Postoperative Bleeding in Children with Hypofibrinogenemia Induced by Cardiopulmonary Bypass
Patients undergoing cardiac surgery with the use of cardiopulmonary bypass are at risk of up to a 40% reduction in plasma fibrinogen levels, with subsequent risk of perioperative bleeding. Children undergoing surgery for congenital heart defects are even more sensitive to the reduction in fibrinogen. What are the possible solutions, and is any one of them significantly better?
Methods for Correcting Hypofibrinogenemia
To correct hypofibrinogenemia, either fresh frozen plasma (FFP), cryoprecipitate, or human fibrinogen concentrate can be used. These products are made from donor plasma and have their own advantages and disadvantages. Frozen plasma contains a lower concentration of fibrinogen but also includes other coagulation factors. If hypofibrinogenemia is severe, a single dose of FFP may not be sufficient; repeated administration can lead to hemodilution and volume overload. Cryoprecipitate is not widely available. Fibrinogen concentrate is a low-volume preparation that does not carry the risk of hemodilution, but it may not be effective enough in cases of bleeding with more complex causes than just hypofibrinogenemia.
Study Design and Population
In terms of efficacy in pediatric patients undergoing cardiac surgery for congenital heart defects, a clinical study conducted in 2014-2015 compared fresh frozen plasma and fibrinogen concentrate. The study included children under 2 years of age with post-surgical fibrinogen levels < 2 g/l and significant bleeding during the first postoperative hour. Patients were treated with either fibrinogen concentrate (70 mg/kg) or FFP (10 ml/kg). In addition to coagulation parameters, the volume of blood in the chest drain was primarily monitored.
The study involved 90 children, 60% of whom were boys, with an average age in both groups between 21 and 22 months.
Findings
Cardiopulmonary bypass was used during the procedure for approximately 125 minutes. During the first 24 hours of postoperative monitoring, the amount of drained blood significantly decreased in both treatment groups (p < 0.04). However, fibrinogen concentrate was slightly more effective, with a lower average volume of drained blood compared to patients receiving FFP (p < 0.02 for comparisons during the first 3 and 6 hours; p < 0.04 for comparisons during the first 12 and 24 hours). The difference in average blood volume drained between the treatment groups was approximately 2.2 ml/kg/hr during the first 3 and 6 hours. Additionally, higher plasma fibrinogen levels were achieved in the fibrinogen concentrate group during the first 24 hours postoperatively.
Postoperative outcomes and the incidence of complications from the cardiac surgery did not differ between the two groups.
Conclusion
Fibrinogen consumption during cardiopulmonary bypass with subsequent bleeding can be managed with both FFP and fibrinogen concentrate in infants. Human fibrinogen concentrate appears to be slightly more effective. In practice, the choice of preparation should primarily be guided by the patient's condition, current coagulation parameters, and the cardiovascular system's volume load.
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Source: Massoumi G., Mardani D., Mousavian S. M., Bigdelian H. Comparison of the effect of fibrinogen concentrate with fresh frozen plasma (FFP) in management of hypofibrinogenemic bleeding after congenital cardiac surgeries: a clinical trial study. ARYA Atheroscler 2018; 14 (6): 248–253, doi: 10.22122/arya.v14i6.1699.
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