First experience with a ROTEM-enhanced transfusion algorithm in patients undergoing aortic arch replacement with frozen elephant trunk technique. A theranostic approach to patient blood management

Study objective: To assess the effect of a rotational thromboelastometry (ROTEM)-enhanced transfusion algorithm with hemostatic agents on allogenic blood transfusion in patients undergoing frozen elephant trunk (FET) surgery. Design: Retrospective observational study conducted in a tertiary-care center. Setting: A tertiary care referral center for cardiac surgery. Patients: All patients undergoing elective FET were included in the study. Intervention: Until 2016, a protocol based on estimated blood losses and conventional coagulation tests was used. After, a ROTEM-enhanced transfusion protocol was adopted. Measurements: The transfusion rate of each blood component was observed and reported. Methods: Retrospective, observational study. Main results: Out of 40 consecutive patients, 19 underwent FET surgery with a conventional transfusion approach and 21 with a ROTEM-enhanced transfusion strategy. Considering the overall transfusion rate, the administration of fresh frozen plasma and platelets was significantly lower in the ROTEM compared to conventional group (1000 [0–2500] vs 0 [0–875] ml, p = 0.015 and 1 [1, 2] vs 0 [0–1], p = 0.016, respectively). ROTEM algorithm allowed to decrease the number of patients who required plasma and platelets transfusion of 31%. Furthermore, a 40% reduction in overall allogenic blood products was observed. Number of red blood cells administered, percentage of patients transfused with red blood cells, blood losses, reoperation for bleeding and mortality did not significantly differ between the two groups. At the multiple linear regression analysis only ROTEM algorithm was associated with a significant decrease in the number of plasma and platelets units administered intraoperatively, at 24 h, at the ICU discharge and overall. ROTEM algorithm allowed to save 1435 ml of plasma, 0.91 unit of platelets and overall transfusion cost of the 21% per patient. Conclusions: A ROTEM-enhanced transfusion strategy halved intraoperative transfusion in the setting of FET. Further studies are needed to confirm the magnitude of our findings on clinically relevant endpoints.