Role of fibrinogen concentrate in coagulation management in complex cardio-vascular surgery

Transcription

1 Role of fibrinogen concentrate in coagulation management in complex cardio-vascular surgery Niels Rahe-Meyer Clinic for Anaesthesiology and Intensive Care Medicine

2 In major blood loss, fibrinogen deficiency develops first Haemostatic factor Critical level Blood loss (%) Platelets 50 x 10 3 /mm Factor II Factor V Factor VII Fibrinogen 1.0 g/l 142 Hiippala ST et al. Anesth Analg 1995; 81:

3 In major blood loss, fibrinogen deficiency develops first Haemostatic factor Critical level Blood loss (%) Platelets 50 x 10 3 /mm Factor II Factor V Factor VII Fibrinogen 1.0 g/l 142 Hiippala ST et al. Anesth Analg 1995; 81:

4 In major blood loss, fibrinogen deficiency develops first Haemostatic factor Critical level Blood loss (%) Platelets 50 x 10 3 /mm Factor II Factor V Factor VII Fibrinogen 1.0 g/l 142 Hiippala ST et al. Anesth Analg 1995; 81:

5 Fibrin formation is more impaired than thrombin generation and platelets immediately following cardiac surgery Solomon C et al. Thromb Res 2011; 128: 277 Franziskus Hospital gem. GmbH Medizinische Hochschule Hannover

6 Clotting time [sec] Effect of thrombin dose on clotting time % effect Jaques J Physiol 1941 Thrombin [units} Franziskus Hospital gem. GmbH Medizinische Hochschule Hannover

7 Effect of fibrinogen level on clot firmness 20% effect Franziskus Bolliger Hospital D et Hannover al. Br Medical J Anaesth School 2009; 102: 793-9

8 What is the target? Increases in fibrinogen increase plasma clot strength linearly up to 300 mg/dl Plasma clot strength is equal to whole blood at 625 mg/dl Franziskus Nielsen Hospital VG Hannover & Levy Medical JH. School Anesth Analg 2007; 105: 902-3

9 Correlation blood loss pre-operative fibrinogen, CABG, RCT, placebo-controlled double blind, n=20 Karlsson M et al. Thromb Haemost 2009; 102:

10 Study design RCT Study sponsored by CSL Behring Monocentric, 61 patients Elective TAAA, ascending aorta, aortic arch Double-blinded/placebo controlled Strict coagulation treatment algorithm, with the trigger of peri-operative bleeding Individually dosed high level fibrinogen

11 Methods

12 Target plasma level of fibrinogen 3.6 g/l 22 mm FIBTEM Fibrinogen (g/l) Despotis 2000 ASA Task Force 2006 Spahn 2007 Weinkove 2008 Fenger- Eriksen 2008 Rahe-Meyer 2009

13 ROTEM FIBTEM-guided administration of fibrinogen concentrate mm After CPB Before therapy mm 20 (MCF=8 mm) 20 (MCF=22 mm) min min CPB, cardiopulmonary FNG, bypass; fibrinogen MCF, concentrate; maximum clot MCF, firmness maximum clot firmness

14 ROTEM FIBTEM-guided administration of fibrinogen concentrate mm After CPB Before therapy mm After 7g fibrinogen concentrate 20 (MCF=8 mm) 20 (MCF=22 mm) min min 7 g 22 mm 8 mm Fibrinogen = (target FIBTEM MCF [mm]) x (bodyweight [kg]/70) dose [g] 2 CPB, cardiopulmonary FNG, bypass; fibrinogen MCF, concentrate; maximum clot MCF, firmness maximum clot firmness

15 Thoraco-abdominal aorta

16 Standardized treatment trigger 5 min bleeding mass 1. After weaning from CPB 2. After heparin reversal (protamine) 3. After surgical haemostasis

17 Intra-operative bleeding after protamin and surgical haemostasis

18 Standardized treatment trigger 5 min bleeding mass

19 Algorithm Removal from CPB, Protamine, Surgical haemostasis No treatment No Bleeding g No treatment Yes Treat as randomised Fibrinogen No Bleeding g Yes Placebo Standardised treatment regimen CPB, cardiopulmonary bypass

