Prediction of bleeding diathesis in patients undergoing cardiopulmonary bypass during cardiac surgery: viscoelastic measures versus routine coagulation test.
ABSTRACT Severe hemorrhagic tendency often complicates cardiopulmonary bypass (CPB) in cardiac surgery. In this study, we compared the effectiveness of thromboelastography (TEG), Sonoclot (SCT), and routine coagulation test (RCT) in the prediction of coagulation defects.
Forty-three patients undergoing cardiac surgery with CPB were included. Blood for RCT, TEG, and SCT profiles was sampled before systemic heparinization and after protamine administration. Clinically significant bleeding was defined as chest tube drainage in excess of 100 ml/h for 3 consecutive hours or 300 ml/h in 1 h. All coagulation parameters obtained before and after CPB were compared. The sensitivity, specificity, accuracy, false positive, and false negative rate were also calculated and compared.
All coagulation tests were within normal range except higher partial thromboplastin time. Variables which were significantly different from those before CPB included platelet count, fibrinogen level, prothrombin time, and thrombin time in RCT, alpha angle and maximum amplitude in TEG, and R2 and peak time in SCT. In the TEG tracing, all variables had high sensitivity, specificity, and accuracy (average 85.4%, 83%, and 83.5% respectively) and low false positive and negative rate (12.5% and 5% respectively). Although SCT had high sensitivity (76.3%) and low false negative rate (6.5%), its specificity and accuracy were all under 50%.
Our data demonstrated that the TEG monitoring is a useful tool for detecting post-CPB bleeding diathesis and can provide much predictive information. RCT and SCT are of limited value because of higher rate of unreliable results.
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ABSTRACT: Aims and Objectives: We assessed the clinical impact of goal-directed coagulation management based on rotational thromboelastometry (ROTEM) in patients undergoing emergent cardiovascular surgical procedures. Materials and Methods: Over a 2-year period, data from 71 patients were collected prospectively and blood samples were obtained for coagulation testing. Administration of packed red blood cells (PRBC) and hemostatic products were guided by an algorithm using ROTEM-derived information and hemoglobin level. Based on the amount of PRBC transfused, two groups were considered: High bleeders (≥5 PRBC; HB) and low bleeders (<5 PRBC; LB). Data were analyzed using Chi-square test, unpaired t-test and analysis of variance as appropriate. Results: Pre-operatively, the HB group (n = 31) was characterized by lower blood fibrinogen and decreased clot amplitude at ROTEM compared with the LB group (n = 40). Intraoperatively, larger amounts of fibrinogen, fresh frozen plasma and platelets were required to normalize the coagulation parameters in the HB group. Post-operatively, the incidence of major thromboembolic and ischemic events did not differ between the two groups (<10%) and the observed in-hospital mortality was significantly less than expected by the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM score, 22% vs. 35% in HB and 5% vs. 13% in LB group). Conclusions: ROTEM-derived information is helpful to detect early coagulation abnormalities and to monitor the response to hemostatic therapy. Early goal-directed management of coagulopathy may improve outcome after cardiovascular surgery.Annals of Cardiac Anaesthesia 01/2014; 17(2):100-8. DOI:10.4103/0971-9784.129829
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ABSTRACT: Multiple blood products are often required during and after ventricular assist device (VAD) implants. Generally, transfusion therapy is empirically guided by conventional laboratory tests. In this study, we aimed to compare a thromboelastography (TEG)-based algorithm with a laboratory coagulation test-based algorithm with respect to blood product utilization in patients undergoing VAD implant. From June 2010 to May 2012, a total of 39 consecutive patients underwent VAD implantation. Patients undergoing VAD implant were retrospectively divided into two groups according to transfusion strategy. In the control group (n=20), the need for blood transfusion was based on clinician's discretion according to standard coagulation test results. In the TEG group (n=19), a strict protocol based on TEG parameters was followed for the usage of all perioperative blood products. Coagulation factors, TEG parameters, and blood transfusions were documented and compared between these two groups. There were no differences in demographic variables with the exception of a decreased CPB time in the TEG group (p=0.019). Prothrombin time (PT) (p<0.001) and international normalized ratio (INR) (p<0.001) in the postprotamine interval were significantly higher in the TEG group than in the control group. No significant difference was detected in any coagulation variable in the postoperative (ICU) period between the two groups. Platelet counts decreased in a linear fashion from baseline to the postoperative period in the two groups (p<0.001). Patients in the TEG group received significantly less fresh-frozen plasma in both the intraoperative (p=0.005) and postoperative (p=0.014) periods. Patients in the TEG group also received significantly less platelets both in the postoperative (p=0.03) period and in total amount (p=0.033). There was no difference in consumption of packed red blood cell units between the two groups. Our results show that the strict use of a TEG-guided algorithm significantly reduces the consumption of blood products in patients undergoing VAD implantJournal of Cardiac Surgery 03/2014; 29(2):238-43. DOI:10.1111/jocs.12302 · 0.89 Impact Factor
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ABSTRACT: Intra-operative cell salvage (CS) was reported to be ineffective, safe and not cost-effective in low-bleeding-risk cardiac surgery with cardiopulmonary bypass (CPB), but studies in high-bleeding-risk cardiac surgery are limited. The objective of this study is to evaluate the efficacy, safety and cost-effectiveness of intra-operative CS in high-bleeding-risk cardiac surgery with CPB. One hundred and fifty patients were randomly assigned to either with intra-operative CS group (Group CS) or without intra-operative CS group (Group C). Study endpoints were defined as perioperative allogeneic red blood cell (RBC) transfusion, perioperative impairment of blood coagulative function, postoperative adverse events and costs of transfusion-related. Both the proportion and quantity of perioperative allogeneic RBC transfusion were significantly lower in Group CS than that in Group C (p=0.0002, <0.0001, respectively). The incidence of residual heparin and total impairment of blood coagulative function in the 24 hours after surgery, the incidence of postoperative excessive bleeding, were significantly higher in Group CS than that in Group C (p=0.018, 0.042, 0.034, respectively). Cost of both allogeneic RBC transfusion and total allogeneic blood transfusion were significantly lower in Group CS than that in Group C (p<0.001, =0.002, respectively). Cost of total blood transfusion was significantly higher in Group CS than that in Group C (p =0.001). Intra-operative CS in high-bleeding-risk cardiac surgery with CPB is effective, generally safe, and cost-effective in developed countries but not in China.International journal of medical sciences 01/2015; 12(4):322-8. DOI:10.7150/ijms.11227 · 1.55 Impact Factor