This cohort study reported 2 different strategies to initiate the management of diffuse bleeding in patients undergoing coronary artery bypass grafting with decreased platelet function: the first began by administering fibrinogen concentrates according to ROTEM results (n = 9), the second administered platelet concentrates and fresh frozen plasma without intraoperative monitoring (n = 19). In the fibrinogen group, a median dose of 6 g was given and increased the fibrinogen concentration from 2.1 to 3.8 g/L at the end of surgery. Total transfusion was lower in the fibrinogen group than in the allogeneic group. Postoperative outcomes were similar in both groups. This small study is very interesting. It is, however, unfortunate that this was a non-randomized study, with the inherent possibility of introducing biases in the interpretation of the results. The choice of the fibrinogen strategy was dependent of ROTEM availability; the allogeneic group was managed at the discretion of the treating physicians without a pre-established transfusion algorithm, whereas transfusion was the primary endpoint. While this study suggests that thromboelastography-guided administration of fibrinogen concentrate may be useful to manage hemorrhage, it could also be concluded that hemostasis monitoring is needed for bleeding patients. It is time for a large randomized trial with robust endpoints evaluating the hemostatic effects of fibrinogen concentrates. The CRASH-2 study has shown that conducting such convincing studies is possible. It is the turn of fibrinogen concentrates.

– Anne Godier