1
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Kenyon RM, Leighton JL. Control of Haemorrhage in Orthopaedic Trauma. J Clin Med 2024; 13:4260. [PMID: 39064300 PMCID: PMC11277702 DOI: 10.3390/jcm13144260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/26/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
This paper aims to outline current practices and examine promising new advancements in the modern management of haemorrhage in orthopaedic trauma. Many prehospital and perioperative haemorrhage control strategies and techniques have been available to clinicians for multiple decades, yet our understanding and utilisation of these practices continues to be refined and optimised. There is a particular focus in this article on issues related to resuscitation and coagulation in trauma. We examine the complex mechanisms that lead to coagulopathy in trauma patients as well as the transformative effect tranexamic acid has had in limiting blood loss. We also explore some emerging technologies such as endovascular interventions and clot-stabilising dressings and devices that are likely to have a significant impact going forward.
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2
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Juffermans NP, Bouzat P. Visco-elastic testing in traumatic bleeding. Intensive Care Med 2024; 50:1152-1153. [PMID: 38695918 DOI: 10.1007/s00134-024-07437-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/07/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Pierre Bouzat
- Grenoble Institute Neurosciences, Université Grenoble Alpes, Grenoble, France
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3
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Thonon H, Van Nieuwenhove M, Thachil J, Lippi G, Hardy M, Mullier F. Hemostasis Testing in the Emergency Department: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38897223 DOI: 10.1055/s-0044-1787661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.
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Affiliation(s)
- Henri Thonon
- Emergency Department, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | | | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Michael Hardy
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle Mont, Université catholique de Louvain (UCLouvain), Yvoir, Belgium
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4
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Auty T, McCullough J, Hughes I, Fanning JP, Czuchwicki S, Winearls J. Fibrinogen levels in severe trauma: A preliminary comparison of Clauss Fibrinogen, ROTEM Sigma, ROTEM Delta and TEG 6s assays from the FEISTY pilot randomised clinical trial. Emerg Med Australas 2024; 36:363-370. [PMID: 38196013 DOI: 10.1111/1742-6723.14356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/19/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE To describe the relationships between different methods of measuring functional fibrinogen levels in severely injured, bleeding trauma patients across multiple timepoints during hospitalisation. METHODS In 100 adult trauma patients enrolled in the FEISTY pilot randomised clinical trial at four tertiary trauma centres in Australia, blood samples were collected prospectively. Consistency of agreement was calculated, comparing functional fibrinogen levels measured by four methods - ROTEM® Delta and Sigma FIBTEM A5, TEG® 6s CFF MA, and gold-standard Clauss Fibrinogen. RESULTS Comparing the ROTEM® Delta and new-generation ROTEM® Sigma machine, consistency of agreement for FIBTEM A5, measured by calculating intraclass correlation coefficients (ICCs), was ≥0.73 across all analysed timepoints, with mean differences (Sigma minus Delta) of 0.10-3.57 mm. Corresponding values comparing the ROTEM® Sigma FIBTEM A5 and TEG® 6s CFF MA were ICC = 0.55-0.82 and ICC = 4.69-7.97 (CFF MA minus A5). Comparing ROTEM® Sigma FIBTEM A5 and Clauss Fibrinogen Analysis (CFA), among statistically significant simple linear regression models, R2 was 0.25-0.67, and comparing TEG® 6s CFF MA and CFA (CFA) 0.65-0.82, although not all differences were significant with the latter comparison. Relationships across all timepoints combined were Clauss Fibrinogen (CF) (g/L) = 0.21𝑥 + 0.004 (where 𝑥 = ROTEM® Sigma FIBTEM A5 in mm) and (g/L) = 0.16𝑥 - 0.06 (where 𝑥 = TEG® 6s CFF MA in mm). CONCLUSIONS The present study revealed acceptable agreement between four different assays measuring functional fibrinogen, with current- and previous-generation ROTEM® machines (Sigma, Delta) performing similarly measuring functional fibrinogen via FIBTEM assay. This suggests that haemostatic resuscitation algorithms designed for the ROTEM® Delta can be applied to the ROTEM® Sigma to guide fibrinogen replacement.
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Affiliation(s)
- Travis Auty
- Intensive Care Unit, Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - James McCullough
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Griffith University, Gold Coast, Queensland, Australia
| | - Ian Hughes
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Office for Research Governance and Development, Gold Coast University Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Jonathon P Fanning
- University of Queensland, Brisbane, Queensland, Australia
- Intensive Care Unit, St Andrew's War Memorial Hospital, UnitingCare Health, Brisbane, Queensland, Australia
- Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Sarah Czuchwicki
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - James Winearls
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Griffith University, Gold Coast, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
- Intensive Care Unit, St Andrew's War Memorial Hospital, UnitingCare Health, Brisbane, Queensland, Australia
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5
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:319-331. [PMID: 38189930 DOI: 10.1007/s00134-023-07303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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6
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LaGrone LN, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96:510-520. [PMID: 37697470 DOI: 10.1097/ta.0000000000004088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.
