Fibrinogen in Resuscitation of Older Adult Trauma Patients: Are They Too Old to Receive New Adjuncts?

Abstract

Introduction

Trauma-induced coagulopathy occurs in a quarter of injured patients and increases the risk of mortality. Recent studies suggest that fibrinogen supplementation (FS), when used as an adjunct for resuscitation, is associated with improved outcomes. There is a lack of data on the role of pharmacologic adjuncts in hemorrhaging older adult (OA) trauma patients. The aim of our study was to compare the outcomes of patients receiving FS as an adjunct to the standard of care among OA versus young adult (YA) trauma patients.

Methods

We performed a 4-y (2017-2020) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database. All adult (age ≥18 y) trauma patients with a shock index > 1 who received early (≤4 h) FS, including fibrinogen concentrate (FC) or cryoprecipitate (Cryo), were included. We excluded patients dead on arrival, those transferred from other facilities, those with bleeding disorders or chronic liver disease, and those on preinjury anticoagulation. Patients were stratified into YA (18-64 y) and OA (≥ 65 y). Primary outcomes were 6-h and 24-h mortality. Secondary outcomes were included in-hospital mortality, major complications, and 4-h blood transfusion requirements. Multivariable regression analyses were performed to identify the independent association of age on the outcomes.

Results

A total of 7103 patients were identified, of which 999 (14.06%) were OA. On presentation, the mean shock index was 1.4, and both study groups had comparable median Injury Severity Score. The median time to FC and Cryo administration was 59 and 120 min, respectively. Overall, the rates of 6-h, 24-h, and in-hospital mortality were 11.1%, 20.6%, and 38.9%, respectively. On multivariable regression analysis, age was not associated with 6-h mortality (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI] [0.95-1.52], P = 0.125), 24-h mortality (aOR: 1.12, 95% CI [0.87-1.43], P = 0.379), and major complications (aOR: 0.79, 95% CI [0.83-1.27], P = 0.125). However, OA had independently higher risk-adjusted odds of in-hospital mortality (aOR: 1.96, 95% CI [1.59-2.41], P < 0.001). Notably, older age was associated with a 5.27-unit decrease in packed red blood cell, 2.82-unit decrease in fresh frozen plasma , and 1.63-unit decrease in platelet requirements at 4 h. A subanalysis of patients receiving Cryo (n = 6409) or FC (n = 694) showed the same trend of outcomes.

Conclusions

FS was associated with early outcomes that were broadly comparable between OA and YA. Despite higher in-hospital mortality, older age was associated with a reduction in blood product transfusion compared with younger patients.