TEG-Directed Transfusion in Complex Cardiac Surgery: Impact on Blood Product Usage

Abstract

Complex cardiac procedures often require blood transfusion because of surgical bleeding or coagulopathy. Thrombelastography (TEG) was introduced in our institution to direct transfusion management in cardiothoracic surgery. The goal of this study was to quantify the effect of TEG on transfusion rates peri- and postoperatively. All patients who underwent complex cardiac surgery, defined as open multiple valve repair/replacement, coronary artery bypass grafting with open valve repair/replacement, or aortic root/arch repair before and after implementation of TEG were identified and retrospectively analyzed. Minimally invasive cases were excluded. Patient characteristics and blood use were compared with t test and chi-square test. A generalized linear model including patient characteristics, preoperative and postoperative lab values, and autotransfusion volume was used to determine the impact of TEG on perioperative, postoperative, and total blood use. In total, 681 patients were identified, 370 in the pre-TEG period and 311 patients post-TEG. Patient demographics were not significantly different between periods. Mean units of red blood cells, plasma, and cryoprecipitate were significantly reduced after TEG was implemented (all, p < .0001); use of platelets was reduced but did not reach significance. Mean units of all blood products in the perioperative period and over the entire stay were reduced by approximately 40% (both, p < .0001). Total proportion of patients exposed to transfusion was significantly lower after introduction of TEG (p < .01). Controlling for related factors on multivariate analysis, such as preoperative laboratory values and autotransfusion volume, use of TEG was associated with significant reduction in perioperative and overall blood product transfusion. TEG-directed management of blood product administration during complex cardiac surgeries significantly reduced the units of blood products received perioperatively but not blood usage more than 24 hours after surgery. Overall, fewer patients were exposed to allogenic blood. The use of TEG to guide blood product administration significantly impacted transfusion therapy and associated costs.

Agreement Between the TEG 6s and TEG 5000 Analyzers in Extracorporeal Membrane Oxygenation

“…To further explore these points, we applied a commonly used TEG interpretation protocol that has been previously evaluated in cardiac surgery to the TEG results from our subjects. 22 Based strictly on this protocol, TEG 5000 and TEG 6s would have resulted in similar clinical management in 26 (76.5%), 33 (97.1%), and 32 (94.1%) of the patients in our study in regards to r-time, MA, and α-angle, respectively. Fresh frozen plasma, platelets, or fibrinogen would have been administered based on abnormal TEG 5000 r-time, MA, or α-angle in four (11.8%), one (2.9%), and two (5.9%) instances where blood product administration would not have been suggested based on TEG 6s results.…”

Review of Thromboelastography (TEG): Medical and Surgical Applications

“…27 A large prepost intervention trial in 2017 by Moront, Fleming, and Redfern including 681 patients showed that mean units of blood products decreased by 40%, decreased risk of reoperation, reduced postoperative length of stay (LOS), and decreased 6-month mortality. 19,28 Trauma surgery is another specialty utilizing TEG to identify coagulopathy and guide therapy. Trauma is the leading cause of death worldwide for people aged 15-49.…”

“…27 A large prepost intervention trial in 2017 by Moront, Fleming, and Redfern including 681 patients showed that mean units of blood products decreased by 40%, decreased risk of reoperation, reduced postoperative length of stay (LOS), and decreased 6-month mortality. 19,28…”