Haemotherapy with Fibrinogen for Perioperative Bleeding Prevention-A View on Arterial Thrombogenesis and Myocardial Infarction in the Rat In Vivo

Prophylactic Fibrinogen Reduces Excessive Bleeding in Total Hip Arthroplasty Surgery: A Randomized Double-blinded Placebo-controlled Trial

Objectives

Excessive blood loss is a critical complication of total hip arthroplasty. We intended to determine whether preoperative fibrinogen administration reduces perioperative bleeding and the need for blood transfusion in total hip arthroplasty surgery.

Methods

In 4 months, 178 patients who underwent total hip arthroplasty were randomly assigned equally to intervention and placebo-control groups in a double-blinded, parallel two-arm randomized controlled trial. Both intravenously, 30 min before the start of the surgery, the intervention group received two grams of fibrinogen concentrate dissolved in 100 ml of distilled water. In contrast, the control group received 100 ml of normal saline solution. The amount of postoperative blood loss served as the main result, and the requirement for blood transfusions served as the secondary outcome.

Results

In comparison to the placebo, administering fibrinogen concentrate considerably reduced the amount of blood loss (P=0.001) and the requirement for blood transfusions (P=0.004). Patients who got fibrinogen concentrate experienced no side effects. In addition, patients in the fibrinogen group had significantly lower hemoglobin and higher fibrinogen levels in the recovery room and received lesser blood transfusions (P<0.005) than the placebo group.

Conclusion

In total hip arthroplasty, fibrinogen concentrate lessens postoperative bleeding and the requirement for blood transfusions.

Effects of Algan hemostatic agent foam in rat femoral artery injury model: A randomized animal trial

Background/Aim: Nowadays, many deaths are related to vessel injury-induced blood loss. Failure to control bleeding also increases the risk of death. This study aimed to investigate the hemostatic effects of the Algan Hemostatic Agent (AHA) foam application in a rat model in which severe femoral artery bleeding was induced. Methods: Fourteen rats were randomly assigned to two groups: (1) control (physiological saline) (n = 7) and (2) AHA foam (n = 7). The left femoral artery of the rats was incised and when the bleeding started, and the area was pressed with another sponge for 10 s in all rats. Afterwards, physiological saline solution impregnated gauze or AHA foam was placed over same area. A chronometer was started and area was checked after 2 min. If no bleeding occurred during the first 2 min of application, it was recorded as “successful”. If bleeding occurred, the same procedure was repeated up to three times. If hemostasis could not be achieved even after the third application, it was considered a failure, and “failed” was recorded. All animals were sacrificed under high anesthesia for least 10 min after the experiment. Results: Application of AHA resulted in complete (100%) control of bleeding in all rats within the first 2 min. In control group, hemostasis was achieved in 1 out of 7 (14.3%) rats by the third application. Failure was recorded for the remaining six rats. The hemostatic success rate of the AHA foam was significantly higher than the rates of control group (P = 0.005). Conclusion: AHA foam is a very effective hemostatic agent and can be applied easily on vascular trauma models. Further studies are needed to elucidate hemostatic features of AHA.

Fibrinogen prophylaxis for reducing perioperative bleeding in patients undergoing radical cystectomy: A double-blind placebo-controlled randomized trial

OBJECTIVE

Excessive bleeding is an important complication of radical cystectomy. We aimed to assess whether preoperative administration of fibrinogen decreases perioperative bleeding and improves the outcome of radical cystectomy.

DESIGN

Double-blinded randomized trial with two parallel arms.

SETTING

The study was conducted in the department of surgery at a teaching hospital affiliated with a University of Medical Sciences.

PATIENTS

In total, 70 men undergoing radical cystectomy were randomized to fibrinogen (n = 35) and placebo-control groups. Mean (SD) age was 64.7 (7.4) years.

