The debate ROTEMs on - the utility of point-of-care testing and fibrinogen concentrate in postpartum haemorrhage

Authors: Agarwal, S. and Laycock, H. C.

Publication: Anaesthesia; 75,9:1247-1251.

Affiliations: Department of Cardiothoracic Anaesthesia and Critical Care, Manchester Royal Infirmary, Manchester, UK; Department of Anaesthesia, Great Ormond Street Hospital, London, UK.

Abstract: In 2019, McNamara et al. reported 4 years of observational data of their experience of rotational thromboelastometry (ROTEM®, Instrumentation Laboratory, Bedford, MA, USA) in a large UK tertiary obstetrics unit to aid the management of major obstetric haemorrhage. They introduced a ROTEM‐guided transfusion algorithm for the treatment of major obstetric haemorrhage, which they defined as an estimated blood loss exceeding 1500 ml with ongoing bleeding or signs of shock. This involved the use of fibrinogen concentrate, rather than fresh frozen plasma (FFP) and/or cryoprecipitate, to treat coagulopathy, based on the FibTEM A5 result. This new management strategy was compared with their previous standard of care; a shock pack for major obstetric haemorrhage that contained four units of FFP, four units of packed red cells and one pool of platelets. Women who suffered from major obstetric haemorrhage and coagulopathy before and after the introduction of the new algorithm were evaluated. The authors found that women managed with the ROTEM‐guided transfusion algorithm had a statistically significant reduction in the number of units and total volume of blood products transfused. In addition, the incidence of transfusion‐associated circulatory overload was reduced with the use of the new algorithm. Notably, out of the 203 women who suffered a major obstetric haemorrhage, only 23% met the study criteria for coagulopathy (FibTEM A5 value < 12mm) and only 54% of these required fibrinogen concentrate based on the new algorithm. The authors argue that not all women who suffer major obstetric haemorrhage are coagulopathic, and the formulaic management of major obstetric haemorrhage with strategies such as shock packs is not justified. This paper adds weight to the argument that point‐of‐care testing should be used to guide transfusion management in major obstetric haemorrhage protocols and the authors’ conclusions support the use of fibrinogen concentrate rather than other products to manage coagulopathy in this setting.