Do Heparinase Thrombelastographs Predict Postoperative Bleeding?

Postoperative hemorrhage is a major cause of morbidity and mortality in patients who undergo cardiopulmonary bypass (CPB). The thrombelastograph (TEG) is a viscoelastic whole blood test that measures clot dynamics from clot formation through clot lysis. Previous studies have shown that post-bypass TEGs are accurate predictors of postoperative bleeding. TEGs from heparinized blood reversed with heparinase may be employed during CPB to evaluate coagulation. CPB heparinase TEGs may allow for earlier recognition of patients who may bleed after bypass. Earlier TEG analysis would allow targeting of specific therapies to begin before the patient bleeds excessively. Fifty-four heparinase TEGs during warming and fifty-four native TEGs post-protamine administration were collected. Parameters evaluated were R, K, alpha angle, MA, MA60, coagulation index, activated clotting time. hematocrit, prothrombin time, partial thromboplastin time, thrombin time, fibrinogen concentration, platelet count, blood loss during and after CPB, and blood and blood product administration. Coagulation indexes for CPB heparinase TEGs that were less than -2 or heparinase TEGs that were fibrinolytic were 87% accurate in predicting patients with excessive intraoperative blood loss, but were not predictive of blood product administration. The sensitivity was 12.5% and the specificity was I 00% in predicting excessive intraoperative bleeding. Post-protamine coagulation index inversely correlated with intraoperative red blood cell administration (r=-0.403, p<0.05), but was not predictive. Patients with fibrinolytic TEGs required blood products to compensate for expected blood loss associated with the fibrinolytic state. Simultaneous routine coagulation tests did not correlate significantly with blood loss or blood product administration, nor were they predictive. The findings of this study suggest that the presence of fibrinolysis in either a heparinase TEG on bypass or a post-protamine TEG is the most important predictor of blood and blood product administration. But, since only 20% of the patients in the study exhibited fibrinolytic TEGs, a study that included a much larger sample of patients would need to be done to confirm this finding.