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Affiliation(s)
- Lacey N LaGrone
- From the Department of Surgery (D.S.), University of Maryland, Baltimore, Maryland; Department of Surgery (L.N.L., C.C.), UCHealth, Loveland, Colorado; Department of Surgery (K.K), University of California San Francisco Fresno, San Francisco, California; Department of Surgery (C.H.), Tulane University, New Orleans, Louisiana; Orthopedic Surgery (A.N.M.), Washington University in St. Louis, St. Louis, Missouri; Department of Surgery (B.S.), University of Pennsylvania, Philadelphia, Pennsylvania; American Society of Anesthesiologists (R.D.), Anesthesia, Waco, Texas; Department of Surgery (E.B.), University of Washington, Seattle, Washington; and Department of Surgery (L.M.N.), University of Michigan, Ann Arbor, Michigan
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7
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Wang P, Yang S, Guoji M, Nan L, Zhang N, Zhang J. The predictive role of the nomogram based on clinical characteristics and thromboelastography markers for rebleeding after hypertensive intracerebral hemorrhage. Biochem Biophys Rep 2024; 37:101638. [PMID: 38288280 PMCID: PMC10823053 DOI: 10.1016/j.bbrep.2024.101638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 01/31/2024] Open
Abstract
Objectives Rebleeding after hypertensive intracerebral hemorrhage is a common and serious postoperative complication in neurosurgery, with high mortality and mental disability rates. The aim of this study was to establish a nomogram to analyze the role of thromboelastography in predicting rebleeding after hypertensive intracerebral hemorrhage. Basic methods We selected 375 patients with hypertensive intracerebral hemorrhage who underwent surgical treatment in Yuebei People's Hospital of Shaoguan City, Guangdong Province from May 2018 to August 2022, and retrospectively analyzed the relevant data of hypertensive intracerebral hemorrhage patients (including general data and clinical thromboelastography data), and analyzed the factors and thromboelastography parameters that affect rebleeding after surgery (45 cases, defined as re-examination of head CT within 72 h after surgery showed that the hematoma in the surgical area exceeded 20 ml). Main results Time from symptom onset to surgery, taking antiplatelet drugs, taking anticoagulant drugs, diabetes mellitus, difficulty in hemostasis during surgery, R value and EPL value in thromboelastography were risk factors for rebleeding after hypertensive intracerebral hemorrhage (P < 0.05). Logistic regression was used to determine the independent risk factors, and based on these risk factors, a nomogram was established and internally validated using a bootstrap method. ROC curve analysis showed that the nomogram model had high diagnostic value for rebleeding after hypertensive intracerebral hemorrhage, with AUC of 0.7314. The calibration curve of the nomogram showed good consistency between the predicted probabilities and the observed values. The decision curve analysis and clinical impact curve also revealed the potential clinical usefulness of the nomogram. Conclusions The nomogram based on clinical characteristics and thromboelastography markers may be useful for predicting rebleeding after hypertensive intracerebral hemorrhage.
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Affiliation(s)
- Peng Wang
- Neurosurgery, Yuebei People's Hospital of Shantou University Medical, Shaoguan, Guangdong, China
| | - Shasha Yang
- Department of Pathology, Yuebei People's Hospital of Shantou University Medical College, Shaoguan, Guangdong, China
| | - Muguo Guoji
- Neurosurgery, Yuebei People's Hospital of Shantou University Medical, Shaoguan, Guangdong, China
| | - Li Nan
- Department of Emergency Medicine, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Neng Zhang
- Neurosurgery, Yuebei People's Hospital of Shantou University Medical, Shaoguan, Guangdong, China
| | - Jing Zhang
- Intensive Care Unit, Yuebei People's Hospital of ShantouUniversity Medical, Shaoguan, Guangdong, China
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8
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Vulliamy P, Armstrong PC. Platelets in Hemostasis, Thrombosis, and Inflammation After Major Trauma. Arterioscler Thromb Vasc Biol 2024; 44:545-557. [PMID: 38235557 DOI: 10.1161/atvbaha.123.318801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Trauma currently accounts for 10% of the total global burden of disease and over 5 million deaths per year, making it a leading cause of morbidity and mortality worldwide. Although recent advances in early resuscitation have improved early survival from critical injury, the mortality rate in patients with major hemorrhage approaches 50% even in mature trauma systems. A major determinant of clinical outcomes from a major injury is a complex, dynamic hemostatic landscape. Critically injured patients frequently present to the emergency department with an acute traumatic coagulopathy that increases mortality from bleeding, yet, within 48 to 72 hours after injury will switch from a hypocoagulable to a hypercoagulable state with increased risk of venous thromboembolism and multiple organ dysfunction. This review will focus on the role of platelets in these processes. As effectors of hemostasis and thrombosis, they are central to each phase of recovery from injury, and our understanding of postinjury platelet biology has dramatically advanced over the past decade. This review describes our current knowledge of the changes in platelet behavior that occur following major trauma, the mechanisms by which these changes develop, and the implications for clinical outcomes. Importantly, supported by research in other disease settings, this review also reflects the emerging role of thromboinflammation in trauma including cross talk between platelets, innate immune cells, and coagulation. We also address the unresolved questions and significant knowledge gaps that remain, and finally highlight areas that with the further study will help deliver further improvements in trauma care.
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Affiliation(s)
- Paul Vulliamy
- Centre for Trauma Sciences (P.V.), Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Paul C Armstrong
- Centre for Immunobiology (P.C.A.), Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, United Kingdom
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9
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Gauss T, Bouzat P. Trauma coagulopathy: Insights from the PROCOAG and CRYOSTAT-2 trials. Coagulation factors are not antibiotics. Anaesth Crit Care Pain Med 2024; 43:101360. [PMID: 38395358 DOI: 10.1016/j.accpm.2024.101360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Tobias Gauss
- Service Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Inserm, U1216, Grenoble Institute Neurosciences, Grenoble, France.
