Congenital Cyanotic Cardiac Surgery in Children: Is Algorithm-Based Point-of-Care Testing Essential to Prevent Bleeding?
12 June 2019 (online)
Background Patients with cyanotic congenital heart disease (CCHD) have multifactorial hematologic abnormalities. In continuation of our previous study titled “Coagulopathies in Cyanotic Cardiac Patients: An Analysis with Three Point-of-Care Testing Devices (Thromboelastography, Rotational Thromboelastometry, and Sonoclot Analyzer),” we extended this prospective observational study to a larger cohort to reconfirmed the need to do a point-of-care (POC) test in bleeding cyanotic children. We formulated an algorithm. We conducted this study now by comparing three different POC parameters in an algorithm-based manner and deciphering the best parameter from an algorithm-based and the best parameter POC from an algorithm-based perspective. We conducted this study to compare three different viscoelastic POC tests: thromboelastography (TEG), rotational thromboelastometry (ROTEM), and Sonoclot analyzer to predict thrombocytopenia and hypofibrinogenemia in cyanotic cardiac surgery patients.
Material and Methods A total of 105 patients of either sex, who were scheduled to undergo elective cardiac surgery for CCHD on cardiopulmonary bypass (CPB), were enrolled after obtaining written and informed consent. Blood samples for TEG, ROTEM, Sonoclot, and standard laboratory coagulation tests were collected after induction of anesthesia (T1) and 30 minutes after protamine reversal (T2).
Results We observed significant correlations between POC parameters, platelet count, and serum fibrinogen levels. Area under the curve (AUC, 0.90) of ROTEM FIBTEM-A10 was found to be superior in detecting hypofibrinogenemia (serum fibrinogen < 200 mg/dL). AUC of TEG α angle (AUC 0.79), TEG MA (AUC 0.77) and Sonoclot CR (AUC 0.73) were comparable. Sonoclot PF was found to have highest AUC (0.95) to detect thrombocytopenia (platelet count < 100,000/μL). ROTEM FIBTEM-A10 at cutoff value ≤ 7.5 mm had highest sensitivity (87.2%) and specificity (80.3%) to detect hypofibrinogenemia. Sonoclot PF at cutoff value ≤ 0.95 had highest sensitivity (100%) and specificity (83.7%) to detect thrombocytopenia. We formulated a POC algorithm based on cutoff value derived from ROC curves.
Conclusion In conclusion, although all three viscoelastic POC devices (TEG, ROTEM, and Sonoclot) can be used to detect hypofibrinogenemia and thrombocytopenia, it was reaffirmed on a larger subset of patients that ROTEM FIBTEM has highest diagnostic accuracy for hypofibrinogenemia, whereas Sonoclot PF has highest diagnostic value for thrombocytopenia in CCHD surgical patients.
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