The importance of the use of rotational thrombelastometry during intraoperative bleeding: Rotational elastometry and intraoperative bleeding

Abstract

Introduction. Massive haemorrhage requires infusion of fluids that do not contain coagulation factors, which leads to dilutional coagulopathy. Blood products therapy based on the results of the coarse screening tests can be unpurposeful. Case report. A 75-year-old patient was addmited to the surgical intensive care unit (ICU) Clinical Center 'Zvezdara; as an emergency with the symptoms of hypovolemic shock. In order to compensate the lost fluid volume administered as crystalloids, colloids, concentrated red cells and fresh frozen plasma. The patient was quickly transported to the operation room for surgical treatment, with the additional lost about 3 L of blood during surgery. Continued treatment with the administration of crystalloid and 5% albumin in relation 1.3:1, concentrated red blood cells, fresh frozen plasma, with the vasoactive support. During the surgery, it was observed that the diffuse bleeding starts. In order to prevent further deterioration of the situation, an analysis of rotation thrombelastometry (ROTEM) is conducted, which showed a low value of MCF <50s in EXTEM and INTEM test, in the FIBTEM less than 9 mm which implies a lack of fibrinogen, and extended CT in INTEM, which indicated a lack of coagulation factors. Also, the extended value of CFT and shortened α angle in EXTEM and INTEM pointed to dysfunction of platelet and low fibrinogen. The therapy was furher continued with application of cryoprecipitate, platelet transfusion and tranexamic acid. The control finding of ROTEM analysis showed prolonged CT> 240s in INTEM, as well as in APTEM, the MCF at the lower limit of the FIBTEM, which indicated the need for replacement of fresh frozen plasma and platelets. Therapy is continued, after which thebleeding is stopped, and at the end of surgery, the patient was hemodynamically stable, adequated urine output, transported to the ICU. Conclusion. Application of modern additional tests of coagulation allows quick differential diagnosis of pathophysiological mechanisms of coagulopathy in massive bleeding.