| | - Pierre Bouzat
- Service Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Inserm, U1216, Grenoble Institute Neurosciences, Grenoble, France
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10
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Juffermans NP, Gözden T, Brohi K, Davenport R, Acker JP, Reade MC, Maegele M, Neal MD, Spinella PC. Transforming research to improve therapies for trauma in the twenty-first century. Crit Care 2024; 28:45. [PMID: 38350971 PMCID: PMC10865682 DOI: 10.1186/s13054-024-04805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
Improvements have been made in optimizing initial care of trauma patients, both in prehospital systems as well as in the emergency department, and these have also favorably affected longer term outcomes. However, as specific treatments for bleeding are largely lacking, many patients continue to die from hemorrhage. Also, major knowledge gaps remain on the impact of tissue injury on the host immune and coagulation response, which hampers the development of interventions to treat or prevent organ failure, thrombosis, infections or other complications of trauma. Thereby, trauma remains a challenge for intensivists. This review describes the most pressing research questions in trauma, as well as new approaches to trauma research, with the aim to bring improved therapies to the bedside within the twenty-first century.
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Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Tarik Gözden
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Jason P Acker
- Canadian Blood Services, Innovation and Portfolio Management, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Michael C Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery Cologne-Merheim Medical Center Institute of Research, Operative Medicine University Witten-Herdecke, Cologne, Germany
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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11
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Schmitt FCF, Schöchl H, Brün K, Kreuer S, Schneider S, Hofer S, Weber CF. [Update on point-of-care-based coagulation treatment : Systems, reagents, device-specific treatment algorithms]. DIE ANAESTHESIOLOGIE 2024; 73:110-123. [PMID: 38261018 PMCID: PMC10850202 DOI: 10.1007/s00101-023-01368-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 01/24/2024]
Abstract
Viscoelastic test (VET) procedures suitable for point-of-care (POC) testing are in widespread clinical use. Due to the expanded range of available devices and in particular due to the development of new test approaches and methods, the authors believe that an update of the current treatment algorithms is necessary. The aim of this article is to provide an overview of the currently available VET devices and the associated reagents. In addition, two treatment algorithms for the VET devices most commonly used in German-speaking countries are presented.
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Affiliation(s)
- Felix C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Herbert Schöchl
- Ludwig Boltzmann Institut für Traumatologie, AUVA Research Center, Wien, Österreich
- Klinik für Anästhesiologie und Intensivmedizin, AUVA Unfallkrankenhaus, Salzburg, Österreich
| | - Kathrin Brün
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Sascha Kreuer
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
- Medizinische Fakultät, Universität des Saarlandes, Homburg, Deutschland
| | - Sven Schneider
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Stefan Hofer
- Klinik für Anästhesiologie, Westpfalz-Klinikum Kaiserslautern, Kaiserslautern, Deutschland
| | - Christian F Weber
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Klinik Wandsbek, Hamburg, Deutschland
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
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12
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Zipperle J, Schmitt FCF, Schöchl H. Point-of-care, goal-directed management of bleeding in trauma patients. Curr Opin Crit Care 2023; 29:702-712. [PMID: 37861185 DOI: 10.1097/mcc.0000000000001107] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to consider the clinical value of point-of-care (POC) testing in coagulopathic trauma patients with traumatic brain injury (TBI) and trauma-induced coagulopathy (TIC). RECENT FINDINGS Patients suffering from severe TBI or TIC are at risk of developing pronounced haemostatic disorders. Standard coagulation tests (SCTs) are insufficient to reflect the complexity of these coagulopathies. Recent evidence has shown that viscoelastic tests (VETs) identify haemostatic disorders more rapidly and in more detail than SCTs. Moreover, VET results can guide coagulation therapy, allowing individualised treatment, which decreases transfusion requirements. However, the impact of VET on mortality remains uncertain. In contrast to VETs, the clinical impact of POC platelet function testing is still unproven. SUMMARY POC SCTs are not able to characterise the complexity of trauma-associated coagulopathy. VETs provide a rapid estimation of underlying haemostatic disorders, thereby providing guidance for haemostatic therapy, which impacts allogenic blood transfusion requirements. The value of POC platelet function testing to identify platelet dysfunction and guide platelet transfusion is still uncertain.
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Affiliation(s)
- Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
| | - Felix C F Schmitt
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
- Paracelsus Medical University, Salzburg, Austria
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13
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Simpson J, McCullough J, Walters K, Wake E, Ho D, Chan E, Campbell D, Winearls J. Rotational thromboelastometry values across age groups in all trauma patients presenting to a level 1 trauma centre: An observational study. Emerg Med Australas 2023; 35:976-982. [PMID: 37423609 DOI: 10.1111/1742-6723.14277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/04/2023] [Accepted: 06/18/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES To describe rotational thromboelastometry (ROTEM) values (FIBTEM A5, EXTEM A5 and EXTEM CT) across age groups and assess for a statistical trend; and to determine whether any trend in ROTEM values is affected by severity of injury and packed red blood cells (PRBC) requirement. METHODS Retrospective observational study at a level 1 trauma centre in Queensland, Australia. A total of 1601 consecutive trauma patients presenting to the ED. ROTEM data described included FIBTEM A5, EXTEM A5 and EXTEM CT. These values are described by age group (≤30 years, 31-45 years, 46-60 years, 61-75 years and >75 years), Injury Severity Score (ISS) category (<12, ≥12, <25 and ≥25) and number of PRBCs transfused in the first 24 h of admission (0 units, 1-4 units, 5-9 units and ≥10 units). RESULTS The median age of participants was 37 years (interquartile range [IQR] 25-54 years), with 48.2% of patients had severe trauma (ISS >12) and 13.2% receiving at least one unit of PRBC in the first 24 h of admission. Median (IQR) values for FIBTEM A5, EXTEM A5 and EXTEM CT were 13 mm (10-16 mm), 45 mm (40-49 mm) and 62 s (56-71 s), respectively. A test for trend over progressive age groups showed an increase in FIBTEM A5 (P < 0.001) and EXTEM A5 values (P < 0.001) and a decrease in EXTEM CT values (P < 0.001). CONCLUSION The present study demonstrated a pattern of increasing coagulability, as defined by ROTEM, with increasing age group in trauma patients, even among the severely injured. Further investigation is required to determine the clinical impact of these findings on both the ROTEM-guided management and longitudinal outcomes of these patients and whether an age-specific approach is beneficial.
