{'fraction_non_alphanumeric': 0.03535573985159319, 'fraction_numerical': 0.0257529463116543, 'mean_word_length': 5.128342245989304, 'pattern_counts': {'":': 0, '<': 1, '<?xml version=': 0, '>': 1, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Fibrinogen in massive haemorrhage – when and how should we replace it?

Management of bleeding is rather like home baking; the recipe varies widely and depends on the cook, local ingredients and taste. Evidence on which to base practice is limited and even the role of the staple ingredient, fresh frozen plasma (FFP), is unclear (Stanworth et al., 2004). However, with the evolution of point of care testing, demonstration of the benefits of fibrinogen-containing products (FFP and cryoprecipitate) in the management of trauma haemorrhage, both on the battle field and in the hospital setting (Stinger et al., 2008; Rourke et al., 2012) and the increasing availability of lyophilised fibrinogen concentrate there is increased interest in the management of major haemorrhage, with the recognition that ‘one size does not fit all’. In this edition of Transfusion Medicine, the roles of cryoprecipitate and fibrinogen concentrate in the management of major haemorrhage are reviewed (Yang et al., 2012). Fibrinogen is essential for clot formation and is depleted early and critically in major haemorrhage (Fries & Martini, 2010). Measurement of Clauss fibrinogen in standard coagulation screens better enables clinicians to assess haemostatic competence. In massive obstetric haemorrhage, for example, both APTT and PT may be normal in the presence of undetectable fibrinogen levels (De Lloyd et al., 2011). BCSH guidelines recommended transfusion of FFP when the APTT is 1·5 times the upper limit of normal (BCSH, 2004) which would be totally inappropriate in such a setting. More recent guidelines recognise that prolongation of the APTT or PT >1·5 times normal or a fibrinogen level <1 g L−1 represents haemostatic failure (AAGBI, 2010). Management of bleeding should aim to prevent, rather than wait for these parameters before replacing coagulation factors. In any major bleeding event management must be multidisciplinary. Management of coagulation abnormalities should be timely but targeted in an effort to avoid circulatory overload and to minimise the risk of transfusion-related complications. Attention should be paid to maintaining platelet count, above a minimum of 50 × 109 L−1, but ideally closer to 100 × 109 L−1 in massive haemorrhage (AAGBI, 2010; Rossaint et al., 2010). The