20 Algorithm No treatment No >60g Yes 5 minutes or 5 minutes >60g Yes 5 minutes or 5 minutes >60g Yes 5 minutes No treatment No Yes >60g/5min >300g/h

21 Results

22 Distribution of operations n=30 n=31 Fib, fibrinogen concentrate, human; TAAA, thoraco-abdominal aortic aneurysm Rahe-Meyer et al. Manuscript accepted: Anesthesiology

23 mg/dl Fibrinogen levels over time Clauss Assay Baseline min Days After CPB Last Suture Solomon C et al. Manuscript submitted Fibrinogen conc. Placebo

24 Safety Adverse events AEs Fib (n = 29) Placebo (n = 32) Overall 24 (82.8%) 27 (84.4%) Serious 5 (17.2%) 5 (15.6%) Fatal 1 (3.4%) 4 (12.5%) Events of special interests: Thromboembolic or haemorrhagic Re-operation because of bleeding Allergic or other reactions to IMP or transfusion (TRALI) Organ failure or paraplegia Data given as number of patients (%); AEs, adverse events; Fib, fibrinogen concentrate Rahe-Meyer et al. Manuscript accepted: Anesthesiology

25 Safety Adverse events AEs Fib (n = 29) Placebo (n = 32) Overall 24 (82.8%) 27 (84.4%) Serious 5 (17.2%) 5 (15.6%) Myocardial infarction Day 30 Fatal 1 (3.4%) 4 (12.5%) 1/29 Fatal AEs 4/32 Operative haemorrhage Day 0 Cardio-respiratory arrest Day1 Cerebral haemorrhage Day 1 Cerebral Infarction Day 1 Data given as number of patients (%); AEs, adverse events; Fib, fibrinogen concentrate

26 Reduction of bleeding by treatment Rahe-Meyer Franziskus Hospital et al. Hannover Manuscript Medical School submitted

27 Reduction of bleeding by treatment Placebo 4FFP or 2PC 4FFP and 2PC Fibrinogen Rahe-Meyer Franziskus Hospital et al. Hannover Manuscript Medical School submitted

28 Total of units of allogeneic blood (RBC, FFP, PC) within 24 h Fib, fibrinogen concentrate; TAAA, thoraco-abdominal aortic aneurysm Rahe-Meyer et al. Manuscript accepted: Anesthesiology

29 Total of units of allogeneic blood (RBC, FFP, PC) within 24 h Fib, fibrinogen concentrate; TAAA, thoraco-abdominal aortic aneurysm Rahe-Meyer et al. Manuscript accepted: Anesthesiology

30 Total of units of allogeneic blood (RBC, FFP, PC) within 24 h p<0.0001* *p< for treatment difference using the unstratified Hodges-Lehmann point estimate and corresponding nonparametric confidence intervals; Fib, fibrinogen concentrate; TAAA, thoraco-abdominal aortic aneurysm Rahe-Meyer et al. Manuscript accepted: Anesthesiology

31 Secondary endpoint Patients with transfusion 100% Allogeneic group Fibrinogen group 80% 60% 40% 20% 0% 100% 55% p<0.0001* *2-sided non-parametric Wilcoxon/Mann Whitney rank sum test Rahe-Meyer et al. Manuscript accepted: Anesthesiology

32 Secondary endpoint Patients with transfusion 100% Allogeneic group Fibrinogen group 80% 60% 40% 20% 0% 100% 55% p<0.0001* *2-sided non-parametric Wilcoxon/Mann Whitney rank sum test 0% 45% Total avoidance of transfusion Rahe-Meyer et al. Manuscript accepted: Anesthesiology

33 Conclusions ESA guidelines: Management of severe perioperative bleeding (publication anticitpated end of 2012) Fibrinogen concentrate infusion guided by point-of-care viscoelastic coagulation monitoring may be used to reduce perioperative blood loss in complex cardiovascular surgery (level of evidence 1+; grade of recommendation B).