INTERVENTIONS

The intervention group received 2 g fibrinogen concentrate diluted in 100 ml distilled water, and the control group received 100 ml normal saline; both intravenously 15 ̶ 30 min before the start of the surgery.

OUTCOME MEASURES

The primary outcome was the amount of perioperative blood loss. The secondary outcomes were hemodynamic features and vital signs.

MAIN RESULTS

Fibrinogen significantly decreased the volume of blood loss (p < 0.001) and the total number of transfused packed-cell units per group (38 vs. 115 units); and compensated the decrease of HCO3 (p = 0.030), the mean arterial pressure (p < 0.001), hemoglobin O2 saturation (p = 0.001), heart rate (p < 0.001), and temperature (p < 0.001) throughout the surgery compared with the placebo. Patients in the fibrinogen group had shorter Intensive Care Unit (p = 0.001) and hospital (p < 0.001) stay. We did not find any adverse reaction in our patients receiving fibrinogen concentrate.

CONCLUSION

Fibrinogen concentrate reduces perioperative bleeding and the need for blood transfusion in radical cystectomy. It improves the outcomes of the surgery and decreases patients' length of stay in the healthcare system following radical cystectomy.

REGISTRATION

Iranian Registry of Clinical Trials (IRCT) http://www.irct.ir/, reference number: IRCT20191013045091N1.

ETHICS CODE

Shahid Beheshti University of Medical Sciences, reference number: IR.SBMU.RETECH.REC.1398.033.

Prevention of postoperative bleeding after complex pediatric cardiac surgery by early administration of fibrinogen, prothrombin complex and platelets: a prospective observational study

Background

Postoperative bleeding is a major problem in children undergoing complex pediatric cardiac surgery. The primary aim of this prospective observational study was to evaluate the effect of an institutional approach consisting of early preventive fibrinogen, prothrombin complex and platelets administration on coagulation parameters and postoperative bleeding in children. The secondary aim was to study the rate of re-intervention and postoperative transfusion, the occurrence of thrombosis, length of mechanical ventilation, ICU stay and mortality.

Methods

In fifty children (age 0–6 years) with one or more predefined risk factors for bleeding after cardiopulmonary bypass (CPB), thrombelastography (TEG) and standard coagulation parameters were measured at baseline (T1), after CPB and reversal of heparin (T2), at sternal closure (T3) and after 12 h in the ICU (T4). Clinical bleeding was evaluated by the surgeon at T2 and T3 using a numeric rating scale (NRS, 0–10).

Results

After CPB and early administration of fibrinogen, prothrombin complex and platelets, the clinical bleeding evaluation score decreased from a mean value of 6.2 ± 1.9 (NRS) at T2 to a mean value of 2.1 ± 0.8 at T3 (NRS; P <  0.001). Reaction time (R), kinetic time (K), maximum amplitude (MA) and maximum amplitude of fibrinogen (MA-fib) improved significantly (P <  0.001 for all), and MA-fib correlated significantly with the clinical bleeding evaluation (r = 0.70, P <  0.001). The administered total amount of fibrinogen (mg kg^− 1) correlated significantly with weight (r = − 0.42, P = 0.002), priming volume as percentage of estimated blood volume (r = 0.30, P = 0.034), minimum CPB temperature (r = − 0.30, P = 0.033) and the change in clinical bleeding evaluation from T2 to T3 (r = 0.71, P <  0.001). The incidence of postoperative bleeding (> 10% of estimated blood volume) was 8%. No child required a surgical re-intervention, and no cases of thrombosis were observed. Hospital mortality was 0%.

Conclusion

In this observational study of children with an increased risk of bleeding after CPB, an early preventive therapy with fibrinogen, prothrombin complex and platelets guided by clinical bleeding evaluation and TEG reduced bleeding and improved TEG and standard coagulation parameters significantly, with no occurrence of thrombosis or need for re-operation.

Trial registration

German Clinical Trials Register DRKS00018109 (retrospectively registered 27th August 2019).