Rotational thromboelastometry (ROTEM)-based coagulation management in cardiac surgery and major trauma.

P ( FOR MAJOR BLEEDING related to severe trauma, major surgery, or chronic anticoagulation, a rapid assessment of emostatic function is crucial so that optimal fluid replaceents and blood transfusion can be administered without deays.1-6 Although the safety of blood products with regard to viral transmission risks has improved in recent years,7,8 transfusions of allogeneic erythrocyte and plasma products have been implicated in serious adverse events, including nosocomial infections, acute lung injury, and organ dysfunction.9-12 Obtaining conventional laboratory tests, such as the prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen level, during acute bleeding is difficult because of a long turn-around time ( 30 min).13,14 Furthermore, laboratory PT/international normalized ratio and aPTT may not be particularly useful in predicting bleeding after trauma or invasive procedures.15,16 The prime example of bleeding management is preemptive transfusions of fresh-frozen plasma (FFP) and platelet concentrates according to the erythrocyte requirement in major trauma cases.17,18 This so-called “damage control resuscitation” (DCR; Table 1) originally was advocated for battlefield resuscitation in which laboratory testing and transfusion resources were limited. However, plasma product transfusion according to DCR became increasingly popular in US civilian trauma centers and operating rooms.17,19 The prevention of trauma-inuced coagulopathy and subsequent nonsurgical bleeding is a ajor advantage of DCR,20 but the DCR approach lacks a specific target for replacement and a consideration for interindividual variability in coagulation factor levels and vascular (endothelial) responses. Implementing transfusion algorithms based on point-of-care (POC) coagulation testing can be effective in decreasing transfusion requirements in elective or urgent cardiac surgical settings.2,5,21-23 In this review, the practical use of thromboelastometry is discussed relating to the diagnosis of coagulopathy and optimizing hemostatic interventions.