You phone goes off – you roll over it is 2am – when you pick up it is a theatre nurse calling to ask if you can urgently come to the hospital immediately – the team are too busy to talk to you. The nurse tells you a woman has just arrived via ambulance from another small peripheral hospital. She had an emergency caesarean about 6 hours ago and hasn’t stopped bleeding since. She has had 4 units of red cells and 4-5 litres of saline but nothing else. When you arrive 15min later surgery is underway but the surgical team tell you “everything we touch is bleeding” and you notice that she is even bleeding from the skin around her iv…… The anaesthetic registrar turns to you and says – “lets give her the fibrinogen concentrate – we need to get on top of this coagulopathy right now!……”
(*Fictitious case example)
This week we are joined by a colleague and a great friend of mine Dr Hamish Mace, one of the co-authors of an article in the 2017 edition of Australasian Anaesthesia (aka the Blue Book) entitled “Fibrinogen concentrate for the treatment of acquired hypofibrinogenaemia”. Hamish is a consultant anaesthetist working in Western Australia – he works at Fiona Stanley Hospital a large tertiary centre in metropolitan Perth – but has also worked in the past in remote regional centres in WA, in retrieval medicine for the RFDS (Royal Flying Doctor Service) and spent time on fellowship in Toronto Canada. Hamish co-ordinates the preoperative anaemia correction service, is on the hospital transfusion committee, has a strong interest in many aspects of patient blood management.
In the interview we briefly discuss the role of fibrinogen in the acquired coagulopathy that often develops during major haemorrhage, the historical treatments used (FFP, cryoprecipitate), the history of fibrinogen concentrate and where we think fibrinogen concentrate might fit into the current management of major haemorrhage – both in tertiary but also remote, regional and retrieval situations.
For those of you who are interested in reading on this topic in detail here is the link to the ANZCA website page where you can access the article written by Hamish and Mansi – the article itself has many great references. Their article is in the 2017 edition. Check out all the other great critical care and anaesthesia articles in this book – a quick shout out to Richard Riley the editor of this great biannual publication.
In the interview we also talk about the value of measuring fibrinogen an coagulation rapidly with point of care viscoelastic tests. Check out our ROTEM learning package right here on this website (of which Hamish was also a co-author).
Advice on mixing and administering fibrinogen concentrate: