Thrombelastometry guided blood-component therapy after cardiac surgery: a randomized study

Background Significant bleeding is a well known complication after cardiac surgical procedures and is associated with worse outcome. Thrombelastometry (ROTEM (R)) allows point-of-care testing of the coagulation status but only limited data is available yet. The aim was to evaluate the ROTEM (R)-guided blood component therapy in a randomized trial. Methods In case of significant postoperative bleeding (> 200 ml/h) following elective isolated or combined cardiac surgical procedures (including 14% re-do procedures and 4% requiring circulatory arrest) patients were randomized to either a 4-chamber ROTEM (R)-guided blood-component transfusion protocol or received treatment guided by an algorithm based on standard coagulation testing (control). One hundred four patients (mean age: 67.2 +/- 10.4 years, mean log. EuroSCORE 7.0 +/- 8.8%) met the inclusion criteria. Mean CPB-time was 112.1 +/- 55.1 min., mean cross-clamp time 72.5 +/- 39.9 min. Results Baseline demographics were comparable in both groups. Overall there was no significant difference in transfusion requirements regarding red blood cells, platelets, plasma, fibrinogen or pooled factors and the re-thoracotomy rate was comparable (ROTEM (R): 29% vs. control: 25%). However, there was a trend towards less 24-h drainage loss visible in the ROTEM (R)-group (ROTEM (R): 1599.1 +/- 834.3 ml vs. control: 1867.4 +/- 827.4 ml; p = 0.066). In the subgroup of patients with long CPB-times (> 115 min.; n = 55) known to exhibit an increased risk for diffuse coagulopathy ROTEM (R)-guided treatment resulted in a significantly lower 24-h drainage loss (ROTEM (R): 1538.2 +/- 806.4 ml vs. control: 2056.8 +/- 974.5 ml; p = 0.032) and reduced 5-year mortality (ROTEM (R): 0% vs. control: 15%; p = 0.03). Conclusion In case of postoperative bleeding following cardiac surgical procedures a treatment algorithm based on point-of-care 4-chamber ROTEM (R) seems to be at least as effective as standard therapy. In patients with long CPB-times ROTEM (R)-guided treatment may result in less bleeding, a marked reduction in costs and long-term mortality.