title: Impact of fibrinogen levels on outcomes after acute injury in patients requiring a massive transfusion.
abstract: BACKGROUND
  For critically injured patients requiring a massive transfusion, the optimal plasma fibrinogen level is unknown. The purpose of this study was to examine the impact of the fibrinogen level on mortality. We hypothesized that decreasing fibrinogen levels are associated with worse outcomes.
  
  
  METHODS
  All patients undergoing a massive transfusion from January 2000 through December 2011 were retrospectively identified. Those with a fibrinogen level measured on admission to the surgical ICU were analyzed according to their fibrinogen level (normal [≥180 mg/dL], abnormal [≥101 to <180 mg/dL], and critical [≤100 mg/dL]). Primary outcome was death. Multivariate analysis evaluated the impact of fibrinogen on survival.
  
  
  RESULTS
  There were 260 patients who met inclusion criteria. Ninety-two patients had normal admission fibrinogen levels, 114 had abnormal levels, and 54 patients had critical levels. Patients with a critical fibrinogen level had significantly higher mortality at 24 hours compared with patients with abnormal (31.5% vs 5.3%; adj. p < 0.001) and normal fibrinogen levels (31.5% vs 4.3%; adjusted p < 0.001). Patients with a critical fibrinogen level had significantly higher in-hospital mortality compared with patients with abnormal (51.9% vs 25.4%; adjusted p = 0.013) and normal fibrinogen levels (51.9% vs 18.5%; adjusted p < 0.001). A critical fibrinogen level was the most important independent predictor of mortality (p = 0.012).
  
  
  CONCLUSIONS
  For patients undergoing a massive transfusion after injury, as the fibrinogen level increased, a stepwise improvement in survival was noted. A fibrinogen level ≤100 mg/dL was a strong independent risk factor for death. The impact of an aggressive fibrinogen replacement strategy using readily available products warrants further prospective evaluation.
authors.affiliation: Division of Trauma and Surgical Critical Care, Department of Surgery, Keck School of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA 90033, USA. Kenji.Inaba@med.usc.edu
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Efstathios
authors.initials: E
authors.lastname: Karamanos
authors.forename: Thomas
authors.initials: T
authors.lastname: Lustenberger
authors.forename: Herbert
authors.initials: H
authors.lastname: Schöchl
authors.forename: Ira
authors.initials: I
authors.lastname: Shulman
authors.forename: Janice
authors.initials: J
authors.lastname: Nelson
authors.forename: Peter
authors.initials: P
authors.lastname: Rhee
authors.forename: Peep
authors.initials: P
authors.lastname: Talving
authors.forename: Lydia
authors.initials: L
authors.lastname: Lam
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
mesh_terms: D000328:Adult; D001803:Blood Transfusion; D016009:Chi-Square Distribution; D005260:Female; D005340:Fibrinogen / Q000032:analysis*; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric; D015996:Survival Rate; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000097:blood* / Q000401:mortality / Q000601:surgery*
chemical_list: D005340:Fibrinogen