The essay by Rincon-Valenzuela et al1 raises excellent points concerning the use of fibrinogen in hemorrhage, and not just in obstetric hemorrhage. The cause-effect relationship between bleeding and fibrinogen has not been adequately examined, and the Bradford Hill criteria are all too often forgotten in modern medicine. It could be argued that, although plausibility can be identified for the use of fibrinogen in bleeding, neither an accurate biological gradient nor experimental proof of the relevance of fibrinogen has been adequately demonstrated in different clinical situations. Even temporality is unclearly demonstrated, because we know that fibrinogen levels fall in the postpartum period even in nonbleeding women. Studies in cardiac surgery2 have, similarly to the Fibrinogen concentrate as initial treatment for Postpartum Haemorrhage trial,3 failed to produce useful data supporting the routine use of fibrinogen. We would like to suggest several factors that need to be considered in future studies. First, the correlation between fibrinogen levels and functional clotting needs to be more clearly delineated and could be achieved by combining fibrinogen level measurements with thromboelastography in specific patient groups. Secondly, the effect on bleeding by adjusting fibrinogen levels to predefined levels in randomized studies needs to be examined. Only then can the relevance of fibrinogen be confirmed. We think it likely that thromboelastography will come to play a much more significant role in the management of bleeding, allowing an individualized management of factor substitution. Only then will the use of fibrinogen as a "magic bullet" end and management become more individualized and appropriate.
Serviços Personalizados
Journal
Artigo
Indicadores
- Citado por SciELO
- Acessos
Links relacionados
- Citado por Google
- Similares em SciELO
- Similares em Google
Compartilhar
Colombian Journal of Anestesiology
versão impressa ISSN 0120-3347
Rev. colomb. anestesiol. vol.46 no.1 Bogotá jan./mar. 2018
LETTER TO THE EDITOR
Thorough epidemiological studies are required to guide further improvements in hemorrhage management
a Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Münich, München, Germany
References
1. Rincon-Valenzuela DA, Bocanegra JC, Guevara J. Fibrinogen and postpartum hemorrhage: association or causality? Rev Colomb Anestesiol 2017;45:136-139. [ Links ]
2. Bilecen S, de Groot JA, Kalkman CJ, et al. Effect of fibrinogen concentrate on intraoperative blood loss among patients with intraoperative bleeding during high-risk cardiac surgery: a randomized clinical trial. JAMA 2017;317:738-747. [ Links ]
3. Wikkelso AJ, Edwards HM, Afshari A, et al. Pre-emotive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth 2015;114:623-633. [ Links ]