Paediatrics
Fibrinogen and other
concentrates in paediatrics
Options for using coagulation factors in children are discussed and
a brief overview of current literature is given
Thorsten Haas MD
Professor of Anaesthesiology
Department of Paediatric Anaesthesia
University Children’s Hospital Zurich
Switzerland
Management of perioperative bleeding in
children is a major challenge for
paediatric anaesthetists. The reasons for
haemostatic changes during major
paediatric surgery is multifactorial and
may be related to dilutional coagulopathy,
loss and consumption of coagulation
factors, hyperfibrinolysis, or surgical
bleeding. 1 Therefore, timely laboratory
testing is crucial in detecting and guiding
adequate management. The most recently
published guidelines recommend
performance of viscoelastic coagulation
testing (for example, ROTEM ® or
TEG ® ), 2,3 which have been shown to be
effective in guiding perioperative bleeding
management. 2,4-8 In addition, such tests
are effective at reducing transfusion
requirements and related costs. 9,10
However, the implementation of fast and
“However, the implementation of fast and reliable
haemostatic testing is just half of the equation;
a tailored and individualised administration of
blood products and factors concentrates to
further improve effectiveness of adequate
bleeding management is also required”
reliable haemostatic testing is just half
of the equation; a tailored and
individualised administration of blood
products and factors concentrates to
further improve effectiveness of adequate
bleeding management is also required.
The targeted usage of purified
coagulation factor concentrates offers
a great alternative to transfusion of
allogeneic blood products, as they are
easy to reconstitute, available in a short
period of time, have no requirement for
blood group-compatible administration,
and are not linked to transfusion-
associated side effects, such as
transfusion-related immunomodulation
(TRIM) or transfusion-related acute lung
injury (TRALI). In addition, the total
volume of reconstituted purified
coagulation factors is markedly less and,
therefore, transfusion-related cardiac
overload (TACO) is less likely.
Fibrinogen concentrate
Fibrinogen is the first coagulation factor
that achieves critically low levels during
massive blood loss, whereas all other
factors seem to be less affected by
haemodilution and blood loss; 11 this
has been observed in both adult and
paediatric perioperative settings. 1
Fibrinogen plays several key roles
in the maintenance of haemostasis. 12,13
Fibrinogen acts by crosslinking platelets
via glycoprotein IIb–IIIa receptors, which
builds the surface for the following
haemostatic process, and is the key
substrate for activated thrombin, which
converts it to fibrin, the key component
of the mechanically stable clot. It is
well known that acquired
hypofibrinogenaemia seems to be the
leading determinant in dilutional
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