Aferição laboratorial de fibrinogênio plasmático como preditor de transfusão de hemocomponentes no período perioperatório em pacientes submetidos à cirurgia ortopédica de grande porte: estudo de coorte
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Data
2022-09-29
Autores
Pagnussatt Neto, Eugenio
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Universidade Estadual Paulista (Unesp)
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Introdução e Objetivos: No processo de hemostasia, o fibrinogênio participa da agregação plaquetária formando uma espécie de rede, além de, após ser clivado pela trombina, resultar em monômeros de fibrina que são polimerizados para formar o coágulo. Há tendência ao aumento do sangramento perioperatório em pacientes com níveis plasmáticos de fibrinogênio inferiores a 200 mg.dL-1. O objetivo deste estudo foi avaliar se há associação entre os valores pré-operatórios de fibrinogênio e a transfusão de hemocomponentes no período perioperatório de cirurgia ortopédica de grande porte. Métodos: Em estudo observacional de coorte, foram incluídos pacientes adultos, de ambos os sexos, submetidos à artroplastia primária ou revisão de artroplastia de quadril por etiologias não traumáticas. No período pré-operatório, foram avaliados o fibrinogênio plasmático, o hemograma, o coagulograma e a contagem de plaquetas para avaliar a associação dessas variáveis com o emprego de hemocomponentes no período perioperatório (até 48 horas após a cirurgia). Estipulou-se o valor do fibrinogênio sérico de 200 mg.dL-1 para os cálculos da predição de transfusão de hemocomponentes. Também foi analisada a associação de fatores intraoperatórios (tipo de cirurgia, técnica anestésica, uso de antifibrinolíticos e tempo cirúrgico) e a necessidade de hemotransfusão. Para validação do teste prognóstico – fibrinogênio plasmático pré- operatório - quanto à sua capacidade de rastreio de pacientes com risco de transfusão, viii foram calculados o valor da sensibilidade, especificidade, valores preditivos, acurácia e as razões de verossimilhança positiva e negativa. Resultados: No total, 195 pacientes foram avaliados. A média (desvio padrão) do valor plasmático de fibrinogênio foi de 315 (83) mg.dL-1 e somente 13 pacientes tiveram valores inferiores a 200 mg.dL-1, sendo que apenas um destes pacientes recebeu transfusão sanguínea, com risco absoluto (1/13) = 7,69% (intervalo de confiança [IC] de 95%: 1,37% - 33,31%). Não houve associação entre o valor plasmático pré-operatório de fibrinogênio e a ocorrência de transfusão sanguínea no perioperatório (p = 0,745). A sensibilidade e o valor preditivo positivo do fibrinogênio plasmático < 200 mg.dL-1 como preditor de transfusão foram 4,17% (IC 95%: 0,11% - 21,12%) e 7,69% (IC 95%: 1,12% - 37,99%), respectivamente, e acurácia de 82,05% (IC 95%: 75,93% - 87,17%). Houve associação entre a ocorrência de transfusão sanguínea e valores pré-operatórios mais baixos de hemoglobina (p = 0,028) e do hematócrito (p = 0,006), assim como entre essas medidas no pós-operatório (p = 0,001). A cirurgia de revisão de artroplastia do quadril (p = 0,005) e o maior tempo cirúrgico (p = 0,001) também foram associados à maior ocorrência de transfusão. A idade, o sexo, a cor de pele, o índice de massa corporal, a classificação do estado físico e os componentes do coagulograma não foram associados à maior incidência de hemotransfusão. Conclusão: O valor pré-operatório do fibrinogênio plasmático nas cirurgias de quadril não está associado à realização de transfusão sanguínea e não é eficaz como biomarcador para risco de transfusão de hemocomponentes. Entretanto, valores menores de hemoglobina e do hematócrito nos períodos pré e pós-operatório, assim como o tipo de cirurgia e o tempo cirúrgico se associam com a realização de hemotransfusão.
