title: Activated coagulation time vs. intrinsically activated modified rotational thromboelastometry in assessment of hemostatic disturbances and blood loss after protamine administration in elective cardiac surgery: analysis from the clinical trial (NCT01281397).
abstract: BACKGROUND
  Excessive bleeding after cardiopulmonary bypass (CPB) is risk factor for adverse outcomes after elective cardiac surgery (ECS). Although many different point-of-care devices to diagnose hemostatic disturbances after CPB are available, the best test is still unclear. The study aim was to compare the accuracy of hemostatic disorder detection between two point-of-care devices.
  
  
  METHODS
  We enrolled 148 patients (105 male and 43 female) undergoing ECS in a prospective observational study. Rotational thromboelastometry (TEM, with InTEM test), and Activated coagulation time (ACT) measurement were performed 15 min after protamine administration. The cohort group was divided into two subgroups according to occurrence of excessive postoperative bleeding. Endpoints were defined in two ways: as total amount of chest tube output (CTO) and blood product transfusion requirements.
  
  
  RESULTS
  Total amount of CTO value of 1507,50 mL presented 75th percentile of distribution, thus cut-off value for bleeder category. InTEM parameters, but not ACT, correlated significantly with CTO. InTEM parameters with the strongest correlation to CTO were tested for accuracy in predicting excessive postoperative bleeding using ROC analysis. InTEM A 10 value of 38 mm, InTEM A 20 value of 49 mm and InTEM A 30 value of 51 mm delineated bleeding tendency. Patients with total amount of CTO exceeding 75th percentile were more frequently transfused with fresh frozen plasma (51.4% vs. 9.9%, p < 0.001), fibrinogen concentrate (21.6% vs. 2.7%, p = 0.001) and platelet concentrate (13.5% vs. 0.9%, p = 0.004).
  
  
  CONCLUSIONS
  Our study showed that InTEM test, but not ACT is useful in prediction of bleeding tendency after protamine administration following weaning from CPB. InTEM test could be used as a first line test in screening of possible hemostatic disorder following protamine administration.
authors.affiliation: Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia. petricevic.mate@gmail.com.
authors.forename: Mate
authors.initials: M
authors.lastname: Petricevic
authors.forename: Bojan
authors.initials: B
authors.lastname: Biocina
authors.forename: Davor
authors.initials: D
authors.lastname: Milicic
authors.forename: Lucija
authors.initials: L
authors.lastname: Svetina
authors.forename: Marko
authors.initials: M
authors.lastname: Boban
authors.forename: Ante
authors.initials: A
authors.lastname: Lekić
authors.forename: Sanja
authors.initials: S
authors.lastname: Konosic
authors.forename: Milan
authors.initials: M
authors.lastname: Milosevic
authors.forename: Hrvoje
authors.initials: H
authors.lastname: Gasparovic
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D017558:Elective Surgical Procedures; D005260:Female; D006494:Heparin Antagonists / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems; D011183:Postoperative Complications / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control; D019106:Postoperative Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control; D011479:Protamines / Q000627:therapeutic use*; D012372:ROC Curve; D012189:Retrospective Studies; D013916:Thrombelastography / Q000379:methods*; D016896:Treatment Outcome; D014914:Whole Blood Coagulation Time; D055815:Young Adult
chemical_list: D006494:Heparin Antagonists; D011479:Protamines