HPE CSL Managing Perioperative Bleeding handbook - Page 24

Trauma in depletion of coagulation proteins but also in a critical drop in platelets. 28 Data from animal studies revealed that high fibrinogen levels might potentially counteract low platelet counts, by increasing overall clot firmness. 29 Velik-Salcher et al investigated the effect of fibrinogen concentrate transfusion on blood loss in a thrombocytopenic swine model (target platelet count < 30,000/┬Ál). Transfusion of fibrinogen concentrate (250mg/kg body weight) resulted in lower blood loss and improved survival rate compared with transfusion of 2U of PC. 29 In situations where platelet count is low or platelet function is compromised and PCs are not available, high fibrinogen 24 hospitalpharmacyeurope.com supplementation might be considered as a treatment option. 30 Fibrinogen supplementation Nascimento et al randomised 50 hypotensive adult trauma patients to either 6g fibrinogen concentrate or placebo. Plasma fibrinogen concentrations remained higher in the fibrinogen concentrate group up to 12h after admission. Mortality and thromboembolic complications were similar between groups. 31 Thrombin generation is initially not deficient in major trauma Compromised thrombin generation does not appear an initial problem in the early stages of TIC. 32,33 Therefore thrombin- generating coagulation factors such as prothrombin complex concentrate (PCC) are not advocated as first-line therapy in trauma. 34 Importantly, prolonged standard coagulation tests such as international normalised ratio (INR), prothrombin time (PT), activated partial thromboplastin time, ROTEM clotting time or TEG r- and k-time do not sufficiently reflect impaired thrombin production. For example, Dunbar and Chandler reported 15 trauma patients with prolonged PT and INR suggestive of TIC. Even though PT was >18 sec and INR was >1.5, thrombin generation was three-fold higher compared with controls (p=0.01). 32