Use of rotation thromboelastometry (ROTEM^®) to achieve successful treatment of polytrauma with fibrinogen concentrate and prothrombin complex concentrate

Abstract

SummaryGoal-directed coagulation therapy is essential in the management of trauma patients with severe bleeding. Due to the complex nature of coagulation disorders in trauma, a quick and reliable diagnostic tool is essential. We report a severely injured multiple trauma patient who received haemostatic therapy with coagulation factor concentrates, guided by rotational thromboelastometry (ROTEM Ò ). Initial therapy consisted of fibrinogen concentrate (Haemocomplettan Ò P), as maximum clot firmness in the ROTEM analyses was low, whereas clotting time was normal. Later on, prothrombin complex concentrate was given to optimise thrombin generation. This approach enabled extended emergency hemihepatectomy to be performed without using fresh frozen plasma. As the EXTEM maximum clot firmness showed good clot quality, no platelets were transfused despite low platelet counts. This case shows the potential success of treatment using both fibrinogen concentrate and prothrombin complex concentrate, not only in restoring haemostasis but also in minimising requirement for transfusion of allogeneic blood products. Coagulopathy is a major challenge in trauma centres worldwide, and uncontrolled bleeding causes around 40% of all trauma-related deaths [1]. Coagulopathy is the likely cause if bleeding continues after a patient has received optimal acute surgical treatment and, if required, mechanical support to close a wound.Accurate and timely measurement of haemostatic potential is clearly needed to optimise the management of coagulopathy. Routine laboratory tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) are widely used, although they have not been developed to guide coagulation therapy. The PT and aPTT are too slow to provide prompt results, while pathologic values in these tests are rarely associated with acute, clinically relevant bleeding. In contrast, thromboelastometry ⁄ thromboelastography support an accurate and timely assessment, not only of coagulation initiation but also the clot formation process and clot stability. A set of reagents helps evaluate different aspects of coagulation, including the stability and amplitude of the fibrin-based clot (thromboelastometric FIBTEM test). Increasingly, point-of-care methods (thrombelastography or thromboelastometry) are recognised as offering more rapid diagnosis of coagulopathy than laboratory tests [2][3][4]. Since 2001, thromboelastometry (ROTEM Ò , Pentapharm, Munich, Germany) has been used in our department as a point-of-care monitoring tool. It plays an essential role in our strategy to avoid or reverse coagulopathy in polytrauma patients.Large amounts of fresh frozen plasma (FFP) are part of treatment protocols in most trauma centres, although the efficacy of this treatment is questionable [5]. At the same time, transfusion has been associated with increased morbidity and mortality [6,7]. The risks associated with FFP include transfusion-related lung injury (TRALI), pathogen transmission [8,9] and immunosupression [10].

Fibrinogen in traumatic haemorrhage: A narrative review

“…It is postulated that early fibrinogen replacement may be efficacious in correction of coagulopathy, assist in haemorrhage control and decrease transfusion requirements (37) (56) (57) (58). Two studies from the military indicate that maintaining higher fibrinogen levels as part of a MHP is associated with improved survival (59) (60).…”

Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting

“…96 Point-of-care coagulation testing has also been used in human studies related to bleeding in adult trauma patients requiring reversal of vitamin K antagonist-induced coagulopathy; improvement in hemostatic efficacy after PCC administration has been illustrated. [97][98][99] PCCs were administered in 1 retrospective analysis of 131 trauma patients who received ≥5 units of packed red blood cells within 24 hours as a part of a factor concentrate-driven, multimodal, coagulation management algorithm using ROTEM guidance. The survival benefit of this approach was determined by predicted mortality modeling in the population compared with actual observed mortality.…”

Point of Care and Factor Concentrate-Based Coagulation Algorithms

“…Hyperfibrinolysis > 3% is associated with massive transfusion [24]. Fibrinogen substitution as a substrate and prothrombin complex concentrate as an enzyme, guided by rotational thrombelastometry, can be safely used to enhance thrombin generation in patients with severe multiple trauma [25][26][27]. Moreover the FIBTEM value can be used to predict massive transfusion in trauma [28].…”