Abstract
Fibrinogen has a central role in coagulation. Following trauma and perioperatively,
low fibrinogen levels have been found to be risk factors for exaggerated bleeding,
transfusion needs, and adverse outcome. Conversely, treatment with exogenous fibrinogen
in critically bleeding patients with low fibrinogen levels has been shown to decrease
transfusion needs. Because following trauma and in many perioperative situations fibrinogen
is the first coagulation “element” to become critically low, it appears reasonable
to target fibrinogen in clinical coagulation algorithms aiming at early specific and
goal-directed treatment. A low fibrinogen can be a low plasma concentration or a low
functional fibrinogen as assessed by point-of-care techniques such as thromboelastography
(TEG) or thromboelastometry (ROTEM). This review summarizes the evidence base for
perioperative algorithm-based fibrinogen administration, including the exact thresholds
for fibrinogen administration used in the different algorithms. 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. Best evidence exists in cardiac
surgery, followed by trauma, postpartum hemorrhage, and liver transplantation. The
introduction of these concepts is highly demanding and requires a tremendous educational
effort to familiarize all health care workers with the necessary knowledge and the
skills of how to run TEG/ROTEM tests. Future research is needed to compare the efficacy,
safety, and costs of different algorithms. This, however, should not prevent us from
introducing these expedient point-of-care–based algorithms clinically today.
Keywords
fibrinogen - blood coagulation - algorithms - patient blood management
