Utility of viscoelastic hemostatic assay to guide hemostatic resuscitation in trauma patients: a systematic review

Clinical Significance of Rotational Thromboelastometry (ROTEM) for Detection of Early Coagulopathy in Trauma Patients: A Retrospective Study

Background: We aimed to evaluate the clinical significance of abnormal rotational thromboelastometry (ROTEM) findings in trauma patients and investigate the relationships between FIBTEM-maximum clot firmness (MCF), fibrinogen concentration and patient outcomes. Methods: A retrospective cohort analysis was conducted on adult trauma patients who underwent on-admission ROTEM testing between January 2020 and January 2021. Univariate analyses compared data based on injury severity, ROTEM findings (normal vs. abnormal), and initial fibrinogen concentration (normal vs. hypofibrinogenemia). ROC curve analysis was performed to determine the diagnostic performance of FIBTEM A10/MCF for its association with hypofibrinogenemia. Results: A total of 1488 patients were included in this study; the mean age was 36.4 ± 14.2 years and 92% were male. In total, 376 (25.3%) patients had ROTEM abnormalities. Severe injuries (ISS ≥ 16) were associated with a higher shock index, positive troponin T levels, standard coagulation abnormalities, hypofibrinogenemia, and abnormal ROTEM parameters (p < 0.05). These patients also had higher rates of massive transfusions and in-hospital mortality (p = 0.001). Coagulation alterations were significantly associated with higher injury severity score (ISS), shock index, head abbreviated injury score (AIS), hypofibrinogenemia, transfusion need, and mortality (p < 0.05). Hypofibrinogenemic patients were younger, sustained severe injuries, had higher shock indices and coagulation marker levels, required more intensive treatments, had longer hospital stays, and had higher mortality (p < 0.05). A significant positive correlation was found between plasma fibrinogen concentration and FIBTEM-MCF (r = 0.294; p = 0.001). Conclusions: Approximately one-fourth of the patients had early traumatic coagulopathy, as assessed by ROTEM. The FIBTEM A10/MCF may serves as a surrogate marker for plasma fibrinogen concentration. While prior studies have established the link between ROTEM and injury severity, our findings reinforce its relevance across varying trauma severity levels. However, prospective studies are warranted to validate its role within diverse trauma systems and evolving resuscitation protocols.

Utility of point of care viscoelastic haemostatic assays for trauma patients in the emergency department

BACKGROUND AND OBJECTIVES

Traumatic haemorrhage often requires initiation of a massive haemorrhage protocol (MHP). The primary aim of this exploratory Emergency Department (ED) study was to examine the utility of point of care Viscoelastic Haemostatic Assays (VHA) in terms of accuracy. The primary outcome was prediction of the need for massive transfusion (MT) at 24-hours.

METHODS

Prospective observational study of consecutive trauma patients investigated with reported using STARD guidelines. Patients in an Australian ED setting < 1-hour from triage enrolled in a three-year window. The point-of-care device used was a TEG6s™ (Haemonetics, Braintree, MA, USA). The primary outcome was accuracy VHA testing for predicting MT delivery at 24-hours (an internationally recognised of massive transfusion was used). Other trauma outcomes such as product transfusion, injury severity score (ISS) and demographics were recorded. For analysis of accuracy the cohort was divided into VHA-normal (n = 44) and VHA-abnormal (n = 70) binary groups. Secondary outcomes included utility of TEG6s™ individual components and accuracy of VHA when combined with validated MHP decision scores.

RESULTS

Among eligible cases (n = 114) in-patient mortality was 7.0% with 91.2% receiving transfusion. Presence of (any) abnormal VHA result provided a 73.6% (95%CI 59.7-84.7) sensitivity and 49.3% (95%CI 36.1-62.3) specificity for predicting MT. Citrated Functional Fibrinogen (CFF) component had a higher performance for MT "rule-in" specificity (86.9%). When VHA was combined with validated MHP decision scores performance was increased. For example, normal VHA with Trauma Associated Severe Haemorrhage score < 8.5 was observed to yield a sensitivity of 96.2% for MT requirement rule-out. Further studies should examine if VHA test parameters can be added or (replace INR) in the existing clinical scores used to make decisions about transfusion in ED patients.

CONCLUSION

The standalone performance of early VHA testing in the ED setting was insufficient to reliably for predict a need for massive transfusion.

Conventional Coagulation Tests are a better predictor of mortality than Viscoelastic Haemostatic Assays in trauma patients with shock: a prospective observational study

PURPOSE

Conventional Coagulation Tests (CCTs) and Viscoelastic Haemostatic Assays (VHAs) are currently used in guiding trauma resuscitation. However, the role of these tests in predicting mortality is less known. This study aims to analyze both CCTs and VHAs in predicting mortality.

