CONTEMPORARY APPROACH IN BLEEDING AND TRAUMA COAGULOPATHY MANAGEMENT: FIBRINOGEN AS A MAGIC BULLET

Abstract

Acute hemorrhage results in blood loss followed by consummation of procoagulants, as well as in circulating clotting factors. In acute bleeding, significant amounts of fibrinogen are lost, therefore both cellular and cascade phase of coagulation could be affected leading to coagulopathy. Fluid resuscitation in bleeding patients leads to dilution coagulopathy lowering the levels of circulating coagulation factors including fibrinogen even more further starting a vicious cycle. Many studies have shown that fibrinogen levels below 1g/l in bleeding patients are associated with bleeding and worse outcome suggesting that fibrinogen levels must be measured in trauma patients serving as a threshold for initiation of fibrinogen replacement therapy. Exogenous fibrinogen as a treatment option in critically bleeding patients with low fibrinogen levels has been shown to decrease transfusion needs. Algorithm-based individualized goal-directed use of fibrinogen resulted in highly significant reduction in transfusion needs, adverse outcomes, in certain studies even mortality, and where investigated - reduced costs, with high safety levels at the same time. It has been well established that low fibrinogen levels in patients who undergo cardiac surgery, liver transplantation surgery, in obstetrics, as well as in trauma patients are associated with higher bleeding risk demanding a proactive approach in early fibrinogen supplementation and replacement in order to a better outcome achievement. Although traditionally fibrinogen replacement and supplementation were performed via administration of fresh frozen plasma or cryoprecipitate, the use of lyophilized fibrinogen (concentrate) has become more prevalent in many countries. Recent reports relating to the efficacy of fibrinogen concentrate, suggest that it is a viable alternative to traditional hemostatic approaches, also being a cost-effective when compared to other replacement options which should be considered in a daily practice as well.