title: The Association Between Cyanosis and Thromboelastometry (ROTEM) in Children With Congenital Heart Defects: A Retrospective Cohort Study.
abstract: Children with congenital heart defects (CHD) have quantitative and qualitative differences in coagulation compared with healthy children. Secondary to polycythemia and increased deformability of red blood cells, cyanosis may be an important confounding factor for altered whole-blood coagulation in this population with potential implications for interpreting intraoperative thromboelastometry (TEM) for children with CHD undergoing major surgery. The primary aim of the study was to evaluate the association between cyanosis in children with CHD and measures of whole-blood coagulation determined using TEM (ROTEM [Tem International, GmbH, Munich, Germany]).
  
  
  
  In this retrospective cohort study, children who underwent congenital cardiac surgery in a 12-month period between April 2014 and 2015 were investigated. Children who were receiving antiplatelet or anticoagulant medications in the preoperative period were excluded. Eligible children were categorized by the presence of cyanosis, defined as an oxyhemoglobin concentration ≤85%. Multivariable linear regression analyses were used to determine the relationship between cyanosis and TEM outcomes (primary outcome, fibrinogen/fibrin polymerization [FibTEM] maximal clot firmness [MCF]) adjusting for potential confounding factors.
  
  
  
  Three hundred forty-five TEM profiles from 320 children were included in the cohort for analysis. Twenty-two percent (76/345) of children had cyanotic CHD. Clot firmness measured using the FibTEM assay was decreased in cyanotic children compared with noncyanotic children, median difference (95% confidence interval) interim [2 (0-3) mm; P = .01], and maximal [2 (1-3) mm; P = .01] clot firmness. The association between cyanosis and fibrinogen/fibrin polymerization clot firmness was not significant (A10, P = .7; MCF, P = .7) after adjusting for confounding factors (hematocrit, platelet count, and sex). There was a significant association between cyanosis and intrinsically activated clot firmness (A10, P = .03; MCF, P = .02), but not other TEM outcomes, after adjusting for confounding factors.
  
  
  
  Cyanotic children had decreased clot firmness in the fibrinogen/fibrin polymerization component of the clot compared with noncyanotic children, but the association between cyanosis and clot firmness was accounted for by differences in hematocrit, platelet count, and sex between groups. These findings will help guide the identification and treatment of coagulopathy in this vulnerable population.
authors.affiliation: From the *Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; †Division of Cardiac Anesthesia, The Hospital for Sick Children, Toronto, Ontario, Canada; ‡Department of Paediatrics and Biochemistry, University of Toronto, Toronto, Ontario, Canada; and §Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Marie-Laure
authors.initials: ML
authors.lastname: Laskine-Holland
authors.forename: Walter H A
authors.initials: WH
authors.lastname: Kahr
authors.forename: Lynn
authors.initials: L
authors.lastname: Crawford-Lean
authors.forename: Tilman
authors.initials: T
authors.lastname: Humpl
authors.forename: Osami
authors.initials: O
authors.lastname: Honjo
authors.forename: Celeste
authors.initials: C
authors.lastname: Foreman
authors.forename: Mehr
authors.initials: M
authors.lastname: Jain
authors.forename: James D
authors.initials: JD
authors.lastname: O'Leary
mesh_terms: D000367:Age Factors; D001777:Blood Coagulation; D002648:Child; D002675:Child, Preschool; D003490:Cyanosis / Q000097:blood / Q000175:diagnosis / Q000209:etiology*; D005260:Female; D005337:Fibrin / Q000378:metabolism; D005340:Fibrinogen / Q000378:metabolism; D006330:Heart Defects, Congenital / Q000097:blood / Q000150:complications* / Q000175:diagnosis; D006400:Hematocrit; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016014:Linear Models; D008297:Male; D015999:Multivariate Analysis; D010976:Platelet Count; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013916:Thrombelastography
chemical_list: D005337:Fibrin; D005340:Fibrinogen