By Lindy Keane Carter
During many complex surgical procedures, a patient’s blood-clotting ability continually changes for a variety of reasons. To effectively manage the patient and minimize unnecessary transfusions, the anesthesiologist must constantly monitor these changes. Unfortunately, conventional coagulation assays can take 30 to 45 minutes to assess clotting factor levels. When surgeons cannot wait, the traditional perioperative blood management practice has been to make a clinical assessment of the patient’s bleeding and administer the blood component that they judge appropriate to minimize the bleeding. This practice has downsides for the patient as well as the hospital. In February 2015, the American Society of Anesthesiologists recommended in its perioperative blood management practice guidelines the use of goal-directed algorithms guided by viscoelastic testing that deliver the critical coagulation information within 10 to 15 minutes.
Since 2013, MUSC Health has used one of the first such testing devices. The ROTEM® Hemostasis Management System (ROTEM®; Tem International GmBH, Munich, Germany) uses a transfusion algorithm that enables anesthesiologists to deliver the right blood component quickly.
This technology is not only faster, it is more informative, according to Jerry Squires, M.D., Ph.D., Associate Professor of Pathology and Laboratory Medicine and Director of Transfusion Medicine at MUSC Health. “The traditional assays measure only clotting factor levels. With ROTEM®, we get a more global picture of hemostasis, which, in turn, helps the clinician choose the appropriate blood product to control bleeding,” he says. This technology is also useful when treating other patients with active bleeding, e.g., complex patients and patients with acute liver failure or trauma. “We are a hospital that treats complex medical problems,” says Squires. “We need to be able to manage our patients effectively and preserve the availability of blood.”
ROTEM® was evaluated at the University of Toronto and Université Paris-Diderot in patients who underwent cardiac bypass surgery before (n=1,311) and after (n=1,170) the hospital instituted ROTEM®. The study’s conclusions, published in the March 2015 issue of Anesthesiology, state that transfusion rates for all blood products (except cryoprecipitate, which did not change) were decreased after the institution of the algorithm. The posttransfusion odds ratios (95% confidence intervals) for erythrocytes, platelets, and plasma were 0.50 (0.32-0.77), 0.22 (0.13-0.37), and 0.20 (0.12-0.34), respectively.
This coagulation testing device is just one component of MUSC Health’s Patient Blood Management Program that is being developed. For trauma and surgical bleeding, the program recommends preoperative and postoperative anemia management and the ROTEM-guided algorithms. For inherited bleeding disorders, the program provides the Anticoagulation and Bleeding Management Consult Service, which ensures the safe replacement of coagulation factors. The service includes, for example, the program nurse coordinator’s daily review of orders for anti-coagulants or blood-clotting factors. Charles S. Greenberg, M.D., Professor in the Division of Hematology-Oncology and Director of the Consult Service, explains, “Our goal is to avoid unnecessary use of blood and blood products because, if you don’t choose wisely, you can cause additional bleeding and other complications. It is well-established that unnecessary transfusions may lead to poor outcomes.” For more information on the Patient Blood Management Program at MUSC Health, see the article “Honoring the Blood Covenant,” in the March-April 2013 issue of Progressnotes.