METHODS

A prospective observational study was conducted on adult trauma patients who presented in shock. They underwent VHA using rotational thromboelastometry (ROTEM ® delta viscoelastic system by Werfen) and CCTs. Univariable and multivariable regression analysis was done to compare the predictive power of mortality between CCTs and VHAs.

RESULTS

Out of 8,765 trauma patients screened, 106 were included. Descriptive statistics showed a majority of blunt injuries with road traffic incidents as the predominant mechanism. The median Injury Severity Score (ISS) was 24 (IQR 14-34). Mortality rate at 24 h was 9.4% and overall 30-day mortality was 26% (n = 28). Univariable analysis showed that reduced clotting time had better survival (p = 0.005) while prolonged INR, reduced fibrinogen and elevated d-dimer levels were associated with mortality. In multivariable analysis, prolonged INR > 1.66 (AUC 0.74, OR 9.4, 95% CI 2.6-34.1) and prolonged clotting time > 384 s (AUC 0.67, OR 7.4, 95% CI 1.1-51.9) had best prediction of mortality. Overall, CCTs were better at predicting mortality than VHA.

CONCLUSION

CCTs, especially INR proved to be a more reliable predictor of mortality compared to VHAs in trauma patients. These findings suggest that CCTs offer better prognostic value, although integrating both testing modalities could potentially enhance overall assessment and management strategies in trauma care.

Comparison of conventional coagulation tests and ROTEM in identifying trauma-induced coagulopathy for massive haemorrhage protocol activation

OBJECTIVES

Trauma-induced coagulopathy (TIC) can be fatal but preventable if recognised early. With emerging uses of rotational thromboelastometry (ROTEM) to guide transfusions in trauma, patient outcomes with TIC-defined by initial ROTEM and conventional coagulation tests (CCTs) during massive haemorrhage protocol (MHP) activations were evaluated at a primary trauma centre in British Columbia.

METHODS

This retrospective observational study included adult trauma patients requiring MHP from June 1, 2020, to May 31, 2022. TIC, defined by initial results including (1) ROTEM-based EXTEM A10 <40 mm, EXTEM CT >100 s, EXTEM ML30 >10%, FIBTEM A10 <10 mm; and (2) CCT-based INR ≥1.8, PTT ≥1.5 times of upper normal limit, platelets <50 x 109/L, and Clauss Fibrinogen <1.5 g/L, was assessed for its correlation with mortality. Modified Poisson regression was used to model 28-day mortality.

RESULTS

Twenty-two of sixty-eight patients (32%) had abnormal ROTEM but normal CCTs. TIC defined by CCTs was associated with increased mortality [24 h: 5/13 (38%) vs. 5/55 (9%), p = 0.025; 28d: 8/13 (62%) vs. 11/55 (20%), p = 0.002]; compared to ROTEM, which was not [24 h: 7/35 (20%) vs. 3/33 (9%), p = 0.307; 28d: 11/35 (31%) vs. 9/33 (27%), p = 0.594], despite requiring significantly higher blood component transfusion within the first 4 and 24 h of MHP (p-values<0.05).

CONCLUSIONS

ROTEM is more sensitive in identifying TIC. Patients with abnormal CCTs had a higher death rate, and those with abnormal ROTEM had no significantly increased mortality. A prospective study is required to assess the effects of ROTEM further.

Survey of pediatric massive transfusion protocol practice at United States level I trauma centers: An AABB Pediatric Transfusion Medicine Subsection study

BACKGROUND

Trauma remains the leading cause of pediatric mortality in the United States. Although use of massive transfusion protocols (MTPs) in this population is widespread, optimal pediatric resuscitation is not well established. We sought to assess contemporary pediatric MTP practice in the United States.

STUDY DESIGN AND METHODS

A web-based survey was designed by the Association for the Advancement of Blood & Biotherapies (AABB) Pediatric Transfusion Medicine Subsection and distributed to select American College of Surgeons (ACS) Level I Verified pediatric trauma centers. The survey assessed current MTP policy, implementation, and recent changes in practice.

RESULTS

Response rate was 55% (22/40). Almost half of the respondents were from the South. The median RBC:plasma ratio was 1 (interquartile range 1-1.5). Protocolized fibrinogen supplementation was common while integration of antifibrinolytic therapy into MTPs was infrequent. Viscoelastic testing (VET) was available at most sites, 71% (15/21, one site did not respond), and was generally utilized on an ad-hoc basis. Roughly, a third of sites had changed their MTP in the past 3 years due to blood supply issues, and about a third reported having group O Whole Blood on-site.