Introduction and Objectives: During hemostasis, fibrinogen plays a role in platelet aggregation by forming a kind of net, in addition to the fact that, after being cleaved by thrombin, results in fibrin monomers that are polymerized to form the clot. There is a tendency towards an increased perioperative bleeding in patients with plasma fibrinogen levels below 200 mg.dL-1 . The aim of this study was to assess whether there is an association between preoperative fibrinogen levels and transfusion of blood components in the perioperative period of major orthopedic surgery. Methods: In an observational cohort study, adult patients from both sexes who underwent primary hip arthroplasty or revision hip arthroplasty of non-traumatic etiologies were evaluated. In the preoperative period, plasma fibrinogen, blood count, coagulogram and platelet count were evaluated for a possible association of these variables with the use of blood components in the perioperative period (up to 48 hours after surgery). Plasma fibrinogen level of 200 mg.dL-1 was the cut-off value to calculate the prediction of blood components transfusion. The association of intraoperative factors (type of surgery, anesthetic technique, use of antifibrinolytics and surgical time) and the need for blood components were also analyzed. To validate the prognostic test – preoperative plasma fibrinogen – regarding its ability to screen patients at risk for transfusion, sensitivity, specificity, predictive values, accuracy and positive and xi negative likehood ratios were calculated. Results: Overall, 195 patients were evaluated. The mean (standard deviation) of plasma fibrinogen value was 315 (83) mg.dL-1 and only 13 patients had values lower than 200 mg.dL-1 , and only one of these patients received a blood transfusion, with absolute risk (1/13) = 7.69% (95% confidence interval [CI]: 1.37% - 33.31%). There was no association between the preoperative plasma value of fibrinogen and the occurrence of perioperative blood transfusion (p = 0.745). The sensibility and the positive predictive value of plasma fibrinogen < 200 mg.dL-1 as a predictor of blood transfusion were 4.17% (95% CI: 0.11% - 21.12%) and 7.69% (95% CI: 1.12% - 37.99%) respectively, and the accuracy of the test was 82.05% (95% CI: 75.93% - 87.17%). There was an association between blood transfusion and lower preoperative values of hemoglobin (0.028) and hematocrit (p = 0.006) as well as their values in postoperative period (p = 0.001). The revision arthroplasty (p = 0.005) and a longer surgical time (p = 0.001) were also associated with a higher occurrence of transfusion. Age, sex, skin color, body mass index, physical status classification and coagulogram were not associated with a higher incidence of blood transfusion. Conclusion: The preoperative value of plasma fibrinogen in hip arthroplasties is not associated with blood transfusion and is not effective as a biomarker for the risk of blood components transfusion. However, lower values of hemoglobin and hematocrit in the pre and postoperative periods, as well as the type of surgery and surgical time, are associated with blood transfusion.
Introduction and Objectives: During hemostasis, fibrinogen plays a role in platelet aggregation by forming a kind of net, in addition to the fact that, after being cleaved by thrombin, results in fibrin monomers that are polymerized to form the clot. There is a tendency towards an increased perioperative bleeding in patients with plasma fibrinogen levels below 200 mg.dL-1 . The aim of this study was to assess whether there is an association between preoperative fibrinogen levels and transfusion of blood components in the perioperative period of major orthopedic surgery. Methods: In an observational cohort study, adult patients from both sexes who underwent primary hip arthroplasty or revision hip arthroplasty of non-traumatic etiologies were evaluated. In the preoperative period, plasma fibrinogen, blood count, coagulogram and platelet count were evaluated for a possible association of these variables with the use of blood components in the perioperative period (up to 48 hours after surgery). Plasma fibrinogen level of 200 mg.dL-1 was the cut-off value to calculate the prediction of blood components transfusion. The association of intraoperative factors (type of surgery, anesthetic technique, use of antifibrinolytics and surgical time) and the need for blood components were also analyzed. To validate the prognostic test – preoperative plasma fibrinogen – regarding its ability to screen patients at risk for transfusion, sensitivity, specificity, predictive values, accuracy and positive and xi negative likehood ratios were calculated. Results: Overall, 195 patients were evaluated. The mean (standard deviation) of plasma fibrinogen value was 315 (83) mg.dL-1 and only 13 patients had values lower than 200 mg.dL-1 , and only one of these patients received a blood transfusion, with absolute risk (1/13) = 7.69% (95% confidence interval [CI]: 1.37% - 33.31%). There was no association between the preoperative plasma value of fibrinogen and the occurrence of perioperative blood transfusion (p = 0.745). The sensibility and the positive predictive value of plasma fibrinogen < 200 mg.dL-1 as a predictor of blood transfusion were 4.17% (95% CI: 0.11% - 21.12%) and 7.69% (95% CI: 1.12% - 37.99%) respectively, and the accuracy of the test was 82.05% (95% CI: 75.93% - 87.17%). There was an association between blood transfusion and lower preoperative values of hemoglobin (0.028) and hematocrit (p = 0.006) as well as their values in postoperative period (p = 0.001). The revision arthroplasty (p = 0.005) and a longer surgical time (p = 0.001) were also associated with a higher occurrence of transfusion. Age, sex, skin color, body mass index, physical status classification and coagulogram were not associated with a higher incidence of blood transfusion. Conclusion: The preoperative value of plasma fibrinogen in hip arthroplasties is not associated with blood transfusion and is not effective as a biomarker for the risk of blood components transfusion. However, lower values of hemoglobin and hematocrit in the pre and postoperative periods, as well as the type of surgery and surgical time, are associated with blood transfusion.
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Palavras-chave
Coagulação, Exames da coagulação, Fibrinogênio, Transfusão de sangue, Cirurgia, Ortopedia, Anestesia, Fibrinogen, Surgery, Orthopedics, Anesthesia, Blood transfusion, Blood coagulation tests