Fibrinogen concentrate linked to fewer transfusions in acquired hypofibrinogenaemia, mainly in cardiac surgery

Design

Systematic review and meta-analysis of 58 comparative studies, with a randomised-trial subanalysis

Population

13,530 patients with acquired hypofibrinogenaemia across surgical settings

Primary outcome

Allogeneic blood product use, mortality and thromboembolic events

Effect

Adults: red cells IRR 0.72 (0.59 to 0.89); plasma 0.69; platelets 0.56; no difference in mortality

A BJA systematic review pooled 58 comparative studies (13,530 patients) in which fibrinogen concentrate was given for acquired hypofibrinogenaemia and compared with all other treatments.

In adults, fibrinogen concentrate was associated with 28% fewer red cell units (IRR 0.72, 95% CI 0.59 to 0.89), 31% fewer plasma units (0.69, 0.54 to 0.89) and 44% fewer platelet units (0.56, 0.33 to 0.95). An analysis restricted to randomised trials also showed less blood product use. Mortality and thromboembolic events did not differ. In children, no outcome differed significantly. The results were driven largely by cardiac surgery.

The pooled studies mixed designs and comparators, and one cannot separate the effect of the product from that of goal-directed protocols that often accompany it. Cost and availability matter in India, where cryoprecipitate is often the practical source of fibrinogen.

• Measure fibrinogen — by Clauss assay or viscoelastic testing — early in major surgical bleeding, especially cardiac surgery.
• Consider fibrinogen concentrate for confirmed hypofibrinogenaemia in adult cardiac surgical bleeding.
• Use cryoprecipitate where concentrate is unavailable or unaffordable; the target is the fibrinogen level, not the product.
• Do not extrapolate the adult findings to children, where no benefit was shown.
• Embed replacement in a goal-directed bleeding protocol rather than giving it empirically.

Why it matters

It strengthens the case for treating measured low fibrinogen early rather than reaching first for plasma.

Don't overread it

Most studies were non-randomised, comparators varied, and results were driven by cardiac surgery.

The statistics, in plain English

An incidence rate ratio of 0.72 means 28% fewer red cell units were given. The platelet interval (0.33 to 0.95) is wide, so the true reduction could be small. A pooled analysis cannot fully separate the product from the protocol that guided its use.

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