CONCLUSION

MTP practice is similar throughout the United States. Though fibrinogen supplementation is common-other emerging interventions such as antifibrinolytic therapy or utilization of routine viscoelastic testing-are not widespread. Pediatric transfusion medicine experts must continue to follow practice change, as contemporary large trials begin to characterize new supportive modalities to optimize resuscitation in pediatric trauma patients.

How do I implement pathogen reduced Cryoprecipitated fibrinogen complex in a tertiary Hospital's blood Bank

BACKGROUND

Kaiser-Permanente Los Angeles Medical Center (LAMC) is a 560 licensed bed facility that provides regional cardiovascular services, including 1200 open heart surgeries annually. In 2021, LAMC explored alternative therapies to offset the impact of pandemic-driven cryo AHF shortages, and implemented Pathogen Reduced Cryoprecipitated Fibrinogen Complex (also known as INTERCEPT Fibrinogen Complex or IFC). IFC is approved to treat and control bleeding associated with fibrinogen deficiency. Unlike cryo AHF, IFC has 5-day post-thaw shelf life with potential operational and clinical benefits. The implementation steps and the operational advantages to the LAMC Blood Bank are described.

STUDY DESIGN AND METHODS

Eighteen months post-implementation, the institution reviewed their product implementation experience and compared IFC with cryo AHF with a retrospective review of transfusion service and cardiac post-op data.

RESULTS

IFC significantly decreased product wastage rates and order-to-issue time. It did not significantly impact post-op product utilization or hospital length of stay (LOS) in cardiac surgery patients when compared with cryo AHF.

DISCUSSION

Implementation of IFC provides improved product supply stability, shorter turnaround times, and reduced wastage.

Hemostasis Testing in the Emergency Department: A Narrative Review

Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.

Contemporary management of major haemorrhage in critical care

Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).

Comparison of Two Viscoelastic Testing Devices in a Parturient Population

Background: Viscoelastic hemostatic assays (VHAs) have become an integral diagnostic tool in guiding hemostatic therapy, offering new opportunities in personalized hemostatic resuscitation. This study aims to assess the interchangeability of ClotPro® and ROTEM® delta in the unique context of parturient women. Methods: Blood samples from 217 parturient women were collected at three timepoints. A total of 631 data sets were eligible for our final analysis. The clotting times were analyzed via extrinsic and intrinsic assays, and the clot firmness parameters A5, A10, and MCF were analyzed via extrinsic, intrinsic, and fibrin polymerization assays. In parallel, the standard laboratory coagulation statuses were obtained. Device comparison was assessed using regression and Bland-Altman plots. The best cutoff calculations were used to determine the VHA values corresponding to the established standard laboratory cutoffs. Results: The clotting times in the extrinsic and intrinsic assays showed notable differences between the devices, while the extrinsic and intrinsic clot firmness results demonstrated interchangeability. The fibrinogen assays revealed higher values in ClotPro® compared to ROTEM®. An ROC analysis identified VHA parameters with high predictive values for coagulopathy exclusion and yet low specificity. Conclusions: In the obstetric setting, the ROTEM® and ClotPro® parameters demonstrate a significant variability. Device- and indication-specific transfusion algorithms are essential for the accurate interpretation of measurements and adequate hemostatic therapy.

Thromboelastography-Guided Correction of Coagulopathy Before Tunneled Central Venous Access in Critically Ill Patients With Liver Disease: A Propensity Score-Matched Study

Importance

Optimal blood product transfusion strategies before tunneled central venous catheter (CVC) placement are required in critically ill coagulopathic patients with liver disease to reduce exposure to allogeneic blood products and mitigate bleeding and thrombotic complications.

Objectives

This study evaluated the safety and efficacy of a thromboelastography-guided transfusion strategy for the correction of coagulopathy in patients with liver disease compared with a conventional transfusion strategy (using international normalized ratio, platelet count, and fibrinogen) before tunneled CVC insertion.

Design Setting and Participants

A retrospective propensity score-matched single-center cohort study was conducted at a quaternary care academic medical center involving 364 patients with liver disease (cirrhosis and acute liver failure) who underwent tunneled CVC insertion in the ICU. Patients were stratified into two groups based on whether they received blood product transfusions based on a thromboelastography-guided or conventional transfusion strategy.

Main Outcomes and Measures

Primary outcomes that were evaluated included the volume, units and cost of blood products (fresh frozen plasma, cryoprecipitate, and platelets) when using a thromboelastography-guided or conventional approach to blood transfusions. Secondary outcomes included the frequency of procedure-related bleeding and thrombotic complications.

Results

The total number of units/volume/cost of fresh frozen plasma (12 U/3,000 mL/$684 vs. 32 U/7,500 mL/$1,824 [p = 0.019]), cryoprecipitate (60 U/1,500 mL/$3,240 vs. 250 U/6,250 mL/$13,500 [p < 0.001]), and platelets (5 U/1,500 mL/$2,610 vs. 13 units/3,900 mL/$6,786 [p = 0.046]) transfused were significantly lower in the thromboelastography-guided transfusion group than in the conventional transfusion group. No differences in the frequency of bleeding/thrombotic events were observed between the two groups.

