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The Bleeding Post-op CT Patient: Coagulation Tests Versus Thromboelastography

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Difficult Decisions in Cardiothoracic Critical Care Surgery

Part of the book series: Difficult Decisions in Surgery: An Evidence-Based Approach ((DDSURGERY))

Abstract

Bleeding is a common complication of cardiac surgery associated with the derangements of the hemostatic system related to cardiopulmonary bypass and the effects and consequences of the disease state. The cause of post-operative bleeding is often multifactorial and minimizing bleeding requires not only the correction of deficiencies, but also balancing of the different blood components that contribute to clot formation. The standard coagulation tests (SCTs) frequently used by clinicians to assess coagulation capacity do not reflect the complexity of the coagulation system and typically do not provide timely information, resulting in empirical management of bleeding. Point-of-care viscoelastic hemostasis assays (VHA) are tests that monitor the different phases from clot formation to clot lysis in whole blood and provide the clinician with more complete information about imbalances in the coagulation system. Coupled with transfusion algorithms, the information provided by VHAs allows clinicians to better identify coagulation defects and improve therapeutic decision-making.

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Authors and Affiliations

  1. Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA

    Oksana Volod

  2. South University Online, Savannah, GA, USA

    Julie Wegner

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  1. Oksana Volod
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  2. Julie Wegner
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Correspondence to Oksana Volod .

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Editors and Affiliations

  1. University of Chicago Medicine, Chicago, IL, USA

    Vassyl A. Lonchyna

Appendix

Appendix

This case demonstrates an accurate assessment of postoperative coagulopathy with VHA (TEG) compared to the SCT.

Coagulation status of a 39-year-old female implanted with total artificial heart (TAH) implantation with anticoagulation being maintained with Coumadin and Aspirin. Routine laboratory study results were as follows: white blood cell (WBC) count, 25 × 109/L (elevated); platelet (PLT) count, 429 × 109/L; prothrombin time (PT), 22.5 s (normal, 11.9–14.4 s); partial thromboplastin time (PTT), 48 s (normal, 22–37 s) and fibrinogen 536 mg/dl (normal 200–400 mg/dl). Concurrent TEG showed normal clotting time (R), but clot lysis indices (LY30 = 30.2% and CI >1) suggesting secondary fibrinolysis, commonly seen in the first phase of sepsis or in disseminated intravascular coagulation (DIC). The excessive rate of clot breakdown clinically presents as bleeding which occurred in this patient few hours later. Her elevated WBC count was initially contributed to corticosteroid therapy. Later it was found that it was due to infection. TEG evaluation allowed a more accurate assessment of all phases of coagulation, which revealed incipient DIC. As a result, more appropriate therapy was instituted with a successful outcome (Fig. 30.2).

Fig. 30.2
figure 2

TEG results of patient implanted with TAH post-operative day 12

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Volod, O., Wegner, J. (2019). The Bleeding Post-op CT Patient: Coagulation Tests Versus Thromboelastography. In: Lonchyna, V. (eds) Difficult Decisions in Cardiothoracic Critical Care Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-030-04146-5_30

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  • DOI: https://doi.org/10.1007/978-3-030-04146-5_30

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