Thromboelastometry-guided therapy of massive gastrointestinal bleeding in a 12-year old boy with severe Graft-versus-Host disease.

Abstract

An increasing number of publications report the use of point-of-care (POC) viscoelastic assessments, e.g. ThromboElastoMetry (ROTEM®, Tem International GmbH, Munich, Germany) and ThrombElastoGraphy (TEG), in the management of transfusion therapy in patients with massive bleeding1. Whole blood thromboelastometry/thrombelastography analysers are attractive tools for studying the simultaneous and integrated effects of different components (i.e. plasma factors, platelets, leucocytes, and red blood cells) involved in the dynamic process of clot formation and lysis2. The main advantages of the use of POC devices are: (i) speed of response; (ii) the possibility of creating an algorithm of action; (iii) bedside monitoring; and (iv) the possibility of exploring different coagulation pathways simultaneously. Three standard assays can be performed by ROTEM®: INTEM, EXTEM, and FIBTEM. In the INTEM and EXTEM assays, the intrinsic or the extrinsic coagulation pathway is triggered, respectively. The FIBTEM assay assesses the specific role of fibrinogen in clot formation following platelet inhibition by cytochalasin D. The activation of the coagulation phase (clotting time [CT], sec), the clot propagation phase (clot formation time [CFT], sec) and the clot stabilisation phase (maximum clot firmness [MCF], mm) are the main parameters that describe the ROTEM® profiles. The thromboelastometry/thrombelastography method offers the possibility of simultaneously applying a therapeutic and diagnostic (so called “theragnostic”) approach able to define early goal-directed therapy3. The fields in which these POC methods have been increasingly applied are those of cardiac surgery4, liver transplantation5 and trauma6. The benefits of POC in paediatric gastrointestinal bleeding are still to be evaluated. We report here the case of a 12-year old boy who experienced haemorrhagic shock due to intestinal Graft-versus-Host disease (GvHD) after bone marrow transplantation. The management of bleeding through the ROTEM® profiles allowed us to optimise the treatment administered for the management of the bleeding. Written informed consent was obtained from the child’s mother.