Utility of viscoelastic hemostatic assay to guide hemostatic resuscitation in trauma patients: a systematic review

Abstract

Objective Viscoelastic hemostatic assay (VHA) provides a graphical representation of a clot’s lifespan and reflects the real time of coagulation. It has been used to guide trauma resuscitation; however, evidence of the effectiveness of VHAs is still limited. This systematic review aims to summarize the published evidence to evaluate the VHA-guided strategy in resuscitating trauma patients. Methods The PubMed, Embase, and Web of Science databases were searched from their inception to December 13, 2021. Randomized controlled trials (RCTs) or observational studies comparing VHA-guided transfusion to controls in resuscitating trauma patients were included in this systematic review. Results Of the 7743 records screened, ten studies, including two RCTs and eight observational studies, met the inclusion criteria. There was great heterogeneity concerning study design, enrollment criterion, VHA device, VHA-guided strategy, and control strategy. Thrombelastography (TEG) was used as a guiding tool for transfusion in eight studies, and rotational thromboelastometry (ROTEM), and TEG or ROTEM were used in the other two studies. The overall risk of bias assessment was severe or mild in RCTs and was severe or moderate in observational studies. The main outcomes reported from the included studies were blood transfusion (n = 10), mortality (n = 10), hospital length of stay (LOS) (n = 7), intensive care unit LOS (n = 7), and cost (n = 4). The effect of the VHA-guided strategy was not always superior to the control. Most of the studies did not find significant differences in the transfusion amount of red blood cells (n = 7), plasma (n = 5), platelet (n = 7), cryoprecipitate/fibrinogen (n = 7), and mortality (n = 8) between the VHA-guided group and control group. Notable, two RCTs showed that the VHA-guided strategy was superior or equal to the conventional coagulation test-guided strategy in reducing mortality, respectively. Conclusion Although some studies demonstrated VHA-guided strategy probable benefit in reducing the need for blood transfusion and mortality when resuscitating trauma patients, the evidence is still not robust. The quality of evidence was primarily downgraded by the limited number of included studies and great heterogeneity and severe risk of bias in these. Further studies are strongly recommended.

Thromboelastography-Guided Correction of Coagulopathy Before Tunneled Central Venous Access in Critically Ill Patients With Liver Disease: A Propensity Score-Matched Study

“…Our analysis also demonstrated that the total cost of blood product transfusions in the thromboelastography-guided transfusion group was significantly lower than in the conventional transfusion group as a result of transfusion avoidance. Although there are conflicting data regarding the cost-effectiveness of thromboelastography across different systematic analyses in various patient populations, such as those with trauma-induced coagulopathy and those undergoing liver and cardiac surgery (37)(38)(39), one study showed that, in patients undergoing liver transplantation, a thromboelastography-based hemostatic management approach compared with the standard of care, lead to significant cost savings associated not only with transfusion avoidance but also with length of ICU stay and reoperation for bleeding (40).…”

Point-of-care, goal-directed management of bleeding in trauma patients

“…Many, although not all, studies have demonstrated that treatment algorithms based on VET resulted in reduced transfusion requirements in TIC [20,29,[81][82][83][84][85][86]. Two studies in trauma patients that compared transfusion requirements before and after implementation of a TEG-guided resuscitation protocol reported significantly lower RBCs and FFP transfusion rates [82,83].…”

Advances in trauma care to save lives from traumatic injury: A narrative review

“…Since there is no score to assess complete coagulation chain and predict massive transfusion in trauma management, Viscoelastic hemostatic assays (VHA) have been proposed for many years to provide personalized management of TIC 49 . ThromboElastoGraphy and ROTational thromboElastoMetry use (TEG/ROTEM) reduces the total amount of blood product transfused, with more fibrinogen and plasma replacement 50 . Viscoelastic hemostatic assays are progressively becoming standard of care for the early diagnosis of TIC, including for coagulation activation evaluation, clot strength and fibrinolysis 51 .…”

“…49 ThromboElastoGraphy and ROTational thromboElastoMetry use (TEG/ROTEM) reduces the total amount of blood product transfused, with more fibrinogen and plasma replacement. 50 Viscoelastic hemostatic assays are progressively becoming standard of care for the early diagnosis of TIC, including for coagulation activation evaluation, clot strength and fibrinolysis. 51 Recent studies are including VHAs to guide therapy after initial WB administration (STORHM trial-NCT04431999, SWAT trial-NCT 03402035).…”