Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review

Abstract

IntroductionThe understanding of coagulopathies in trauma has increased interest in thromboelastography (TEG®) and thromboelastometry (ROTEM®), which promptly evaluate the entire clotting process and may guide blood product therapy. Our objective was to review the evidence for their role in diagnosing early coagulopathies, guiding blood transfusion, and reducing mortality in injured patients.MethodsWe considered observational studies and randomized controlled trials (MEDLINE, EMBASE, and Cochrane databases) to February 2014 that examined TEG®/ROTEM® in adult trauma patients. We extracted data on demographics, diagnosis of early coagulopathies, blood transfusion, and mortality. We assessed methodologic quality by using the Newcastle-Ottawa scale (NOS) for observational studies and QUADAS-2 tool for diagnostic accuracy studies.ResultsFifty-five studies (12,489 patients) met inclusion criteria, including 38 prospective cohort studies, 15 retrospective cohort studies, two before-after studies, and no randomized trials. Methodologic quality was moderate (mean NOS score, 6.07; standard deviation, 0.49). With QUADAS-2, only three of 47 studies (6.4%) had a low risk of bias in all domains (patient selection, index test, reference standard and flow and timing); 37 of 47 studies (78.8%) had low concerns regarding applicability. Studies investigated TEG®/ROTEM® for diagnosis of early coagulopathies (n = 40) or for associations with blood-product transfusion (n = 25) or mortality (n = 24). Most (n = 52) were single-center studies. Techniques examined included rapid TEG® (n =12), ROTEM® (n = 18), TEG® (n = 23), or both TEG® and rapid TEG® (n = 2). Many TEG®/ROTEM® measurements were associated with early coagulopathies, including some (hypercoagulability, hyperfibrinolysis, platelet dysfunction) not assessed by routine screening coagulation tests. Standard measures of diagnostic accuracy were inconsistently reported. Many abnormalities predicted the need for massive transfusion and death, but predictive performance was not consistently superior to routine tests. One observational study suggested that a ROTEM®-based transfusion algorithm reduced blood-product transfusion, but TEG®/ROTEM®-based resuscitation was not associated with lower mortality in most studies.ConclusionsLimited evidence from observational data suggest that TEG®/ROTEM® tests diagnose early trauma coagulopathy and may predict blood-product transfusion and mortality in trauma. Effects on blood-product transfusion, mortality, and other patient-important outcomes remain unproven in randomized trials.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0518-9) contains supplementary material, which is available to authorized users.

Thromboelastography and Rotational Thromboelastometry use in trauma

“…While several studies have examined TEG and ROTEM in a variety of clinical settings to demonstrate the feasibility and application of guiding transfusions and resuscitation, they are retrospective and the results have been heterogeneous [9]. However, these studies have demonstrated that when compared to traditional coagulation assays, TEG and ROTEM can rapidly and correctly identify patients with coagulopathy in real time [10].…”

Trauma-induced coagulopathy and critical bleeding: the role of plasma and platelet transfusion

“…However, traumatic coagulopathy was recently shown to already develop at the trauma scene, before any medical intervention [7]. This finding is of particular relevance given that traumatic coagulopathy results in considerably increased mortality [4,5,8,9].…”

The importance of the use of rotational thrombelastometry during intraoperative bleeding: Rotational elastometry and intraoperative bleeding

“…Najčešće je u upotrebi ROTEM, koji omogućava visokoelastična merenja jačine koagulacije u celoj krvi 16,17,18,19,20 . Rotaciona tromboelastometrija omogućava pravovremenu i pouzdanu detekciju disfunkcije fibrinogena i poremećaja polimerizacije fibrina, hiperfibrinolize, statusa trombocita, efekata heparina na koagulacioni sistem, a takođe i stanja hiperkoagulabilnosti.…”