Perioperacijska procjena rizika krvarenja kardiokirurških bolesnika primjenom impendacijske agregometrije i tromboelastometrije [Perioperative bleeding risk assessment in patients following cardiac surgery using whole blood impedance aggregometra and rotational thromboelastometry]

Petričević, Mate (2014) Perioperacijska procjena rizika krvarenja kardiokirurških bolesnika primjenom impendacijske agregometrije i tromboelastometrije [Perioperative bleeding risk assessment in patients following cardiac surgery using whole blood impedance aggregometra and rotational thromboelastometry]. PhD thesis, Sveučilište u Zagrebu.

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Abstract

Introduction Excessive bleeding after cardiopulmonary bypass (CPB) is risk factor for adverse outcomes after elective cardiac surgery (ECS). Differentiating between patients who bleed due to surgical issues and those whose excessive chest tube output (CTO) is due to coagulopathy, remains challenging. Bedside suitable tests to identify hemostatic disturbances and predict excessive bleeding are desirable. The study sought to evaluate prediction of excessive bleeding after ECS using two bedside suitable devices for platelet function and viscoelastic blood clot properties assessment. ----- Methods We enrolled 148 patients (105 male and 43 female) undergoing ECS in a prospective observational study. Patients were characterized as bleeders if their 24 hour CTO exceeded the 75th percentile of distribution. Multiple electrode aggregometry (MEA, with ASPI, ADP and the TRAP test) and rotational thromboelastometry (TEM, with ExTEM, HepTEM and FibTEM test), were performed at three time points: preoperatively (T1), during CPB (T2), and after protamine administration (T3). The primary endpoint was CTO and the secondary endpoint was administration of blood products, 30-day and 1 year mortality. ----- Results The best predictors of increased bleeding tendency were the tests performed after protamine administration (T3). At T3, patients characterized as bleeders had significantly lower MEA ASPI (median, 14 vs. 27 AUC, p=0.004) and ADP test values (median, 22 vs. 41 AUC, p=0.002) as well as TEM values expressed in maximum clot firmness after 30 min (MCF 30) for ExTEM (53 vs. 56 mm, p=0.005), HepTEM (48 vs. 52 mm, p=0.003) and FibTEM (8 vs. 11 mm, p<0.001) test. 24 hour CTO inversely correlated with both the MEA (ASPI test: r=-0.236, p=0.004; ADP test: r=-0.299, p<0.001), and TEM MCF 30 (ExTEM: r=-0.295, p<0.001; HepTEM: -0.329, p<0.001; FibTEM: -0.377, p<0.001) test values. ----- Conclusion Our study showed that MEA and TEM are useful methods for prediction of excessive bleeding after ECS. In order to prevent excessive postoperative CTO, hemostatic interventions with timely and targeted blood component therapy according to MEA and TEM results should be considered.

Abstract in Croatian

Uvod Ekscesivno krvarenje nakon kardiokirurških zahvata rizični je faktor za nastanak neželjenih ishoda liječenja. Razlikovanje između bolesnika koji krvare radi kirurških razloga od onih kod kojih je krvarenje uvjetovano poremećajem hemostaze predstavlja izazov u svakodnevnoj praksi. Cilj studije je ispitati mogućnost predikcije ekscesivnog krvarenja upotrebom uređaja za procjenu funkcije trombocita te svojstava krvnog ugruška. ----- Metode Prospektivna opservacijska studija uključila je 148 bolesnika (od čega je 43 ženskog spola) Ekscesivno krvarenje karakterizirano je kao krvarenje koje nadilazi 75.-tu percentilu distribucije torakalne drenaže u prva 24 sata. Impedancijska agregometrija (MEA, s ASPI, ADP te TRAP testom) i rotaciona tromboelastometrija (TEM, s ExTEM, HepTEM i FibTEM testovima) izvedeni su u tri vremenske točke: prijeoperacijski (T1) , za vrijeme ekstrakorporalne cirkulacije (T2) te nakon aplikacije protamina (T3). Primarni iahod razmatranja je drenaža na torakalne drenove dok je sekundarna mjera ishoda transfuzija krvnih produkata te 30 – dnevni i jednogodišnji mortalitet. ----- Rezultati Testovi izvedeni nakon aplikacije (T3) protamina bili su najbolji prediktori ekscesivnog krvarenja. Bolesnici koji su ekscesivno krvarili imali su u točki T3 značajno niže vrijednosti MEA ASPI testa (median, 14 vs. 27 AUC, p=0.004) i ADP testa (median, 22 vs. 41 AUC, p=0.002) kao i vrijednosti TEM testova iskazane u maksimalnoj čvrstoći ugruška nakon 30 minuta (iskazana u mm) (MCF 30) za ExTEM (53 vs. 56 mm, p=0.005), HepTEM (48 vs. 52 mm, p=0.003) i FibTEM (8 vs. 11 mm, p<0.001) testove. Drenaža na torakalne drenove u prva 24 sata inverzno je korelirala s MEA parametrima (ASPI test: r=-0.236, p=0.004; ADP test: r=-0.299, p<0.001), i parametrima rotacione tromboelastometrije TEM MCF 30 (ExTEM: r=-0.295, p<0.001; HepTEM: -0.329, p<0.001; FibTEM: -0.377, p<0.001). ----- Zaključak: Istraživanje je potvrdilo MEA i TEM kao korisne uređaje u predikciji ekscesivnog krvarenja. U cilju prevencije ekscesivnog krvarenja nakon operacije , pravovremeno i ciljano liječene temeljeno na nalazima MEA i TEM uređaja trebalo bi biti razmotreno u svakodnevnoj kardiokirurškoj praksi.

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