Meizoso Jonathan P, Moore Ernest E, Pieracci Fredric M, Saberi Rebecca A, Ghasabyan Arsen, Chandler James, Namias Nicholas, Sauaia Angela
From the Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO (Meizoso, Moore, Pieracci).
Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO (Meizoso, Moore, Pieracci, Ghasabyan, Chandler, Sauaia).
J Am Coll Surg. 2022 Apr 1;234(4):465-473. doi: 10.1097/XCS.0000000000000078.
Fibrinogen is the first coagulation factor to decrease after massive hemorrhage. European massive transfusion guidelines recommend early repletion of fibrinogen; however, this practice has not been widely adopted in the US. We hypothesize that hypofibrinogenemia is common at hospital arrival and is an integral component of trauma-induced coagulopathy.
This study entailed review of a prospective observational database of adults meeting the highest-level activation criteria at an urban level 1 trauma center from 2014 through 2020. Resuscitation was initiated with 2:1 red blood cell (RBC) to fresh frozen plasma (FFP) ratios and continued subsequently with goal-directed thrombelastography. Hypofibrinogenemia was defined as fibrinogen below 150 mg/dL. Massive transfusion (MT) was defined as more than 10 units RBC or death after receiving at least 1 unit RBC over the first 6 hours of admission.
Of 476 trauma activation patients, 70 (15%) were hypofibrinogenemic on admission, median age was 34 years, 78% were male, median New Injury Severity Score (NISS) was 25, and 72 patients died (15%). Admission fibrinogen level was an independent risk factor for MT (odds ratio [OR] 0.991, 95% CI 0.987-0.996]. After controlling for confounders, NISS (OR 1.034, 95% CI 1.017-1.052), systolic blood pressure (OR 0.991, 95% CI 0.983-0.998), thrombelastography angle (OR 0.925, 95% CI 0.896-0.954), and hyperfibrinolysis (OR 2.530, 95% CI 1.160-5.517) were associated with hypofibrinogenemia. Early cryoprecipitate administration resulted in the fastest correction of hypofibrinogenemia.
Hypofibrinogenemia is common after severe injury and predicts MT. Cryoprecipitate transfusion results in the most expeditious correction. Earlier administration of cryoprecipitate should be considered in MT protocols.
纤维蛋白原是大量出血后首个下降的凝血因子。欧洲大量输血指南建议早期补充纤维蛋白原；然而，这种做法在美国尚未被广泛采用。我们推测低纤维蛋白原血症在入院时很常见，并且是创伤性凝血病的一个重要组成部分。
本研究对2014年至2020年在一家城市一级创伤中心符合最高级别激活标准的成人前瞻性观察数据库进行了回顾。复苏开始时红细胞（RBC）与新鲜冰冻血浆（FFP）的比例为2:1，随后继续进行目标导向的血栓弹力图检查。低纤维蛋白原血症定义为纤维蛋白原低于150mg/dL。大量输血（MT）定义为入院后前6小时内输注超过10单位红细胞或接受至少1单位红细胞后死亡。
在476例创伤激活患者中，70例（15%）入院时存在低纤维蛋白原血症，中位年龄为34岁，78%为男性，中位新损伤严重程度评分（NISS）为25，72例患者死亡（15%）。入院时纤维蛋白原水平是大量输血的独立危险因素（比值比[OR]0.991，95%置信区间0.987-0.996）。在控制混杂因素后，NISS（OR 1.034，95%置信区间1.017-1.052）、收缩压（OR 0.991，95%置信区间0.983-0.998）、血栓弹力图角度（OR 0.925，95%置信区间0.896-0.954）和高纤维蛋白溶解（OR 2.530，95%置信区间1.160-5.517）与低纤维蛋白原血症相关。早期输注冷沉淀导致低纤维蛋白原血症纠正最快。
严重损伤后低纤维蛋白原血症很常见，并可预测大量输血。输注冷沉淀能最迅速地纠正低纤维蛋白原血症。在大量输血方案中应考虑更早输注冷沉淀。
