Discussion
bleeding, ®, trauma, blood loss, haemorrhage, PPH, unawareness, hypocoagulation, blood coagulation
BLEEDING, BLOOD LOSS, HAEMORRHAGE, CARDIOVASCULAR COLLAPSE, UTERINE ATONY
Use of ROTEM® thromboelastometry might decrease administration of plasma by avoiding unnecessary OctaplasLG® transfusions. This finding agrees with similar studies conducted in other patient groups, such as those who underwent aorticAs experience from trauma patients suggested the benefit of a greater FFP/RBC ratio, there has been a tendency among clinicians to administer FFP at a lower threshold, even against current guidelines.Fibrinogen concentrate was also used more often (25.9% We did not find a significant difference in RBC transfusions as presumed, although the median number of RBC units administered was lower in the ROTEM group. When moving from the ‘shock-pack’ era towards more individualised care of bleeding, this might be expected but is seen also in randomised and prospective studies.Other laboratory parameters measuring blood coagulation and adequacy of fluid therapy were comparable and within accepted limits. The difference in post-treatment Extem ML measurement (6% in the ROTEM group, 8% in the control group; Of interventions to control haemorrhage, only sulprostone infusion was more often frequent in the control group. Sulprostone is a synthetic prostaglandin E2 derivative and a prostaglandin E3 agonist, a second-line therapy used to control uterine atony,To our knowledge, this is the only randomised controlled study among parturients comparing a ROTEM-guided treatment protocol with a conventional coagulation testing-guided approach. In this pragmatic study, the protocols were made simple enough to ensure implementation, patients were recruited no matter the day or time and by 22 different anaesthesiologists, and not only those involved in the study group. As this might have led to some heterogeneity in how subjects were treated and protocols followed, this is often the case even when using standard operating procedures.Our study had several weaknesses. As the median blood loss was 2.5–3.0 L and 1:1:1 transfusion was seldom needed, we might have missed parturients with lack of fibrinogen or other situations where early diagnosis of hypocoagulation could change the course of haemorrhage. Also, in a true emergency with patients on the verge of cardiovascular collapse, perhaps combined with shortage of personnel, suitable patients might not have been recruited. The attending anaesthesiologist was primarily taking care of the patient, not the study and we had no study personnel to help during on-call hours. Some patients were also missed because of unawareness of the ongoing study. This might explain why the study period was longer than planned. However, the treatment protocols remained unchanged during the study period.Subjects had a mean RBC transfusion amount of 2.6 units (In conclusion, we provide evidence that viscoelastic testing leads to more reasonable use of FFP or OctaplasLG®, and possibly diminishes bleeding, amongst patients with severe PPH. Larger randomised and controlled studies that apply a greater bleeding threshold for inclusion are warranted to assess the effects on red cell administration, morbidity, and mortality.