title: Higher fibrinogen concentrations for reduction of transfusion requirements during major paediatric surgery: A prospective randomised controlled trial.
abstract: BACKGROUND
  Hypofibrinogenaemia is one of the main reasons for development of perioperative coagulopathy during major paediatric surgery. The aim of this study was to assess whether prophylactic maintenance of higher fibrinogen concentrations through administration of fibrinogen concentrate would decrease the volume of transfused red blood cell (RBCs).
  
  
  METHODS
  In this prospective, randomised, clinical trial, patients aged 6 months to 17 yr undergoing craniosynostosis and scoliosis surgery received fibrinogen concentrate (30 mg kg(-1)) at two predefined intraoperative fibrinogen concentrations [ROTEM(®) FIBTEM maximum clot firmness (MCF) of <8 mm (conventional) or <13 mm (early substitution)]. Total volume of transfused RBCs was recorded over 24 h after start of surgery.
  
  
  RESULTS
  Thirty children who underwent craniosynostosis surgery and 19 children who underwent scoliosis surgery were treated per protocol. During craniosynostosis surgery, children in the early substitution group received significantly less RBCs (median, 28 ml kg(-1); IQR, 21 to 50 ml kg(-1)) compared with the conventional fibrinogen trigger of <8 mm (median, 56 ml kg(-1); IQR, 28 to 62 ml kg(-1)) (P=0.03). Calculated blood loss as per cent of estimated total blood volume decreased from a median of 160% (IQR, 110-190%) to a median of 90% (IQR, 78-110%) (P=0.017). No significant changes were observed in the scoliosis surgery population. No bleeding events requiring surgical intervention, postoperative transfusions of RBCs, or treatment-related adverse events were observed.
  
  
  CONCLUSIONS
  Intraoperative administration of fibrinogen concentrate using a FIBTEM MCF trigger level of <13 mm can be successfully used to significantly decrease bleeding, and transfusion requirements in the setting of craniosynostosis surgery, but not scoliosis.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01487837.
authors.affiliation: Department of Anaesthesia, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland thorsten.haas@kispi.uzh.ch.
authors.forename: T
authors.initials: T
authors.lastname: Haas
authors.affiliation: Department of Anaesthesia, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland.
authors.forename: N
authors.initials: N
authors.lastname: Spielmann
authors.affiliation: Department of Anaesthesia, University Hospital Zurich, Zurich, Switzerland.
authors.forename: T
authors.initials: T
authors.lastname: Restin
authors.affiliation: Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
authors.forename: B
authors.initials: B
authors.lastname: Seifert
authors.affiliation: Department of Anaesthesia, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland.
authors.forename: G
authors.initials: G
authors.lastname: Henze
authors.affiliation: Department of Oral and Maxillofacial Surgery, University Children's Hospital Zurich, Zurich, Switzerland.
authors.forename: J
authors.initials: J
authors.lastname: Obwegeser
authors.affiliation: Swiss Scoliosis, Centre for Spinal and Scoliosis Surgery, Zurich, Switzerland.
authors.forename: K
authors.initials: K
authors.lastname: Min
authors.affiliation: Department of Spine Surgery and Neurosurgery, Schulthess Clinic, Zurich, Switzerland.
authors.forename: D
authors.initials: D
authors.lastname: Jeszenszky
authors.affiliation: Department of Anaesthesia, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland.
authors.forename: M
authors.initials: M
authors.lastname: Weiss
authors.affiliation: Department of Haematology, University Children's Hospital Zurich, Zurich, Switzerland.
authors.forename: M
authors.initials: M
authors.lastname: Schmugge
mesh_terms: D000293:Adolescent; D001803:Blood Transfusion; D002648:Child; D002675:Child, Preschool; D003398:Craniosynostoses; D005260:Female; D005340:Fibrinogen / Q000008:administration & dosage* / Q000032:analysis; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D008297:Male; D011446:Prospective Studies; D012600:Scoliosis / Q000601:surgery*; D016037:Single-Blind Method
chemical_list: D005340:Fibrinogen
keywords: blood, coagulation; coagulation; coagulopathy; hemorrhage; pediatrics; thrombelastography; transfusion