Comparing Rotational Thromboelastometry and Standard Coagulation Assays for Predicting Intraoperative Bleeding in Pediatric Liver Transplantation

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Abstract
Background: Utility of preoperative rotational thromboelastometry (ROTEM) over standard coagulation assays (SCAs) in predicting intraoperative bleeding during orthotopic liver transplantation (OLT) in children with liver failure (LF) remains unclear. Methods: In this single‐center retrospective cohort of pediatric OLT recipients, we compared the predictive values of preoperative ROTEM parameters (intrinsic pathway (INTEM) maximum clot firmness (MCF), extrinsic pathway (EXTEM) clotting time (CT), INTEM CT, and fibrinogen‐based (FIBTEM) MCF) and the corresponding SCAs (platelet count, international normalized ratio (INR), activated partial thromboplastin time (aPTT), and fibrinogen level, respectively) for significant intraoperative bleeding (blood loss of > 22 mL/kg; i.e., ≥ 85th percentile for the cohort). Results: Seventy‐two children (44 with chronic liver disease, 15 with acute liver failure, and 13 with acute‐on‐chronic liver failure), with a median age of 39 (IQR 13–159) months, were included. Twelve children (17%) had significant intraoperative bleeding. Most ROTEM parameters and the corresponding SCAs strongly correlated, except for EXTEM CT and INR (Rho of 0.501 and confidence interval (CI) of 0.298–0.660). A combination of SCA parameters performed better than the combination of corresponding ROTEM parameters (area under the curve of 0.862 vs. 0.760; p = 0.029) in predicting significant intraoperative bleeding. Among coagulation parameters, only platelet count was associated with significant intraoperative bleeding (adjusted Odds Ratio of 1.02, CI of 1.00–1.04; p = 0.009). Conclusions: ROTEM parameters and SCAs have comparable predictive value for significant intraoperative bleeding in children with LF requiring OLT. Further investigation is required to assess how ROTEM can be effectively used in managing coagulopathy in pediatric LF.

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