Thromboelastography and Rotational Thromboelastometry use in trauma

Abstract

The appropriate resuscitation of patients in hemorrhagic shock is critical to improving survival. Current strategies for massive transfusions utilize fixed ratio protocols to rapidly deliver plasma and platelets to the patient. However, there is some concern that these larger volumes of transfusions can lead to untoward effects. Efforts are ongoing to provide patient-specific transfusion therapy in order to avoid excess transfusions. Thromboelastography (TEG) or Rotational Thromboelastometry (ROTEM) are two viscoelastic analyzers capable of providing Viscoelastic testing.

Impact of Early Thromboelastography-Directed Therapy in Trauma Resuscitation

“…Significant evidence exists of increased morbidity and mortality in patients receiving excessive transfusions, resulting in continued efforts to safely reduce the use of blood products in severely injured or hemorrhagic patients [5]. The 2016 European guidelines on management of major bleeding and coagulopathy following trauma encourages restriction in volume replacement during resuscitation and guidance by goaldirected strategies [10].…”

“…This evolving visco-elastic test based strategy does not require adhering to the fixed-ratio approach used in most MTP. Although a fixed-ratio strategy attempts to mimic whole blood concentrations and improves survival, it tends not to occur without complications (described earlier) in those who receive excessive transfusions [5]. Thus, implementation of strategies that both avoid (a) excessive transfusion and (b) provide appropriate and adequate replacement while preserving these ratios, seem sensible.…”

“…Effects of TIC include uncontrolled bleeding, massive transfusion, and multi-organ failure. Further, TIC corresponds to having longer intensive care unit (ICU) and hospital length of stay (LOS), as well as a fourfold increase in mortality [5]. Conventional coagulation tests (CCTs) offer valuable information in monitoring the different aspects of coagulation.…”

“…Indiscriminate administration of crystalloids, albumin, or even packed red blood cells (PRBCs) may cause cardiac and pulmonary complications, gastrointestinal dysmotility, and coagulation disturbances. Hence, visco-elastic tests can provide detailed information on which blood products would prove most efficacious to the hemorrhaging trauma patient and accordingly help guide transfusion therapy in appropriate quantities [5,12]. Since the bleeding trauma patient often requires a significant amount of resources, goal directed restriction in blood products may also help with reducing the economic burden of caring for these patients [10].…”

Tromboelastografi – nyttig når det blør?

“…Enkelte studier har vist at ved tidlig bruk av transfusjonspakker sammen med trombelastografi for å veilede transfusjonsbehandlingen har man klart å redusere mortaliteten hos pasienter med moderate traumer (15,16) Man kan ikke utelukke at innføring av nye transfusjonsrutiner i seg selv kan føre til bedre overlevelse hos disse pasientene. Samtidig viser flere studier at det kan vaere sammenheng mellom enkelte tromboelastografivariabler og mortalitet (17,18), noe som kan vaere nyttig ved valg av behandlingsalternativer. Det poengteres dog at det er behov for ytterligere forskning på dette feltet.…”