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Peritoneal Surface Malignancies

E340: The use of ROTEM in detection of coagulopathy and altered hemostasis in patients undergoing CRS/HIPEC

Introduction: Patients undergoing Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for peritoneal malignancies are at risk of coagulopathy. Routine laboratory tests like INR and PTT provide limited insight into coagulation status and may not be adequate to guide intra- and post-operative resuscitation. This study aims to evaluate the potential role of rotational thromboelastometry (ROTEM) to detect alterations in hemostasis and coagulation during and after CRS/HIPEC.

Methods: A prospective pilot study was conducted on patients undergoing CRS/HIPEC for peritoneal malignancies at a single tertiary care center. All consecutive CRS/HIPEC patients from April 2021 to December 2022 were enrolled. Participants were monitored with ROTEM, INR, PTT, Fibrinogen, and CBC at 4 time points (pre-incision, post-HIPEC, and on post-operative days 1 and 3). Administration of blood products was recorded. A linear regression model was utilized to identify associations between pre-incision ROTEM parameters and blood loss. The anesthesia team noted whether ROTEM influenced their intra-operative clinical decision-making.

Results:

A total of 35 patients were enrolled and 5 were excluded due to the planned procedure being aborted or lab tests not being performed as specified. Patients were predominantly male (63.3%) with a median age of 57 years. Underlying histologies included adenocarcinoma (46.6%), low-grade appendiceal mucinous neoplasm (26.6%), and mesothelioma (23%). Significant changes were observed from pre-incision to post-HIPEC time points in INR, PTT and ROTEM values. Specifically, mean FIBTEM readings decreased from 19.2mm to 10.4mm and mean fibrinogen decreased from 3.5g/L to 2.1g/L , p< 0.05. During surgery, 5 patients (17%) were given fibrinogen, while no packed red blood cell transfusions were required. Pre-incision fibrinogen was significantly associated with intra-operative blood loss, p< 0.05. Anesthesiologist teams indicated that intra-operative ROTEM influenced their clinical management in 17% of cases (5/30).

Conclusions: CRS/HIPEC is associated with changes in patients’ coagulation profiles until at least postoperative day 3. Use of ROTEM intra-operatively may aid in predicting blood loss and inform the need for blood product administration.

Learning Objectives:

  • Upon completion, participants will be able to describe the limitations of conventional coagulation tests in monitoring coagulation status for patients undergoing CRS/HIPEC, and articulate the potential advantages of using ROTEM.
  • Upon completion, participants will be able to appreciate the association between pre-incision fibrinogen levels and intraoperative blood loss, exploring ROTEM's predictive utility in CRS/HIPEC procedures.
  • Upon completion, participants will be able to evaluate how intra-operative ROTEM monitoring can influence intra-operative resuscitation in CRS/HIPEC