AM24-SN-02-O: New Directions in Coagulation Management and Transfusion Practice with Viscoelastic Testing in the OR (Enduring)

Anesthetic and surgical techniques have greatly improved blood loss outcomes in patients undergoing surgery, especially in heart and liver transplantation, but substantial blood use and critical decision points remain. New viscoelastic tests for coagulation system monitoring are being incorporated into algorithms for hemostasis management. Careful assessment is required as transfusion triggers may differ based on different testing methods. Conventional laboratory testing such as INR and fibrinogen level and different viscoelastic testing indices between rotational thromboelastometry (ROTEM), thromboelastography (TEG), and Quantra sonorheometry methods do not correlate highly and can lead to variability in transfusion management. In this session, a coagulation laboratory expert will first describe the principles of viscoelastic testing and different available viscoelastic testing platforms and methods. An anesthesiologist will explain how viscoelastic testing and conventional coagulation assays are utilized during different stages of surgery including liver transplant (pre-anhepatic, anhepatic, and neohepatic). Examples and challenges in setting up transfusion algorithms using viscoelastic and conventional coagulation testing in setting of surgery and massive bleeding will be discussed. There is increased interest in the use of antifibrinolytic therapy (particularly tranexamic acid) perioperatively, and literature about its safety and efficacy will be discussed. Threshold values for hemostatic intervention must be validated at each center. Areas for future research will be discussed including refinement of coagulation monitoring, correlation of different coagulation test parameters, and goal-directed transfusion and factor concentrate therapy based on patient population and available hemostatic components.