Development of a specific algorithm to guide haemostatic therapy in children undergoing cardiac surgery A single-centre retrospective study

BACKGROUND Although rotational thromboelastometry (ROTEM) is increasingly used to guide haemostatic therapy in a bleeding patient, there is a paucity of data guiding its use in the paediatric population. OBJECTIVE The objective of this study is to develop an algorithm on the basis of ROTEM values obtained in our paediatric cardiac population to guide the management of the bleeding child. DESIGN A retrospective analysis. SETTING Department of Anaesthesiology, Queen Fabiola Children's University Hospital. Data were collected between September 2010 and January 2012. PATIENTS All children who underwent elective cardiac surgery requiring cardiopulmonary bypass (CPB) were reviewed. INTERVENTION None. MAIN OUTCOME MEASURES Significant postoperative bleeding was defined as blood loss more than 10% of the child's estimated blood volume within the first six postoperative hours, dividing our population according to high blood loss (HBL) or low blood loss (LBL). Factors independently associated with postoperative bleeding determined the bleeding probability. Receiving operating characteristics (ROC) curves were constructed with the aim of determining relevant ROTEM parameters (including clot amplitude 10 min after administration of protamine [A10]) to be used in our algorithm. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined for the developed algorithm. RESULTS One-hundred and fifty children were included in our study. Univariate and multivariate logistic regression analysis revealed that preoperative weight (kg), presence of a cyanotic disease (yes/no) and wound closure duration (min) were independent predictors of postoperative bleeding. Analysis of our ROTEM parameters revealed that clotting time (CT) >= 111 s, A10 <= 38mm measured on the EXTEM and A10 <= 3mm obtained on the FIBTEM tests were the three relevant parameters to guide haemostatic therapy. If the ROTEM-based algorithm was applied according to the bleeding risk (n = 65), 27 out of 29 of the HBL and 24 out of 36 of the LBL group would have been treated. CONCLUSION This study describes an algorithm starting with the detection of abnormal bleeding in which ROTEM could be used to guide haemostatic therapy in bleeding children after CPB. Further studies are needed to test the efficacy of this specific algorithm-based approach.