Abstract

PURPOSE Intraoperative bleeding should be regularly assessed visually to guide coagulation management. Whereas viscoelastic testing with ROTEM® measurement has been proven to be useful in detecting coagulopathies, the visual assessment is not standardized. This study therefore aims to compare a standardized visual assessment with ROTEM® results. METHODS A 5-point bleeding score was created and applied in a recently published randomized controlled trial in major pediatric non-cardiac surgery. This score assesses overall bleeding tendency and the occurrence of diffuse bleeding, aqueous bleeding, bleeding outside the operative field, and the ability to control bleeding. Validity of this score was tested by post hoc comparison to the results of simultaneously performed ROTEM® measurements. RESULTS Signs of coagulopathic bleeding were assessed at 183 time points. Mild to moderate bleeding intensity was judged at 103 time points, in 42 % abnormal ROTEM® traces were obtained simultaneously. When severe bleeding was scored, abnormal ROTEM values occurred in 58 %, and FIBTEM-values were significantly lower than in the "no bleeding group". Altogether, the correlation between bleeding score and ROTEM® measurements was not significant. CONCLUSIONS The standardized visual assessment did not correlate well with ROTEM® measurements, suggesting that it is not useful to detect coagulopathy. Trial registry number: ClinicalTrials.gov identifier No. NCT01487837.

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.

Abstract

BACKGROUND Systematic preoperative coagulation testing is still widely used in children scheduled for surgery, although current guidelines recommend that a bleeding history should be the first choice for hemostatic assessment. We performed a systematic review with meta-analysis to evaluate the pertinence of bleeding questionnaire and screening laboratory testing to detect bleeding disorders (BDs) in children and to predict abnormal surgical blood loss. METHODS A search was conducted in PubMed, EMBASE, MEDLINE(R), Cochrane Central Register of Controlled Trials, Health technology Assessment, and all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED and EBM Reviews) up to October 22, 2013. Prospective trials containing 20 children or more and any tests evaluating either the ability of the test to detect a congenital BD or the ability of the test to predict increased surgical blood loss were retained. The quality of the study was judged with the Cochrane Collaboration Tool and two investigators extracted data independently. Data were combined to calculate the pooled diagnostic odds ratio (DOR) and their 95% confidence intervals (CI 95%). I(2) statistics were used to assess statistics heterogeneity. RESULTS Data could be extracted from 16 studies. Best results for detecting a congenital abnormality at potential risk for increased surgical blood loss were obtained with the PFA-100 (DOR = 113.0; 95% CI, 22.6-566.2; I(2) = 0%) in two studies, followed by the bleeding time in two other studies (DOR = 110.7; 95% CI, 24.4-502.3; I(2) = 0%). With a high amount of heterogeneity, questionnaires showed disappointing performances (DOR = 7.9; 95% CI: 3.5-17.5; I(2) = 72.6%). CONCLUSION Current evidence does not identify a tool that adequately predicts BDs and/or abnormal surgical blood loss in children. Questionnaires currently available do not perform well. In the setting of a pediatric coagulation clinic, the PFA-100 has the highest chance of detecting a BD. This meta-analysis highlights the weakness of the literature regarding the prediction of perioperative bleeding due to congenital hemostatic disorders in children.Copyright © 2015 John Wiley & Sons Ltd.

Abstract

BACKGROUND Critically ill, extremely premature infants develop anemia because of intensive laboratory blood testing and undergo multiple red blood cell (RBC) transfusions in the early weeks of life. To date, researchers have had only limited success in finding ways to reduce transfusions significantly in this patient population. OBJECTIVE To reduce RBC transfusions for these infants by using a point-of-care bedside monitor that returns analyzed blood to the patient. DESIGN, SETTING, AND PATIENTS This was a prospective, 2-center, randomized, open, controlled, clinical trial with a 1:1 assignment of extremely low birth weight infants (weighing 500-1000 g at birth) to control or monitor groups and analysis with the intention-to-treat approach. Predefined RBC transfusion criteria were applied uniformly in the 2 groups. INTERVENTIONS Clinical treatment of study subjects with an in-line, ex vivo, bedside monitor that withdraws blood through an umbilical artery catheter, analyzes blood gases and sodium, potassium, and hematocrit levels, and returns the sample to the patient. MAIN OUTCOME MEASURES The total volume and number of RBC transfusions during the first 2 weeks of life and the total volume of blood removed for laboratory testing. RESULTS The trial was terminated prematurely when one center's NICU changed its standard method of laboratory testing. In the first 2 weeks of life, there was a nonsignificant 17% lower cumulative RBC transfusion volume in the monitor group (n = 46), compared with the control group (n = 47). However, data from the first week only (the period of greater catheter use) demonstrated a significant 33% lower cumulative RBC transfusion volume in the monitor group. Cumulative phlebotomy loss was approximately 25% less in the monitor group throughout the 2-week study period. There was no difference between groups in neonatal mortality, morbidity, and neurodevelopmental outcome rates at 18 to 24 months. This is the first randomized trial documenting that RBC transfusions administered to neonates can by reduced by decreasing laboratory phlebotomy loss. CONCLUSIONS As long as an umbilical artery catheter is available for blood sampling with an in-line blood gas and chemistry monitor, significant reductions in neonatal RBC transfusions can be achieved. The patients most likely to benefit from monitor use are the smallest, most critically ill newborns.