Comparison of acute normovolemic hemodilution and preoperative autologous blood donation in clinical practice

STUDY OBJECTIVE: To compare, by model simulation, acute normovolemic hemodilution (ANH) and preoperative autologous blood donation (PABD) to predict their efficacy in current clinical practice. To discuss their similarities and offer guidelines based on expected operative blood loss. DESIGN: Model simulation using data obtained from total hip arthroplasty procedures. SETTING: University medical center. PATIENTS: 91 patients who participated in PABD undergoing single, primary, total hip replacement surgeries from January to December 1997. INTERVENTIONS: A nonanemic (Hb baseline 14 g/dL), average-sized patient (estimated blood volume 5,000 mL) who donated two units by either PABD or ANH was assumed for model simulation. The Hb-final, as a function of 250-mL blood loss increments after retransfusion of two autologous units, was calculated for each technique and compared to a control (nondonor) to predict the effectiveness of PABD and ANH in conserving red cell mass. Data from hip arthroplasties over a 12-month period were used to determine the parameters for the model. Results were subjected to regression analysis and tested for parallelism of slopes, with p < 0.05 accepted to indicate a statistical difference. MAIN RESULTS: The difference in Hb-final between PABD and ANH was not statistically different over a wide range of blood loss. When compared to control, there was no difference in Hb-final measurements in the estimated blood loss (EBL) range of less than 1,000 mL. ANH and PABD provide some benefit when EBL is greater than 1,500 mL in nonanemic, average-sized patients. As blood loss increases, the benefit of autologous collection becomes more clinically evident. CONCLUSION: PABD exemplifies a "chronic" form of ANH in current clinical practice and offers little advantage over ANH as a blood conservation technique for high-blood-loss operations. When surgical blood loss is predictably mild to moderate (range 250 to 1,000 mL), neither blood conservation technique is necessary.     

Difference in autologous blood transfusion-induced inflammatory responses between acute normovolemic hemodilution and preoperative donation

Purpose  The inflammatory response triggered by transfusion is implicated in the pathophysiology of transfusion-related immunomodulation. The authors hypothesized that two distinctive autotransfusion methods, acute normovolemic hemodilution (ANH) and preoperative donation (PD), have different influences on both inflammatory mediator generation during storage and the inflammatory response after a transfusion. The purpose of this study was to compare the plasma concentrations of neutrophil elastase (NE), interleukin (IL)-6, IL-8, and IL-10 in patients who underwent either of these two autologous transfusion methods. Methods  With institutional review board approval, the plasma concentrations of the above inflammatory mediators were determined in 23 patients with ANH and 8 patients with PD at the following time points: after anesthetic induction, at the end of the operation, and the morning of postoperative day 1. The concentrations of these inflammatory mediators were also measured in the donated blood obtained by either ANH or PD before retransfusion. Results  The mean storage durations were 3.7 h and 6.1 days for ANH and PD, respectively. Higher concentrations of NE and IL-10 were detected in the PD blood than in the ANH blood. Long duration of storage and/or low temperature may have been responsible for the increased NE and IL-10 concentrations in the PD blood. However, the difference between the two groups in the extent of increased plasma concentrations of these inflammatory mediators was not statistically significant. Conclusion  Inflammatory mediators were significantly increased in PD blood during storage compared to the blood obtained by ANH. However, their effects on the inflammatory response elicited in the recipients were not significantly different.     

Effectiveness of acute normovolemic hemodilution to minimize allogeneic blood transfusion in major liver resections

BACKGROUND: Liver resection is a major operation for which, even with the improvements in surgical and anesthetic techniques, the reported rate of blood transfusion was rarely less than 30%. About 60% of transfused patients require only 1 or 2 units of blood, a blood requirement that may be accommodated by the use of acute normovolemic hemodilution (ANH). METHODS: The efficacy, hemodynamic effects, and safety of ANH were investigated in a randomized, active-control study in patients with American Society of Anesthesiologists status I-II who were undergoing major liver resection with fentanyl-nitrous oxide-isoflurane anesthesia. Patients were randomized to the ANH (n = 39) or control group (n = 39). Patients in the ANH group underwent hemodilution to a target hematocrit of 24%. The indication for blood transfusion was standardized. In both groups transfusion was started at a hematocrit of 20%. The primary efficacy endpoint was the avoidance of allogeneic blood transfusion in the intraoperative period and first 72 h after surgery. Various laboratory and hemodynamic parameters as well as postoperative morbidity were monitored to define the safety of ANH in this patient population. RESULTS: During the perioperative period, 14 control patients (36%) received at least one unit of allogeneic blood compared with 4 patients (10%) in the ANH group ( < 0.05). The hemodilution process was not associated with significant changes in patients' hemodynamics. Morbidity was similar between the control and the ANH groups. Postoperative hematocrit levels and biochemical liver, renal, and standard coagulation test results were similar in both groups. CONCLUSIONS: Acute normovolemic hemodilution in patients with American Society of Anesthesiologists status I-II undergoing major liver resection may allow a significant number of patients to avoid exposure to allogeneic blood.     

