Practical Use of Thromboelastometry in the Management of Perioperative Coagulopathy and Bleeding

•Thromboelastometry is suited for a timely assessment of rapid and dynamic changes in coagulation status during major cardiovascular surgery.•Continuous assessment on the quality of fibrin polymerizaiton allows timely and efficacious hemostatic interventions, which may reduce overall allogeneic blood use.•Thromboelastometry appears to be sensitive to DOACs, but it is not sensitive to aspirin, P2Y12 inhibitors, and endogenous anticoagulant deficiencies 13 (eg, AT, protein C).

Achieving hemostasis after complex cardiovascular and transplant surgical procedures is one of the greatest challenges anesthesiologists face. Preoperative coagulation disturbances due to underlying disease or antithrombotic therapy are common, and they are worsened by intraoperative blood loss and fluid replacement. The coagulation reactions in vivo are incredibly complex interactions among blood cells, proteins, and vasculature, standing in sharp contrast to rather simple treatment options including transfusion of platelets, plasma, and cryoprecipitate. The long turnaround time of laboratory coagulation testing, and intraoperative heparin use also make timely coagulation assessment difficult during cardiopulmonary bypass, and thus, hemostatic components are often empirically ordered and administered without knowing their actual need or efficacy. However, increasing clinical experience with viscoelastic coagulation testing in cardiac and transplant anesthesia has introduced a paradigm shift, enabling clinicians to obtain clinically relevant coagulation data in a timely fashion and to treat a specific element of coagulation that is dysfunctional. Viscoelastic coagulation testing may facilitate an optimal use of blood components and other hemostatic agents, but its application is often practice specific (ie, type of surgery), and there are technical limitations and learning curves. The aims of this review are thus to summarize recent clinical data on viscoelastic coagulation testing and to provide practical examples of its use in complex cardiac surgical and transplant cases.