Therapie von Fibrinogenmangelzuständen

The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage

Haemorrhage is a common complication of childbirth with 0.65% of deliveries associated with significant (>1500 mL) peripartum blood loss. Hypofibrinogenaemia secondary to dilutional and consumptive coagulopathies can be challenging to correct quickly with conventional blood and plasma therapy. Fibrinogen concentrate offers rapid restoration of fibrinogen levels with a small volume infusion and minimal preparation time. It is effective in treating patients with congenital hypofibrinogenaemia, but there are few reports of its use in association with continuing obstetric haemorrhage. Six cases of obstetric haemorrhage, associated with hypofibrinogenaemia, treated with fibrinogen concentrate in conjunction with platelets, fresh frozen plasma, packed red blood cells, uterotonics and obstetric intervention are described. In all cases, laboratory assessed coagulation was rapidly normalised and severe haemorrhage improved. These cases suggest that fibrinogen concentrate may be an effective addition to conventional treatments for obstetric haemorrhage associated with hypofibrinogenaemia.

Fibrinogen concentrate for acquired hypofibrinogenaemic states

This study aims to assess the efficacy and safety of fibrinogen concentrate in acquired hypofibrinogenaemic states. Cryoprecipitate is standard treatment for replacement of fibrinogen in acquired hypofibrinogenaemia. A virally inactivated fibrinogen concentrate (Haemocomplettan((R)); CSL Behring, Marburg, Germany) is licensed in some European countries. Clinical data for its use in acquired hypofibrinogenaemic states are scarce. Demographic and pretreatment clinical data of patients treated with fibrinogen concentrate for acquired hypofibrinogenaemia were retrospectively reviewed. Pretreatment and posttreatment fibrinogen levels, transfusion requirements, outcomes and adverse events were recorded. Thirty adult patients who received fibrinogen concentrate for acquired hypofibrinogenaemia (fibrinogen <1.5 g L(-1)) were included in the study. Causes of hypofibrinogenaemia included placental abruption, disseminated intravascular coagulation as a result of massive blood loss and transfusion, liver failure and cardiac surgery. Following a median dose of 4 g fibrinogen concentrate, median Clauss fibrinogen level rose from 0.65 to 2.01 g L(-1), with a median fibrinogen increment of 0.25 g L(-1) per 1 g fibrinogen concentrate administered. Forty-six per cent of patients stopped bleeding with blood components and fibrinogen concentrate alone, and a further 29% stopped bleeding with surgical or endoscopic intervention. Inpatient mortality was 40%. No venous thromboses were observed. Four patients with massive perioperative haemorrhage and hypotension (including three postcardiothoracic surgery) had arterial ischaemic events, none of which was attributable to fibrinogen overreplacement. The cost of fibrinogen concentrate was comparable with that of cryoprecipitate. Purified, virally inactivated fibrinogen concentrate appears effective in the management of acquired hypofibrinogenaemic states and enables rapid administration of a known fibrinogen dose in an emergency setting.

Efficacy and tolerability of human fibrinogen concentrate administration to patients with acquired fibrinogen deficiency and active or in high-risk severe bleeding

BACKGROUND AND OBJECTIVES

Fibrinogen deficiency is a cause for massive haemorrhage whose management in emergency situations is the subject of debate. Plasma-derived fibrinogen concentrates are indicated for reversing the haemorrhagic diathesis found in congenital and acquired deficiencies.

MATERIALS AND METHODS

We report on the results of an observational study that evaluated the effects of fibrinogen concentrates in patients suffering from various forms of acquired severe hypofibrinogenaemia with life-threatening consumptive thrombo-haemorrhagic disorders (surgery, trauma and digestive haemorrhage), or underlying disease states that limit fibrinogen synthesis (hepatic dysfunction, haematological malignancies).

RESULTS

Sixty-nine patients were identified and included, in whom most of the processes (62%) corresponded to consumptive hypofibrinogenaemia. After a median dose of 4 g, a mean absolute increase of 1.09 g/l in plasma fibrinogen was measured and coagulation parameters were significantly improved (P < 0.001). Mortality rates of 32.3% and 44.2% were reported after 24 h and 72 h, respectively.

CONCLUSION

We conclude that the administration of fibrinogen concentrates in unresponsive, life-threatening haemorrhage with acquired hypofibrinogenaemia improves laboratory measures of coagulation, and may also be life saving. Although observational in nature, our data indicate a direct relationship between plasma fibrinogen levels and survival in acquired fibrinogen deficiency. Further studies are warranted to ascertain a clear relationship between fibrinogen levels and survival.

Hemostatic Changes After Crystalloid or Colloid Fluid Administration During Major Orthopedic Surgery: The Role of Fibrinogen Administration

BACKGROUND

To explore whether disturbed fibrin polymerization is the main problem underlying dilutional coagulopathy and can be reversed by fibrinogen administration, we conducted a prospective study using modified thrombelastography (ROTEM).

METHODS

Sixty-six orthopedic patients randomly received modified gelatin solution, hydroxyethyl starch 130/0.4, or exclusively Ringer lactate solution. ROTEM analysis was performed, concentrations of coagulation factors and markers of thrombin generation were measured. Fibrinogen concentrate (Hemocomplettan) was administered (30 mg/kg) when thrombelastographically measured fibrinogen polymerization was critically decreased.

RESULTS

The alpha angle, clot firmness, and fibrinogen polymerization (median [min to max]) significantly decreased in the patients receiving hydroxyethyl starch (area under the curve minus baseline (-5 [-9 to -2]), followed by gelatin solution (-3 [-8 to 0]), with the least reductions seen for Ringer lactate solution (-2 [- 4 to 1]) (colloids versus Ringer lactate P < 0.0001). Thirteen patients in the colloid groups but none in the Ringer lactate group needed fibrinogen concentrate to maintain borderline clot firmness. Activity of FVII, FVIII, FIX, and von Willebrand ristocetin activity decreased significantly with colloids. Thrombelastographically measured coagulation time, molecular markers of thrombin generation, and activity of all other coagulation factors were comparable in all groups.

CONCLUSION

Disturbance of fibrinogen/fibrin polymerization is the primary problem triggering dilutional coagulopathy during major orthopedic surgery. The magnitude of clot firmness reduction is determined by the type of fluid used, with hydroxyethyl starch showing the most pronounced effects. These undesirable effects of intravascular volume therapy can be reversed by increasing fibrinogen concentration by administering fibrinogen concentrate, even during continuing blood loss and intravascular volume replacement.