Rotational Thromboelastometry Values Research Articles

P204 Utility of Rotational Thrombo-Elastometry as an Objective Measure of Hypercoagulability in Patients with Ulcerative Colitis-A Prospective Case Control Study

Abstract Background Inflammatory bowel disease (IBD) has an increased risk of venous thromboembolism (VTE) with factors like hospitalization and surgery increasing this risk. Although few recent guidelines recommend anticoagulation thromboprophylaxis for hospitalised IBD patients, there is wide variation in reported practices for VTE prophylaxis. This study was aimed to evaluate Rotational Thrombo-Elastometry (ROTEM) for assessing blood coagulation status in ulcerative colitis (UC) and to evaluate the relationship between ROTEM, disease severity and response to treatment. Methods This was a prospective age- and sex-matched study with 60 patients each in UC and irritable bowel syndrome (IBS) groups, latter being controls. Clinical details, blood investigations including ROTEM and D-dimer were collected and analysed after taking informed consent. Hypercoagulable state was defined using Kaufmann’s classification. ROTEM parameters [clotting time (CT), clot formation time (CFT), alpha angle (AA), maximum clot firmness (MCF), maximum lysis (ML)] and D-dimer levels were compared between the two groups. Results Of the 60 UC patients (age: 38.6±11.64 years, 44 males); 15(25%) were in remission, 18(30%), 17(28.3%) and 10(16.7%) had mild, moderate, and severe disease respectively. The UC group had significantly more hypercoagulable ROTEM than the control group (66.7% vs. 36.7%, p=0.001). Hypercoagulable ROTEM was found in 9(60%), 8(44.4%), 14(82.3%) and 9(90%) of those in remission, with mild, moderate and severe UC respectively. Compared to controls; CT [292.36±70.45 vs 337.56±77.89, p=0.001], CFT [103.15±30.31 vs 128.61±40.18, p=0.0001], AA [69.88±5.19 vs 65.36±6.4, p=0.00004], MCF [65.75±5.64 vs 63.25±4.43, p=0.008] and D-dimer levels [329(63-2358) vs 145.5(54-1304), p=0.00001) were significantly abnormal in UC group. Among UC patients with mild, moderate and severe disease; only CFT, AA and D-dimer were significantly different between the groups. There was no significant difference in ROTEM values and D-dimer level in patients with severe UC after one week of treatment. On univariate analysis; partial Mayo score [OR: 1.49, 95% CI: 1.04-2.12, p=0.028], serum albumin [OR: 0.32, 95% CI: 0.10-0.98, p=0.04], hemoglobin [OR: 0.59, 95% CI: 0.40-0.86, p=0.007], and platelets [OR: 1, 95% CI: 1.01-1.02, p=0.035], were predictors of hypercoagulable state in active UC. On multivariate analysis; only haemoglobin [OR: 0.61, 95% CI: 0.38-0.98, p=0.04] was found to be significant independent predictor. Conclusion UC patients had hypercoagulable ROTEM regardless of activity of inflammatory process. The degree of hypercoagulability increased with disease activity. Low haemoglobin was found to predictive of hypercoagulable state in active UC patients.

P65: Predictors of Bleeding with Rotational Thromboelastometry in Patients with a Left Ventricular Assist Device

Purpose: Bleeding events are a significant source of morbidity and mortality in patients with left ventricular assist devices (LVAD). Rotational thromboelastometry (ROTEM) is a form of viscoelastographic testing that provides a real-time analysis of clot initiation, clot strength, and fibrinolysis. There is limited data regarding the use of ROTEM in predicting bleeding events in patients with LVADs post-implantation. Therefore, the purpose of this study is to determine if any component in ROTEM is associated with bleeding events in LVAD patients. Methods: This was a retrospective, single-centered, cohort study of LVAD patients implanted between January 2013 to December 2022 that compared ROTEM values between patients admitted due to bleeding and non-bleeding controls. ROTEM values drawn within 24 hours of separate hospitalizations were included. Patient encounters were excluded for the following reasons: ROTEM drawn after receiving blood or anticoagulant reversal agent, parenteral anticoagulation, or direct oral anticoagulants, and admission related to thrombotic events, index implantation, or device exchange. The primary outcome was to determine if ROTEM values were associated with bleeding events. Results: Of the 327 patient admissions evaluated, 266 patient encounters met inclusion criteria with 59 (22.2%) bleeding events and 207 (77.2%) controls. Of the excluded patients, 28 patients were excluded due to ROTEM drawn after receiving blood or an anticoagulant reversal agent. Baseline characteristics including age, gender, race, ethnicity, device type, last ejection fraction, and indication for implant were similar between groups. Patients admitted for a bleeding event were more likely to have a history of any bleeding event (p=0.01). There was no significant difference seen in the regression analysis evaluating INTEM clot time (p=0.55), INTEM clotting formation time (p=0.45), EXTEM clotting time (p=0.72), FIBTEM clot formation time (p=0.78), and FIBTEM clotting time (p=0.78) for patients experiencing a bleeding event vs those without a bleeding event (table 1). Conclusion: There are no differences in ROTEM values in LVAD patients admitted for bleeding events compared to non-bleeding admissions. Table 1.

