Thromboelastometry-guided hemostatic therapy for hemorrhagic shock in the postoperative period of vascular surgery: a case report

Tomaz Crochemore, Felicio A. Savioli

Hemorrhagic shock is a medical emergency that often complicates vascular surgery and can lead to death. Hemorrhagic shock is characterized by hypoperfusion and hemodynamic abnormalities leading to the collapse of homeostasis due to massive blood loss. Early diagnosis is critical for a favorable outcome. Thromboelastometry has been considered an effective tool for bleeding management in critically ill patients. Thromboelastometry can guide transfusion therapy quickly, reducing the need for blood products. Therefore, it could be an alternative test to guide hemostatic therapy in complex cases of hemorrhagic shock as a result of vascular surgeries. We report our successful experience with a case of hemorrhagic shock in postoperative care in vascular surgery, in which bleeding management was guided by thromboelastometry and bleeding control was achieved with hemostatic drugs and coagulation factor concentrates. We report a case of an 82-year-old Afro-Brazilian man who presented to the intensive care unit with hemorrhagic shock in the postoperative period of vascular surgery. He underwent surgery for correction of iliac artery aneurysm with endoleak. His laboratory tests revealed severe anemia (hemoglobin 7.4 mg/dL), metabolic acidosis (bicarbonate 10 mEq/L, pH 7.11), acute kidney injury (creatinine 3.1 mg/dL), thrombocytopenia (platelets count 83 × 103/mm3), hypofibrinogenemia (70 mg/dL), international nationalized ratio 1.95, activated partial thromboplastin time 64.5 seconds, and lactate 87 mmol/L. There was active bleeding in surgical site. Bleeding management was guided by thromboelastometry. The first test showed fulminant hyperfibrinolysis, which was corrected with the administration of tranexamic acid. The second thromboelastometry test showed improvement of hyperfibrinolysis but severe hypocoagulability. Fibrinogen concentrate, platelet apheresis, cryoprecipitate, and prothrombin complex concentrate were sequentially administrated. Thromboelastometry was completely corrected after 2 hours. Arteriography to evaluate mechanical cause of bleeding was normal. No more bleeding was identified, and neither was any further transfusion needed. He was discharged from the intensive care unit from the ward 3 days after admission. Thromboelastometry may be considered a useful, feasible and safe tool to monitor and manage coagulopathy in patients with hemorrhagic shock. Moreover, it has the potential benefit of allowing rapid diagnosis,  goal-directed therapy with hemostatic drugs and coagulation factor concentrates and thus, avoiding unnecessary blood component transfusion.