Thromboelastography in the assessment of bleeding following surgery for congenital heart disease
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Published on: November 28, 2018
Robert A Niebler1, Joan C Gill, Christopher P Brabant
1Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.
Insights
Thromboelastography (TE) can help identify coagulation issues in pediatric cardiac surgery patients experiencing bleeding. Early TE abnormalities after cardiopulmonary bypass may predict and guide treatment for significant postoperative hemorrhage.
Area of Science:
- Pediatric Cardiac Surgery
- Hemostasis and Thrombosis
- Point-of-Care Diagnostics
Background:
- Perioperative bleeding is a significant concern in pediatric cardiac surgery.
- Standard coagulation tests often fail to fully capture bleeding derangements in these patients.
- Thromboelastography (TE) offers a more comprehensive assessment of coagulation.
Purpose of the Study:
- Establish normal preoperative TE parameters in pediatric patients undergoing cardiopulmonary bypass.
- Compare TE findings with standard coagulation tests postoperatively.
- Evaluate TE's utility in identifying and managing significant postoperative hemorrhage.
Main Methods:
- Prospective observational study of 60 pediatric patients undergoing cardiopulmonary bypass.
- TE measurements taken preoperatively, intraoperatively, and postoperatively.
- TE data compared with standard coagulation parameters and clinical bleeding outcomes.
- TE was not used for clinical decision-making during the study.
Main Results:
- Preoperative TE parameters aligned with existing pediatric norms.
- TE-guided transfusion recommendations differed significantly from standard test results.
- Postoperative TE measures showed significant differences in patients with bleeding early after protamine.
- Bleeding cessation correlated with interventions aligned with TE recommendations.
Conclusions:
- Abnormalities in TE are common early post-cardiopulmonary bypass in pediatric patients with significant bleeding.
- TE effectively illustrates coagulation system derangements.
- TE may assist clinicians in managing postoperative bleeding in pediatric cardiac surgery.
Background:
Perioperative bleeding is common in pediatric cardiac surgery patients. Traditional laboratory tests do not adequately characterize coagulation derangements in patients with bleeding. We sought to establish preoperative thromboelastography parameters in children prior to cardiopulmonary bypass, to compare thromboelastography assessment with standard coagulation parameters postoperatively, and to assess thromboelastography in children with significant hemorrhage.
Methods:
Sixty patients requiring cardiopulmonary bypass were enrolled in a prospective observational study of perioperative thromboelastography. Thromboelastography measures were obtained preoperatively, intraoperatively after protamine administration, upon admit to the intensive care unit, and when patients were treated for bleeding. Thromboelastography measures were not used for clinical care. Postoperative thromboelastography measurements were compared with the standard coagulation parameters. Intraoperative thromboelastography, postoperative thromboelastography, and clinical outcomes were compared among patients who did and did not have significant postoperative bleeding.
Results:
Preoperative thromboelastography parameters were similar to other published normal values for pediatric patients. Transfusion recommendations based on thromboelastography measurements were significantly different from those based on the standard coagulation testing. Thromboelastography measures after initial protamine administration were significantly different in patients with postoperative bleeding. This difference was not present upon arrival to the intensive care unit. Patients with significant bleeding tended to cease bleeding when clinical interventions were in agreement with recommendations based on thromboelastography.
Conclusions:
Pediatric patients with significant postoperative bleeding after surgery are more likely to have abnormal thromboelastography early after cessation of cardiopulmonary bypass. Thromboelastography illustrates derangements in the coagulation system and may aid in the treatment of postoperative bleeding.
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