Baseline rotational thromboelastometry (ROTEM) values in a healthy, diverse obstetric population and parameter changes by pregnancy-induced comorbidities

Background Point-of-care testing provides a representation of the patient’s coagulability status during effective postpartum hemorrhage management. Baseline values of rotational thromboelastometry (ROTEM) have not yet been reported in a heterogeneous obstetric population. This study aimed to establish a baseline for a diverse population representative of the United States. The secondary aim was to evaluate the association of these hematologic parameters with comorbidities, race, and socioeconomic factors. Methods The study was a retrospective review of collected ROTEM values of women undergoing vaginal or cesarean delivery with a history of or at risk for postpartum hemorrhage. Patients were divided into healthy and comorbid groups. Exclusion criteria for both groups included active or recent bleeding, receipt of blood products or clot-enhancing factors, and liver disease. Mean values of ROTEM by race and comorbidities were included. Median values were reported for intrinsic pathway thromboelastometry (INTEM), extrinsic pathway thromboelastometry (EXTEM), and fibrin polymerization thromboelastometry (FIBTEM) amplitude at 10 minutes (A10) and 20 minutes (A20), coagulation time, clot formation time, and maximum clot firmness. Results A total of 681 records were reviewed; 485 met inclusion criteria, and 267 met healthy criteria. The mean (standard deviation) demographics for maternal age (years), body mass index (kg/m2), and gestational age (weeks) were 32.2 (5.7), 34 (7.3), and 35.4 (5), respectively. The median INTEM, EXTEM, and FIBTEM A10 were 63, 65, and 23 mm. The mean for INTEM, EXTEM, and FIBTEM A10 was increased for those who were Black or obese, whereas a decreased FIBTEM and EXTEM A10 was noted in those who were Asian or those who had the hemolysis, elevated liver enzymes, low platelet syndrome. Conclusions Our heterogeneous population presents ROTEM values within the interquartile range of those previously reported in European studies. Black race, obesity, and preeclampsia were associated with hypercoagulable profiles.

The use of rotational thromboelastometry parameters in understanding the coagulopathy following hump-nosed viper (Hypnale spp) bites: a preliminary study

BackgroundHump-nosed vipers (HNV; Hypnale spp) are one of the medically important venomous snakes in Sri Lanka and South-Western regions of India. The haemostatic dysfunction due to HNV bites is poorly characterized by standard diagnostic tests performed to identify coagulopathy. We aimed to determine the usefulness of rotational thromboelastometry (ROTEM) parameters compared to 20-minute whole blood clotting test (WBCT20) and prothrombin time (PT) in understanding the coagulopathy of HNV bites.MethodsTwenty-three HNV snakebite patients in a prospective study of 127 consecutive snakebites were recruited. After recording details of the clinical presentation, PT/international normalized ratio (INR), WBCT20 and ROTEM delta were performed at presentation.ResultsIn this preliminary study, none of the patients had clinically apparent bleeding. Coagulopathy was detected by either WBCT20, INR or ROTEM in 13 HNV patients. Eleven had a coagulopathy detectable by ROTEM (either abnormal EXTEM-CT, INTEM-CT or FIBTEM-MCF) but with negative WBCT20. Of them, only two had prolonged INR values. Two patients had positive WBCT20 but with normal ROTEM and INR values. The remaining 10 patients did not show any coagulopathy either by INR, ROTEM or WBCT20.ConclusionIn this preliminary study with small number of sample size, ROTEM parameters appeared to be more sensitive to subtle changes in coagulation compared to WBCT20. The clinical utility of detecting these changes and their usefulness in managing snakebite should be explored further in a larger study.

