Authors: A Talvasto et al.
Source: Canadian Journal of Anesthesia / Journal canadien d’anesthésie, (2025) October 30; DOI: 10.1007/s12630-025-03046-7
Summary
This observational post-hoc analysis of the ALBICS trial examined 1,386 patients undergoing on-pump cardiac surgery to determine how plasma fibrinogen levels, both before and after cardiopulmonary bypass (CPB), relate to the risk of severe bleeding and need for resternotomy. Severe bleeding was defined using the Universal Definition of Perioperative Bleeding (UDPB) classification, where classes 3–4 indicated major bleeding.
Among all patients, 8.1% experienced UDPB-high bleeding, and 3.6% required resternotomy. Importantly, no patient with a preoperative fibrinogen level above 4.7 g/L (6.5% of the cohort) experienced severe bleeding or resternotomy. After adjustment for laboratory and clinical factors, preoperative fibrinogen was a modest independent predictor of both outcomes (odds ratio [OR] 0.77 per 0.9 g/L increase for severe bleeding; OR 0.65 for resternotomy).
Post-CPB fibrinogen levels were more strongly associated: no patient with a post-bypass level above 3.1 g/L (5.3% of the cohort) had major bleeding or required resternotomy. Each 0.9 g/L increase corresponded to substantially reduced odds (OR 0.51 for severe bleeding; OR 0.31 for resternotomy).
The authors conclude that post-CPB fibrinogen concentration—rather than preoperative level—has the strongest relationship with major bleeding risk, suggesting it may serve as a more relevant target for guiding replacement therapy or transfusion decisions. However, as an observational study, causality cannot be assumed.
What You Should Know
• Fibrinogen levels measured after CPB appear to better predict perioperative bleeding than those measured preoperatively.
• Thresholds of > 4.7 g/L (pre-CPB) and > 3.1 g/L (post-CPB) were associated with zero cases of major bleeding or resternotomy.
• These findings argue for focusing on post-bypass hemostatic status when managing coagulopathy after cardiac surgery.
• Because this analysis was post-hoc, prospective studies are still needed to validate optimal fibrinogen thresholds and assess whether supplementation truly reduces bleeding risk.
Thank you to the Canadian Journal of Anesthesia for allowing us to use this article.