Monitoring Hemostatic Function during Cardiac Surgery with Point-of-Care Viscoelastic Assays: A Narrative Review

Brandon Jin An Ong; Hui Xin See Tow; Alyssa Tze Wei Fong; Ryan Ruiyang Ling; Kiran Shekar; Kristine Teoh; Lian Kah Ti; Graeme MacLaren; Bingwen Eugene Fan; Kollengode Ramanathan

doi:10.1055/s-0045-1802573

Seminars in Thrombosis and Hemostasis, Table of Contents

Semin Thromb Hemost
DOI: 10.1055/s-0045-1802573

Review Article

Monitoring Hemostatic Function during Cardiac Surgery with Point-of-Care Viscoelastic Assays: A Narrative Review

Brandon Jin An Ong^*

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

,

Hui Xin See Tow^*

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

,

Alyssa Tze Wei Fong

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

,

Ryan Ruiyang Ling

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

²Australia and New Zealand Intensive Care Research Centre, School of Preventive Medicine and Public Health, Monash University, Melbourne, Victoria, Australia

³Department of Anaesthesia, National University Hospital, National University Health System, Singapore

,

Kiran Shekar

⁴Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia

⁵Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia

⁶Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, Australia

⁷Faculty of Health, Queensland University of Technology, University of Queensland, Brisbane, Queensland, Australia

,

Kristine Teoh

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

⁹Division of Adult Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore

,

Lian Kah Ti

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

³Department of Anaesthesia, National University Hospital, National University Health System, Singapore

,

Graeme MacLaren

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

¹⁰Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore

,

Bingwen Eugene Fan

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

¹¹Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore

¹²Department of Hematology, Tan Tock Seng Hospital, Singapore

,

Kollengode Ramanathan

¹Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

¹⁰Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore

› Author Affiliations

Abstract

Bleeding is a well-known and severe complication of cardiac surgery. Cardiopulmonary bypass, along with heparinization and hemodilution, is thought to affect all pathways of the hemostatic process, leading to excessive bleeding and worsened morbidity and mortality. The traditionally used standard laboratory tests (SLTs) were not designed for the surgical setting, have long turnaround times, and are poor predictors of bleeding. This review aims to give an overview of viscoelastic assays (VEAs), compare VEAs to conventional testing methods, and summarize the evidence for VEAs in cardiac surgery. A search of Medline via Pubmed, Scopus, and Embase yielded 2,868 papers, which we reviewed and summarized the key findings. VEAs such as rotational thromboelastometry and thromboelastography provide a quick turnaround, graphical, global impression of hemostasis in whole blood. VEAs allow for the analysis of specific contributors to the coagulation process and may facilitate cause-oriented hemostatic treatment and the development of treatment algorithms. VEAs have been found to have a high specificity and high negative predictive value for coagulopathic bleeding. Patients treated with VEA-based algorithms have been shown to have lower rates of bleeding, transfusion requirements, and exposure to allogeneic blood products. However, VEA-based algorithms have not demonstrated a mortality benefit and evidence for outcomes such as surgical re-exploration and hospital length of stay remains equivocal. In conclusion, VEAs have been shown to be comparable if not superior to SLTs in cardiac surgery. Further large-scale studies are needed to better evaluate the impact of VEAs on clinical outcomes.

Keywords

viscoelastic assays - cardiac surgery - hemostasis - rotational thromboelastometry - thromboelastography

Full Text

References

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