Klaus Görlinger is a medical director who has experience in perioperative bleeding management. He discloses past and present conflicts of interest related to companies that produce hemostatic medications and point-of-care testing devices. In his presentation, he discusses different transfusion strategies for managing perioperative bleeding and emphasizes the importance of using point-of-care tests like ROTEM to guide individualized, targeted treatment based on the underlying coagulopathy. Studies show ROTEM-guided management can reduce blood product use, re-exploration rates, and costs compared to conventional laboratory-driven protocols.

1. Klaus Görlinger, MD
University Hospital Essen, Germany
klaus@goerlinger.net
Point-of-Care Testing Efficacy
ANEMO14, Strategie di Risparmio del Sangue,
Policlinico San Donato Milanese, 7-8 Marzo 2014

2. Conflicts of interest
• Dec 1986 - June 2012: Senior Consultant at the Department of
Anesthesiology and Intensive Care Medicine, University Hospital
Essen, Germany
• 2010 - 2012: Chair of the DIVI Section Clinical Haemotherapy
and Haemostasis Management of the German Interdisciplinary
Association of Critical Care and Emergency Medicine
• 2010 - 2012: Member of the ESA Scientific Subcommittee
Transfusion and Haemostasis and the Task Force / co-author of
the ESA Guidelines on the Management of Severe Perioperative
Bleeding
• Honoraria for Scientific Lectures from CSL Behring GmbH,
Marburg, Germany, Octapharma AG, Lachen, Switzerland, Tem
International GmbH, Munich, Germany, and Verum Diagnostica
GmbH, Munich, Germany
• Since July 2012, Medical Director of Tem International GmbH,
Munich, Germany

3. Perioperative Bleeding Management
Cost
effectiveness
Efficacy Safety

4. Transfusion strategies
• Formula driven (1:1:1-concept):
PRBC - FFP - Platelets - rFVIIa
• Lab-driven protocol
• Individualized POC-driven:
Fibrinogen/Cryo - Plt - PCC/FFP

5. EXTEM A5

6. Lactate
clearance

8. Results: ... Patients arrived in the ICU 6.8 ± 0.3
hours after admission. Coagulopathy, present at
hospital admission (pre-ICU INR, 1.8 ± 0.2)
persisted at ICU admission (initial ICU INR, 1.6 ±
0.1). ... In the ICU during resuscitation mean INR
decreased to 1.4 ± 0.03 within 8 hours, indicating
moderate coagulopathy. ... The ratio of FFP:PRBC
was 1:1. ... Statistical analysis found severity of
coagulopathy (INR) at ICU admission associated
with survival outcome (p = 0.02).
1:1 → 14.8 hours to achieve an INR < 1.5 !

9. CONCLUSION: MTP (massive transfusion protocol
with 1:1:1 ratio) therapy worsened mortality in
penetrating MOI (mechanism of injury) patients
receiving 10U or more RBC, indicating a continued need
for TEG-directed therapy. A 1:1:1 strategy may not be
adequate in all patients.

11. ROTEM®
analysis enables rapid detection of
most coagulation disorders; this study
demonstrates the additional benefit of MT
risk stratification using results available within
10 minutes after CT (FIBTEM®
A10).

12. Avoid FFP transfusion
(potential harmful)!
Treat trauma-induced
coagulopathy early!

15. Why does the patient bleed ?

17. Standard coagulation test results were available
after a median of 53 min [inter-quartile range
(IQR): 45–63 min], whereas 10 min values of
ROTEM results were available online after 23 min
(IQR: 21–24 min).
Further time saving was 11 minutes (8-16
minutes) if ROTEM® measurements were
performed bedside (p<0.001).

20. Fibrinogen
deficiency
Thrombocyto-
penia
Fibrinolysis
sensitive to
aprotinin /
TXA
CF deficiency
intrinsic pw
CF deficiency
extrinsic pw
Heparin
effect
Fibrinogen /
Cryoprecipitate
Platelet
concentrate
Tranexamic
acid
PCC
Protamine
FFP

21. EXTEM cut-off
(Sens/Spec):
CFT < 51 s (89/94)
MCF > 68 mm (94/94)
TPI > 3.5 (100/93)
FIBTEM cut-off
(Sens/Spec): MCF > 24
mm (77/88)

22. ROTEM®
delta
• 4 Channels
viscoelastic tests
ROTEM®
platelet
• 2 Channels
impedance aggrego-
metry
ROTEM®
(all-in-one)

23. 30-day incidence of ST and
major bleeding
hyper normal low

24. ADPtest 31 – 46 AU (patients with DES)
EXTEMMCF45-68mm
FIBTEMMCF8-24mm
EXTEMCT40-80s

26. Platelet function?
Tranexamic acid
Preconditions
Bleeding patient !
Order Fibrinogen /
Cryo or Platelets ?
Protamine
Fibrinogen (Cryo)
4F-PCC (or FFP)
Platelets
FXIII or rFVIIa ?
Fibrinogen ↑
Surgical bleeding?

