Download PDF
Semin Thromb Hemost 2023; 49(02): 134-144
DOI: 10.1055/s-0042-1753510
Review Article

Rotational Thromboelastometry Predicts Transfusion Requirements in Total Joint Arthroplasties

Andreas G. Tsantes    *
1   Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Dimitrios V. Papadopoulos   *
2   Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, Pennsylvania
,
Anastasios G. Roustemis
3   First Department of Orthopaedics, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Ioannis G. Trikoupis
3   First Department of Orthopaedics, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Daniele Piovani
4   Department of Biomedical Sciences, Humanitas University, Milan, Italy
5   IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
,
Konstantina A. Tsante
1   Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Petros G. Mantzios
1   Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Andreas F. Mavrogenis
3   First Department of Orthopaedics, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Rozeta Sokou 
1   Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Styliani I. Kokoris
1   Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Anastasios G. Kriebardis
6   Department of Biomedical Science, Laboratory of Reliability and Quality Control in Laboratory Hematology, School of Health and Caring Science, University of West Attica, Athens, Greece
,
Panayiotis J. Papagelopoulos
1   Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Stefanos Bonovas
4   Department of Biomedical Sciences, Humanitas University, Milan, Italy
5   IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
,
Argirios E. Tsantes
1   Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

The frequency of red blood cell (RBC) transfusions is high in total joint arthroplasties, and the hemorrhagic risk is associated with both surgery- and patient-related factors. This study aims to assess the ability of rotational thromboelastometry (ROTEM) to identify patients at high risk for transfusion and excessive bleeding. A prospective observational study was conducted including 206 patients who underwent total knee or hip arthroplasties. Assessment of the coagulation status was performed preoperatively and immediately postoperatively using ROTEM analysis and conventional coagulation tests. The number of RBC transfusions and the postoperative hemoglobin drop were recorded. ROTEM findings were compared between transfused and nontransfused patients, and also between patients with and without excessive bleeding. Higher values of postoperative FIBTEM maximum clot firmness (MCF) were associated with lower risks of transfusion (odds ration [OR]: 0.66, 95% confidence interval [CI]: 0.57–0.78, p<0.001) and excessive bleeding (OR: 0.58, 95% CI: 0.36–0.94, p=0.028). A postoperative FIBTEM MCF value ≤10mm had 80.1% (95% CI: 73.1–85.9%) sensitivity with 75.5% (95% CI: 60.4–87.1%) specificity to predict transfusion requirements, and 70.5% (95% CI: 63.6–76.8%) sensitivity with 88.8% (95% CI: 51.7–99.7%) specificity to predict excessive bleeding. The estimated average probability of transfusion in patients with FIBTEM MCF values of 0 to 4mm is 86.3%. ROTEM assay demonstrated high predictive ability for transfusion and excessive bleeding. Identification of patients at risk for transfusion could allow blood banks to ensure adequate blood supply, while also more intense blood-salvaging strategies could be implemented in these patients.

Keywords

bleeding risk - coagulopathy - joint replacements - rotational thromboelastometry - transfusion

* Both authors have equal contribution.


