THE IMPACT OF ROTATIONAL THROMBOELASTOMETRY (ROTEM) ON IN-HOSPITAL OUTCOMES AND BLOOD PRODUCT UTILIZATION FOLLOWING CARDIAC SURGERY
CCC ePoster Library. MacLeod J. 10/26/19; 280552; 317
Jeffrey MacLeod
Jeffrey MacLeod
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Abstract
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BACKGROUND: Point-of-care viscoelastic coagulation testing, including rotational thromboelastometry (ROTEM) and thromboelastography (TEG), was introduced in cardiac surgery to allow for the quick diagnosis of coagulopathies and for the targeted treatment of bleeding patients. Despite the purported benefits of these tests, studies evaluating their value have proven conflicting in their results. The purpose of this study was to determine the contemporary effect of ROTEM on in-hospital outcomes and blood product utilization in patients undergoing cardiac surgery.

METHODS AND RESULTS: Patients undergoing first-time, non-emergent cardiac surgery at the New Brunswick Heart Centre were considered. ROTEM was implemented at the New Brunswick Heart Centre over the course of 2016. As such, pre-ROTEM patients included those operated on in 2015, while post-ROTEM patients included those operated on in 2017. Comparisons were made on the basis of baseline characteristics, intra-operative characteristics, in-hospital post-operative outcomes and rates of blood product utilization intra-operatively and/or within the first 24 hours following surgery. A total of 1,438 patients were included (pre-ROTEM: n=691; post-ROTEM: n=747). ROTEM was used in 0% of pre-ROTEM and 15.5% of post-ROTEM patients. No differences in baseline characteristics were noted, including age≥70 years (39.1% vs. 38.2%, p=0.76), female sex (22.6% vs. 21.7%, p=0.73), BMI≥30kg/m2 (40.4% vs. 39.2%, p=0.71), renal failure (3.9% vs. 3.6%, p=0.88), urgent status (55.3% vs. 57.3%, p=0.47) and mean baseline hematocrit (36.3% vs. 36.5%, p=0.56). Intra-operatively, pre-ROTEM patients were less likely to undergo isolated CABG and isolated valve procedures and more likely to undergo combined CABG/valve and other procedures (p < 0.0001). In-hospital mortality (2.5% vs. 1.5%, p=0.25), re-operation for bleeding (0.7% vs. 1.9%, p=0.09) and stroke (1.0% vs. 1.9%, p=0.25) did not differ between the two groups. While rates of coagulation product use, defined as ≥1 dose of FFP, platelets, cryoprecipitate, FEIBA and/or fibrinogen concentrate, were comparable between the pre- and post-ROTEM patients, rates of pRBC use were lower in the post-ROTEM population (Table 1). Following risk adjustment, ROTEM was significantly associated with reduced pRBC use (OR 0.53, 95% CI 0.39-0.73,p < 0.0001) but was not associated with coagulation product use (OR 0.88, 95% CI 0.64-1.21,p=0.43).

CONCLUSION: The institution of ROTEM at our centre did not have an effect on in-hospital outcomes or coagulation product utilization. It was, however, associated with reduced pRBC use, although it is not clear as to whether or not this phenomenon was the result of ROTEM use or the result of overall changes in clinical practice patterns.
BACKGROUND: Point-of-care viscoelastic coagulation testing, including rotational thromboelastometry (ROTEM) and thromboelastography (TEG), was introduced in cardiac surgery to allow for the quick diagnosis of coagulopathies and for the targeted treatment of bleeding patients. Despite the purported benefits of these tests, studies evaluating their value have proven conflicting in their results. The purpose of this study was to determine the contemporary effect of ROTEM on in-hospital outcomes and blood product utilization in patients undergoing cardiac surgery.

METHODS AND RESULTS: Patients undergoing first-time, non-emergent cardiac surgery at the New Brunswick Heart Centre were considered. ROTEM was implemented at the New Brunswick Heart Centre over the course of 2016. As such, pre-ROTEM patients included those operated on in 2015, while post-ROTEM patients included those operated on in 2017. Comparisons were made on the basis of baseline characteristics, intra-operative characteristics, in-hospital post-operative outcomes and rates of blood product utilization intra-operatively and/or within the first 24 hours following surgery. A total of 1,438 patients were included (pre-ROTEM: n=691; post-ROTEM: n=747). ROTEM was used in 0% of pre-ROTEM and 15.5% of post-ROTEM patients. No differences in baseline characteristics were noted, including age≥70 years (39.1% vs. 38.2%, p=0.76), female sex (22.6% vs. 21.7%, p=0.73), BMI≥30kg/m2 (40.4% vs. 39.2%, p=0.71), renal failure (3.9% vs. 3.6%, p=0.88), urgent status (55.3% vs. 57.3%, p=0.47) and mean baseline hematocrit (36.3% vs. 36.5%, p=0.56). Intra-operatively, pre-ROTEM patients were less likely to undergo isolated CABG and isolated valve procedures and more likely to undergo combined CABG/valve and other procedures (p < 0.0001). In-hospital mortality (2.5% vs. 1.5%, p=0.25), re-operation for bleeding (0.7% vs. 1.9%, p=0.09) and stroke (1.0% vs. 1.9%, p=0.25) did not differ between the two groups. While rates of coagulation product use, defined as ≥1 dose of FFP, platelets, cryoprecipitate, FEIBA and/or fibrinogen concentrate, were comparable between the pre- and post-ROTEM patients, rates of pRBC use were lower in the post-ROTEM population (Table 1). Following risk adjustment, ROTEM was significantly associated with reduced pRBC use (OR 0.53, 95% CI 0.39-0.73,p < 0.0001) but was not associated with coagulation product use (OR 0.88, 95% CI 0.64-1.21,p=0.43).

CONCLUSION: The institution of ROTEM at our centre did not have an effect on in-hospital outcomes or coagulation product utilization. It was, however, associated with reduced pRBC use, although it is not clear as to whether or not this phenomenon was the result of ROTEM use or the result of overall changes in clinical practice patterns.
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