title: Evaluation of a novel transfusion algorithm employing point-of-care coagulation assays in cardiac surgery: a retrospective cohort study with interrupted time-series analysis.
abstract: BACKGROUND
  Cardiac surgery requiring the use of cardiopulmonary bypass is frequently complicated by coagulopathic bleeding that, largely due to the shortcomings of conventional coagulation tests, is difficult to manage. This study evaluated a novel transfusion algorithm that uses point-of-care coagulation testing.
  
  
  METHODS
  Consecutive patients who underwent cardiac surgery with bypass at one hospital before (January 1, 2012 to January 6, 2013) and after (January 7, 2013 to December 13, 2013) institution of an algorithm that used the results of point-of-care testing (ROTEM; Tem International GmBH, Munich, Germany; Plateletworks; Helena Laboratories, Beaumont, TX) during bypass to guide management of coagulopathy were included. Pre- and postalgorithm outcomes were compared using interrupted time-series analysis to control for secular time trends and other confounders.
  
  
  RESULTS
  Pre- and postalgorithm groups included 1,311 and 1,170 patients, respectively. Transfusion rates for all blood products (except for cryoprecipitate, which did not change) were decreased after algorithm institution. After controlling for secular pre- and postalgorithm time trends and potential confounders, the posttransfusion odds ratios (95% CIs) for erythrocytes, platelets, and plasma were 0.50 (0.32 to 0.77), 0.22 (0.13 to 0.37), and 0.20 (0.12 to 0.34), respectively. There were no indications that the algorithm worsened any of the measured processes of care or outcomes.
  
  
  CONCLUSIONS
  Institution of a transfusion algorithm based on point-of-care testing was associated with reduced transfusions. This suggests that the algorithm could improve the management of the many patients who develop coagulopathic bleeding after cardiac surgery. The generalizability of the findings needs to be confirmed.
authors.affiliation: From the Department of Anesthesia and Pain Management, and Toronto General Research Institute, Toronto General Hospital, University Health Network, University of Toronto and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada (K.K.); Department of Anesthesia (S.A.M.), Department of Laboratory Medicine (R.S.), and Division of Cardiac Surgery, Department of Surgery (V.R.), Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (J.C.); Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (J.F.); Department of Anesthesia, Université Paris-Diderot, Paris, France (T.T.); and Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada (D.R.).
authors.forename: Keyvan
authors.initials: K
authors.lastname: Karkouti
authors.forename: Stuart A
authors.initials: SA
authors.lastname: McCluskey
authors.forename: Jeannie
authors.initials: J
authors.lastname: Callum
authors.forename: John
authors.initials: J
authors.lastname: Freedman
authors.forename: Rita
authors.initials: R
authors.lastname: Selby
authors.forename: Tarik
authors.initials: T
authors.lastname: Timoumi
authors.forename: Debashis
authors.initials: D
authors.lastname: Roy
authors.forename: Vivek
authors.initials: V
authors.lastname: Rao
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001777:Blood Coagulation / Q000502:physiology; D001803:Blood Transfusion / Q000379:methods / Q000592:standards*; D006348:Cardiac Surgical Procedures / Q000379:methods / Q000592:standards*; D015331:Cohort Studies; D006801:Humans; D065186:Interrupted Time Series Analysis / Q000379:methods / Q000592:standards*; D008875:Middle Aged; D019095:Point-of-Care Systems / Q000592:standards*; D012189:Retrospective Studies