Thromboelastography after Cardiopulmonary Bypass: Does it Save Blood Products?

Hasan, Omar; Tung, Robert; Freeman, Hadley; Taylor, Whitney; Helmer, Stephen D.; Reyes, Jared; Grizzell, Brett E.

doi:10.17161/kjm.vol15.15789

Cited by 6 publications

(4 citation statements)

References 14 publications

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“…These investigators obtained point-of-care (POC-TEG) results within a couple of minutes. However, average number of platelet units transfused per patient did not decline [4]. In their data, mortality was only 2.5% and re-exploration rate was only 2%.…”

Section: Discussionmentioning

confidence: 85%

“…In Deppe's data, re-exploration rates were 4.2%, regardless of being before or after adoption of TEG, emphasizing that TEG data has shown variable results. Some authors state it is useful for reducing platelet transfusions [4,5]. Deppe's group showed NNT with TEG is 9 to reduce one unit of transfusion of any product, and NNT is 6.6 for FFP [5].…”

Section: Discussionmentioning

confidence: 99%

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The Significant Role of Point-Of Care Coagulation Studies: Shorter Cardiac Surgery, Better Renal Function and Tranexamic Acid Can Not Alone Reduce Early Platelet Transfusions

Skidmore,

Borne,

Kallurkar

et al. 2023

Preprint

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Introduction: In recent years, platelets have been in short supply and high demand. Approximately one in five cardiac surgery patients require platelets. In our safety-net hospital, however, the incidence is over 40%. Renal dysfunction, long cardiopulmonary bypass (CPB) times, and absence of tranexamic acid (TXA) are common risk factors for requiring platelet transfusions. Methods: Our hypothesis was fewer platelets would be transfused within two hours after bypass under these three conditions: creatinine is low, predicted surgery duration is short, and TXA is uniformly administered. Our anesthesia department designed this retrospective before-and-after observational study when the surgery department decided to narrow preoperative criteria respective to these three elements. The Institutional Review Board of Louisiana State University Health Sciences Center Shreveport approved of the protocol and waived individual informed consent. We compared timing of platelet transfusions (within 7 days) in consecutive patients who had CPB during the first ninety days of 2022 to those in 2023 using t-tests in SAS 9.3. Confounders included age, weight, anticoagulants, gender, and the platelet counts and hemoglobin immediately prior to platelet transfusion. Secondary outcomes were postoperative day two creatinine and other components transfused. Results: Preoperatively creatinine tended to be higher in 2022 at 1.5 vs 1.1, reaching significance postoperatively at 1.9 vs 1.1 (p=0.02). Bypass times decreased from 174 to 124 minutes (p=0.06). TXA use increased from 18 of 28 to 26 of 29 patients. Platelet counts increased on bypass from 142 to 173 (p=0.06). Platelet and hemoglobin nadirs were higher (day 3: 8g/dL vs 8.8, p=0.04; 98 vs 138, p=0.005). Platelet units transfused per patient tended to increase (0.75+/-1 vs 0.93+/-1.5); if exposed, patients tended to receive more units (2.1+/-1.3 vs 2.5+/-1.4) sooner. Changes in transfusions for red cells were nonsignificant at 1.97 per patient to 1.21, cryoprecipitate 0.36 to 0.69, and FFP 0.93 to 0.83. Conclusions: This is the first study examining timing of platelet transfusions after bypass. In the present investigation, we measured platelet count during bypass and prothrombin hours after arrival in the intensive care. Platelets were often administered in sets of two because of scarce immediate supply, partly from lack of an agitator table. More importantly, these data support a need for point-of-care thromboelastograms intraoperatively, but the cost has been prohibitive. Some centers’ algorithms list triggers for transfusion by fibrinogen and prothrombin times, available immediately after separation from bypass.

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Section: Discussionmentioning

confidence: 85%

Section: Discussionmentioning

confidence: 99%

The Significant Role of Point-Of Care Coagulation Studies: Shorter Cardiac Surgery, Better Renal Function and Tranexamic Acid Can Not Alone Reduce Early Platelet Transfusions

Skidmore,

Borne,

Kallurkar

et al. 2023

Preprint

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mentioning

confidence: 99%

“…Product TransfusionThe use of TEG in cardiovascular surgeries significantly reduced blood product transfusion compared to clinician-guided practice[67][68][69][70][71][72][73][74][75][76]. However, it was not associated with any change in ICU stay or mortality[69,71,72]. Redfern et al 2020 found that TEG-guided protocol significantly reduced blood product use, costs, and reoperation rates; however, it did not impact mortality compared to clinician discretion in 1098 US cardiac patients[74] Sun et al 2014.…”

mentioning

confidence: 99%

Thromboelastography in the Perioperative Period: A Literature Review

Ramanujam¹,

DiMaria²,

Varma³

2023

Cureus

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Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.

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