贮存式自体成分输血对胃肠肿瘤患者围术期免疫功能的影响

目的观察贮存式自体成分输血与异体输血对胃肠恶性肿瘤患者围术期细胞免疫和体液免疫的影响。方法选择择期全麻下行胃肠肿瘤根治手术患者60例,男33例,女27例,年龄53~69岁,体重47~70 kg,ASAⅠ或Ⅱ级。术中出血200~400 ml,Hb70 g/L时启动输血,将患者随机分为两组,每组30例。贮存式自体成分输血组(P组):术中输血时采用贮存式自体成分输血;异体输血组(A组):输血时采用异体输血。测定入室时、术毕即刻、术后1、3、7 d外周血中T淋巴细胞亚群、NK细胞百分比和IL-2、IL-10、TNF-α、穿孔素(perforin,PF)浓度。结果与入室时比较,术毕即刻至术后7 d A组CD3~+、CD4~+、NK细胞百分比和CD4~+/CD8~+比值明显降低(P0.05);术后3、7 d A组CD3~+、CD4~+、NK细胞百分比和CD4~+/CD8~+比值明显低于P组(P0.05);术后1~7 d A组IL-2浓度明显低于,IL-10浓度明显高于P组(P0.05)。与入室时比较,术毕即刻至术后3 d A组Ig G、Ig A含量明显降低(P0.05);术毕即刻P组Ig G、Ig A含量明显降低(P0.05),术后1、3 d恢复至术前水平。结论围术期异体输血可降低肿瘤患者T细胞亚群和NK细胞百分比并延长其恢复时间,也可一过性降低血浆中免疫球蛋白Ig G、Ig A含量,从而影响患者的免疫功能,而贮存式自体成分输血对肿瘤患者术后免疫功能的影响轻微。     

Absence of beneficial effect of acute normovolemic hemodilution combined with aprotinin on allogeneic blood transfusion requirements in cardiac surgery

BACKGROUND: The efficacy of acute normovolemic hemodilution (ANH) in decreasing allogeneic blood requirements remains controversial during cardiac surgery. METHODS: In a prospective, randomized study, 80 adult cardiac surgical patients with normal cardiac function and no high risk of ischemic complications were subjected either to ANH, from a mean hematocrit of 43% to 28%, or to a control group. Aprotinin and intraoperative blood cell salvage were used in both groups. Blood (autologous or allogeneic) was transfused when the hematocrit was less than 17% during cardiopulmonary bypass, less than 25% after cardiopulmonary bypass, or whenever clinically indicated. RESULTS: The amount of whole blood collected during ANH ranged from 10 to 40% of the patients' estimated blood volume. Intraoperative and postoperative blood losses were not different between control and ANH patients (total blood loss, control: 1,411 +/- 570 ml, n = 41; ANH: 1,326 +/- 509 ml, n = 36). Allogeneic blood was given in 29% of control patients (median, 2; range, 1-3 units of packed erythrocytes) and in 33% of ANH patients (median, 2; range, 1-5 units of packed erythrocytes; P = 0.219). Preoperative and postoperative platelet count, prothrombin time, and partial thromboplastin time were similar between groups. Perioperative morbidity and mortality were not different in both groups, and similar hematocrit values were observed at hospital discharge (33.7 +/- 3.9% in the control group and 32.6 +/- 3.7% in the ANH group; nonsignificant) CONCLUSIONS: Hemodilution is not an effective means to lower the risk of allogeneic blood transfusion in elective cardiac surgical patients with normal cardiac function and in the absence of high risk for coronary ischemia, provided standard intraoperative cell saving and high-dose aprotinin are used.     

