Scott John P, Niebler Robert A, Stuth Eckehard A E, Newman Debra K, Tweddell James S, Bercovitz Rachel S, Benson D Woodrow, Cole Regina, Simpson Pippa M, Yan Ke, Woods Ronald K
1 Section of Pediatric Anesthesiology, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA.
2 Section of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
World J Pediatr Congenit Heart Surg. 2018 Jul;9(4):424-433. doi: 10.1177/2150135118771318.
Thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass (CPB) contribute to bleeding and morbidity. Rotational thromboelastometry (ROTEM) is a viscoelastic assay with a rapid turnaround time. Data validating ROTEM during neonatal cardiac surgery remain limited. This study examined perioperative hemostatic trends in neonates treated with standardized platelet and cryoprecipitate transfusion during CPB. We hypothesized that ROTEM would predict thrombocytopenia, hypofibrinogenemia, and the correction thereof.
Forty-four neonates undergoing CPB were included in this prospective observational study. Blood samples were obtained at Baseline, On CPB, Post-CPB, and Postoperative. The ROTEM analysis included extrinsically activated (Extem) and fibrinogen-specific (Fibtem) assays. Platelet-specific thromboelastometry (Pltem) values were calculated. Platelet and cryoprecipitate transfusion was initiated prior to termination of CPB.
Platelet count and Extem amplitude decreased significantly On CPB ( P < .0001), increased significantly Post-CPB ( P < .0001), and Postoperative values were not significantly different from Baseline. Extem amplitude at 10 minutes (A10) > 46.5 mm (AUC = 0.941) and Pltem A10 > 37.5 mm [area under curve (AUC) = 0.960] predicted platelet count > 100 × 10/μL, and they highly correlated with platelet count ( R = 0.89 and R = 0.90, respectively). Fibrinogen concentration and Fibtem amplitude decreased significantly On CPB ( P ≤ .0001) and normalized after cryoprecipitate transfusion. Fibtem A10 > 9.5 mm predicted fibrinogen >200 mg/dL (AUC = 0.817), but it correlated less well with fibrinogen concentration ( R = 0.65).
ROTEM analysis during neonatal cardiac surgery is sensitive and specific for thrombocytopenia and hypofibrinogenemia, identifying deficits within 10 minutes. Platelet and cryoprecipitate transfusion during neonatal CPB normalizes platelet count, fibrinogen level, and ROTEM amplitudes.
新生儿体外循环（CPB）期间的血小板减少和纤维蛋白原血症会导致出血和发病。旋转血栓弹力图（ROTEM）是一种周转时间短的粘弹性检测方法。关于新生儿心脏手术期间ROTEM有效性的数据仍然有限。本研究探讨了在CPB期间接受标准化血小板和冷沉淀输血治疗的新生儿围手术期止血趋势。我们假设ROTEM可以预测血小板减少、纤维蛋白原血症及其纠正情况。
本前瞻性观察性研究纳入了44例接受CPB的新生儿。在基线、CPB期间、CPB后和术后采集血样。ROTEM分析包括外源性激活（Extem）和纤维蛋白原特异性（Fibtem）检测。计算血小板特异性血栓弹力图（Pltem）值。在CPB结束前开始输注血小板和冷沉淀。
CPB期间血小板计数和Extem振幅显著下降（P <.0001），CPB后显著增加（P <.0001），术后值与基线无显著差异。10分钟时的Extem振幅（A10）> 46.5 mm（AUC = 0.941）和Pltem A10 > 37.5 mm [曲线下面积（AUC）= 0.960]预测血小板计数> 100×10/μL，且它们与血小板计数高度相关（分别为R = 0.89和R = 0.90）。纤维蛋白原浓度和Fibtem振幅在CPB期间显著下降（P≤.0001），冷沉淀输血后恢复正常。Fibtem A10 > 9.5 mm预测纤维蛋白原> 200 mg/dL（AUC = 0.817），但与纤维蛋白原浓度的相关性较差（R = 0.65）。
新生儿心脏手术期间的ROTEM分析对血小板减少和纤维蛋白原血症敏感且特异，可在10分钟内识别缺陷。新生儿CPB期间输注血小板和冷沉淀可使血小板计数、纤维蛋白原水平和ROTEM振幅恢复正常。
