Subscribe to RSS
The Prognostic Performance of Rotational Thromboelastometry for Excessive Bleeding and Increased Transfusion Requirements in Hip Fracture Surgeries
Background Hip fracture surgeries are associated with considerable blood loss, while the perioperative coagulopathy is associated with the bleeding risk of these patients. We aimed to evaluate the ability of rotational thromboelastometry (ROTEM) to detect patients at high risk for excessive bleeding and increased transfusion requirements.
Methods We conducted a prospective observational study of 221 patients who underwent hip fracture surgeries. ROTEM analysis was performed preoperatively and immediately postoperatively. Blood loss parameters including blood loss volume, number of transfused red blood cell (RBC) units, and drop in hemoglobin levels were recorded. ROTEM parameters were compared between patients with and without excessive bleeding, and between patients with and without increased transfusion requirements (i.e., ≥2 RBC units).
Results The postoperative FIBTEM MCF value ≤15 mm had 66.6% (95% confidence interval [CI]: 59.7–74.1%) sensitivity and 92.0% (95% CI: 80.7–97.7%) specificity to prognose excessive bleeding, and preoperative FIBTEM MCF value ≤15 mm had 80.4% (95% CI: 73.5–86.2%) sensitivity and 91.2% (95% CI: 80.7–97.0%) specificity to prognose increased transfusion requirements. Preoperative FIBTEM MCF ≤11 mm and postoperative FIBTEM MCF ≤15 mm were associated with considerably increased risks of excessive bleeding (odds ratio [OR]: 44.8, 95% CI: 16.5–121.3, p < 0.001; and OR: 23.0, 95% CI: 7.8–67.0, p < 0.001, respectively).
Conclusion ROTEM parameters demonstrated high prognostic accuracy for excessive bleeding and increased transfusion requirements. This can enable implementation of blood sparing strategies in high-risk patients, while blood banks could be better prepared to ensure adequate blood supply.
The work has been performed at the “Attikon” University Hospital of Athens.
A.G.T. and A.E.T. conceptualized the project. A.G.T., D.V.P., I.G.T., A.E.T., and S.B. designed the methodology. K.A.T., A.F.M., P.K., A.G.V., D.P., G.K.N., S.K., and P.J.P. were involved in data collection, analysis, and interpretation. A.G.T. wrote the manuscript.
* Andreas G. Tsantes and Dimitrios V. Papadopoulos have equal contribution.
Received: 10 July 2021
Accepted: 09 September 2021
Article published online:
31 October 2021
© 2021. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
- 1 Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 2009; 301 (05) 513-521
- 2 Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA 2009; 302 (14) 1573-1579
- 3 Spiezia L, Vasques F, Behr A. et al. Perioperative coagulation assessment of patients undergoing major elective orthopedic surgery. Intern Emerg Med 2016; 11 (06) 793-801
- 4 Foss NB, Kehlet H. Hidden blood loss after surgery for hip fracture. J Bone Joint Surg Br 2006; 88 (08) 1053-1059
- 5 Kragh AM, Waldén M, Apelqvist A, Wagner P, Atroshi I. Bleeding and first-year mortality following hip fracture surgery and preoperative use of low-dose acetylsalicylic acid: an observational cohort study. BMC Musculoskelet Disord 2011; 12: 254
- 6 Wei W, Wei B. Comparison of topical and intravenous tranexamic acid on blood loss and transfusion rates in total hip arthroplasty. J Arthroplasty 2014; 29 (11) 2113-2116
- 7 Grassetto A, Fullin G, Cerri G, Simioni P, Spiezia L, Maggiolo C. Management of severe bleeding in a ruptured extrauterine pregnancy: a theragnostic approach. Blood Coagul Fibrinolysis 2014; 25 (02) 176-179
- 8 Jakoi A, Kumar N, Vaccaro A, Radcliff K. Perioperative coagulopathy monitoring. Musculoskelet Surg 2014; 98 (01) 1-8
- 9 Gurunathan U, Stanton LM, Weir RM, Hay KE, Pearse BL. A preliminary study using rotational thromboelastometry to investigate perioperative coagulation changes and to identify hypercoagulability in obese patients undergoing total hip or knee replacement. Anaesth Intensive Care 2019; 47 (05) 461-468