Efficacy of preoperative autologous blood donation: analysis of blood loss and transfusion practice in total hip replacement

STUDY OBJECTIVE: To determine the frequency of allogeneic transfusion for total hip replacement (THR) surgery and to examine the efficacy of preoperative autologous blood donation (PABD) under specified, standardized blood transfusion guidelines. DESIGN: Prospective, nonrandomized study. SETTING: University medical center. PATIENTS: All ASA physical status I, II, III, and IV patients undergoing single, primary, THR surgery from April 1998 to March 1999. INTERVENTIONS: All patients received standardized transfusion and anticoagulation therapy. Demographic, blood loss, and transfusion data were collected and compared between all patients participating in PABD (donors) and patients not participating in PABD (nondonors). Overall allogeneic blood exposure was established. Since most anemic patients could not participate in PABD, allogeneic transfusion frequency was also examined in a subset of nonanemic patients (hemoglobin > or =12 g/dL) who were potentially able to participate in PABD. MEASUREMENTS AND MAIN RESULTS: n = 231 patients, 142 donors and 89 nondonors. Mean estimated blood volume (EBV) of donors was 4991 +/- 1042 mL versus nondonors 4631 +/- 1108 mL (p < 0. 01). ASA physical status I-II/III-IV among donors was 118/24 versus nondonors 61/28 (p < 0.01). Overall allogeneic blood exposure was 22% (51/231). Allogeneic transfusion frequency for all donors was 15% (22/142) versus nondonors 33% (29/89) (p < 0.05). Among nonanemic patients, donor versus nondonor EBV and ASA physical status I-II/III-IV were 5074 +/- 1019 mL versus 4743 +/- 1172 mL and 107/20 versus 48/15 (p = NS); allogeneic transfusion frequency reduced to 13% (16/127) versus 17% (11/63) (p = NS), respectively. CONCLUSIONS: Allogeneic blood exposure was >10% despite the use of PABD. The efficacy of PABD has been obscured by the fact that donors of autologous blood tend to be larger and healthier than nondonors. After exclusion of anemic patients, autologous donors and nondonors were clinically comparable and the difference in allogeneic blood exposure was not statistically significant. PABD offers only a modest, if any, benefit for THR surgery.     

Blood loss and the need for homologous blood transfusion in elective general surgery as a basis for indications for preoperative autologous blood donation

The records of 279 surgical patients of 1986 were retrospectively evaluated for blood loss and blood-transfusion in order to provide a basis for an autologous blood donation program. 90% of the large bowel resections, gastrectomy and peripheral artery interventions with a blood loss between 0.5 and 1.51 could have been performed with the sole use of autologous blood. 50% of the operations of the abdominal aorta and all operations of the oesophagus would have required the additional use of other autotransfusion techniques or homologous blood transfusions.     

Clinical experience of autologous blood transfusion in patients undergoing nephrectomy with renal cell carcinoma]

We studied the possibility of performing radical nephrectomy with only predeposit autologous blood transfusion in the treatment of patients with renal cell carcinoma. A total of 15 patients who ranged in age from 32 to 69 years and had a hemoglobin concentration of over 12 g/dl on admission underwent radical nephrectomy with preoperative autologous blood donation. Five patients did not need transfusions. Seven patients were transfused only autologous blood. The other 3 required some homologous blood in addition to their own banked blood. In our series, patients were able to donate 600 ml of blood during the last week before surgery and their hemoglobin concentration did not decrease by over 2 g/dl except in the case of two patients with advanced disease. Therefore, it was concluded that an adequate autologous blood volume for nephrectomy was 600 ml and that 80% of renal cell carcinoma surgery could be performed without homologous blood transfusion. For patients requiring resection of renal cell carcinoma, autologous transfusion is recommended as safe and convenient.     