Conclusions and Relevance

A thromboelastography-guided transfusion strategy for correction of coagulopathy in critically ill patients with liver disease before tunneled CVC insertion, compared with a conventional transfusion strategy, reduces unnecessary exposure to allogeneic blood products and associated costs without increasing the risk for peri-procedural bleeding and thrombotic complications.

Point-of-care, goal-directed management of bleeding in trauma patients

PURPOSE OF REVIEW

The purpose of this review is to consider the clinical value of point-of-care (POC) testing in coagulopathic trauma patients with traumatic brain injury (TBI) and trauma-induced coagulopathy (TIC).

RECENT FINDINGS

Patients suffering from severe TBI or TIC are at risk of developing pronounced haemostatic disorders. Standard coagulation tests (SCTs) are insufficient to reflect the complexity of these coagulopathies. Recent evidence has shown that viscoelastic tests (VETs) identify haemostatic disorders more rapidly and in more detail than SCTs. Moreover, VET results can guide coagulation therapy, allowing individualised treatment, which decreases transfusion requirements. However, the impact of VET on mortality remains uncertain. In contrast to VETs, the clinical impact of POC platelet function testing is still unproven.

SUMMARY

POC SCTs are not able to characterise the complexity of trauma-associated coagulopathy. VETs provide a rapid estimation of underlying haemostatic disorders, thereby providing guidance for haemostatic therapy, which impacts allogenic blood transfusion requirements. The value of POC platelet function testing to identify platelet dysfunction and guide platelet transfusion is still uncertain.

A Retrospective Study Comparing the Effect of Conventional Coagulation Parameters Vs. Thromboelastography-Guided Blood Product Utilization in Patients With Major Gastrointestinal Bleeding

Background

The use of thromboelastography (TEG) has demonstrated decreased blood product utilization in patients with specific etiologies of major gastrointestinal bleeding (GIB), such as variceal and non-variceal bleeding in cirrhosis patients; however, in a non-cirrhosis patient with GIB, there is far less evidence in the literature. Our retrospective study compares the effect of TEG-guided blood product utilization in patients with major GIB with all etiologies, including cirrhosis, admitted to medical intensive care unit (MICU).

Methods

A retrospective chart review was conducted on patients admitted to the MICU of a tertiary academic medical center diagnosed with GIB using ICD-9/10 codes from 2014 to 2018. A total of 1,889 patients were identified, and validation criteria such as "GI or hepatology consult note", type and screen, pantoprazole, or octreotide drip" were used, which resulted in 997 patients, out of which 369 had a diagnosis of cirrhosis. Propensity score matching was done for baseline variables (age, sex, and race), ICU length of stay, hospital length of stay, ventilator days, and vasopressor use. As a result, 88 patients were included in the final analysis, with 44 in TEG and 44 in non-TEG group. A sub-group analysis was done in 46 patients with cirrhosis, 23 in TEG group and 23 in non-TEG group after propensity score matching.

Results

There was significantly higher total blood volume (4,207 mL vs. 2,568 mL, P = 0.04) in the TEG group as compared to the non-TEG group, including total volume of cryoprecipitate (80 mL vs. 55 mL, P = 0.03) and total volume of platelet (543 mL vs. 327 mL, P = 0.03). In the cirrhosis sub-group, there was no significant difference in the amount of blood products transfused between the two groups.

Conclusion

This study revealed that TEG is not superior to conventional coagulation parameters in limiting the volume of blood product transfusion in major GIB patients in ICU settings.

Advances in trauma care to save lives from traumatic injury: A narrative review

ABSTRACT

Recent advances on trauma management from the prehospital setting to in hospital care led to a better surviving severe trauma rate. Mortality from exsanguination remains the first preventable mortality. Damage-control resuscitation and surgery are evolving and thus some promising concepts are developing. Transfusion toolkit is brought on the prehospital scene while temporary bridge to hemostasis may be helpful. Panel transfusion products allow an individualized ratio assumed by fresh frozen or lyophilized plasma, fresh or cold-stored whole blood, fibrinogen, four-factor prothrombin complex concentrates. Growing interest is raising in whole blood transfusion, resuscitative endovascular balloon occlusion of the aorta use, hybrid emergency room, viscoelastic hemostatic assays to improve patient outcomes. Microcirculation, traumatic endotheliopathy, organ failures and secondary immunosuppression are point out since late deaths are increasing and may deserve specific treatment.As each trauma patient follows his own course over the following days after trauma, trauma management may be seen through successive, temporal, and individualized aims.