrombosis mainly in the elderly. J Thromb Haemost. 2003;1:2677–8.CrossRef
23.
Solomon C, Hagl C, Rahe-Meyer N. Time course of haemostatic effects of fibrinogen concentrate administration in aortic surgery. Br J Anaesth. 2013;110:947–56.CrossRefPubMedPubMedCentral
24.
Schlimp CJ, Voelckel W, Inaba K, Maegele M, Schochl H. 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. Scand J Trauma Resusc Emerg Med. 2013;21:74.CrossRefPubMedPubMedCentral
25.
Schochl H, Voelckel W, Maegele M, Kirchmair L, Schlimp CJ. Endogenous thrombin potential following hemostatic therapy with 4-factor prothrombin complex concentrate: a 7-day observational study of trauma patients. Crit Care. 2014;18:R147.CrossRefPubMedPubMedCentral
26.
Schochl H, Voelckel W, Grassetto A, Schlimp CJ. Practical application of point-of-care coagulation testing to guide treatment decisions in trauma. J Trauma Acute Care Surg. 2013;74:1587–98.CrossRefPubMed
27.
Curry N, Rourke C, Davenport R, Beer S, Pankhurst L, Deary A, et al. Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial. Br J Anaesth. 2015;115:76–83.CrossRefPubMed
28.
Zentai C, Braunschweig T, Schnabel J, Rose M, Rossaint R, Grottke O. Fibrinogen concentrate does not suppress endogenous fibrinogen synthesis in a 24-h porcine trauma model. Anesthesiology. 2014;121:753–64.CrossRefPubMed
29.
30.
Görlinger K, Dirkmann D, Hanke AA, Kamler M, Kottenberg E, Thielmann M, et al. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion in cardiovascular surgery: a retrospective, single-center cohort study. Anesthesiology. 2011;115:1179–91.PubMed
31.
Schaden E, Kimberger O, Kraincuk P, Baron DM, Metnitz PG, Kozek-Langenecker S. Perioperative treatment algorithm for bleeding burn patients reduces allogeneic blood product requirements. Br J Anaesth. 2012;109:376–81.CrossRefPubMed
32.
Rahe-Meyer N, Solomon C, Hanke A, Schmidt DS, Knoerzer D, Hochleitner G, et al. Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial. Anesthesiology. 2013;118:40–50.CrossRefPubMed
33.
Weber CF, Gorlinger K, Meininger D, Herrmann E, Bingold T, Moritz A, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology. 2012;117:531–47.CrossRefPubMed
34.
Martini J, Maisch S, Pilshofer L, Streif W, Martini W, Fries D. Fibrinogen concentrate in dilutional coagulopathy: a dose study in pigs. Transfusion. 2014;54:149–57.CrossRefPubMed
35.
Grottke O, Braunschweig T, Henzler D, Coburn M, Tolba R, Rossaint R. Effects of different fibrinogen concentrations on blood loss and coagulation parameters in a pig model of coagulopathy with blunt liver injury. Crit Care. 2010;14:R62.CrossRefPubMedPubMedCentral
36.
Fries D, Haas T, Klingler A, Streif W, Klima G, Martini J, et al. Efficacy of fibrinogen and prothrombin complex concentrate used to reverse dilutional coagulopathy--a porcine model. Br J Anaesth. 2006;97:460–7.CrossRefPubMed
37.
Solomon C, Groner A, Ye J, Pendrak I. Safety of fibrinogen concentrate: analysis of more than 27 years of pharmacovigilance data. Thromb Haemost. 2015;113:759–71.CrossRefPubMed
38.
Zentai C, Solomon C, Meijden PE, Spronk HM, Schnabel J, Rossaint R, et al. Effects of fibrinogen concentrate on thrombin generation, thromboelastometry parameters, and laboratory coagulation testing in a 24-h porcine trauma model. Clin Appl Thromb Hemost. 2015.
39.
Mosesson MW. Update on antithrombin I (fibrin). Thromb Haemost. 2007;98:105–8.PubMed
40.
Stansbury LG, Hess AS, Thompson K, Kramer B, Scalea TM, Hess JR. The clinical significance of platelet counts in the first 24 h after severe injury. Transfusion. 2013;53:783–9.CrossRefPubMed
41.
Giannoudis PV, Smith MR, Evans RT, Bellamy MC, Guillou PJ. Serum CRP and IL-6 levels after trauma. Not predictive of septic complications in 31 patients. Acta Orthop Scand. 1998;69:184–8.CrossRefPubMed
42.
Meisner M, Adina H, Schmidt J. Correlation of procalcitonin and C-reactive protein to inflammation, complications, and outcome during the intensive care unit course of multiple-trauma patients. Crit Care. 2006;10:R1.CrossRefPubMedPubMedCentral
43.
Fenger-Eriksen C, Jensen TM, Kristensen BS, Jensen KM, Tonnesen E, Ingerslev J, et al. Fibrinogen substitution improves whole blood clot firmness after dilution with hydroxyethyl starch in bleeding patients undergoing radical cystectomy: a randomized, placebo-controlled clinical trial. J Thromb Haemost. 2009;7:795–802.CrossRefPubMed
44.
45.
Grottke O, Rossaint R, Henskens Y, van Oerle R, Ten Cate H, Spronk HM. Thrombin generation capacity of prothrombin complex concentrate in an in vitro dilutional model. PLoS One. 2013;8, e64100.CrossRefPubMedPubMedCentral
Metadata
Title
Fibrinogen levels in trauma patients during the first seven days after fibrinogen concentrate therapy: a retrospective study
Authors
Christoph J. Schlimp
Martin Ponschab
Wolfgang Voelckel
Benjamin Treichl
Marc Maegele
Herbert Schöchl
Publication date
01-12-2016
Publisher
BioMed Central
DOI
https://doi.org/10.1186/s13049-016-0221-8

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