Association Between Thromboelastometry Identified Hypercoagulability and Thromboembolic Complications After Arthroplasty: A Prospective Observational Study in Patients With Obesity.

The prothrombotic state of obesity can increase the risk of thromboembolism. We aimed to investigate if there was an association between baseline hypercoagulable rotational thromboelastometry (ROTEM) profile and thromboembolic complications in arthroplasty patients with obesity. Patients with a body mass index ≥ 25 kg/m2 and/or waist circumference ≥94 cm (M) and 80 cm (F) undergoing hip and knee arthroplasty had pre- and postoperative ROTEM. ROTEM values were compared by outcome status using an independent sample equal-variance t-test. Of the 303 total participants, hypercoagulability defined as extrinsically activated thromboelastometry maximum clot firmness G score ≥ 11 K dyne/cm2, was observed in 90 (30%) of the 300 participants with preoperative ROTEM assays. Clinically significant thromboembolic complications occurred in 5 (1.7%) study participants before discharge and in 10 (3.3%) by 90 days. These included 6 with pulmonary emboli, 3 with deep venous thrombus, and 1 with myocardial infarction. We found no evidence for an association between baseline hypercoagulability and incident thromboembolic events, analysis limited by the number of events. Postoperative decrease in platelets and an increase in fibrinogen were observed. ROTEM parameter changes differed across obesity categories.

Impaired fibrinolysis in severe Covid-19 infection is detectable in early stages of the disease.

A significant degree of mortality and morbidity in Covid-19 is due to thromboembolic disease. Coagulopathy has been well described in critically unwell patients on ICU. There is less clear evidence regarding these changes at the time of presentation to the Emergency Department and the progression of disease over time. We sought to investigate whether coagulation markers can predict severity and how they change over the disease course. Patients presenting to a single University Teaching Hospital were recruited and followed up if PCR was positive. Alongside routine blood testing, Rotational Thromboelastometry (ROTEM) was performed. Outcome data was recorded for all patients, and ROTEM values were compared across outcome groups. Extem and Intem Maximum Lysis were significantly reduced in those who died or required an ICU admission, indicating a reduced ability to break down clot mass in the most critically unwell patients. Comparisons between groups demonstrated that one distinguishing feature between those who require ICU admission or die of Covid-19 compared with those who survive a hospital stay to discharge was the extent to which fibrinolysis could occur. Mortality and morbidity in Covid-19 infection appears in part driven by an inability to break down clot mass.

Specific Parameters of Intraoperative Changes in the Hemostasis System during Liver Resection in Children

The objective: to determine severity of changes in the hemostasis system in children occurring at main stages of liver resection as well as the need for their intraoperative correction.Subjects and Methods. A single-center prospective pilot study of coagulogram and rotational thromboelastometry values was conducted in 25 children aged 0–11 years old with hepatoblastoma after a course of chemotherapy according to the PRETEX IV regimen who underwent hemihepatectomy.Results. There were no statistically significant differences in parameters of the ROTEM tests both when comparing groups and when comparing hemihepatectomy stages within the same age group of patients. At the beginning of the separation of the liver parenchyma INTEM: CT 200.00 (186.00; 238.00), CFT 88.00 (83.00; 139.00), MCF 54.00 (51.00; 61.00), ML 0.00 (0.00; 5.00) in Group I, CT 191.00 (179.00; 199.00), CFT 84.00 (79.00; 103.00), MCF 60.00 (58.00; 64.00), 4,00 (3.00; 9.00) in Group II, respectively, p > 0.05. After separation of the liver parenchyma INTEM: CT 201.00 (161.00; 237.50), CFT 93.00 (95.00; 112.00), MCF 54.00 (52.50; 59.50), ML 6.00 (2.00; 10.00) in Group I, CT 229.00 (201.00; 285.00), CFT 93.00 (78.00; 177.00), MCF 59.00 (49.00; 60.00), ML 5.00 (5.00; 10.00) in Group II, respectively, p > 0.05.Conclusion. After chemotherapy courses, children aged 0–11 years suffering from hepatoblastoma, maintain normal functional activity of the hemostasis system at all stages of surgical treatment. In children under 11 years of age, routine hemostasis correction with blood products and prothrombin complex factor concentrate is not required during the main stages of hemihepatectomy.

