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J Thorac Cardiovasc Surg 2009;138:694-702
© 2009 The American Association for Thoracic Surgery

Perioperative Management

Thromboelastometry-guided administration of fibrinogen concentrate for the treatment of excessive intraoperative bleeding in thoracoabdominal aortic aneurysm surgery

Niels Rahe-Meyer, MD, MSc, PhDa,*, Cristina Solomon, MDa, Michael Winterhalter, MDa, Siegfried Piepenbrock, MDa, Kenichi Tanaka, MD, MSc, PhDb, Axel Haverich, MDc, Maximilian Pichlmaier, MDc

a Department of Anesthesiology, Hannover Medical School, Hannover, Germany
b Department of Anesthesiology, Emory University, Atlanta, Ga
c Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany

Received for publication July 28, 2008; revisions received October 28, 2008; accepted for publication November 22, 2008.

* Address for reprints: Niels Rahe-Meyer, MD, MSc, PhD, Hannover Medical School, Department of Anaesthesiology, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany. (Email: Rahe-Meyer.Niels{at}MH-Hannover.de).

Objective: Thoracoabdominal aortic aneurysm operations are associated with extensive blood loss and high requirements for allogeneic blood product transfusion. We assessed the efficacy of intraoperative post–cardiopulmonary bypass administration of fibrinogen concentrate in elective thoracoabdominal aortic aneurysm surgery.

Methods: In a retrospective group (group A, n = 12) of patients undergoing elective thoracoabdominal aortic aneurysm surgery, clinically relevant diffuse bleeding after weaning from cardiopulmonary bypass was treated with allogeneic blood products (platelet concentrates, followed by fresh frozen plasma) according to a predetermined algorithm.

In a prospective group (group F, n = 6) a first therapy step with fibrinogen concentrate was added to the algorithm. The dose of fibrinogen concentrate was estimated by using thromboelastometric data (ROTEM FIBTEM). Before each step of hemostatic therapy, blood loss in the range of 60 to 250 g per 5 minutes was confirmed.

Results: In group F, administration of 7.8 ± 2.7 g of fibrinogen concentrate established hemostasis, completely avoiding intraoperative transfusion of fresh frozen plasma and platelet concentrates. Transfusion of blood products after cardiopulmonary bypass and during the 24 hours after surgical intervention was markedly lower in group F than in group A (2.5 vs 16.4 units; 4/6 patients in group F required no transfusion of blood products), as was 24-hour drainage volume (449 vs 1092 mL). Fibrinogen plasma levels, standard coagulation parameters, and hemoglobin and hematocrit values were comparable between the 2 groups on the first postoperative day.

Conclusions: FIBTEM-guided post–cardiopulmonary bypass administration of fibrinogen concentrate resulted in improved intraoperative management of coagulopathic bleeding in thoracoabdominal aortic aneurysm operations and reduced transfusion and 24-hour drainage volume.

Abbreviations and Acronyms CPB = cardiopulmonary bypass; ECC = extracorporeal circulation; EXTEM = ROTEM test with extrinsic activation of coagulation; FFP = fresh frozen plasma; FIBTEM = ROTEM test with extrinsic activation of coagulation and platelet inhibition with cytochalasin D; ICU = intensive care unit; MCF = maximum clot firmness; PC = platelet concentrate; RBC = red blood cell; ROTEM = thromboelastometry; TAAA = thoracoabdominal aortic aneurysm; TEG = thromboelastography






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