27. 1718 2147

28. (thromboembolic)

30. • Primary outcome parameter (CON vs. POC):
– PRBC: 5(4/9) vs. 3(2/6); p < 0.001
• Secondary outcome parameter:
– FFP: 5(3/8) vs. 0(0/3); p < 0.001
– PC: 2(0/5) vs. 2(0/2); p = 0.010
– rFVIIa: 0(0/0) vs. 0(0/0); p = 0.001

31. 16
24
16
75
16
2 2
10
20
56
0
20
40
60
80
100
Massive
Transfusion
rFVIIa Rescue
Therapy
Re-exploration Coagulopathy Extubation
within 6 h
CON
POC
p = 0.031
p = 0.002
p = 0.071
p = 0.112
p < 0.001
Incidence of MT, RT, Re-Exploration and Outcomes

32. 20
14
4
0
38
6
2
0 0
8
0
5
10
15
20
25
30
35
40
ARF Sepsis TAE Allergy CAE
CON
POC
p = 0.071
p = 0.059
p = 0.495
p < 0.001
Incidence of adverse events

33. 4%
20%

35. Pre-program
(2012; n = 1390)
Post-program
(2013; n = 239)
P-value
RBC % 51% 37% < 0.0001
RBC Units 1 (0, 3) 0 (0, 1) < 0.0001
Platelets % 33% 18% < 0.0001
Platelets Units 0 (0, 5) 0 (0, 0) < 0.0001
Plasma % 33% 14% < 0.0001
Plasma Units 0 (0, 2) 0 (0, 0) < 0.0001
Cryo % 4% 2% 0.1
CT drainage (1 hr) 75 (45, 140) 60 (35, 110) 0.001
CT drainage (24 hrs) 460 (350, 640) 410 (315, 565) 0.0006
Discharge Hb 98 (91, 107) 98 (93, 106) 0.5
Keyvan Karkouti, Toronto General, Canada:
Improving Outcomes with Point-of-Care Hemostasis
Testing in Cardiac Surgery: A Pilotstudy

36. Pre-program
(2012; n = 1390)
Post-program
(2013; n = 239)
P-value
Re-exploration 6.5% 2.5% 0.01
Large-volume RBC
Transfusion (≥ 5 units)
13.2% 5.4% 0.0007
Low output syndrome 2.8% 1.7% 0.3
Renal failure (new-dial.) 1.9% 0.4% 0.1
Atrial fibrillation 34% 39% 0.1
Stroke 2.2% 1.7% 0.6
Sternal infection 1.7% 1.3% 0.6
Death 2.4% 2.1% 0.8
Ventilation time 6.3 (4.7, 12.0) 6.2 (4.4, 10.6) 0.2
ICU LOS 2 (1, 3) 2 (1, 3) 0.6
Hospital LOS 7 (6, 10) 7 (6, 9) 0.2
Keyvan Karkouti, Toronto General, Canada:
Improving Outcomes with Point-of-Care Hemostasis
Testing in Cardiac Surgery: A Pilotstudy

37. POCT using ROTEM® can assist clinicians in making appropriate
and timely decisions regarding the treatment of bleeding in cardiac
surgery patients.
This allows for more targeted use of blood products, and whether
the decision to transfuse in the first place is warranted.
At The Prince Charles Hosiptal, Brisbane, the use of ROTEM® as
an element in a multi-factorial approach to patient blood
management, has resulted in a decrease in the amount of blood
products transfused during cardiac surgery.

38. - 39.2%
- 48.3%
$ 928,998

42. 45.4% reduction in in-hospital mortality, 50% reduction in 24h mortality,
and 45.6% reduction in multiple organ failure within 1 year
TRAUMA MANAGEMENT

44. 1B
1A
1C
2C

45. Cost-effectiveness of ROTEM®-guided
bleeding management
COSTS
OUTCOMES
Increased
costs and
worse
outcomes
Reduced
costs and
worse
outcomes
Increased
costs and
improved
outcomes
Reduced
costs and
improved
outcomes