Fibrinogen concentrate use in the operating theatre at a quaternary hospital in Australia

Abstract

At our quaternary teaching hospital in Queensland, Australia, there has been a rapid increase from 2019 to 2022 in the usage of fibrinogen concentrate (FC) in preference to cryoprecipitate for cardiac surgery. FC is indicated for patients having major trauma requiring haemostatic resuscitation, major intraoperative haemorrhage, or liver transplant patients with major intraoperative haemorrhage. These patients must exhibit severe hypofibrinogenaemia, which is assessed using assay cut-offs of thromboelastogram (TEG) (citrated functional fibrinogen [CFF] ≤ 10 mm) or rotational thromboelastometry (ROTEM) (FIBTEM A5 ≤ 8 mm). FC usage over cryoprecipitate for cardiac surgery is an ongoing debate due to advantages such as dose predictability, rapid reconstitution, viral inactivation, and minimal transfusion-related adverse events; however, it is expensive. The aim of this study was to capture prescribing patterns of FC and appropriateness against local guidelines. Retrospective data were analysed, and the practice was compared to hospital guidelines. Data from 52 patients over a 4-year period (2019–2022) showed intraoperative haemorrhage was the leading indication for FC use (65%, n = 34), followed by liver transplantation (27%, n = 14), and major trauma (8%, n = 4). When breaking down the cause of intraoperative haemorrhage, cardiothoracic surgery, both elective (50%, n = 17) and emergency procedures (41%, n = 14), accounted for 91% of all operative bleeding requiring FC. There were 34 (65%) of 52 patients who received a differing dose of FC compared to what was recommended in the hospital guideline, with 50% (n = 17) receiving a higher than recommended dose and 50% (n = 17) receiving lower than recommended doses. This project was exempt due to the local policy requirements that constitute research by the Metro South Human Research Ethics Committee (Reference no: CM2305202303). The justification for this exemption was as follows: the study presented no foreseeable risk of patient harm as it involved evaluation of standard care involved the use of existing non-identifiable patient records.