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Affiliation(s)
- Jack Simpson
- Department of Intensive Care, Gold Coast University Hospital, Queensland Health, Gold Coast, Queensland, Australia
| | - James McCullough
- Department of Intensive Care, Gold Coast University Hospital, Queensland Health, Gold Coast, Queensland, Australia
| | - Kerin Walters
- Department of Trauma, Gold Coast University Hospital, Queensland Health, Gold Coast, Queensland, Australia
| | - Elizabeth Wake
- Department of Trauma, Gold Coast University Hospital, Queensland Health, Gold Coast, Queensland, Australia
| | - Debbie Ho
- Department of Trauma, Gold Coast University Hospital, Queensland Health, Gold Coast, Queensland, Australia
| | - Erick Chan
- Department of Trauma, Gold Coast University Hospital, Queensland Health, Gold Coast, Queensland, Australia
| | - Don Campbell
- Department of Trauma, Gold Coast University Hospital, Queensland Health, Gold Coast, Queensland, Australia
| | - James Winearls
- Department of Intensive Care, Gold Coast University Hospital, Queensland Health, Gold Coast, Queensland, Australia
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14
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Abstract
Viscoelastic testing methods examine the real-time formation of a clot in a whole blood sample, and include thromboelastography (TEG), rotational thromboelastometry (ROTEM), and several other testing platforms. They allow for concurrent assessment of multiple aspects of clotting, including plasmatic coagulation factors, platelets, fibrinogen, and the fibrinolytic pathway. This testing is rapid and may be performed at the point-of-care, allowing for prompt identification of coagulopathies to guide focused and rational administration of blood products as well as the identification of anticoagulant effect. With recent industry progression towards user-friendly, cartridge-based, portable instruments, viscoelastic testing has emerged in the 21st century as a powerful tool to guide blood transfusions in the bleeding patient, and to identify and treat both bleeding and thrombotic conditions in many operative settings, including trauma surgery, liver transplant surgery, cardiac surgery, and obstetrics. In these settings, the use of transfusion algorithms guided by viscoelastic testing data has resulted in widespread improvements in patient blood management as well as modest improvements in select patient outcomes. To address the increasingly wide adoption of viscoelastic methods and the growing number of medical and laboratory personnel tasked with implementing, performing, and interpreting these methods, this chapter provides an overview of the history, physiology, and technology behind viscoelastic testing, as well as a practical review of its clinical utility and current evidence supporting its use. Also included is a review of testing limitations and the contextual role played by viscoelastic methods among all coagulation laboratory testing.
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Affiliation(s)
- Timothy Carll
- Department of Pathology, University of Chicago, Chicago, IL, United States.
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15
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Fuja C, Carll TC, Mikrut K, Wool GD. Sensitivity and specificity of thromboelastography for hyperfibrinolysis: Comparison of TEG 5000 and TEG 6S CK LY30 systems. Am J Clin Pathol 2023; 160:455-465. [PMID: 37415401 DOI: 10.1093/ajcp/aqad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/15/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVES The sensitivity and specificity of clot lysis at 30 minutes after maximum clot strength (LY30), as measured by thromboelastography (TEG), for clinically significant hyperfibrinolysis have not been compared across the 2 US Food and Drug Administration-approved instruments (the TEG 5000 and TEG 6s [Haemonetics]). METHODS We performed a retrospective, single-center analysis of these 2 instruments using the kaolin (CK) reagent. RESULTS Local verification studies showed that the TEG 5000 and TEG 6s CK LY30 upper limits of normal (ULNs) were distinct (5.0% and 3.2%, respectively). Retrospective analysis of patient data showed that abnormal LY30 was 6 times more prevalent with the TEG 6s than with the TEG 5000 instrument. LY30 was a significant predictor of mortality with both instruments (TEG 6s: receiver operating characteristic [ROC] area under the curve [AUC] = 0.836, P ≤ .0001; TEG 5000: ROC AUC = 0.779, P = .028). The optimal LY30 cut point was determined based on these mortality data for each instrument. The TEG 6s showed superior mortality prediction than the TEG 5000 at lower LY30 levels (≥10%), with likelihood ratios of 8.22 and 2.62 for the TEG 6s and TEG 5000, respectively. Patients with a TEG 6s CK LY30 of 10% or higher were significantly more likely to die, receive cryoprecipitate, receive transfusions, or receive massive transfusion than patients with a TEG 6s LY30 of 3.3% to 9.9% (all P < .01). Patients with a TEG 5000 LY30 of 17.1% or higher were significantly more likely to die or use cryoprecipitate (P < .05); transfusion and massive transfusion protocol were not significantly different. Whole blood spiking studies showed that 70 ng/mL tissue plasminogen activator (tPA) achieved an average LY30 of approximately 10% for both instruments. CONCLUSIONS CK LY30 above the ULN is a sensitive but not specific cutoff for hyperfibrinolysis. At least moderately elevated CK LY30 carries more clinical portent on the TEG 6s instrument than on the TEG 5000. These TEG instruments are not sensitive to low concentrations of tPA.
