Plasma fibrinogen level on admission to the intensive care unit is a powerful predictor of postoperative bleeding after cardiac surgery with cardiopulmonary bypass.

In a large prospective single-centre observational cohort study, Kindo et al. investigated the role of perioperative fibrinogen concentration as a predictor of excessive postoperative bleeding in 1956 patients (30-month study period, 2008-2011) having undergone cardiac surgery (CABG, valve/thoracic aorta surgery) with cardiopulmonary bypass (CBP).

“Excessive bleeding” was defined as a 24-hour blood loss exceeding the 90th percentile of distribution (i.e. chest tube output ≥1200 mL). The different potential risk factors for significant postoperative bleeding were tested using a multivariate logistical regression analysis. A receiver operating characteristic curve analysis was performed to identify the best postoperative fibrinogen cutoff level to predict significant postoperative bleeding.

Of the 1956 patients, 189 (9.7%) had excessive postoperative bleeding. Multivariate analysis identified fibrinogen concentration upon ICU admission (not preoperative fibrinogen concentration!) as an independent risk factor and the best laboratory test to predict excessive postoperative bleeding. The best “cutoff” fibrinogen concentration was 2.2 g/L. The second best parameter to predict excessive postoperative bleeding was prothrombin time.

Further studies are needed to validate the concept of intraoperative administration of fibrinogen concentrate and prothrombin complex concentrate to reduce postoperative bleeding and allogeneic transfusion after cardiac surgery with CPB.

– Oliver Habler