Impact of Preoperative Fibrinogen Testing on Blood Loss in Adult Spinal Deformity Surgery

31st Annual Meeting of the North American Spine Society Highlight

Literature shows that intraoperative and postoperative bleeding can lead to higher rates of surgical morbidity and increased care costs, but there’s less evidence on the role of preoperative fibrinogen level—despite it being one of the key biomarkers for blood loss risk. Eeric Truumees, MD presented findings that sought to understand the potential association between fibrinogen, bleeding, and transfusion requirements in adult spinal deformity corrections during the 31st Annual Meeting of the North American Spine Society, October 26-29, in Boston. 
Fibrinogen test tube"Fibrinogen is one of the first factors consumed, and when depleted, excessive bleeding may occur."Fibrinogen is a soluble protein synthesized in the liver. It’s a key protein in the coagulation cascade that goes through the vascular tree until it is lysed by thrombin into the insoluble fibrin, which then forms a netting onto which clots can form.

“However, during large procedures, as bleeding continues, fibrinogen is one of the first factors consumed, and when depleted, excessive bleeding may occur,” he said. Dr. Truumees is an orthopaedic spine surgeon and Chief Executive Officer of Seton Brain and Spine Institute where he practices. Furthermore, he is Professor of Surgery at Dell Medical School also in Austin, TX. “We came into this study through our increased use of TEG [thromboelastography] to identify patients at higher bleeding risk, and better drive blood product and clotting factor replacement.”

Understanding the Impact of Fibrinogen Level on Adult Spinal Deformity Correction
Over two years, the research team performed a retrospective analysis of 190 consecutive adult patients undergoing scoliosis corrections. The patient population was predominantly female with an average age of 57 years. There was a mix of ethnicities in the cohort, though Caucasian patients had the highest representation.

The team collected an array of clinical variables, including age, sex, operative time, the TEG parameters, total blood loss, and any transfusions required.

While both males and females had normal TEG values and fibrinogen levels, there were some differences between the sexes. Females had statistically higher platelet counts, and males had higher hemoglobin counts.

The team used Pearson’s test to investigate the correlations.

“We found that preoperative fibrinogen concentration correlated significantly and positively with total bleeding volume and negatively with the number of transfusions, “Dr. Truumees said. “Interestingly, it also correlated with operating time.”

Additionally, the data revealed that TEG parameters and preoperative fibrinogen levels correlated significantly with each other.

On the other hand, more typical clotting parameters, such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count, did not correlate with preoperative fibrinogen levels.

Putting the Results to Practice
Dr. Truumees and his research team found that preoperative fibrinogen concentration correlates significantly with the total bleeding volume during and after adult scoliosis surgical correction. This finding is supported by similar research in adult idiopathic scoliosis, cardiothoracic surgery, and pediatric general surgery.

“We suggest that preoperative fibrinogen levels should be assessed and incorporated into perioperative blood management programs in patients undergoing spine surgery for scoliosis,” Dr. Truumees said.

He also noted there is still controversy as to what spine surgeons might do with the results.

“Often, ‘oozy’ patients are given platelets or FFP [fresh frozen plasma], which may not be the most rational response,” Dr. Truumees said. “Fibrinogen concentrates are available, and increasingly things like TEA [tranexamic acid] are used. This is an issue we’ll continue to study prospectively.”

To view additional meeting highlights from the 31st Annual Meeting of NASS, click here.

Updated on: 10/26/17
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