- 10 Tsantes AG, Trikoupis IG, Papadopoulos DV. et al. Higher coagulation activity in hip fracture patients: a case-control study using rotational thromboelastometry. Int J Lab Hematol 2021; 43 (03) 477-484
- 11 Tsantes AG, Papadopoulos DV, Trikoupis IG. et al. Rotational thromboelastometry findings are associated with symptomatic venous thromboembolic complications after hip fracture surgery. Clin Orthop Relat Res 2021; 479 (11) 2457-2467
- 12 Sokou R, Piovani D, Konstantinidi A. et al. A risk score for predicting the incidence of hemorrhage in critically ill neonates: development and validation study. Thromb Haemost 2021; 121 (02) 131-139
- 13 Parastatidou S, Sokou R, Tsantes AG. et al. The role of ROTEM variables based on clot elasticity and platelet component in predicting bleeding risk in thrombocytopenic critically ill neonates. Eur J Haematol 2021; 106 (02) 175-183
- 14 Carson JL, Guyatt G, Heddle NM. et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA 2016; 316 (19) 2025-2035
- 15 Good L, Peterson E, Lisander B. Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth 2003; 90 (05) 596-599
- 16 Haase DR, Templeton KJ, Rosenthal HG, Sweeney KR. Tranexamic acid in patients with cancer undergoing endoprosthetic reconstruction: a retrospective review. J Am Acad Orthop Surg 2020; 28 (06) 248-255
- 17 Lassen MR, Ageno W, Borris LC. et al; RECORD3 Investigators. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med 2008; 358 (26) 2776-2786
- 18 Anderson DR, Dunbar M, Murnaghan J. et al. Aspirin or rivaroxaban for VTE prophylaxis after hip or knee arthroplasty. N Engl J Med 2018; 378 (08) 699-707
- 19 Schulman S, Angerås U, Bergqvist D, Eriksson B, Lassen MR, Fisher W. Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. J Thromb Haemost 2010; 8 (01) 202-204
- 20 Dötsch TM, Dirkmann D, Bezinover D. et al. Assessment of standard laboratory tests and rotational thromboelastometry for the prediction of postoperative bleeding in liver transplantation. Br J Anaesth 2017; 119 (03) 402-410
- 21 Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 1983; 148 (03) 839-843
- 22 Fries D, Martini WZ. Role of fibrinogen in trauma-induced coagulopathy. Br J Anaesth 2010; 105 (02) 116-121
- 23 Caspers M, Schäfer N, Fröhlich M. et al. How do external factors contribute to the hypocoagulative state in trauma-induced coagulopathy? - In vitro analysis of the lethal triad in trauma. Scand J Trauma Resusc Emerg Med 2018; 26 (01) 66
- 24 Dahl OE, Molnar I, Rø JS, Vinje A. Global tests on coagulation and fibrinolysis in systemic and pulmonary circulation accompanying hip arthroplasty with acrylic cement. Thromb Res 1988; 50 (06) 865-873
- 25 Bosch P, Kenkre TS, Londino JA, Cassara A, Yang C, Waters JH. Coagulation profile of patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. J Bone Joint Surg Am 2016; 98 (20) e88
- 26 Kane I, Ong A, Orozco FR, Post ZD, Austin LS, Radcliff KE. Thromboelastography predictive of death in trauma patients. Orthop Surg 2015; 7 (01) 26-30
- 27 Bosch Y, Weerwind P, ten Cate H. et al. The association between rotational thromboelastometry parameters and blood loss after cardiac surgery with cardiopulmonary bypass. Cardiovasc Thorac Open 2015; 1: 205555201559964
- 28 Fayed N, Mourad W, Yassen K, Görlinger K. Preoperative thromboelastometry as a predictor of transfusion requirements during adult living donor liver transplantation. Transfus Med Hemother 2015; 42 (02) 99-108
- 29 Ghavidel AA, Toutounchi Z, Shahandashti FJ, Mirmesdagh Y. Rotational thromboelastometry in prediction of bleeding after cardiac surgery. Asian Cardiovasc Thorac Ann 2015; 23 (05) 525-529
- 30 Soh S, Kwak YL, Song JW, Yoo KJ, Kim HJ, Shim JK. Rotational thromboelastometry predicts increased bleeding after off-pump coronary bypass surgery. Ann Thorac Surg 2017; 104 (04) 1318-1324
- 31 Davidson SJ, McGrowder D, Roughton M, Kelleher AA. Can ROTEM thromboelastometry predict postoperative bleeding after cardiac surgery?. J Cardiothorac Vasc Anesth 2008; 22 (05) 655-661