Perioperative coagulation assessment of patients undergoing major elective orthopedic surgery

Abstract

Traditional coagulative parameters are of limited use in identifying perioperative coagulopathy occurring in patients undergoing major elective orthopedic surgery (MEOS). The aim of our study was to evaluate the coagulation changes in patients undergoing MEOS and to facilitate an early detection of perioperative coagulopathy in patients experiencing major intraoperative bleeding. We enrolled 40 consecutive patients (M/F 10/30, age range 34-90 years) who underwent MEOS at the Orthopedic Unit of the Padua University Hospital, Italy, between January 2014 and January 2015. Blood samples were obtained at the following time points: T0-pre: 30 min before surgery; T0-post: 30 min after the end of the procedure; T1: morning of the first postoperative day; T2: 7 ± 2 days after surgery. Patients who experienced an intraoperative blood loss ≥250 mL/h were considered as cases. Routine coagulative parameters, thromboelastometry and thrombin generation (TG) profiles were evaluated. At baseline, a significantly lower platelet count and FIBTEM MCF/AUC were observed in patents with excessive bleeding (p < 0.05 and 0.02/0.01, respectively). At T0-post and T1 intervals, cases showed hypocoagulation characterized by a significantly low platelet count (p = 0.001), prolonged CFT INTEM/EXTEM, reduction of alpha-angle and MaxV INTEM/EXTEM, MCF and AUC INTEM/EXTEM/FIBTEM (p < 0.05 in all comparisons). The only TG parameter standing out between study groups was time to peak at T0-pre. A low platelet count and fibrinogen activity were associated with significant intraoperative bleeding in patients undergoing MEOS. Thromboelastometry performed by ROTEM(®) identifies patients with coagulopathy.

Clinical and pathophysiologic aspects of ECMO-associated hemorrhagic complications

“…Another interesting result of our study is the association of reduced intrinsic pathway maximal clot firmness (MCFin) and increased extrinsic pathway clot formation time (CFT ex ) with ECMO-associated bleeding (Fig 2). These parameters reflect the functional activity of platelets, fibrinogen, fibrin stabilizing factor XIII and von Willebrand factor [27,31,33]. Taking into account normal or increased levels of fibrinogen, it can be concluded that diminished platelet hemostasis and/or FXIII dysfunction and/or acquired von Willebrand syndrome is a likely mechanism of ECMO-associated hemorrhagic complications.…”

Preoperative FIBTEM Predicts Postoperative Hemorrhage in Total Knee Arthroplasty

“…Spiezia et al reported that patients with a reduced FIBTEM MCF had excessive bleeding, and recommended that thromboelastometry be one of the routine preoperative coagulation tests in patients undergoing major orthopedic surgery. 10 Görlinger et al found that FIBTEM A10 correlated with FIBTEM MCF and concluded that early FIBTEM would be useful for managing hemorrhagic patients undergoing noncardiac surgery. 11 The preoperative FIBTEM A10 was strongly correlated with the preoperative FIBTEM MCF in this study (ρ ¼ 0.990, P < 0.001).…”

“…8,9 A few studies have suggested that intraoperative thromboelastometry could be a guide for hemostatic therapy in patients undergoing noncardiac surgery, including major orthopedic surgery. 10,11 Early thromboelastometry-guided transfusion therapy reduces the amount of transfusion and hemorrhage-related morbidity and mortality. [12][13][14] Recently, Na et al found that the FIBTEM maximum…”

Does rotational thromboelastometry accurately predict coagulation status in patients with lupus anticoagulant?

“…The use of ROTEM to guide therapy has been described in multiple clinical settings including trauma, obstetrical hemorrhage, cardiac surgery, orthopedic surgery, and craniosynostosis surgery . The benefit of viscoelastic testing is that this assay accounts for the contribution of platelets and fibrinogen to clot formation and, therefore, is expected to better predict in vivo coagulation status than traditional laboratory testing.…”

“…3,4 The use of ROTEM to guide therapy has been described in multiple clinical settings including trauma, obstetrical hemorrhage, cardiac surgery, orthopedic surgery, and craniosynostosis surgery. [5][6][7][8][9] The benefit of viscoelastic testing is that this assay accounts for the contribution of platelets and fibrinogen to clot formation and, therefore, is expected to better predict in vivo coagulation status than Abstract Introduction: Rotational thromboelastometry (ROTEM) is increasingly used as a tool for monitoring coagulation status. However, ROTEM is susceptible to misinterpretation due to particular coagulation abnormalities.…”