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. 2012 Apr;39(2):121-128.
doi: 10.1159/000337723. Epub 2012 Mar 15.

Thromboelastometry Based Early Goal-Directed Coagulation Management Reduces Blood Transfusion Requirements, Adverse Events, and Costs in Acute Type A Aortic Dissection: A Pilot Study

Alexander A Hanke  1 , Ulf Herold, Daniel Dirkmann, Konstantinos Tsagakis, Heinz Jakob, Klaus Görlinger
Affiliations

Thromboelastometry Based Early Goal-Directed Coagulation Management Reduces Blood Transfusion Requirements, Adverse Events, and Costs in Acute Type A Aortic Dissection: A Pilot Study

Alexander A Hanke et al. Transfus Med Hemother. 2012 Apr.

Abstract
in English, German

BACKGROUND: In aortic surgery bleeding complications can be fatal. Therefore, rotational thromboelastometry(ROTEM™)-based coagulation management was introduced. METHODS: After 5 cases of acute type A aortic dissection and aortic arch replacement had been treated based on ROTEM findings (ROTEM group; RG), 5 cases without ROTEM were matched as control group (CG). CG treatment was based on conventional tests and clinical findings. Blood component and coagulation factor requirements, ventilation time, duration of stay at intensive care unit (ICU), hospitalization, and thrombotic or bleeding incidents as well as transfusion-associated costs were compared. RESULTS: Administration of blood products and coagulation factor concentrates, ventilation time, ICU length of stay, and hospitalization tended to be lower in RG. Postoperative plasma transfusion (p = 0.038), recognized incidents (p = 0.048), and resulting costs on coagulation treatment (p = 0.049) were significantly reduced. CONCLUSION: Our data suggest that ROTEM-based coagulation management can reduce transfusion requirements and corresponding costs in patients with aortic arch replacement. These data has to be confirmed by prospective randomized trials.

Hintergrund: Blutungskomplikationen in der Aortenchirurgie gehen mit erheblichen Risiken für die Patienten einher und können fatale Folgen haben. Aus diesem Grund wurde ein Rotationsthromboelastometrie(ROTEM™)-basierter Algorithmus zum Gerinnungsmanagement eingeführt.

Methoden: Nach 5 Fällen von Patienten mit akuter Typ-A-Aorten-Dissektion und entsprechendem Aortenbogenersatz, welche gemäß dem genannten Algorithmus therapiert wurden (ROTEM-Gruppe; RG), wurden 5 Fälle ohne ROTEM-Monitoring als Kontrollgruppe (CG) genutzt. Die Therapie der CG basierte auf konventionellen Labortests und klinischen Eindrücken. Der Verbrauch von Blutkomponenten und Gerinnungsfaktorkonzentraten, Ventilations-und Liegezeiten auf der Intensivstation wie auch die Dauer des Intensivaufenthalts und der Hospitalisierung wurden erfasst. Ferner wurden thrombembolische und Blutungskomplikationen sowie die transfusionsassoziierten Kosten analysiert.

Ergebnisse: Der Verbrauch von Blutprodukten und Gerinnungsfaktorkonzentraten, die Beatmungsdauer, die Intensivliegedauer sowie die Hospitalisierung waren tendenziell niedriger in der RG. Der postoperative Verbrauch an gefrorenem Frischplasma (p = 0,038), die Komplikationshäufigkeit (p = 0,048) und die transfusionsassoziierten Kosten (p = 0,049) waren in der RG signifikant reduziert.

Schlussfolgerung: Unsere Daten deuten darauf hin, dass durch ein ROTEM-basiertes Gerinnungsmanagement der Bedarf an Transfusionen und die entsprechend assoziierten Kosten bei Patienten mit akuter Typ-A-Dissektionen reduziert werden können. Dies muss künftig durch prospektive randomisierte Studien belegt werden.

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Figures

Fig. 1
Fig. 1
Algorithm for point-of-care coagulation management in patients with acute type A aortic dissection based on results of rotational thromboelastometry (ROTEM). ROTEM parameter: CT = clotting time; MCF = maximum clot firmness. ROTEM Assays: EX = EXTEM; FIB = FIBTEM; IN = INTEM; HEP = HEPTEM. Other abbreviations: Cai = ionized calcium; CPB = cardiopulmonary bypass; DDAVP = desmopressin; FXIII = factor XIII concentrate; FFP = fresh frozen plasma; Hb = hemoglobin; PCC = prothrombin complex concentrate; PRBC = packed red blood cells; rFVIIa = activated recombinant factor VII; Tc = core temperature.
Fig. 2
Fig. 2
Requirements for allogeneic blood products and coagulation factor concentrates during surgery: In the ROTEM group (white bars) less packed red blood cells (RBC), fresh frozen plasma (FFP), fibrinogen concentrate, prothrombin complex concentrate (PCC), and antithrombin concentrate (ATIII) were used as compared to control group (grey bars). None of these reductions achieved statistical significance during surgery alone. PC = platelet concentrates.
Fig. 3
Fig. 3
Requirements for allogeneic blood products and coagulation factor concentrates during the first 24 postoperative h at ICU: In the ROTEM group (white bars) less packed red blood cells (RBC) and fresh frozen plasma (FFP) were transfused, but only the reduction in FFP transfusion achieved statistical significance (p = 0.038). PC = platelet concentrates, PCC = prothrombin complex concentrate, ATIII = antithrombin concentrate.
Fig. 4
Fig. 4
Requirements for allogeneic blood products and coagulation factor concentrates during the whole study period (during surgery and the first 24 postoperative h at ICU): In the ROTEM group (white bars) less packed red blood cells (RBC), fresh frozen plasma (FFP), fibrinogen concentrate, prothrombin complex concentrate (PCC), and antithrombin concentrate (ATIII) was used. Only reduction of FFP transfusion and ATIII administration achieved statistically significance in this pilot study. PC = platelet concentrate.
Fig. 5
Fig. 5
Postoperative ventilation time, duration of stay at ICU, and hospitalization time. All parameters showed a trend to reduction in the ROTEM group (white bars) without achieving statistically significance. ICU = intensive care unit.
Fig. 6
Fig. 6
Primary costs of transfused allogeneic blood products and coagulation factor concentrates per case: Primary costs of intra- and postoperative transfusion of allogeneic blood products and administered coagulation factor concentrates per case were reduced in the ROTEM group (white bars). Only reduction of overall costs (sum of intra- and postoperative costs) achieved statistically significance in this pilot study (p = 0.049).
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