Data-driven Development of ROTEM and TEG Algorithms for the Management of Trauma Hemorrhage

Baksaas-Aasen, Kjersti; Dieren, Susan van; Balvers, Kirsten; Juffermans, Nicole P.; Næss, P. l A.; Rourke, Colin; Eaglestone, Simon; Ostrowski, Sisse Rye; Stensballe, Jakob; Stanworth, Simon; Maegele, Marc; Goslings, J. C.; Johansson, Pär I.; Brohi, Karim; Gaarder, Christine

doi:10.1097/sla.0000000000002825

Cited by 112 publications

(126 citation statements)

References 32 publications

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“…The same cut-off values have been recommended by the consensus group on viscoelastic test-based transfusion guidelines for early trauma resuscitation and the German AWMF guidelines on the management of multiple traumas [164][165][166]. Similar cut-off values are used in the European multicenter RCT iTACTIC (implementing Treatment Algorithms for the Correction of Trauma-Induced Coagulopathy; ClinicalTrials.gov, ID: NCT02593877): A5 FIB < 10 mm for fibrinogen substitution and (A5 EX -A5 FIB ) < 30 mm for platelet transfusion [167]. This is also in line with the FIBTEM cut-off values published by Na et al [29] to predict massive bleeding in total hip replacement arthroplasty.…”

Section: In Trauma and Orthopedic Surgerymentioning

confidence: 99%

“…Impaired thrombin generation with the need for plasma transfusion or four-factor PCC administration is considered in our trauma algorithm if CT EX > 80 s and A5 FIB ≥ 9 mm according to the consensus group on viscoelastic test-based transfusion guidelines for early trauma resuscitation and the German AWMF guidelines on the management of multiple trauma [164][165][166]. This is also in line with the iTACTIC protocol [167]. In severe traumatic hemorrhage, fixed-ratio RBC and plasma transfusion is not effective to treat ATC and to reduce mortality [12][13][14][15][16][17]171].…”

Section: In Trauma and Orthopedic Surgerymentioning

confidence: 99%

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The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Görlinger

Pérez-Ferrer

Dirkmann

et al. 2019

Korean J Anesthesiol

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163

138

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Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management ('theranostic' approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient's safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration. Fig. 1. ROTEM trace ('temogram') displaying the clinically most important parameters and their informative value. FDPs: fibrin (ogen) split products. Courtesy of Klaus Görlinger, Germany.

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Section: In Trauma and Orthopedic Surgerymentioning

confidence: 99%

Section: In Trauma and Orthopedic Surgerymentioning

confidence: 99%

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Görlinger

Pérez-Ferrer

Dirkmann

et al. 2019

Korean J Anesthesiol

Self Cite

163

138

View full text Add to dashboard Cite

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“…infections, volume overload, immunosuppression and kidney injury) [11][12][13][14] and it has been shown that a reduced transfusion requirement improved clinical outcomes including mortality [15,16]. Therefore, a factor-based, goal-directed coagulation management guided by viscoelastic point of care tests [2] has been proposed as a new approach of haemostatic resuscitation [1,7,[17][18][19]. This coagulation management was proven to decrease transfusion requirement with beneficial outcomes in trauma patients [1,7,17,18].…”

Section: Discussionmentioning

confidence: 99%

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

Stein

Rössler

Braun

et al. 2019

Scand J Trauma Resusc Emerg Med

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Background: A factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines. However, concerns about the thromboembolic risk of this approach are still prevalent. Our study therefore aims to assess if such a haemostatic management is associated with an increased risk for thromboembolic events. Methods: In this retrospective observational study carried out at the University Hospital Zurich we compared two three-year periods before (period 1: 2005-2007) and after (period 2: 2012-2014) implementation of a factor-based coagulation algorithm. We included all adult patients following major trauma primarily admitted to the University Hospital Zurich. Thromboembolic events were defined as a new in-hospital appearance of any peripheral thrombosis, arterial embolism, pulmonary embolism, stroke or myocardial infarction. A logistic regression was performed to investigate the association of thromboembolic events with possible confounders such as age, sex, specific Abbreviated Injury Scale (AIS) subgroups, allogeneic blood products, and the coagulation management. Results: Out of 1138 patients, 772 met the inclusion criteria: 344 patients in period 1 and 428 patients in period 2. Thromboembolic events were present in 25 patients (7.3%) of period 1 and in 42 patients (9.8%) of period 2 (raw OR 1.39, 95% CI 0.83 to 2.33, p = 0.21). Only AIS extremities (adjusted OR 1.26, 95% CI 1.05 to 1.52, p = 0.015) and exposure to allogeneic blood products (adjusted OR 2.39, 95% CI 1.33 to 4.30, p = 0.004) were independently associated with thromboembolic events in the logistic regression, but the factor-based coagulation management was not (adjusted OR 1.60, 95% CI 0.90-2.86, p = 0.11). Conclusion: There is no evidence that a goal-directed, factor-based coagulation management is associated with an increased risk for thromboembolic events following major trauma.

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“…These assays provide real-time quantification of different aspects of coagulation and yield meaningful results within five minutes of initiating the test. More recently, there has been growing interest in whether these assays can be used to direct blood product transfusion and TXA administration based on alterations in clot initiation, clot strength and clot breakdown (Baksaas-Aasen et al, 2018). Although this approach has been adopted in some centres, high quality evidence from randomized trials is still awaited this knowledge gap will be addressed by the multicentre iTACTIC (implementation of Treatment Algorithms for the Management of Trauma Induced Coagulopathy) trial which has completed recruitment and will report in the next year (Baksaas-Aasen et al, 2017).…”

Section: Goal-directed Resuscitationmentioning

confidence: 99%

What's new for trauma haemorrhage management?

2019

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Uncontrolled haemorrhage is the leading cause of preventable death from injury and is a major contributor to the global burden of disease. The majority of deaths resulting from bleeding occur within the first 3 hours of hospital admission, and the window for meaningful intervention is therefore extremely small. Resuscitative efforts during active bleeding should focus on maintaining haemostatic function with blood product transfusion and early administration of tranexamic acid. Achieving control of haemorrhage is the overarching treatment priority and may require temporising measures before definitive surgical or radiological intervention. This review summarizes the contemporary approaches to resuscitation of bleeding trauma patients, options for achieving haemorrhage control, and current areas of active research including organ protective resuscitation and suspended animation.

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Data-driven Development of ROTEM and TEG Algorithms for the Management of Trauma Hemorrhage

Abstract: We describe a systematic approach to define threshold parameters for ROTEM and TEG. These parameters were incorporated into algorithms to support data-driven adjustments of resuscitation with therapeutics, to optimize damage control resuscitation practice in trauma.

Cited by 112 publications

References 32 publications

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

What's new for trauma haemorrhage management?

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