The line shown on each graph represents the median ratio (FFP:RBC 1; fibrinogen:RBC 0.9; PCC Calcitriol [in hundreds of units]:RBC …Data relating to subsequent outcomes were available for all patients. The median duration of postoperative intubation was 9.5 days (IQR: 3.5, 14) in the fibrinogen-PCC group, significantly longer than the 7 days (IQR: 2, 16) in the FFP group (P = 0.005). Median length of stay (LOS) in the ICU, however, was comparable in the two groups: 14.5 days (IQR: 8.5, 21) in the fibrinogen-PCC group and 14 days (IQR: 6, 23) in the FFP group (P = 0.95). In contrast, the median LOS in the hospital was significantly different between the two groups: 23 days (IQR: 14.5, 40.5) in the fibrinogen-PCC group and 32 days (IQR: 20, 49) in the FFP group (P = 0.005). Mortality was 10.

0% in the FFP group and 7.5% in the fibrinogen-PCC group (P = 0.69, not significant).DiscussionThe present study compared TEM-guided haemostatic therapy using fibrinogen concentrate and PCC, with standard FFP-based therapy, in trauma patients. RBC transfusion was avoided in 29% of patients in the fibrinogen-PCC group, and these patients received no transfusion of any allogeneic blood products. In contrast, RBC transfusion was avoided in only 3% of patients in the FFP group. Transfusion of platelet concentrate was avoided in 91% of patients in the fibrinogen-PCC group, compared with 56% in the FFP group. In our trauma centre, TEM-guided haemostatic therapy with fibrinogen concentrate and PCC has been associated with a continuing decrease in the use of all types of allogeneic blood products.

Minimising or avoiding exposure to allogeneic blood products is clearly desirable. The reasons for developing alternative treatments include intermittent supply shortages and public concern regarding the safety of allogeneic blood products [20,21]. Transfusion of FFP, for instance, carries the risk of transfusion-related lung injury, transfusion-associated circulatory overload, acute respiratory distress syndrome, transfusion-related immunomodulation and pathogen transmission [22-24]. Attempts to reduce FFP transfusion are complicated by the fact that small quantities of FFP are not effective in correcting coagulopathy [25,26]. Therefore, administration of FFP in larger amounts should be recommended, but high doses may have a dilutional effect on haematocrit, leading to an increase in RBC transfusion.

In contrast, our study showed a reduction in RBC and platelet concentrate transfusion among patients treated with fibrinogen Anacetrapib concentrate and PCCs. High levels of fibrinogen increase maximum clot firmness even in patients with a low platelet count, suggesting possible compensation for reduced platelet levels (it is hypothesised that an increased number of fibrin molecules binding a smaller number of platelets may be feasible without compromising clot integrity) [13,14].