Supplementary Material



Publication History

Article published online:
02 September 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Ponnusamy KE, Kim TJ, Khanuja HS. Perioperative blood transfusions in orthopaedic surgery. J Bone Joint Surg Am 2014; 96 (21) 1836-1844
    Google Scholar
  • 2 Song K, Pan P, Yao Y, Jiang T, Jiang Q. The incidence and risk factors for allogenic blood transfusion in total knee and hip arthroplasty. J Orthop Surg Res 2019; 14 (01) 273
    CrossrefPubMedGoogle Scholar
  • 3 Menendez ME, Lu N, Huybrechts KF. et al. Variation in use of blood transfusion in primary total hip and knee arthroplasties. J Arthroplasty 2016; 31 (12) 2757-2763.e2 , e2
    CrossrefPubMedGoogle Scholar
  • 4 Naik BI, Pajewski TN, Bogdonoff DI. et al. Rotational thromboelastometry-guided blood product management in major spine surgery. J Neurosurg Spine 2015; 23 (02) 239-249
    CrossrefPubMedGoogle Scholar
  • 5 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
    CrossrefPubMedGoogle Scholar
  • 6 Jakoi A, Kumar N, Vaccaro A, Radcliff K. Perioperative coagulopathy monitoring. Musculoskelet Surg 2014; 98 (01) 1-8
    CrossrefPubMedGoogle Scholar
  • 7 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
    CrossrefPubMedGoogle Scholar
  • 8 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
    CrossrefPubMedGoogle Scholar
  • 9 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
    CrossrefPubMedGoogle Scholar
  • 10 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
    CrossrefPubMedGoogle Scholar
  • 11 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 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
    CrossrefPubMedGoogle Scholar
  • 13 Tsantes AG, Papadopoulos DV, Trikoupis IG. et al. The prognostic performance of rotational thromboelastometry for excessive bleeding and increased transfusion requirements in hip fracture surgeries. Thromb Haemost 2022; 122 (06) 895-904
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 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
    CrossrefPubMedGoogle Scholar
  • 15 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
    CrossrefPubMedGoogle Scholar
  • 16 Schöchl H, Cotton B, Inaba K. et al. FIBTEM provides early prediction of massive transfusion in trauma. Crit Care 2011; 15 (06) R265
    CrossrefPubMedGoogle Scholar
  • 17 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
    Google Scholar
  • 18 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
    CrossrefPubMedGoogle Scholar
  • 19 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
    CrossrefPubMedGoogle Scholar
  • 20 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 22 Tsantes AG, Papadopoulos DV, Trikoupis IG. et al. The procoagulant effect of COVID-19 on the thrombotic risk of patients with hip fractures due to enhanced clot strength and fibrinolysis shutdown. J Clin Med 2021; 10 (15) 3397
    CrossrefPubMedGoogle Scholar
  • 23 Tsantes AG, Trikoupis IG, Papadopoulos DV. et al. The safety and efficacy of tranexamic acid in oncology patients undergoing endoprosthetic reconstruction and a ROTEM-based evaluation of their hemostatic profile: a pilot study. Cancers (Basel) 2021; 13 (16) 3951
    CrossrefPubMedGoogle Scholar
  • 24 Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7 (01) 29
    CrossrefPubMedGoogle Scholar
  • 25 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
    CrossrefPubMedGoogle Scholar
  • 26 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
    CrossrefPubMedGoogle Scholar
  • 27 Hagemo JS, Christiaans SC, Stanworth SJ. et al. Detection of acute traumatic coagulopathy and massive transfusion requirements by means of rotational thromboelastometry: an international prospective validation study. Crit Care 2015; 19 (01) 97
    CrossrefPubMedGoogle Scholar
  • 28 Lier H, Vorweg M, Hanke A, Görlinger K. Thromboelastometry guided therapy of severe bleeding. Essener Runde algorithm. Hamostaseologie 2013; 33 (01) 51-61
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Schöchl H, Nienaber U, Hofer G. et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010; 14 (02) R55
    CrossrefPubMedGoogle Scholar
  • 30 Görlinger K, Pérez-Ferrer A, Dirkmann D. et al. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019; 72 (04) 297-322
    CrossrefPubMedGoogle Scholar
  • 31 Haensig M, Kempfert J, Kempfert PM, Girdauskas E, Borger MA, Lehmann S. Thrombelastometry guided blood-component therapy after cardiac surgery: a randomized study. BMC Anesthesiol 2019; 19 (01) 201
    CrossrefPubMedGoogle Scholar
  • 32 Jonas J, Tomas V, Broz T, Durila M. Utility of rotational thromboelastometry in total hip replacement revision surgery (case-control study). Medicine (Baltimore) 2020; 99 (51) e23553
    CrossrefPubMedGoogle Scholar
  • 33 Guan J, Cole CD, Schmidt MH, Dailey AT. Utility of intraoperative rotational thromboelastometry in thoracolumbar deformity surgery. J Neurosurg Spine 2017; 27 (05) 528-533
    CrossrefPubMedGoogle Scholar
  • 34 Smart L, Mumtaz K, Scharpf D. et al. Rotational thromboelastometry or conventional coagulation tests in liver transplantation: comparing blood loss, transfusions, and cost. Ann Hepatol 2017; 16 (06) 916-923
    CrossrefPubMedGoogle Scholar
  • 35 Buell TJ, Taylor DG, Chen CJ. et al. Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study. Neurosurg Focus 2019; 46 (04) E17
    CrossrefPubMedGoogle Scholar
  • 36 Jonas J, Durila M, Malosek M. et al. Usefulness of perioperative rotational thrombelastometry during scoliosis surgery in children. J Neurosurg Spine 2020; 32: 1-6
    CrossrefPubMedGoogle Scholar
  • 37 Hanke AA, Herold U, Dirkmann D, Tsagakis K, Jakob H, Görlinger K. Thromboelastometry based early goal-directed coagulation management reduces blood transfusion requirements, adverse events, and costs in acute type A aortic dissection: a pilot study. Transfus Med Hemother 2012; 39 (02) 121-128
    CrossrefPubMedGoogle Scholar
  • 38 Görlinger K, Dirkmann D, Solomon C, Hanke AA. Fast interpretation of thromboelastometry in non-cardiac surgery: reliability in patients with hypo-, normo-, and hypercoagulability. Br J Anaesth 2013; 110 (02) 222-230
    CrossrefPubMedGoogle Scholar
  • 39 Lang T, Bauters A, Braun SL. et al. Multi-centre investigation on reference ranges for ROTEM thromboelastometry. Blood Coagul Fibrinolysis 2005; 16 (04) 301-310
    CrossrefPubMedGoogle Scholar
  • 40 Ryan SP, Klement MR, Green CL, Blizzard DJ, Wellman SS, Seyler TM. Preoperative hemoglobin predicts postoperative transfusion despite antifbrinolytics during total knee arthroplasty. Orthopedics 2019; 42 (02) 103-109
    CrossrefPubMedGoogle Scholar
  • 41 Cao G, Huang Z, Huang Q, Zhang S, Xu B, Pei F. Incidence and risk factors for blood transfusion in simultaneous bilateral total joint arthroplasty: a multicenter retrospective study. J Arthroplasty 2018; 33 (07) 2087-2091
    CrossrefPubMedGoogle Scholar
  • 42 Pempe C, Werdehausen R, Pieroh P. et al. Predictors for blood loss and transfusion frequency to guide blood saving programs in primary knee- and hip-arthroplasty. Sci Rep 2021; 11 (01) 4386
    CrossrefPubMedGoogle Scholar
  • 43 Slover J, Lavery JA, Schwarzkopf R, Iorio R, Bosco J, Gold HT. Incidence and risk factors for blood transfusion in total joint arthroplasty: analysis of a statewide database. J Arthroplasty 2017; 32 (09) 2684-2687.e1
    CrossrefPubMedGoogle Scholar