Thromboelastometry-guided treatment algorithm in postpartum haemorrhage. Comment on Br J Anaesth 2023; 130: 165–74

Editor—We read with interest the paper by Jokinen and colleagues. 1 Jokinen S. Kuitunen A. Uotila J. Yli-Hankala A. Thromboelastometry-guided treatment algorithm in postpartum haemorrhage: a randomised, controlled pilot trial. Br J Anaesth. 2023; 130: 165-174 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar We commend the authors for conducting one of the first prospective RCTs investigating the use of rotational thromboelastometry (ROTEM®) to guide administration of blood products in the management of postpartum haemorrhage (PPH). Despite success predominantly in trauma, vascular, and cardiac surgeries, there is limited evidence to support the integration of viscoelastic haemostatic assays into obstetric massive transfusion protocols, as noted by major international consensus bodies. 2 National Institute for Health and Care ExcellenceDetecting, managing and monitoring haemostasis: viscoelastometric point-of-care testing (ROTEM, TEG and Sonoclot systems. 2014https://www.nice.org.uk/guidance/dg13Date accessed: January 5, 2023 Google Scholar ,3 Wikkelsø A. Wetterslev J. Møller A.M. Afshari A. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst Rev. 2016; 2016: CD007871 PubMed Google Scholar The topic is one of live debate, however, with guidelines from various anaesthetic and haematological societies all recommending the use of viscoelastic haemostatic assays as part of the PPH treatment algorithm. 4 Association of Anaesthetists/Obstetric Anaesthetists’ AssociationOAA/AAGBI guidelines for obstetric anaesthetic services. 2013https://www.oaa-anaes.ac.uk/assets/_managed/editor/File/Guidelines/obstetric_anaesthetic_services_2013.pdfDate accessed: January 5, 2023 Google Scholar ,5 Curry N.S. Davenport R. Pavord S. et al. The use of viscoelastic haemostatic assays in the management of major bleeding. Br J Haematol. 2018; 182: 789-806 Crossref PubMed Scopus (134) Google Scholar Previous observational cohort studies 6 Mallaiah S. Barclay P. Harrod I. Chevannes C. Bhalla A. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia. 2014; 70: 166-175 Crossref PubMed Scopus (138) Google Scholar ,7 Snegovskikh D. Souza D. Walton Z. et al. Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. J Clin Anesth. 2018; 44: 50-56 Crossref PubMed Google Scholar have shown that replacement of fixed-ratio massive transfusion packs with a more individualised, ROTEM-guided, goal-directed protocol can reduce overall blood product use and possibly reduce transfusion-associated morbidity. Consequently, an RCT in this setting has been eagerly anticipated. Thromboelastometry-guided treatment algorithm in postpartum haemorrhage: a randomised, controlled pilot trialBritish Journal of AnaesthesiaVol. 130Issue 2PreviewPostpartum haemorrhage causes significant mortality among parturients. Early transfusion of blood products based on clinical judgement and conventional coagulation testing has been adapted to the treatment of postpartum haemorrhage, but rotational thromboelastometry (ROTEM) may provide clinicians means for a goal-directed therapy to control coagulation. We conducted a parallel design, randomised, controlled trial comparing these two approaches. We hypothesised that a ROTEM-guided protocol would decrease the need for red blood cell transfusion. Full-Text PDF Open Access