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Affiliation(s)
- Christine Fuja
- Department of Pathology, University of Chicago, Chicago, IL, US
| | - Timothy C Carll
- Department of Pathology, University of Chicago, Chicago, IL, US
| | - Krzysztof Mikrut
- Clinical Laboratories, University of Chicago Medicine, Chicago, IL, US
| | - Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, IL, US
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16
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Wool GD, Carll T. Viscoelastic testing: Critical appraisal of new methodologies and current literature. Int J Lab Hematol 2023; 45:643-658. [PMID: 37559473 DOI: 10.1111/ijlh.14144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/25/2023] [Indexed: 08/11/2023]
Abstract
United States Food and Drug Administration (FDA)-approved viscoelastic testing (VET) methodologies have significantly changed in the last 10 years, with the availability of cartridge-based VET. Some of these cartridge-based methodologies use harmonic resonance-based clot detection. While VET has always allowed for the evaluation of real-time clot formation, cartridge-based VET provides increased ease of use as well as greater portability and robustness of results in out-of-laboratory environments. Here we review the use of VET in a variety of clinical contexts, including cardiac surgery, trauma, liver transplant, obstetrics, and hypercoagulable states such as COVID-19. As of now, high quality randomized trial evidence for new generation VET (TEG 6s, HemoSonics Quantra, ROTEM sigma) is limited. Nevertheless, the use of VET-guided transfusion algorithms appears to result in reduced blood usage without worsening of patient outcomes. Future work comparing the new generation VET instruments and continuing to validate clinically important cut-offs will help move the field of point-of-care coagulation monitoring forward and increase the quality of transfusion management in bleeding patients.
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Affiliation(s)
- Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Timothy Carll
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
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17
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Bouzat P, Hunt BJ, Juffermans NP. Four-factor prothrombin complex concentrate in trauma patients. Intensive Care Med 2023; 49:1242-1244. [PMID: 37486378 DOI: 10.1007/s00134-023-07170-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Pierre Bouzat
- CHU Grenoble Alpes, Grenoble Institute Neurosciences, Université Grenoble Alpes, Inserm, U1216, 38000, Grenoble, France.
- Pôle d'Anesthésie-Réanimation, Hôpital Albert Michallon, BP 217, 38043, Grenoble, France.
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nicole P Juffermans
- Department Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
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18
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Rossetto A, Torres T, Platton S, Vulliamy P, Curry N, Davenport R. A new global fibrinolysis capacity assay for the sensitive detection of hyperfibrinolysis and hypofibrinogenemia in trauma patients. J Thromb Haemost 2023; 21:2759-2770. [PMID: 37207863 DOI: 10.1016/j.jtha.2023.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Conventional clotting tests are not expeditious enough to allow timely targeted interventions in trauma, and current point-of-care analyzers, such as rotational thromboelastometry (ROTEM), have limited sensitivity for hyperfibrinolysis and hypofibrinogenemia. OBJECTIVES To evaluate the performance of a recently developed global fibrinolysis capacity (GFC) assay in identifying fibrinolysis and hypofibrinogenemia in trauma patients. METHODS Exploratory analysis of a prospective cohort of adult trauma patients admitted to a single UK major trauma center and of commercially available healthy donor samples was performed. Lysis time (LT) was measured in plasma according to the GFC manufacturer's protocol, and a novel fibrinogen-related parameter (percentage reduction in GFC optical density from baseline at 1 minute) was derived from the GFC curve. Hyperfibrinolysis was defined as a tissue factor-activated ROTEM maximum lysis of >15% or LT of ≤30 minutes. RESULTS Compared to healthy donors (n = 19), non-tranexamic acid-treated trauma patients (n = 82) showed shortened LT, indicative of hyperfibrinolysis (29 minutes [16-35] vs 43 minutes [40-47]; p < .001). Of the 63 patients without overt ROTEM-hyperfibrinolysis, 31 (49%) had LT of ≤30 minutes, with 26% (8 of 31) of them requiring major transfusions. LT showed increased accuracy compared to maximum lysis in predicting 28-day mortality (area under the receiver operating characteristic curve, 0.96 [0.92-1.00] vs 0.65 [0.49-0.81]; p = .001). Percentage reduction in GFC optical density from baseline at 1 minute showed comparable specificity (76% vs 79%) to ROTEM clot amplitude at 5 minutes from tissue factor-activated ROTEM with cytochalasin D in detecting hypofibrinogenemia but correctly reclassified >50% of the patients with false negative results, leading to higher sensitivity (90% vs 77%). CONCLUSION Severe trauma patients are characterized by a hyperfibrinolytic profile upon admission to the emergency department. The GFC assay is more sensitive than ROTEM in capturing hyperfibrinolysis and hypofibrinogenemia but requires further development and automation.
