Flatline Thromboelastography During Massive Intraoperative Bleeding in a Patient With Multiple Myeloma: A Case Report

Multiple myeloma is a malignant plasma cell disorder associated with complex coagulation abnormalities that may increase the perioperative bleeding risk. We report the case of a 38-year-old man with multiple myeloma, chronic kidney disease on maintenance haemodialysis, thrombocytopenia, and recent clopidogrel use, who underwent posterior spinal decompression and instrumented fusion from C7 to T6 for an epidural abscess. Intraoperatively, he developed massive hemorrhage with an estimated blood loss of 5,000 mL, accompanied by profound hemodynamic instability requiring vasopressor support. Thromboelastography (TEG) showed a flatline tracing, indicating near-complete failure of clot formation. Prompt recognition of the coagulopathy and aggressive goal-directed transfusion with 5 units of packed red blood cells, 10 units of fresh frozen plasma, and 10 units of platelets resulted in successful hemostatic resuscitation and stabilization. The coagulopathy was likely multifactorial, due to a combination of hemostatic dysfunction associated with multiple myeloma, uremic platelet dysfunction, thrombocytopenia, recent antiplatelet therapy, and ongoing surgical bleeding. This case highlights the importance of viscoelastic testing in identifying severe coagulopathy in patients with plasma cell malignancies and guiding perioperative transfusion management.