Current perspective on fibrinogen concentrate in critical bleeding

ABSTRACT

Introduction

. Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates.

Areas covered

. We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events.

Expert opinion

. Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.

KEYWORDS:

• Bleeding
• cardiac surgery
• coagulopathy
• fibrinogen concentrate
• a5-FIBTEM
• ratio
• postpartum hemorrhage
• rotem
• trauma-induced coagulopathy
• trauma

Acknowledgments

Medical writing, in the form of editorial support and language editing, was provided by Laura Buck, and Leigh O’Connor-Jones, of Fishawack Communications Ltd.

Declaration of interest

S. Leal-Novel, M. Casado-Mendez and M. Munoz-Gomez have received honorarium for lectures and courses of CSL Behring. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed consulting for Octapharma. Another has declared employment for Tem Innovations. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose

Additional information

Funding

This study was partially supported by Fondo de Investigación Sanitaria (FIS) PI 15/00512, Instituto de Salud Carlos III, Ministry of Health, Government of Spain, and European Regional Development Fund (ERDF).