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Affiliation(s)
- Andrea Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health National Health Service Trust, London, UK.
| | - Tracy Torres
- Barts Health National Health Service Trust, London, UK
| | - Sean Platton
- Barts Health National Health Service Trust, London, UK
| | - Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health National Health Service Trust, London, UK
| | - Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals Foundation Trust, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health National Health Service Trust, London, UK
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Rosebery L, Miller M, Loizou P, Ho SJ, Adkins KJ, Deshpande K. A retrospective validation of ROTEM algorithms for detecting hyperfibrinolysis demonstrates poor agreement for prediction of in-hospital mortality and transfusion requirement in a general, non-cardiac, surgical population. Thromb Res 2023; 229:170-177. [PMID: 37517207 DOI: 10.1016/j.thromres.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/02/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Hyperfibrinolysis diagnosed on Rotational Thromboelastography (ROTEM) is associated with increased transfusion requirements and mortality in trauma. The diagnosis and significance of hyperfibrinolysis in a mixed, non-cardiac, general surgical population has not been investigated. We aimed to measure agreement between four ROTEM algorithms for diagnosing hyperfibrinolysis and transfusion requirements and mortality in general surgical patients. These algorithms mostly incorporate measures of early or late clot amplitude reduction on the Extrinsic Clotting Pathway Test with Tissue Factor (EXTEM) channel. METHOD Four hospital administrative data sets were linked from 2019 to 2022. Adults >18 years were included if a ROTEM was performed during their surgery (intraoperative period) or within 24-h of the surgery completion (postoperative period). The four hyperfibrinolysis criteria were applied to the ROTEM data and assessed for their agreement, intraoperative and postoperative transfusion requirements and in-patient mortality. RESULTS We linked 933 ROTEMs to 558 patient-procedures. One algorithm identified hyperfibrinolysis on only three patients so was excluded. Agreement between the remaining three was slight (Cohens Kappa 0.18 (p < 0.001)) with hyperfibrinolysis diagnosed between 22 and 69 % of the procedures. The association between hyperfibrinolysis diagnosis and intraoperative or postoperative transfusion requirement was inconsistent between the criteria. However, an algorithm put forward by Goerling et al. was more often associated with transfusion requirement and inpatient mortality. DISCUSSION The poor agreement between criteria suggests that some ROTEM criteria may not transfer directly to general surgical patients. Future research should focus on optimising hyperfibrinolysis cut-off values to update algorithms for bleeding general surgical patients.
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Affiliation(s)
- Leon Rosebery
- Intensive Care Unit, St George Hospital, Gray St, Kogarah 2217, Australia
| | - Matthew Miller
- Department of Anaesthesia, St George Hospital, Gray St, Kogarah 2217, Australia; Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia.
| | - Peter Loizou
- Blood Bank Department, StG Public Hospital, Kogarah, NSW 2217, Australia
| | - Shir Jing Ho
- Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia; Department of Haematology, St George Hospital, Kogarah, NSW 2217, Australia
| | - Keith J Adkins
- Department of Perfusion, St George Hospital, Gray St, Kogarah, NSW 2217, Australia
| | - Kush Deshpande
- Intensive Care Unit, St George Hospital, Gray St, Kogarah 2217, Australia; Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia
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20
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Davies RL, Thompson J, McGuire R, Smith JE, Webster S, Woolley T. Haemostatic resuscitation in practice: a descriptive analysis of blood products administered during Operation HERRICK, Afghanistan. BMJ Mil Health 2023:e002408. [PMID: 37400127 DOI: 10.1136/military-2023-002408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/10/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Life-threatening haemorrhage is the leading cause of potentially survivable injury in battlefield casualties. During Operation HERRICK (Afghanistan), mortality rates improved year on year due to a number of advances in trauma care, including haemostatic resuscitation. Blood transfusion practice has not previously been reported in detail during this period. METHODS A retrospective analysis of blood transfusion at the UK role 3 medical treatment facility (MTF) at Camp Bastion between March 2006 and September 2014 was performed. Data were extracted from two sources: the UK Joint Theatre Trauma Registry (JTTR) and the newly established Deployed Blood Transfusion Database (DBTD). RESULTS 3840 casualties were transfused 72 138 units of blood and blood products. 2709 adult casualties (71%) were fully linked with JTTR data and were transfused a total of 59 842 units. Casualties received between 1 unit and 264 units of blood product with a median of 13 units per patient. Casualties wounded by explosion required almost twice the volume of blood product transfusion as those wounded by small arms fire or in a motor vehicle collision (18 units, 9 units, and 10 units, respectively). More than half of blood products were transfused within the first 2 hours following arrival at the MTF. There was a trend towards balanced resuscitation with more equal ratios of blood and blood products being used over time. CONCLUSION This study has defined the epidemiology of blood transfusion practice during Operation HERRICK. The DBTD is the largest combined trauma database of its kind. It will ensure that lessons learnt during this period are defined and not forgotten; it should also allow further research questions to be answered in this important area of resuscitation practice.
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Affiliation(s)
- Rhys L Davies
- Anaesthetic Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Thompson
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - S Webster
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - T Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
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21
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Maegele M. [Viscoelasticity-based point of care coagulation diagnostics in the context of resuscitation room management of severely injured and bleeding trauma patients : Diagnostics and treatment of trauma-induced coagulopathy]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:542-551. [PMID: 36976344 DOI: 10.1007/s00113-023-01300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 03/29/2023]
Abstract
Uncontrolled bleeding with associated trauma-induced coagulopathy (TIC) remains the leading cause of preventable death after severe trauma. Meanwhile, TIC is recognized as a separate clinical entity with substantial impact on downstream morbidity and mortality. In clinical practice severely injured and bleeding patients are often still being treated according to established damage control surgery (DCS) procedures with surgical bleeding control and empirical transfusion of classical blood products in predefined ratios in the sense of damage control resuscitation (DCR); however, algorithms are also available, which have been constructed from established viscoelasticity-based point of care (POC) diagnostic procedures and target value-oriented treatments. The latter enables a timely qualitative assessment of coagulation function from whole blood at bedside and provides rapid and clinically useful information on the presence, development and dynamics of the coagulation disorder. The early implementation of viscoelasticity-based POC procedures in the context of resuscitation room management of severely injured and bleeding patients was uniformly associated with reductions in potentially harmful blood products, especially overtransfusions, and an overall improvement in outcome including survival. The present article reviews the clinical questions around the use of viscoelasticity-based procedures as well as recommendations for the early and acute management of bleeding trauma patients taking the current literature into account.