Rotational Thromboelastometry Values After On-Pump Cardiac Surgery - A Retrospective Cohort Study.

Viscoelastic coagulation monitoring is recommended for coagulation management after cardiac surgery, but optimum target values are poorly defined. To determine "to-be-expected" values in rotational thromboelastometry (ROTEM) after heparin reversal, to correlate ROTEM parameters with fibrinogen levels and platelet count, and to estimate the effect of hemoglobin levels on these measurements. We retrospectively analyzed 571 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass from 12/2018 to 08/2020. ROTEM and conventional laboratory measurements were performed 5 to 10 minutes after protamine administration. Clotting times in EXTEM, INTEM, and FIBTEM were significantly prolonged (72.6%, 96.1%, and 31.8% above reference ranges, respectively). Clot firmness parameters in EXTEM and INTEM were relevantly reduced (7.9% to 14.4% and 9.1% to 32.3% below the reference ranges, respectively). There was an excellent linear correlation of FIBTEM amplitude after 10 min (A10) and of maximal clot firmness (MCF) with fibrinogen concentrations (r = .81 and .80). Areas under receiver operating characteristic (AUROC) for identifying hypofibrinogenemia <1.5 g/L were between .80 and .87. No effect of hematocrit was observed. We also found a linear correlation of EXTEM, INTEM, and EXTEM-FIBTEM at both A10 and MCF with platelet counts (.32 to .68). The AUROCs for identifying thrombocytopenia (<100,000/μL) were .79 to .84, and were greater for A10 than for MCF measurements (P=.074, .001, and <.001, respectively). "To-be-expected" ROTEM values after CPB are different from the published reference ranges. ROTEM parameters might allow for reliable estimation of fibrinogen level and platelet count without being influenced by hematocrit.

Coagulopathy Underlying Rotational Thromboelastometry Derangements in Trauma Patients: A Prospective Observational Multicenter Study.

Viscoelastic hemostatic assays such as rotational thromboelastometry (ROTEM) are used to guide treatment of trauma induced coagulopathy. The authors hypothesized that ROTEM derangements reflect specific coagulation factor deficiencies after trauma. This was a secondary analysis of a prospective cohort study in six European trauma centers in patients presenting with full trauma team activation. Patients with dilutional coagulopathy and patients on anticoagulants were excluded. Blood was drawn on arrival for measurement of ROTEM, coagulation factor levels, and markers of fibrinolysis. ROTEM cutoff values to define hypocoagulability were as follows: EXTEM clotting time greater than 80 s, EXTEM clot amplitude at 5 min less than 40 mm, EXTEM lysis index at 30 min less than 85%, FIBTEM clot amplitude at 5 min less than 10 mm, and FIBTEM lysis index at 30 min less than 85%. Based on these values, patients were divided into seven deranged ROTEM profiles and compared to the reference group (ROTEM values within reference range). The primary endpoint was coagulation factors levels and fibrinolysis. Of 1,828 patients, 732 (40%) had ROTEM derangements, most often consisting of a combined decrease in EXTEM and FIBTEM clot amplitude at 5 min, that was present in 217 (11.9%) patients. While an isolated EXTEM clotting time greater than 80 s had no impact on mortality, all other ROTEM derangements were associated with increased mortality. Also, coagulation factor levels in this group were similar to those of patients with a normal ROTEM. Of coagulation factors, a decrease was most apparent for fibrinogen (with a nadir of 0.78 g/l) and for factor V levels (with a nadir of 22.8%). In addition, increased fibrinolysis can be present when the lysis index at 30 min is normal but EXTEM and FIBTEM clot amplitude at 5 min is decreased. Coagulation factor levels and mortality in the group with an isolated clotting time prolongation are similar to those of patients with a normal ROTEM. Other ROTEM derangements are associated with mortality and reflect a depletion of fibrinogen and factor V. Increased fibrinolysis can be present when the lysis index after 30 min is normal.