Large volume acute normovolemic hemodilution in patients undergoing cardiac surgery with intermediate-high risk of transfusion: A randomized controlled trial

Study Objective: To investigate whether large volume acute normovolemic hemodilution (L-ANH), compared with moderate acute normovolemic hemodilution (M-ANH), can reduce perioperative allogeneic blood transfusion in patients with intermediate-high risk of transfusion during cardiac surgery with cardiopulmonary bypass (CPB).Design: Prospective randomized controlled trial.Setting: University hospital.Patients: Patients with transfusion risk understanding scoring tool (“TRUST”) ≥2 points undergoing cardiac surgery with CPB in the Second Affiliated Hospital of Zhejiang University from May 2020 to January 2021 were included.Interventions: The patients were randomly assigned with a 1:1 ratio to M-ANH (5 to 8 mL/kg) or L-ANH (12 to 15 mL/kg).Measurements: The primary outcome was perioperative red blood cell (RBC) transfusion units. The composite outcome included new-onset atrial fibrillation, pulmonary infection, cardiac surgery associated acute kidney injury (CSA-AKI) class ≥2, surgical incision infection, postoperative excessive bleeding, and resternotomy. Main results: Total 159 patients were screened and 110 (55 L-ANH and 55 M-ANH) were included for final analysis. Removed blood volume of L-ANH is significantly higher than M-ANH (886 ± 152 vs. 395 ± 86 mL, P < 0.001). Perioperative RBC transfusion was median 0 unit ([25th, 75th] percentiles: 0–4.4) in M-ANH group vs. 0 unit ([25th, 75th] percentiles: 0–2.0) in L-ANH group (P = 0.012) and L-ANH was associated with lower incidence of transfusion (23.6% vs. 41.8%, P = 0.042, rate difference: 0.182, 95% confidence interval [0.007–0.343]). The incidence of postoperative excessive bleeding was significantly lower in L-ANH vs. M-ANH (3.6% vs. 18.2%, P = 0.029, rate difference: 0.146, 95% confidence interval [0.027–0.270]) without significant difference for other second outcomes. The volume of ANH was inversely related to perioperative RBC transfusion units (Spearman r = −0.483, 95% confidence interval [−0.708 to −0.168], P = 0.003), and L-ANH in cardiac surgery was associated with a significantly reduced risk of perioperative RBC transfusion (odds ratio: 0.43, 95% confidence interval: 0.19–0.98, P = 0.044).Conclusions: Compared with M-ANH, L-ANH during cardiac surgery inclined to be associated with reduced perioperative RBC transfusion and the volume of RBC transfusion was inversely proportional to the volume of ANH. In addition, LANH during cardiac surgery was associated with a lower incidence of postoperative excessive bleeding.     

急性高容量血液稀释联合控制性降压和自体血回收在全髋关节置换术中的应用

目的 观察急性高容量血液稀释(AHH)联合控制性降压(CH)和自体血回收回输技术应用于全髋关节置换术的临床效果与安全性.方法 60例全髋关节置换术,用抽签法随机均分成观察组(A组)和对照组(C组),A组全麻诱导后30 min内输入6%羟乙基淀粉130/0.4 15 ml/kg.手术开始时用硝酸甘油行CH,维持MAP(65±5)mmHg,并应用自体血液回收仪回收回输术野出血.C组除未行CH外,余操作均同A组,两组术中连续监测HR、MAP、中心静脉压(CVP);记录出血量、异体血输入量及手术时间,并分别于AHH前、AHH后、术毕测定Hb、血细胞比容(Hct)及凝血酶原时间(PT)、活化的部分凝血酶原时间(APTT)和纤维蛋白原(FG).结果 A组失血量(515±123)ml和回输洗涤红细胞量(275±53)ml均显著低于C组(950±183)ml和(425±97)ml(P<0.01);两组Hct、Hb在AHH后和术毕较AHH前降低(P<0.01),两组PT、APTT在AHH后和术毕均长于AHH前(P<0.01),而FG低于AHH前(P<0.01),但均在正常范围.A组未输入异体血,C组3例输入少浆血2 U,5例输入新鲜冰冻血浆200ml.两组均无肺水肿、心衰及创面异常出血等并发症.结论 AHH联合CH可安全用于全髋关节置换术,并明显减少术中出血量,术中配合自体血回收回输技术可减少甚至避免异体输血.     

Evaluation of a new hydroxyethyl starch solution (HES 130/0.4) in patients undergoing preoperative autologous blood donation.

