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Combined Use of Rotational Thromboelastometry (Rotem) and Platelet Impedance Aggregometry (Multiplate Analyzer) in Cyanotic and Acyanotic Infants and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass: Subgroup Analysis of a Randomized Clinical Trial
Dieu, A., Van Regemorter, V., Detaille, T., Houtekie, L., Eeckhoudt, S., Khalifa, C., Kahn, D., Clement De Clety, S., Poncelet, A., Momeni, M.
Journal of Cardiothoracic and Vascular Anesthesia. 2021;35(7):2115-2123
Abstract
OBJECTIVES Few studies have investigated the Multiplate platelet function analyzer in pediatrics. The authors evaluated Multiplate combined with Rotem in terms of guiding platelet transfusion after pediatric cardiac surgery with cardiopulmonary bypass (CPB). The authors further compared coagulation parameters between cyanotic and acyanotic patients. DESIGN Subgroup analysis of a randomized clinical trial. SETTING Tertiary hospital. PARTICIPANTS Patients weighing between seven and 15 kg. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Rotem and Multiplate tests were performed (1) after anesthesia induction, (2) upon CPB separation, and (3) upon intensive care unit arrival. Among a total of 59 subjects, 9 patients required platelet transfusion. In multivariate linear regression, analysis EXTEM maximum clot firmness upon CPB separation was associated with the volume of transfused platelets (regression coefficient = -0.348 [95% confidence interval -1.006 to -0.028]; p = 0.039). No such association was found for the Multiplate test. Acyanotic and cyanotic heart disease were present in 32 and 27 children, respectively. There were no significant differences between these two groups in terms of platelet count and function. Postoperative blood loss was significantly higher in the cyanotic group compared with the acyanotic arm (p = 0.015; difference [95% confidence interval -2.40 {-4.20 to -0.60}]). There were no differences between groups regarding transfusion of allogeneic blood products. CONCLUSIONS This study showed that Rotem, but not Multiplate results, were associated with platelet transfusion in pediatric cardiac surgery with no intake of platelet inhibitors. The usefulness of combining these tests in platelet transfusion decision-making needs to be evaluated in larger populations.
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Use of Coagulation Point-of-Care Tests in the Management of Anticoagulation and Bleeding in Pediatric Cardiac Surgery: A Systematic Review
Bianchi P, Beccaris C, Norbert M, Dunlop B, Ranucci M
Anesth Analg. 2019
Abstract
Bleeding and coagulation management are essential aspects in the management of neonates and children undergoing cardiac surgery. The use of point-of-care tests (POCTs) in a pediatric setting is not as widely used as in the adult setting. This systematic review aims to summarize the evidence showed by the literature regarding the use of POCTs in children undergoing cardiac surgery. We included all studies examining the pediatric population (<18 years old) undergoing cardiac surgery in which the coagulation profile was assessed with POCTs. Three electronic databases (PubMed, Embase, and the Cochrane Controlled Clinical Trials register) were searched. Tests involved were heparin effect tests, viscoelastic tests, and platelet function tests. Due to the wide heterogeneity of the patients and tests studied, a formal meta-analysis was impossible, and the results are therefore presented through a systematic review. Eighty articles were found, of which 47 are presented in this review. At present, literature data are too weak to define POCTs as a "gold standard" for the treatment of perioperative bleeding in pediatric cardiac surgery. Nevertheless, introduction of POCTs into postoperative algorithms has shown to improve bleeding management, patient outcome, and cost efficiency.
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Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after paediatric cardiac surgery
Nakayama Y, Nakajima Y, Tanaka KA, Sessler DI, Maeda S, Iida J, Ogawa S, Mizobe T
British Journal of Anaesthesia. 2015;114((1):):91-102.
Abstract
BACKGROUND Thromboelastometric evaluation of coagulation might be useful for prediction and management of bleeding after paediatric cardiac surgery. We tested the hypothesis that the use of a thromboelastometry-guided algorithm for blood product management reduces blood loss and transfusion requirements. METHODS We studied 78 patients undergoing paediatric cardiac surgery with cardiopulmonary bypass (CPB) for the initial 12 h after operation. Stepwise multiple linear regression was used to develop an algorithm to guide blood product transfusions. Thereafter, we randomly assigned 100 patients to conventional or algorithm-guided blood product management, and assessed bleeding and red cell transfusion requirements. RESULTS CPB time, post-bypass rotational thromboelastometry (ROTEM()) EXTEM amplitude at 10 min (A10), and FIBTEM-A10 were independently associated with chest tube drainage volume during the initial 12 h after operation. Discriminative analysis determined cut-off values of 30 mm for EXTEM-A10 and 5 mm for FIBTEM-A10, and estimated optimal intraoperative fresh-frozen plasma and platelet concentrate transfusion volumes. Thromboelastometry-guided post-bypass blood product management significantly reduced postoperative bleeding (9 vs 16 ml kg(-1), P<0.001) and packed red cell transfusion requirement (11 vs 23 ml kg(-1), P=0.005) at 12 h after surgery, and duration of critical care stay (60 vs 71 h, P=0.014). CONCLUSIONS Rotational thromboelastometry-guided early haemostatic intervention by rapid intraoperative correction of EXTEM-A10 and FIBTEM-A10 reduced blood loss and red cell transfusion requirements after CPB, and reduced critical care duration in paediatric cardiac surgical patients. CLINICAL TRIAL REGISTRATION UMIN Clinical Trials Registry UMIN000006832 (December 4, 2011). The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
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Perioperative monitoring of thromboelastograph on blood protection and recovery for severely cyanotic patients undergoing complex cardiac surgery
Cui Y, Hei F, Long C, Feng Z, Zhao J, Yan F, Wang Y, Liu J
Artificial Organs. 2010;34((11):):955-60.
Abstract
In this study, we assessed the clinical effect of a new transfusion therapy guided by thromboelastograph (TEG) on blood protection. Thirty-one children with severe cyanosis (hematocrit ≥ 54%), who were diagnosed as having transposition of the great arteries or double outlet right ventricle with or without pulmonary valve stenosis, and underwent arterial switch operation or double roots transplantation, were involved and were divided into two groups. In group F (n=17), the transfusion therapy after cardiopulmonary bypass was performed with fibrinogen administration combined with traditional transfusion, guided by TEG. In group C (n=14), traditional transfusion guided by clinical experiences only was performed. We observed the blood protection effects and recovery conditions of these patients. In surgery, compared with group C, the chest closure time, fresh-frozen plasma (FFP), and platelet (PLT) volume used at closure time had no significant reductions in group F (P>0. 05, respectively), and the patients in group F had no significant reductions in the amount of chest drainage (P>0. 05). The total PLT and total red blood cells usage were also the same (P>0. 05). But during the first 24h, FFP usage in the intensive care unit (ICU) and total perioperative FFP usage had significantly dropped in group F (P<0. 05); the mechanical ventilator time, ICU stay, and hospitalization time in group F were much shorter than those in group C (P<0. 05). So, TEG was effective in perioperative blood protection. Fibrinogen could be a substitute for FFP to restore hemostasis and improve the prognosis for these patients.