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Amniotic Fluid Embolism
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Zaid Diken, Antonio F. Saad, Luis D. Pacheco
In the United States, most of the fibrinogen replacement is done in the form of cryoprecipitates (150–350 mg of fibrinogen per unit of cryoprecipitate). Each unit of cryoprecipitate will increase the serum fibrinogen by 10 mg/dL. Just like fresh frozen plasma, cryoprecipitate needs to be thawed before its use and carries the risk for virus transmission. Although not widely available in the United States, fibrinogen concentrates have emerged as another alternative to replenish serum fibrinogen levels without the risk of viral transmission or transfusion reactions like TRALI (transfusion related acute lung injury). It is stored at room temperature and available for immediate use. Fibrinogen concentrates contain high concentrations of fibrinogen (100 ml contains 2 g of fibrinogen). In any case, either cryoprecipitate or fibrinogen concentrates should be administered in bleeding patients to maintain a serum fibrinogen above 150–200 mg/dL.
Postpartum hemorrhage
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Wade D. Schwendemann, William J. Watson
Fibrinogen should be replaced to keep the level above 100 mg/dL (56). Hemostasis can generally be achieved when the activity of coagulation factors is at least 25% of normal, and when the level of fibrinogen is 100 mg/dL. Since the plasma volume in adults is approximately 40 mL/kg, 10–15 mL/kg of fresh frozen plasma may be needed. This dose is approximately three to five units of FFP for adult patients with BMI in the normal range, and may lead to volume overload. Replacement of fibrinogen can be accomplished in two ways. Transfusion of FFP, one unit (200–300 mL), can be expected to increase the fibrinogen level 7 to 10 mg//dL. FFP also has the advantage of containing virtually all clotting factors, making its administration ideal in the treatment of disseminated intravascular coagulation. Cryoprecipitate contains fibrinogen as well as factors V, VIII, XIII, and vWF. One bag of cryoprecipitate will raise the fibrinogen of the patient by 7 mg/dL. The advantage of cryoprecipitate is the smaller volume that must be infused. This presents an advantage in patients where fluid overload is a concern, such as those with severe pre-eclampsia/HELLP syndrome.
Complications of open thoracoabdominal aortic aneurysm repair
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
Postoperative bleeding may result in a return to the operating room, which is associated with additional morbidity and mortality.63 First-line treatment in the ICU should be to achieve normothermia. We routinely initiate a fresh frozen plasma drip at 50 cc/hr for the first 12–24 hours postoperatively to assist with coagulopathy, particularly when there has been liver ischemia intraoperatively. Strict blood pressure control should be enforced to balance the risk of suture line bleeding with the risk of spinal cord and other end-organ ischemia which may contribute to ongoing acidemia and coagulopathy. The typical blood pressure goal is a MAP between 80–90 mmHg. A lower blood pressure goal can be tolerated in patients with evidence of bleeding or patients with connective tissue disorders, though our preference is a posture toward early and aggressive re-exploration for bleeding as prolonged postoperative hypotension may substantially increase the risk of spinal cord injury. In many cases, occult splenic injury resulting from the left medial visceral rotation is the culprit and necessitates rapid splenectomy. Cryoprecipitate consists of von Willebrand factor, factor VIII, factor XIII and fibrinogen.
Rare inherited coagulation disorders in young children in Oman
Published in Pediatric Hematology and Oncology, 2022
Surekha Tony, Roshan Mevada, Abdulhakim Al Rawas, Yasser Wali, Mohamed Elshinawy
The older sibling, aged 7 years is a female patient who presented at the age of 3 years with a history of trauma and poorly controlled gum bleeding for twelve days (FXIII level 19.7 IU/dL). At 4.5 years of age, she had an episode of left fronto-parietal deep white matter hemorrhage extending to the left lateral ventricle and left basal ganglia with mass effect over ipsilateral cerebral hemisphere and left lateral ventricle with contralateral midline shift. The younger brother aged 4.5 years had right axial acute hemorrhage with significant mass effect and grade III intraventricular hemorrhage at 1 month of age (FXIII level 13.9 IU/dL). Both patients were treated with FFP and cryoprecipitate infusions. Both had normal neurodevelopment and continue to receive monthly prophylaxis with cryoprecipitate.
Comparison of the efficacy of two human fibrinogen concentrates to treat dilutional coagulopathy in vitro
Published in Scandinavian Journal of Clinical and Laboratory Investigation, 2018
Thorsten Haas, Melissa M. Cushing, Lars M. Asmis
Accumulating evidence suggests that acquired hypofibrinogenemia is the leading determinant for the development of perioperative dilutional coagulopathy [1–3]. Traditional treatment of acquired hypofibrinogenemia includes transfusion of FFP, cryoprecipitate or administration of purified fibrinogen concentrate. Cryoprecipitate is an allogeneic product that contains considerably higher concentrations of fibrinogen, factor VIII, von Willebrand factor, factor XIII and fibronectin compared to FFP. Cryoprecipitate was withdrawn from the market in many European countries due to concerns about the risk of immunologic reactions and transmission of infectious agents related to multiple donor exposures in this pooled product. Alternatively, intraoperative substitution with fibrinogen concentrate can be safely and effectively used to treat fibrinogen deficiency [3–5]. To assess fibrinogen activity perioperatively, viscoelastic point-of-care tests such as rotational thromboelastometry (ROTEM®, TEM, Munich, Germany) have shown to be valid and effective for the timely diagnosis of dilutional coagulopathy and thus can guide fibrinogen administration [3,6].
Hemostatic defects in massive transfusion: an update and treatment recommendations
Published in Expert Review of Hematology, 2021
Individualized management of the hemostatic defects during major bleeding is required, and viscoelastic testing can be helpful in this regard. But many other questions regarding optimal treatment of hemostatic defects in hemorrhage remain: Is whole blood superior to blood component therapy in patients with acute hemorrhage?What is the optimal calcium replacement strategy for patients requiring massive transfusion?Is early cryoprecipitate transfusion required in all trauma patients presenting with hemorrhage?For bleeding patients with fibrinogen deficiency, is fibrinogen concentrate or cryoprecipitate the optimal treatment strategy to promote definitive hemorrhage control?Which hemorrhage patients in mature trauma systems benefit from tranexamic acid therapy?What is the best laboratory test to diagnose hemostatic defects, coagulopathy and TIC?Is viscoelastic testing superior to conventional coagulation testing for TIC treatment?Are factor concentrates superior to blood component therapy for patients with coagulopathy?