STUDY OBJECTIVE: To compare the tolerance and efficacy of the new hydroxyethyl starch (HES) 130/0.4 with a current HES solution (HES 200/0.5) in patients undergoing preoperative autologous blood donation as a model of surgical blood loss. HES 130/0.4 is expected to be a plasma substitute as efficacious as current HES solutions while offering such advantages as more complete renal elimination and reduced tissue storage. DESIGN: Controlled, randomized, double-blind, phase II clinical trial. SETTING: 1500-bed university hospital. PATIENTS: 60 ASA physical status II and III patients scheduled for elective cardiac and noncardiac surgery, and meeting selection criteria for autologous blood donors. INTERVENTIONS: Collection of 500 mL of blood with simultaneous intravenous (IV) infusion of 500 mL of either HES 130/0.4 or HES 200/0.5 (mean molecular weight 130 kD and 200 kD, degree of substitution 0.4 and 0.5, respectively). MEASUREMENTS: Noninvasive measurements of heart rate and arterial blood pressure were obtained every 5 minutes until 1 hour after blood donation and infusion of the study drugs; laboratory studies (complete blood counts, electrolytes, markers of renal and liver function) were performed; and follow-up assessment of adverse events was undertaken by questionnaire 24 hours after blood donation and infusion of the study drugs. MAIN RESULTS: Both hemodynamics and laboratory test results did not differ significantly between the groups at any time. Hemodynamics remained stable in each group, and no adverse event was observed in any patient until one hour after blood donation and infusion of the study drugs. Adverse events elicited by postphlebotomy questionnaire were mild and probably unrelated to HES infusion. CONCLUSIONS: Intravenous infusion of 500 mL of the new HES 130/0.4 was tolerated well and maintained cardiovascular stability in patients undergoing preoperative autologous blood donation. HES 130/0.4 proved equivalent to HES 200/0.5 in every measured respect. Its pharmacokinetic profile may render HES 130/0.4 an attractive alternative to current HES solutions.     

Acute "normovolemic" hemodilution with 3.5% polygel (Haemaccel) for patients in the Wertheim-Meigs-operation. Blood loss of 87% blood volume without perioperative blood transfusion

Question. Is polygeline (Haemaccel^®) a suitable colloid to perform preoperative acute normovolemic hemodilution (ANH) and to replace a large intraoperative blood loss? Methods. In a sixty-eight-year-old patient undergoing radical hysterectomy preoperative ANH was performed to a hematocrit of 23% using 3.5% polygeline (Haemaccel^®). Intraoperative retransfusion of ANH blood was started at a hematocrit of 13%. Plasma volume (indocyanine green-dilution technique) and hematocrit were measured before and after ANH, 3 times intraoperatively (once before retransfusion) and postoperatively. Red cell volume (by labelling erythrocytes with fluorescein) was determined before and after ANH, before retransfusion, and postoperatively. Results. After removal of 1,940 ml of blood and replacement with 15% more of colloid, blood volume decreased by 760 ml. After a mean blood loss of 4,600 ml, 290 ml and 260 ml of red cells were saved due to ANH and use of a cell saver, respectively. Conclusions. The exact double label measurements of blood volume demonstrated that polygeline, which has a volume effect of only 50%, cannot be considered to be a suitable colloidal substitute during ANH.     

Effects of cell saver autologous blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing cardiac surgery on- versus off-cardiopulmonary bypass: a randomised trial.

OBJECTIVE: Off-pump CABG is potentially associated with reduced intraoperative blood loss and homologous blood transfusion in comparison to on-pump CABG. In this randomised controlled study we investigated the effects of autologous cell saver blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing CABG on- versus off-CPB. METHODS: Eighty patients were randomised into one of four groups: (A) on-CPB with cell saver blood transfusion (CSBT), (B) on-CPB without CSBT, (C) off-pump with CSBT and (D) off-pump without CSBT. Volume of intraoperative autologous blood transfusion, postoperative mediastinal blood loss and homologous blood transfusion requirements were measured. Homologous blood was transfused when haemoglobin concentration fell below 8 g/dl postoperatively. Pre- and postoperatively prothrombin time and partial thromboplastin time were measured. RESULTS: Preoperative patient characteristics were well matched among the four groups. The amount of salvaged mediastinal blood available for autologous transfusion was significantly higher in the on-pump group (A) compared to the off-CPB group (C) (433+/-155 ml vs 271+/-144 ml, P=0.001). Volume of homologous blood transfusion was significantly higher in group B vs groups A, C and D (595+/-438 ml vs 179+/-214, 141+/-183 and 230+/-240 ml, respectively, P<0.005). The cell saver groups (A and C) received significantly less homologous blood than the groups without cell saver (160+/-197 ml vs 413+/-394 ml, respectively, P<0.005). Patients undergoing off-CPB surgery received significantly less homologous blood than those undergoing on-CPB CABG irrespective of cell saver blood transfusion (184+/-214 ml vs 382+/-397 ml, P<0.05). Postoperative blood loss was similar in the four groups (842+/-276, 1023+/-291, 869+/-286 and 903+/-315 ml in groups A to D, respectively, P>0.05). Clotting test results revealed no significant difference between the groups. There was no significant difference in postoperative morbidity between groups. CONCLUSION: Off-pump CABG is associated with significant reduction in intraoperative mediastinal blood loss and homologous transfusion requirements. Autologous transfusion of salvaged washed mediastinal blood reduced homologous transfusion significantly in the on-CPB group. Cell saver caused no significant adverse impact on coagulation parameters in on- or off-CPB CABG. Postoperative morbidity and blood loss were not affected by the use of CPB or autologous blood transfusion. We recommend the use of autologous blood transfusion in both on- and off-pump CABG surgery.     

