The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Abstract

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management ('theranostic' approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient's safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration. Fig. 1. ROTEM trace ('temogram') displaying the clinically most important parameters and their informative value. FDPs: fibrin (ogen) split products. Courtesy of Klaus Görlinger, Germany.

<p>Bleeding Management Practices of Australian Cardiac Surgeons, Anesthesiologists and Perfusionists: A Cross-Sectional National Survey Incorporating the Theoretical Domains Framework (TDF) and COM-B Model</p>

“…There is a significant body of literature in cardiac surgery demonstrating a move away from use of SLTs, an increased use of pont of care diagnostic assays and reduced ABT in situations that require rapid assessment and treatment of bleeding. 36,[48][49][50] The key advantage of these assays is short result turnaround time, allowing clinicians to diagnose and treat bleeding promptly, as well as track treatment response. This is supported by a Cochrane review (2018) which states there is "growing evidence that application of TEG-or ROTEM-guided transfusion strategies may reduce the need for blood products, and improve morbidity in patients with bleeding".…”

“…The results from point of care diagnostic assays are routinely used in conjunction with bleeding management treatment algorithms. 50 However, reported use of algorithms was low, despite recommendations by CPGs;…”

“…We recommend the application of intervention algorithms incorporating pre-defined triggers and targets based on VHA coagulation monitoring to guide individualised haemostatic intervention in the case of perioperative bleeding. (Grade 1C) 13,14,17 This is notable because the incidence of coagulopathy and bleeding in cardiac surgery is high, 1,50,55 and use of algorithms has been shown to independently improve standardization and reduce morbidities, including reductions ABT. 49,50,56 A cited barrier was the lack of multi-disciplinary agreement required for the development and use of algorithms.…”

“…(Grade 1C) 13,14,17 This is notable because the incidence of coagulopathy and bleeding in cardiac surgery is high, 1,50,55 and use of algorithms has been shown to independently improve standardization and reduce morbidities, including reductions ABT. 49,50,56 A cited barrier was the lack of multi-disciplinary agreement required for the development and use of algorithms. Implementation literature regarding uptake of CPGs identified decision support systems and social interactions as successful strategies for practice improvement.…”

Performance characteristics of thromboelastometry assays using incompletely filled and prolonged stored samples

“…Thrombelastometry (TEM) and thrombelastography (TEG) are whole blood functional clotting tests used to identify coagulopathies using real time graphic depiction of viscoelastic changes in the blood . While TEM/TEG were originally used in transplant and cardiac surgery, both were later introduced in traumatology and intensive care medicine for the development of personalized transfusion strategies for patients with coagulopathies . As part of a large, regional tertiary care hospital's patient blood management program, TEM in the form of ROTEM delta (TEM International GmbH) was implemented at Odense University Hospital (OUH; Odense, Denmark) in January 2016.…”