Estimation of plasma fibrinogen levels based on hemoglobin, base excess and Injury Severity Score upon emergency room admission

Abstract

IntroductionFibrinogen plays a key role in hemostasis and is the first coagulation factor to reach critical levels in massively bleeding trauma patients. Consequently, rapid estimation of plasma fibrinogen (FIB) is essential upon emergency room (ER) admission, but is not part of routine coagulation monitoring in many centers. We investigated the predictive ability of the laboratory parameters hemoglobin (Hb) and base excess (BE) upon admission, as well as the Injury Severity Score (ISS), to estimate FIB in major trauma patients.MethodsIn this retrospective study, major trauma patients (ISS ≥16) with documented FIB analysis upon ER admission were eligible for inclusion. FIB was correlated with Hb, BE and ISS, alone and in combination, using regression analysis.ResultsA total of 675 patients were enrolled (median ISS 27). FIB upon admission correlated strongly with Hb, BE and ISS. Multiple regression analysis showed that Hb and BE together predicted FIB (adjusted R2 = 0.46; loge(FIB) = 3.567 + 0.223.Hb - 0.007.Hb2 + 0.044.BE), and predictive strength increased when ISS was included (adjusted R2 = 0.51; loge(FIB) = 4.188 + 0.243.Hb - 0.008.Hb2 + 0.036.BE - 0.031.ISS + 0.0003.ISS2). Of all major trauma patients admitted with Hb <12 g/dL, 74% had low (<200 mg/dL) FIB and 54% had critical (<150 mg/dL) FIB. Of patients admitted with Hb <10 g/dL, 89% had low FIB and 73% had critical FIB. These values increased to 93% and 89%, respectively, among patients with an admission Hb <8 g/dL. Sixty-six percent of patients with only a weakly negative BE (<−2 mmol/L) showed low FIB. Of patients with BE <−6 mmol/L upon admission, 81% had low FIB and 63% had critical FIB. The corresponding values for BE <−10 mmol/L were 89% and 78%, respectively.ConclusionsUpon ER admission, FIB of major trauma patients shows strong correlation with rapidly obtainable, routine laboratory parameters such as Hb and BE. These two parameters might provide an insightful and rapid tool to identify major trauma patients at risk of acquired hypofibrinogenemia. Early calculation of ISS could further increase the ability to predict FIB in these patients. We propose that FIB can be estimated during the initial phase of trauma care based on bedside tests.

How I use fibrinogen replacement therapy in acquired bleeding

“…69 Fibrinogen repletion is increasingly used as hemostatic treatment of trauma-induced coagulopathy, especially with concentrates.…”

Trauma Induced Coagulopathy

“…In Rourke's study, coagulopathic patients had 33 % reduction in fibrinogen levels and 58 % reduction when defining coagulopathy as PT >1.2 [28•]. Schlimp retrospectively studied 675 trauma patients and found that in the presence of acidemia (Base Deficit <−6 mmol/L), 81 % had fibrinogen levels <2 g/L and 63 % had levels <1.5 g/L [29]. Taken together, these studies show that fibrinogen depletion is acute and results in coagulopathy, especially in the most severely injured.…”

„Hämoglobinorientierter und gerinnungsfaktorbasierter Algorithmus“

“…Dies bedeutet, dass bei einem Großteil der Traumapatienten aus dem SR-Hb-Wert auf die entsprechenden Gerinnungsparameter geschlossen werden kann. Eine ähnlich gute Korrelation zwischen SRHb-Wert und den obigen Gerinnungsparametern konnte mittlerweile auch an über 40.000 Patienten des TR-DGU [18] sowie zwischen Hb und Fibrinogen [41] nachgewiesen werden.…”

“…Grundlage des verwendeten Gerinnungsalgorithmus sind der mithilfe POCBlutgasanalyse ermittelte SR-Hb, dessen Korrelation mit Standardgerinnungsparametern, wie er an dem Patientengut eines überregionalen Traumazentrums [12,13] sowie den Patienten des TR-DGU nachgewiesen werden konnte [18], und dessen Korrelation mit dem Fibrinogenwert bei Schockraumaufnahme [41]. Beispielhaft verdeutlicht .…”