Perioperative dilutional coagulopathy treated with fresh frozen plasma and fibrinogen concentrate: a prospective randomized intervention trial.

Lancé and colleagues present the results of a randomized clinical trial investigating the effect of administration of 4 fresh frozen plasma (FFP) units (21 patients) vs. 2 FFP units together with 2 g of fibrinogen concentrate (22 patients) on hemostasis in patients undergoing major elective surgery and experiencing massive bleeding, defined as blood loss >150 mL/h or 1.5 mL/kg/20 min or >700 mL at one time. Additionally, hemostasis was also assessed by calibrated automated thrombin generation (CAT) and rotational thromboelastometry (ROTEM) before and after the intervention.

No difference with regard to efficacy of the interventions was observed with insufficient hemostasis in 4/21 in the FFP group vs. 5/22 in the FFP + fibrinogen group (p = 0.93). A likely explanation for the poor response is that patients were suboptimally transfused prior to the intervention as illustrated by pre-intervention ROTEM analysis demonstrating increased clotting time and reduced maximal clot firmness, both outside normal reference values, most probably due to dilutional coagulopathy. Consequently the patients should have been transfused with both FFP and platelets earlier during surgery, and such an approach probably would have avoided the development of massive bleeding. As expected, the group receiving only FFP developed improved thrombin generation as compared to those receiving FFP + fibrinogen, whereas the latter developed a stronger clot.

In conclusion, the limitations of the present study demonstrate that goal-directed timely interventions with FFP and platelets may be warranted in patients with substantial blood loss.

– Pär Johansson