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Affiliation(s)
- Marc Maegele
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland.
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Köln, Deutschland.
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22
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Wojack CA, Marrocco AM, Enstrom JC, Casida J. Thromboelastography: A Novel Approach to Hemostasis in Cardiac Surgery. AACN Adv Crit Care 2023; 34:139-144. [PMID: 37289626 DOI: 10.4037/aacnacc2023957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Cristina A Wojack
- Cristina A. Wojack is Nurse Practitioner, Cardiac Surgery Intensive Care Unit, Henry Ford Health, 2799 West Grand Boulevard, Detroit, MI 48202
| | - Anna M Marrocco
- Anna M. Marrocco is Nurse Practitioner, Cardiac Surgery Intensive Care Unit, Henry Ford Health, and PhD student, Wayne State University, Detroit, Michigan
| | - Jeanne Caitlyn Enstrom
- Jeanne Caitlyn Enstrom is Instructor of Nursing, Vanderbilt University School of Nursing, and Nurse Practitioner, Cardiac Intensive Care Unit, Nashville, Tennessee
| | - Jesus Casida
- Jesus Casida is Endowed Professor and Executive Director, Eleanor Mann School of Nursing, University of Arkansas, Fayetteville, Arkansas
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23
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Barquero M, Yanes GJ, Blasi A, Colomina MJ. Use of viscoelastic tests in the principle bleeding scenarios in Spanish hospitals. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:284-296. [PMID: 36934845 DOI: 10.1016/j.redare.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/17/2022] [Indexed: 03/19/2023]
Abstract
Viscoelastic tests are designed to study the dynamics of clot formation, identify coagulopathies in real time, arrive at a diagnosis, and guide patient-specific administration of haemostatics. They are mainly used to treat clinically significant bleeding in any setting, and are also used in other situations involving clinically relevant alterations in haemostasis, such as coagulopathy in critically ill patients. These tests are administered following evidence-based algorithms that vary depending on the clinical context. This review summarises the results of a survey conducted in several hospitals to determine the prevalence and standardisation of viscoelastic tests in cardiac surgery, liver transplantation, and multiple trauma patients in Spain. The results reveal divergent opinions on key aspects, ranging from the diagnostic capacity of these tests to the interpretation of the basic parameters. On the basis of these findings, we propose a number of potential areas in which further research will improve the performance of these tests.
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Affiliation(s)
- M Barquero
- Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | - G J Yanes
- Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - A Blasi
- Hospital Clínic, Barcelona, Spain; Institut d'Investigacio Biomèdica Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M J Colomina
- Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain; Departamento de Ciencias Clínicas, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain
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24
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Bouzat P, Charbit J, Abback PS, Huet-Garrigue D, Delhaye N, Leone M, Marcotte G, David JS, Levrat A, Asehnoune K, Pottecher J, Duranteau J, Courvalin E, Adolle A, Sourd D, Bosson JL, Riou B, Gauss T, Payen JF. Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial. JAMA 2023; 329:1367-1375. [PMID: 36942533 PMCID: PMC10031505 DOI: 10.1001/jama.2023.4080] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/05/2023] [Indexed: 03/22/2023]
Abstract
Importance Optimal transfusion strategies in traumatic hemorrhage are unknown. Reports suggest a beneficial effect of 4-factor prothrombin complex concentrate (4F-PCC) on blood product consumption. Objective To investigate the efficacy and safety of 4F-PCC administration in patients at risk of massive transfusion. Design, Setting, and Participants Double-blind, randomized, placebo-controlled superiority trial in 12 French designated level I trauma centers from December 29, 2017, to August 31, 2021, involving consecutive patients with trauma at risk of massive transfusion. Follow-up was completed on August 31, 2021. Interventions Intravenous administration of 1 mL/kg of 4F-PCC (25 IU of factor IX/kg) vs 1 mL/kg of saline solution (placebo). Patients, investigators, and data analysts were blinded to treatment assignment. All patients received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1) and were treated according to European traumatic hemorrhage guidelines. Main Outcomes and Measures The primary outcome was 24-hour all blood product consumption (efficacy); arterial or venous thromboembolic events were a secondary outcome (safety). Results Of 4313 patients with the highest trauma level activation, 350 were eligible for emergency inclusion, 327 were randomized, and 324 were analyzed (164 in the 4F-PCC group and 160 in the placebo group). The median (IQR) age of participants was 39 (27-56) years, Injury Severity Score was 36 (26-50 [major trauma]), and admission blood lactate level was 4.6 (2.8-7.4) mmol/L; prehospital arterial systolic blood pressure was less than 90 mm Hg in 179 of 324 patients (59%), 233 patients (73%) were men, and 226 (69%) required expedient hemorrhage control. There was no statistically or clinically significant between-group difference in median (IQR) total 24-hour blood product consumption (12 [5-19] U in the 4F-PCC group vs 11 [6-19] U in the placebo group; absolute difference, 0.2 U [95% CI, -2.99 to 3.33]; P = .72). In the 4F-PCC group, 56 patients (35%) presented with at least 1 thromboembolic event vs 37 patients (24%) in the placebo group (absolute difference, 11% [95% CI, 1%-21%]; relative risk, 1.48 [95% CI, 1.04-2.10]; P = .03). Conclusions and Relevance Among patients with trauma at risk of massive transfusion, there was no significant reduction of 24-hour blood product consumption after administration of 4F-PCC, but thromboembolic events were more common. These findings do not support systematic use of 4F-PCC in patients at risk of massive transfusion. Trial Registration ClinicalTrials.gov Identifier: NCT03218722.