Investigation of predictors of bleeding complications in COVID-19 using rotational thromboelastometry (ROTEMⓇ): A retrospective study.

BackgroundHemorrhagic complications in patients with coronavirus 19 disease (COVID‐19) are infrequent but associated with a prognosis. This study aimed to elucidate the risk factors for bleeding complications in patients with COVID‐19 using rotational thromboelastometry (ROTEM) parameters and blood tests performed at admission.MethodsIn total, 31 patients with severe COVID‐19 treated intensively at Saga University Hospital were included in this study. Patients were divided into two groups according to the presence or absence of hemorrhagic complications. Results from the blood tests performed at admission and during hospitalization, and ROTEM values acquired upon admission, were compared between the two groups.ResultsThere were significant differences in ROTEM values upon admission between the bleeding and non‐bleeding groups. Receiver operating curve analysis showed that the area under the curve for prothrombin time international normalized ratio (PT‐INR) and extrinsically‐activated test with tissue factor (EXTEM) amplitude at 10 min (A10) were 0.82 (0.52–0.92) and 0.81 (0.58–0.93), respectively. Logistic regression analysis with PT‐INR and EXTEM A10 as factors calculated an odds ratio of 1.94 (1.04–3.62) and EXTEM A10 0.86 (0.71–1.05) for bleeding complications occurrence.ConclusionROTEM may be a sensitive predictor for bleeding complications in patients with COVID‐19.

Abstract WP117: Post-procedural Screening With ROTEM For Risk Of Hemorrhage Following Revascularization Therapy For Acute Ischemic Stroke

Introduction: Hyperfibrinolysis is associated with intracerebral hemorrhage (ICH) after the use of tPA for acute ischemic stroke (AIS). Point-of-care Rotational ThromboElastoMetry (ROTEM) testing may rapidly detect hyperfibrinolysis and identify AIS patients at high risk for hemorrhage. Hypothesis: Evidence of fibrinogen depletion on ROTEM will accurately predict bleeding following revascularization therapy for AIS. Methods: We reviewed medical records of AIS patients who underwent revascularization therapy between 2019-2020. All patients underwent ROTEM testing post-procedure to facilitate targeted blood product transfusion should hemorrhage occur. However, transfusion was not performed prophylactically. Repeat imaging with dual-energy CT was performed within 24 hours. A quality control registry of all AIS patients who undergo revascularization is maintained for purposes of Joint Commission certification. All variables, including ROTEM values and occurrence of intra- and extracranial hemorrhage, were entered prospectively. We examined the predictive value of a FIBTEM-A10 &lt;10mm for post-procedural hemorrhage. Results: A total of 52 patients were included. Median age was 68 years (Interquartile Range, IQR 60-83), and median admission NIHSS was 16 (IQR 10-20). Thirty-four patients (65%) received tPA, 46 (88%) received mechanical thrombectomy, and 28 (54%) received both. Median post-procedure FIBTEM-A10 was 16mm (IQR 14-22); 5 patients had values &lt;10mm. Overall, 19 (37%) suffered radiographic ICH, 5 (10%) symptomatic ICH, and 3 (6%) extracranial hemorrhage. FIBTEM-A10 &lt;10mm had sensitivity 17% and specificity 97% for any post-procedural hemorrhage. For symptomatic ICH, sensitivity was 0% and specificity 89%. Conclusions: The use of ROTEM to identify hyperfibrinolysis following AIS revascularization therapy achieved poor sensitivity and high specificity for prediction of any post-procedural hemorrhage, but was inaccurate for the prediction of symptomatic ICH.

Rotational Thromboelastometry Derivative Fibrinogen-Platelet Ratio Predicts Thrombosis in Microsurgery.

Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability. We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t-tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR). Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative (p = 0.027) and postoperative (p = 0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR ≥ 30 was the most sensitive and FPR ≥ 40 was the most specific. Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.

Higher coagulation activity in hip fracture patients: A case-control study using rotational thromboelastometry.

