Hellmann Christina, Schmutz Axel, Kalbhenn Johannes
Department of Anesthesiology and Critical Care, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg, Germany.
Perfusion. 2018 May;33(4):289-296. doi: 10.1177/0267659117746231. Epub 2017 Nov 30.
Veno-venous extracorporeal membrane oxygenation (vvECMO) used for respiratory support is associated with clinical bleeding in at least one third of patients. Mechanisms promoting bleeding, like acquired von Willebrand syndrome, cannot be identified by routine coagulation tests. This study was performed to evaluate rotational Thrombelastography (ROTEM™) for specific results predicting bleeding events during vvECMO.
Five hundred and thirty-four ROTEM™ analyses of 57 patients over 574 days have been evaluated. Patients were graded into three groups according to the severity of bleeding, following the Freiburg ECMO bleeding assessment. ROTEM™ results and basic as well as comprehensive laboratory coagulation tests have been compared among the three groups and overall between defined time points.
Fourteen patients (25 %) presented without bleeding, 22 patients (39 %) showed mild bleeding and 21 patients (36 %) became evident with relevant clinical bleeding. No bleeding shock and no fatal bleeding event occurred. No case of hyperfibrinolysis was observed. Neither a statistical difference for ECMO blood flow nor duration of therapy among the groups could be shown. The only significant difference was clotting time (CT) in the InTEM analysis, with a median (IQR) of 175 (37.5) seconds in Group 1, 190 (54.5) seconds in Group 2 and 204 (90) seconds in Group 3. When comparing overall ROTEM™ analyses between defined time points, continuous worsening of CT can be found in ExTEM, FibTEM and ApTEM. Reduced A10, A20 and congruently maximum clot firmness, especially, developed in ExTEM and ApTEM and with a minor characteristic in InTEM, but not in FibTEM. ROTEM™ and coagulation-parameter results before 19 clinical relevant bleeding episodes compared to all other results only showed differences in FibTEM.
ROTEM™ as a functional viscoelastic analysis does not provide additional information to basic and comprehensive laboratory tests during vvECMO. Bleeding events cannot be predicted by the means of specific ROTEM™ results.
用于呼吸支持的静脉-静脉体外膜肺氧合（vvECMO）在至少三分之一的患者中会引发临床出血。促进出血的机制，如获得性血管性血友病综合征，无法通过常规凝血试验识别。本研究旨在评估旋转血栓弹力图（ROTEM™），以获取预测vvECMO期间出血事件的特定结果。
对57例患者在574天内进行的534次ROTEM™分析进行了评估。根据弗莱堡ECMO出血评估，将患者按出血严重程度分为三组。比较了三组之间以及在特定时间点总体上的ROTEM™结果、基础以及全面的实验室凝血试验结果。
14例患者（25%）未出现出血，22例患者（39%）表现为轻度出血，21例患者（36%）出现明显的临床相关出血。未发生出血性休克和致命性出血事件。未观察到高纤维蛋白溶解病例。各组之间在ECMO血流量或治疗持续时间方面均未显示出统计学差异。唯一的显著差异是InTEM分析中的凝血时间（CT），第1组的中位数（IQR）为175（37.5）秒，第2组为190（54.5）秒，第3组为204（90）秒。在比较特定时间点之间的总体ROTEM™分析时，ExTEM、FibTEM和ApTEM中的CT持续恶化。特别是在ExTEM和ApTEM中，A10、A20以及最大血凝块硬度降低，在InTEM中有轻微特征，但在FibTEM中没有。与所有其他结果相比，19次临床相关出血事件之前的ROTEM™和凝血参数结果仅在FibTEM中显示出差异。
ROTEM™作为一种功能性粘弹性分析，在vvECMO期间并未为基础和全面的实验室检测提供额外信息。无法通过特定的ROTEM™结果预测出血事件。
