Ranucci Marco, Pistuddi Valeria, Baryshnikova Ekaterina, Colella Dionisio, Bianchi Paolo
Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan.
Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan.
Ann Thorac Surg. 2016 Jul;102(1):78-85. doi: 10.1016/j.athoracsur.2016.01.005. Epub 2016 Mar 26.
Low fibrinogen levels immediately after cardiac surgical procedures have been associated with postoperative bleeding and transfusions. However, no sound data on the adequate trigger values for fibrinogen supplementation and target values for fibrinogen concentration exist.
This retrospective study examined prospectively collected data, including data on 2,800 adult patients undergoing cardiac operations. Standard coagulation parameters at the arrival in the intensive care unit were retrieved, inclusive of fibrinogen levels. Postoperative bleeding was assessed based on the chest drain output (mL/12 h). Severe bleeding (SB) was defined as chest drain output greater than 1,000 mL/12 h.
Postoperative blood loss was associated with low values of fibrinogen and platelet count, as well as with a prolonged activated partial thromboplastin time and international normalized ratio. At multivariable analysis, fibrinogen levels lower than 220 mg/dL remained independently associated with SB (odds ratio: 2.25; 95% confidence interval: 1.54 to 3.28). A cutoff value of 115 mg/dL yielded a positive predictive value for SB of 50% and may be proposed as a trigger value for fibrinogen supplementation, with a target value of 280 mg/dL (98% negative predictive value for SB). In actively bleeding patients, these values are increased to 215 and 375 mg/dL, respectively.
These data confirm the independent role of fibrinogen levels as determinants of SB after cardiac surgical procedures and suggest adequate cutoff values and fibrinogen concentrate doses to prevent or treat SB. However, the identified trigger and target values should be confirmed in prospective series of patients undergoing fibrinogen supplementation.
心脏外科手术后立即出现的低纤维蛋白原水平与术后出血和输血有关。然而，关于纤维蛋白原补充的适当触发值和纤维蛋白原浓度的目标值，目前尚无可靠数据。
这项回顾性研究检查了前瞻性收集的数据，包括2800例接受心脏手术的成年患者的数据。收集患者进入重症监护病房时的标准凝血参数，包括纤维蛋白原水平。根据胸腔引流液量（毫升/12小时）评估术后出血情况。严重出血（SB）定义为胸腔引流液量大于1000毫升/12小时。
术后失血与纤维蛋白原和血小板计数低值、活化部分凝血活酶时间延长及国际标准化比值有关。多变量分析显示，纤维蛋白原水平低于220毫克/分升仍与严重出血独立相关（比值比：2.25；95%置信区间：1.54至3.28）。115毫克/分升的临界值对严重出血的阳性预测值为50%，可作为纤维蛋白原补充的触发值，目标值为280毫克/分升（对严重出血的阴性预测值为98%）。对于正在出血的患者，这些值分别提高到215和375毫克/分升。
这些数据证实了纤维蛋白原水平作为心脏外科手术后严重出血决定因素的独立作用，并提出了预防或治疗严重出血的适当临界值和纤维蛋白原浓缩剂剂量。然而，确定的触发值和目标值应在前瞻性的纤维蛋白原补充患者系列中得到证实。