Trauma-induced coagulopathy has been extensively investigated in the multitrauma setting, but only sparsely following moderate orthopedic trauma. The purpose of this study was to evaluate changes in the hemostatic profile of patients with hip fractures, using rotational thromboelastometry (ROTEM). 198 patients with hip fractures who underwent surgery were included in the study. A matched group of 52 healthy individuals was also enrolled. Demographics, conventional laboratory assays, and ROTEM parameters were recorded and compared between patients and healthy adults. The preoperative and postoperative ROTEM values of fractured patients were also compared. The conventional coagulation assays were similar for the 2 groups. However, several ROTEM parameters including EXTEM MCF (P<.001), EXTEM alpha angle (P<.001), INTEM MCF (P<.001), INTEM A10 (P<.001), and INTEM alpha angle (P<.001) significantly differed between the 2 groups indicating a higher coagulation potential following hip fractures. Also, fractured patients had significantly lower INTEM and EXTEM CT values (P=.008 and P=.012, respectively) and significantly lower INTEM and EXTEM CFT values (P<.001). Adjusted analysis for confounders further confirmed the direct relationship between hip fracture and higher coagulation activity. Last, INTEM CT and CFT significantly decreased (P=.008 and P<.001, respectively), while INTEM MCF, A10, and alpha angle significantly increased (P<.001) postoperatively, indicating that surgery further increases the coagulation potential. A higher coagulation activity following hip fractures and surgical treatment can be detected by ROTEM shortly after the injury, even when this is undetectable by conventional coagulation assays.

Association between intraoperative rotational thromboelastometry or conventional coagulation tests and bleeding in liver transplantation: an observational exploratory study

IntroductionLiver transplantation is associated with major blood loss and transfusions. Our objective was to evaluate the association between coagulation results (rotational thromboelastometry (ROTEM) and conventional coagulation tests) and intraoperative bleeding or perioperative red blood cell (RBC) transfusions in liver transplantation. MethodsWe measured ROTEM values and conventional coagulation tests at the beginning of surgery, after graft reperfusion and at the end of surgery. We did bivariate correlation and multivariable regression analyses to explore the association between test results and either intraoperative bleeding or perioperative RBC transfusions. ResultsWe enrolled 75 consecutive patients. Median [Q1–Q3] intraoperative blood loss was 1400 mL [675−2300] and 59% of patients did not receive any RBC transfusion either intraoperatively or postoperatively. In multivariable analyses, FIBTEM maximal clot firmness (MCF) measured at the beginning of surgery was associated with lower intraoperative blood loss (ß = −106 mL for each mm; 95% CI, −203 to −9 mL). Both a higher haemoglobin concentration (multiplicative factor = 0.89 for each g/L; 95% CI, 0.84 to 0.95) and FIBTEM MCF measured at the end of surgery (multiplicative factor = 0.68 for each mm; 95% CI, 0.48 to 0.95) were associated with fewer postoperative RBC transfusions. ConclusionFIBTEM MCF was strongly associated with intraoperative blood loss and postoperative transfusions while other coagulation results were not. This study might inform future clinical trials on ROTEM-based interventions in liver transplantation. Study registrationClinical Trials.gov: NCT 02356068.

ROTEM diagnostic capacity for measuring fibrinolysis in neonatal sepsis

BackgroundHypofibrinolysis has been demonstrated in several studies in adult sepsis. Although fibrinolysis is an important and integral part of the hemostatic system, few data are available regarding its role in neonatal sepsis. Our purpose was to define fibrinolytic profiles across neonatal sepsis spectrum using rotational thromboelastometry (ROTEM). Material and methodsThis study was performed in a Greek tertiary General Hospital during an 18 month-period and included 44 neonates with confirmed sepsis and 22 with suspected sepsis; 110 healthy neonates served as controls. Whenever sepsis was suspected, EXTEM and APTEM assays were performed, clinical findings and laboratory data were recorded. ResultsAlthough most EXTEM parameters were significantly different among the 3 groups, Maximal Lysis (ML) and Lysis Index at 60 min (LI60) levels were similar (p = 0.11 and p = 0.20, respectively). Hyperfibrinolysis, as defined by ROTEM parameters, did not significantly differ among the study populations (p = 0.41). On the contrary, fibrinolysis shutdown, defined as an EXTEM LI60 ≥98%, was more common in septic neonates than in healthy (p < 0.001) and neonates with suspected sepsis (p = 0.042). A weak to moderate correlation of LI60 and ML with mortality (Spearman rho = 0.43 and − 0.40, p = 0.005 and 0.007, respectively) and SNAPE score (Spearman rho = 0.35 and − 0.33, p = 0.02 and 0.03, respectively) was noticed in sepsis group. ConclusionsROTEM, based on fibrinolytic parameters, showed a more frequent fibrinolysis shutdown in neonatal sepsis, but it could neither effectively discriminate septic neonates, nor predict their clinical outcome. The considerable overlap among numerical ROTEM values probably compromises their diagnostic clinical utility in neonatal sepsis.

