Pre-emptive administration of fibrinogen concentrate contributes to improved prognosis in patients with severe trauma

Abstract

BackgroundPatients with severe trauma often present with critical coagulopathy, resulting in impaired hemostasis, massive hemorrhage, and a poor survival prognosis. The efficacy of hemostatic resuscitation in correcting coagulopathy and restoring tissue perfusion has not been studied. We assessed a novel approach of pre-emptive administration of fibrinogen concentrate to improve critical coagulopathy in patients with severe trauma.MethodsWe retrospectively compared blood transfusion volumes and survival prognosis between three groups of patients with trauma, with an Injury Severity Score (ISS) ≥26 over three consecutive periods: group A, no administration of fibrinogen concentrate; group B, administration of 3 g of fibrinogen concentrate after evaluation of trauma severity and a plasma fibrinogen level <1.5 g/L; group C, pre-emptive administration of 3 g of fibrinogen concentrate immediately on patient arrival based on prehospital information, including high-severity injury or assessed need for massive transfusion before measurement of fibrinogen.Results∼56% of patients with an ISS ≥26 and transfused with red blood cell concentrates ≥10 units, had hypofibrinogenemia (fibrinogen <1.5 g/L) on arrival. Patients who received fibrinogen concentrate in group C showed significantly higher fibrinogen levels after treatment with this agent than those in group B (2.41 g/L vs 1.88 g/L; p=0.01). Although no significant difference was observed in blood transfusion volumes between the groups, the 30-day survival of patients in group C (all, and those with an ISS ≥26) was significantly better than in group A (p<0.05). The 48-hour mortality rate in patients with an ISS ≥26 was significantly lower in group C than in group A (8.6% vs 22.9%; p=0.005). Further, among patients with an ISS ≥41, the overall mortality was significantly lower in group C than in group A (20% vs 50%; p=0.02).ConclusionPre-emptive administration of fibrinogen concentrate for patients with trauma with critical coagulopathy may contribute to improved survival.Level of evidenceLevel IV.

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

“…Timely management of haemorrhage is widely recommended [49, 50]. The availability of red cells has improved over the last few years with availability in some pre-hospital services but needs to be accompanied by coagulation products, such as freeze-dried plasma and fibrinogen [51–53].…”

Multiple trauma management in mountain environments - a scoping review

“…Reversal of trauma-induced coagulopathy with fresh frozen plasma (FFP) can fail from lack of fibrinogen. Empiric administration of 3 g of fibrinogen concentrate IV decreased mortality in multiple trauma in a Japanese study [ 99 ]. Fibrinogen concentrate may decrease blood transfusion needs, multi-organ failure and mortality [ 100 ].…”

Whole Blood, Fixed Ratio, or Goal-Directed Blood Component Therapy for the Initial Resuscitation of Severely Hemorrhaging Trauma Patients: A Narrative Review

“…Recent studies indicate that timely soluble fibrinogen concentrate administration is possible in the prehospital and urban hospital environment, with ROTEM evidence of increased clot stability. Future studies have been proposed to provide soluble fibrinogen and 4-factor PCC in the prehospital and hospital civilian urban setting as an alternative to fixed ratio or WB resuscitation [ 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 ]. Since 2017 in Australia, the Fibrinogen Early In Severe Trauma study (FEISTY) is a RCT attempting to address the validity of soluble fibrinogen for early resuscitation of severely bleeding trauma patients [ 97 ].…”