Protocolised thromboelastometric‐guided haemostatic management in patients with traumatic brain injury: a pilot study

Abstract

Coagulopathy in patients with traumatic brain injury is associated with an increase in morbidity and mortality. Although timely and aggressive treatment of coagulopathy is of paramount importance, excessive transfusion of blood products has been linked with poor long-term outcomes in patients with traumatic brain injury. A pointof-care thromboelastometric-guided algorithm could assist in creating a more individually tailored approach to each patient. The aim of this study was to evaluate the feasibility of implementing a thromboelastometricguided algorithm in centres that were formerly na€ ıve to thromboelastometry. Hence, we developed such an algorithm and provided training to four centres across Europe to direct the haemostatic management of patients with severe traumatic brain injury. The primary outcome was adherence to the algorithm and timing of the availability of relevant results. Thirty-two patients were included in the study. Complete adherence to the algorithm was observed in 20 out of 32 cases. The availability of thromboelastometric results after hospital admission was reported significantly earlier than conventional coagulation tests (median (IQR [range]) 33 (20-40 [14-250]) min vs. 71 (51-101 [32-290]) min; p = 0.037). Although only 5 out of 32 patients had abnormalities of conventional coagulation tests, 21 out of 32 patients had a coagulopathic baseline thromboelastometric trace. Implementing a thromboelastometric-guided algorithm for the haemostatic therapy of traumatic brain injury is feasible in centres formerly na€ ıve to this technology and may lead to more rapid and precise coagulation management. Further large-scale studies are warranted to confirm the results of this pilot trial and evaluate clinical outcomes.

Implementation of Thromboelastometry for Coagulation Management in Isolated Traumatic Brain Injury Patients Undergoing Craniotomy

“…A pilot study by Gratz et al [ 12 ] aiming to evaluate ROTEM-based algorithm implementation success in TBI patients found high protocol adherence rates of 88% to 91%. However, that study did not include any clinical outcomes.…”

“…Evidence from clinical studies in trauma and cardiac surgery highlight decreased perioperative bleeding and blood product use in patients managed based on a goal-directed approach [ 9 – 11 ]. The interest in whether such an approach could be applicable to neurosurgical patients is increasing [ 12 – 14 ]. Theoretically, targeted optimization of coagulation could lead to improved outcome.…”

Massive Hemorrhage: The Role of Whole Blood Viscoelastic Assays

“…A multicenter trial evaluated adherence to a ROTEM-guided treatment algorithm in patients with traumatic brain injury. 35 Participating physicians received a 2-day training in operating with a ROTEM sigma device, interpreting the results, and applying them to the treatment algorithm. Overall, the algorithm was followed with complete adherence in 20 out of 32 patients.…”

Trauma-Induced Coagulopathy and Massive Bleeding: Current Hemostatic Concepts and Treatment Strategies

“…8,9 Viscoelastic testing (VET)-using tests such as ClotPro (Enicor, Munich, Germany), rotational thromboelastometry (Tem Innovations, Munich, Germany), or thromboelastography (TEG; Haemo-netics Corporation, Boston, Massachusetts, United States)-is used to evaluate the individual hemostatic competence of bleeding trauma patients. 10 Thereafter, adapted coagulation therapy-primarily based on purified coagulation factor concentrates (CFCs)-is administered according to the patient's individual need. 11,12 In this concise review, we discuss the pathophysiology of TIC and summarize the current evidence for different diagnostic and therapeutic strategies.…”