Correlation between thromboelastography and rotational thromboelastometry values in adult liver transplant recipients.

Background and Aims:Viscoelastic haemostatic assays (VHA) namely Thromboelastogram (TEG) and Rotational thromboelastometry (ROTEM) are used for global assessment of coagulopathy and guiding transfusion during living donor liver transplant (LDLT).We conducted a study to compare the interchangeability of the values obtained from these devices in patients with End stage liver disease (ESLD) undergoing LDLT.Methods:In 76 patients undergoing LDLT, ROTEM and TEG were performed and assessed for interchangeability using Spearman Correlation. The direction and strength of correlation between equivalent parameters was calculated using Inter Class Correlation (ICC) and Bland Altman analysis.Results:The correlation ρ between CT (clotting time) of ROTEM and R of TEG was 0.16 (P = 0.19).The ICC was 0.15, with 95% confidence interval (CI) of -0.38-0.48 (P = 0.25).The ρ of CFT (ROTEM) with K (TEG) was 0.425 (P=<0.001). The ICC was0.49 with 95% CI of 0.17-0.69, P = 0.003.Alpha of ROTEM correlated with Angle of TEG with ρ of 0.475 (P=<0.001). The ICC was 0.61, with 95% CI of 0.36-0.76, P=<0.001.Maximum Clot firmness (MCF) correlated with maximum amplitude (MA) with ρ=0.76 (P=<0.001).The ICC was 0.86, with 95% CI of 0.77-0.92, P=<0.001. Lysis index (L30) of ROTEM correlated clot lysis (CL30) of TEG with ρ of 0.16 (P = 0.18).However, the ICC was 0.45, with 95% CI of 0.11-0.66, P = 0.08. The correlation between CT of ROTEM and R of TEG as well as L30 of ROTEM and CL30 of TEG was not significant.The strongest correlation was found between MCF and MA (P < 0.001). However the MCF/MA showed an agreement of only 86% (ICC = 0.86).Conclusion:Values from ROTEM and TEG were not found to be interchangeable.

The effects of Plasma-Lyte 148 solution on blood coagulation: an in-vitro, volunteer study using rotational thromboelastometry.

The current study aimed to measure the effects of Plasma-Lyte 148 solution on the blood coagulation profile according to the hemodilution level using rotational thromboelastometry (ROTEM) tests. Venous blood was collected from 12 healthy volunteers and divided into four specimen bottles, which were diluted at different levels with Plasma-Lyte 148 (0, 20, 40, and 60%). Following this, ROTEM tests were performed on the study samples. We found that as the hemodilution level increased, the ROTEM values showed a hypocoagulable pattern. The change rate of the maximum clot firmness (MCF) of INTEM was greater in the 40 (P = 0.015) and 60% (P < 0.001) dilutions than it was in the 20% dilution. Greater lengthening of the clot formation time of EXTEM was observed in the 60% dilution than it was in the 20% dilution (P < 0.001). The alpha-angle of EXTEM showed a greater decrease in the 60% dilution than it did in the 20% dilution (P < 0.001). A larger change rate of the MCF of EXTEM was observed in the 40 (P = 0.003) and 60% (P < 0.001) dilutions than it was in the 20% dilution. A greater decrease in the MCF of FIBTEM was identified in the 40 (P = 0.009) and 60% (P < 0.001) dilutions than in the 20% dilution. All coagulation pathways exhibited hypocoagulable patterns as the hemodilution level increased. However, most of the mean values of ROTEM parameters were within the normal reference range, except for those of the 60% dilution.

Liver transplantation for acute liver failure due to hepatitis E in a pregnant patient.

Liver transplantation for acute liver failure due to hepatitis E in a pregnant patient.

