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ROTEM® thrombelastometry in on-pump cardiac surgery patients

Objective

On-pump cardiac surgery is frequently associated with intraoperative and postoperative bleeding. ROTEM® is a point-of-care method that reflects more closely than classical coagulation tests the in vivo haemostatic activity and the contribution of fibrinogen and platelets to clot formation.

Methods

Two hundred and thirty-two patients (age 67 ± 10 years) with elective cardiac surgery and an on-pump time >45 minutes (mean 112 ± 52 min) were enrolled. Preoperative, intraoperative and postoperative blood samples were taken from an arterial catheter. The ROTEM® system and test kits (INTEM/EXTEM = intrinsic/extrinsic activation, FIBTEM = EXTEM with inhibition of platelets) were from Pentapharm (Munich, Germany).

Results

The clot formation time (CFT) and maximum clot firmness (MCF), but not clotting time (CT), were strongly correlated with the fibrinogen level and platelet count. Surgery significantly decreased the ROTEM haemostatic activity, but normalised in most patients within 14–18 h postoperation. Lowest haemostatic activity (dramatic increase in CT and CFT, decrease in MCF) was seen when patients were conditioned for cardiopulmonary bypass (CPB). When connected to CPB, the CT and CFT turned to recover, but MCF in EXTEM remained unchanged and MCF in FIBTEM declined further indicating continuous fibrinogen consumption. In 12.5% of our patients, postoperative MCF in FIBTEM was reduced to <9 mm indicating a need for fibrinogen substitution. Low postoperative activity in ROTEM® was associated with high postoperative blood loss. The positive predictive value and specificity of FIBTEM were clearly superior to those of the APTT or prothrombin time. Up to 50% of patients had an increased haemostatic activity in preoperative ROTEM®, and this was associated with high CRP levels and intraoperative blood loss.

Conclusion

ROTEM® is a valuable tool to monitor perioperative haemostasis. The decreases in haemostatic activity and postoperative bleeding are probably due to anticoagulant therapy as well as fibrinogen and platelet consumption. An increased preoperative haemostatic activity is probably due to an acute phase reaction associated with advanced atherosclerosis, and the high intraoperative bleeding in these patients might be due to the atherosclerotic vessels rather than due to an insufficient haemostasis.

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Loesche, W., Reinhöfer, M., Macholdt, C. et al. ROTEM® thrombelastometry in on-pump cardiac surgery patients. Crit Care 11, P367 (2007). https://doi.org/10.1186/cc5527

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Keywords

  • Fibrinogen
  • Postoperative Bleeding
  • Clot Time
  • Cardiac Surgery Patient
  • Postoperative Blood Loss