The Debate ROTEMs on–the Utility of Point-of-care Testing and Fibrinogen Concentrate in Postpartum Hemorrhage

Abstract

(Anaesthesia. 2020;75:1247–1251) A 2019 report by McNamara et al revealed 4 years of data from their use of rotational thromboelastometry (ROTEM) to help guide the treatment of major obstetric hemorrhage (PPH; defined as >1500 mL estimated blood loss with continued bleeding or evidence of shock). Their proposed ROTEM-guided strategy for transfusion called for fibrinogen concentrate to treat coagulopathy in place of fresh frozen plasma (FFP) and/or cryoprecipitate. The ROTEM-based protocol was compared to the previous care standard, which included a shock pack containing four units of FFP, four units of packed red cells, and one pooled unit of platelets. The authors of the original report noted that use of the ROTEM-guided transfusion algorithm had a statistically significant reduction in the number of units and total volume of blood products transfused. This, in turn, pushed them to argue that not all women who experience major PPH are coagulopathic suggesting that perhaps goal-directed transfusion guided by point-of-care (POC) testing is more justified than the routine use of transfusion shock packs in these cases. This issue of Clinical Consequences aims to discuss several controversies: use of fibrinogen concentrates in PPH-related coagulopathy, utility of POC testing in obstetrics and impact of POC testing in guidelines for PPH management; and finally the McNamara et al paper’s likely influence on clinical practice.