Development of a specific algorithm to guide haemostatic therapy in children undergoing cardiac surgery: a single-centre retrospective study.

Although rotational thromboelastometry (ROTEM) is increasingly used to guide haemostatic therapy in a bleeding patient, there is a paucity of data guiding its use in the paediatric population. The objective of this study is to develop an algorithm on the basis of ROTEM values obtained in our paediatric cardiac population to guide the management of the bleeding child. A retrospective analysis. Department of Anaesthesiology, Queen Fabiola Children's University Hospital. Data were collected between September 2010 and January 2012. All children who underwent elective cardiac surgery requiring cardiopulmonary bypass (CPB) were reviewed. None. Significant postoperative bleeding was defined as blood loss more than 10% of the child's estimated blood volume within the first six postoperative hours, dividing our population according to high blood loss (HBL) or low blood loss (LBL). Factors independently associated with postoperative bleeding determined the bleeding probability. Receiving operating characteristics (ROC) curves were constructed with the aim of determining relevant ROTEM parameters (including clot amplitude 10 min after administration of protamine [A10]) to be used in our algorithm. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined for the developed algorithm. One-hundred and fifty children were included in our study. Univariate and multivariate logistic regression analysis revealed that preoperative weight (kg), presence of a cyanotic disease (yes/no) and wound closure duration (min) were independent predictors of postoperative bleeding. Analysis of our ROTEM parameters revealed that clotting time (CT) ≥ 111 s, A10 ≤ 38 mm measured on the EXTEM and A10 ≤ 3 mm obtained on the FIBTEM tests were the three relevant parameters to guide haemostatic therapy. If the ROTEM-based algorithm was applied according to the bleeding risk (n = 65), 27 out of 29 of the HBL and 24 out of 36 of the LBL group would have been treated. This study describes an algorithm starting with the detection of abnormal bleeding in which ROTEM could be used to guide haemostatic therapy in bleeding children after CPB. Further studies are needed to test the efficacy of this specific algorithm-based approach.

Rotational thromboelastometry predicts thromboembolic complications after major non-cardiac surgery

Thromboembolic complications contribute substantially to perioperative morbidity and mortality. Routine laboratory tests do not detect patients with acquired or congenital hypercoagulability who may be at increased risk of perioperative thromboembolism. Rotational thromboelastometry (ROTEM) is a digitized modification of conventional thromboelastography that is stable and technically easy to use. We designed a prospective observational study to evaluate whether preoperative ROTEM can identify patients at increased risk for postoperative thromboembolic complications after major non-cardiac surgery. Preoperative ROTEM analysis using extrinsic rotational thromboelastometry (EXTEM), intrinsic rotational thromboelastometry (INTEM), and fibrinogen rotational thromboelastometry (FIBTEM) activators was performed on 313 patients undergoing major non-cardiac surgery. Patients’ medical records were reviewed after discharge for results of standard coagulation studies - partial thromboplastin time (PTT), international normalized ratio (INR), platelet count - and evidence of thromboembolic complications during their hospital stay. A thromboembolic complication was defined as a new arterial or deep venous thrombosis, catheter thrombosis, or pulmonary embolism diagnosed by ultrasound or spiral chest computed tomography. Ten patients developed postoperative thromboembolic complications, of whom 9 had received standard prophylaxis with subcutaneous enoxaparin or heparin. There was no indication of by PTT, INR, or platelet count. Preoperative EXTEM and INTEM activators that assess fibrin clot formation and platelet interaction indicated that these patients had significantly lower clot formation time (CFT) and significantly higher alpha angle (α) and maximum clot firmness (MCF), compared to patients without thromboembolic complications. There was no significant difference for any parameter using FIBTEM activator, which excludes platelet interaction. Receiver operating characteristic (ROC) curves were constructed for these variables. INTEM clot firmness at 10 min (A10) was the best predictor of thromboembolic complications, with an ROC area under the curve of 0.751. Our results indicate that preoperative ROTEM assays that include fibrin clot and platelet interaction may detect patients at increased risk for postoperative thromboembolic complications after major non-cardiac surgery. Future studies need to evaluate the clinical utility and cost effectiveness of preoperative ROTEM and better define the association between ROTEM values and specific hypercoagulable conditions.