Bloodless surgery in a patient with thalassemia minor. Usefulness of erythropoietin, preoperative blood donation and intraoperative blood salvage

A patient with thalassemia minor and idiopathic scoliosis was scheduled for posterior vertebral arthrodesis. The diagnosis of thalassemia minor was made during the preoperative assessment. Preoperative blood cell count displayed the following data: red blood count 5.4 x 106/microL, haemoglobin 11.6 g/dL and hematocrit 36.9%. As corrective surgery for scoliosis is associated with major blood loss, the patient was scheduled for preoperative treatment with human recombinant erythropoietin (rHuEPO), autologous blood donation, intraoperative blood cell salvage and administration of tranexamic acid. The use of rHuEPO was intended to increase hemoglobin (12.1 g/dL) levels at the moment of surgery following the donation of 2 autologous blood units. 1000 mL of salvaged blood were processed. The output line of the blood cell salvage machine did not show any sign of increased red cell haemolysis. The postoperative course was uneventful and the patient was discharged from the postoperative intensive care unit on day 7 after surgery with no allogenic blood transfusion. No references detailing the use of rHuEPO and autologous blood donation preoperatively in patients with thalassemia minor and only one case report discussed the utility of intraoperative blood cell salvage in a patient with thalassemia intermedia. Although further experience is needed, this case report suggests that even for patients with thalassemia minor, methods focused on allogenic blood salvage can be used safely.     

First experience with a ROTEM-enhanced transfusion algorithm in patients undergoing aortic arch replacement with frozen elephant trunk technique. A theranostic approach to patient blood management

Study objectiveTo assess the effect of a rotational thromboelastometry (ROTEM)-enhanced transfusion algorithm with hemostatic agents on allogenic blood transfusion in patients undergoing frozen elephant trunk (FET) surgery.DesignRetrospective observational study conducted in a tertiary-care center.SettingA tertiary care referral center for cardiac surgery.PatientsAll patients undergoing elective FET were included in the study.InterventionUntil 2016, a protocol based on estimated blood losses and conventional coagulation tests was used. After, a ROTEM-enhanced transfusion protocol was adopted.MeasurementsThe transfusion rate of each blood component was observed and reported.MethodsRetrospective, observational study.Main resultsOut of 40 consecutive patients, 19 underwent FET surgery with a conventional transfusion approach and 21 with a ROTEM-enhanced transfusion strategy. Considering the overall transfusion rate, the administration of fresh frozen plasma and platelets was significantly lower in the ROTEM compared to conventional group (1000 [0–2500] vs 0 [0–875] ml, p = 0.015 and 1 [1, 2] vs 0 [0–1], p = 0.016, respectively).ROTEM algorithm allowed to decrease the number of patients who required plasma and platelets transfusion of 31%. Furthermore, a 40% reduction in overall allogenic blood products was observed. Number of red blood cells administered, percentage of patients transfused with red blood cells, blood losses, reoperation for bleeding and mortality did not significantly differ between the two groups. At the multiple linear regression analysis only ROTEM algorithm was associated with a significant decrease in the number of plasma and platelets units administered intraoperatively, at 24 h, at the ICU discharge and overall. ROTEM algorithm allowed to save 1435 ml of plasma, 0.91 unit of platelets and overall transfusion cost of the 21% per patient.ConclusionsA ROTEM-enhanced transfusion strategy halved intraoperative transfusion in the setting of FET. Further studies are needed to confirm the magnitude of our findings on clinically relevant endpoints.