Sample times - solomet.dk

ROTEM® Management in Cardiac Surgery
Recommendations from the ROTEM® Expert Meeting Working Group, Munich 2007

Sample times

1. Anaesthesia FIBTEM

Optional1 INTEM EXTEM

2. CPB Either INTEM or EXTEM

30 min before coming off bypass HEBTEM
FIBTEM
3. Protamine
Optional2 1. Baseline testing left
10 min after protamine to clinician preference
INTEM - may be helpful for
ICU comparison with
Optinals subsequent tests
2. EXTEM useful to guide
HEBTEM EXTEM PCC or FFP use in some
centres. Monitor EXTEM
FIBTEM if using aprotinin which
prolongs CTINTEM

ROTEM® Management in Cardiac Surgery
Recommendations from the ROTEM® Expert Meeting Working Group, Munich 2007

Result and Action

Anaesthesia FIBTEM
CPB
INTEM EXTEM
Protamine
ICU HEBTEM Markedly abnormal results during CPB may suggest a high risk of bleeding post bypass.
FIBTEM Consider requesting blood products:

INTEM HEPTEM MCF < 35 & FIBTEM MCF > 8: request PLATELETS
HEBTEM FIBTEM MCF < 5: request FIBRINOGEN (Cryoppt/FFP)

FIBTEM Only TREAT if the patient is BLEEDING:
CTINTEM >> CTHEPTEM (> 25% difference) : circulation has excess heparin - PROTAMINE
FIBTEM MCF < 8: low fibrinogen, likely < 1g/L - FIBRINOGEN (or Cryoppt or FFP)
HEPTEM MCF < 45: assuming FIBTEM MCF > 8 - give PLATELETS
- Some institutions advise aiming for FIBTEM MCF >12 before considering platelets
CTHEPTEM > 300 s or CTEXTEM > 100 s: - FFP or PCC
(Aprotinin therapy may increase CTINTEM/HEPTEM: therefore use EXTEM instead in these cases)
But correct FIBTEM first; low fibrinogen prolongs CT

Near-normal result: consider platelet function tests or give platelets if recent anti-platelet therapy.
High bleeding rate: unlikely to be coagulopathy – consider RESTERNOTOMY

ROTEM® Management in Cardiac Surgery & Trauma
Recommendations from the ROTEM® Expert Meeting Working Group, Munich 2007

Indications and Sample Times

Major procedures • Baseline tests (optional) EXTEM
with large blood loss expected • When significant bleeding occurs FIBTEM
Unexpected bleeding problems • When the problem becomes apparent
INTEM

Emergency surgery for major EXTEM
haemorrhage
Major multiple trauma/ • When the problem becomes apparent
traumatic brain injury
APTEM FIBTEM

INTEM

Repeat after therapeutic interventions and if Ensure satisfactory pH (>7.25), temperature (>35°C),Ca++ HEPTEM
bleeding continues/clinical condition deteriorates The bleeding patient may benefit from target Hct >25% In any case of suspected
Continue until clinical situation and ROTEM® heparin effect
results are satisfactory APTEM
Repeat ROTEM® tests after admission to ICU If hyperfibrinolysis is
likely or suspected e.g.
liver transplant

ROTEM® Management in Cardiac Surgery & Trauma
Recommendations from the ROTEM® Expert Meeting Working Group, Munich 2007

Result and Therapeutic Options – Clotting Activation

EXTEM CTEXTEM > 100 s Treat if bleeding – unless CTINTEM
APTEM CTINTEM /HEPTEM > 300 prolongation due to desired heparin effect

INTEM FFP / coagulation factors concentrate (PCC)
Fibrinogen if FIBTEM MCF is very low
In hyper-fibrinolysis only APTEM If appropriate: protamine to reverse heparin
CT is a valid guide to treatment
Note: aprotinin therapy can cause
a prolongation of CT in INTEM &
HEPTEM

HEPTEM. In any case of
suspected heparin effect

ROTEM® Management in Cardiac Surgery & Trauma
Recommendations from the ROTEM® Expert Meeting Working Group, Munich 2007

Result and Therapeutic Options – Clot Firmness

EXTEM MCF 30-45 mm Treat if bleeding or high risk of bleeding
APTEM CFT 200-300 s
MCF < 30 mm Treat - rapidly and aggressively
INTEM CFT > 300 s
Therapy will be fibrinogen/FFP/cryoprecipitate
FIBTEM MCF 5-8 mm or platelets depending on FIBTEM results
MCF < 5 mm
In hyper-fibrinolysis only Treat if bleeding
APTEM MCF/CFT are
valid guides to treatment Treat
Consider higher target (e.g.
10-12 mm) if bleeding isn’t Fibrinogen/FFP/cryoprecipitate
controlled despite standard
treatment or in bleeding
multiple trauma patients

ROTEM® Management in Cardiac Surgery & Trauma
Recommendations from the ROTEM® Expert Meeting Working Group, Munich 2007

Result and Therapeutic Options – Hyperfibrinolysis

EXTEM Early lysis (ML>15%) of the Treat
APTEM clot (onset within 40 min) Treat if bleeding Repeat ROTEM
in INTEM or EXTEM
INTEM Late lysis (ML>15%) of the
clot (onset after 40 min)
in INTEM or EXTEM

In hyper-fibrinolysis only APTEM CT/MCF/CFT Therapy will be an antifibrinolytic agent, e.g. aprotinin
are valid guides as to whether other (500 000 – 1 Million IU) or tranexamic acid (2 g)
abnormalities are also present