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Affiliation(s)
- Pierre Bouzat
- Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institute Neurosciences, Grenoble, France
| | - Jonathan Charbit
- Trauma Critical Care Unit, Montpellier University Hospital, F-34295 Montpellier Cedex 5, France
| | - Paer-Selim Abback
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, Clichy, France
| | - Delphine Huet-Garrigue
- Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Lille, Surgical Critical Care, Lille, France
| | - Nathalie Delhaye
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d’Anesthésie Réanimation, Paris, France
| | - Marc Leone
- Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Department of Anesthesiology and Intensive Care Unit, North Hospital, and Centre for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Marseille, France
| | - Guillaume Marcotte
- Hospices Civils de Lyon, Hopital Edouard Herriot, Department of Anesthesia and Intensive Care, Lyon, France
| | - Jean-Stéphane David
- University Claude Bernard Lyon 1, INSERM U1290, Research on Healthcare Performance (RESHAPE), and Hospices Civils de Lyon, Groupement Hospitalier Sud, Department of Anesthesia and Intensive Care, Pierre Benite, France
| | | | - Karim Asehnoune
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d'Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service d’Anesthésie-Réanimation & Médecine Péri-Opératoire - Université de Strasbourg, Faculté de Médecine, FMTS, ER3072, Strasbourg, France
| | - Jacques Duranteau
- Département d’Anesthésie-Réanimation, Hôpitaux Universitaires Paris Sud, Université Paris XI, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre, France
| | - Elie Courvalin
- Trauma Critical Care Unit, Montpellier University Hospital, F-34295 Montpellier Cedex 5, France
| | - Anais Adolle
- Pôle d’Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Dimitri Sourd
- Univ. Grenoble Alpes, CNRS, Public Health department CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France
| | - Jean-Luc Bosson
- Univ. Grenoble Alpes, CNRS, Public Health department CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France
| | - Bruno Riou
- Sorbonne Université, UMR-S INSERM 1166, IHU ICAN, and Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Department of Emergency medicine and Surgery, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, Clichy, France
| | - Jean-François Payen
- Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institute Neurosciences, Grenoble, France
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25
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Abstract
Massive trauma remains the leading cause of mortality among people aged younger than 45 years. In this review, we discuss the initial care and diagnosis of trauma patients followed by a comparison of resuscitation strategies. We discuss various strategies including use of whole blood and component therapy, examine viscoelastic techniques for management of coagulopathy, and consider the benefits and limitations of the resuscitation strategies and consider a series of questions that will be important for researchers to answer to provide the best and most cost-effective therapy for severely injured patients.
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Affiliation(s)
- Carter M Galbraith
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845, Birmingham, AL 35249, USA
| | - Brant M Wagener
- Division of Critical Care Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL 35294, USA; Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL 35294, USA
| | - Athanasios Chalkias
- Department of Anesthesiology, University of Thessaly, Biopolis, Larisa 41500, Greece; Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 East 17th Avenue, 7th Floor, Aurora, CO 80045, USA.
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Selby R. “TEG” talks: technology worth spreading? Res Pract Thromb Haemost 2023; 7:100022. [PMID: 36970744 PMCID: PMC10031362 DOI: 10.1016/j.rpth.2022.100022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/08/2022] [Indexed: 03/02/2023] Open
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Roh DJ, Chang TR, Kumar A, Burke D, Torres G, Xu K, Yang W, Cottarelli A, Moore E, Sauaia A, Hansen K, Velazquez A, Boehme A, Vrosgou A, Ghoshal S, Park S, Agarwal S, Claassen J, Connolly ES, Wagener G, Francis RO, Hod E. Hemoglobin Concentration Impacts Viscoelastic Hemostatic Assays in ICU Admitted Patients. Crit Care Med 2023; 51:267-278. [PMID: 36661453 PMCID: PMC11149397 DOI: 10.1097/ccm.0000000000005700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Low hemoglobin concentration impairs clinical hemostasis across several diseases. It is unclear whether hemoglobin impacts laboratory functional coagulation assessments. We evaluated the relationship of hemoglobin concentration on viscoelastic hemostatic assays in intracerebral hemorrhage (ICH) and perioperative patients admitted to an ICU. DESIGN Observational cohort study and separate in vitro laboratory study. SETTING Multicenter tertiary referral ICUs. PATIENTS Two acute ICH cohorts receiving distinct testing modalities: rotational thromboelastometry (ROTEM) and thromboelastography (TEG), and a third surgical ICU cohort receiving ROTEM were evaluated to assess the generalizability of findings across disease processes and testing platforms. A separate in vitro ROTEM laboratory study was performed utilizing ICH patient blood samples. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Relationships between baseline hemoglobin and ROTEM/TEG results were separately assessed across patient cohorts using Spearman correlations and linear regression models. A separate in vitro study assessed ROTEM tracing changes after serial hemoglobin modifications from ICH patient blood samples. In both our ROTEM (n = 34) and TEG (n = 239) ICH cohorts, hemoglobin concentrations directly correlated with coagulation kinetics (ROTEM r: 0.46; p = 0.01; TEG r: 0.49; p < 0.0001) and inversely correlated with clot strength (ROTEM r: -0.52, p = 0.002; TEG r: -0.40, p < 0.0001). Similar relationships were identified in perioperative ICU admitted patients (n = 121). We continued to identify these relationships in linear regression models. When manipulating ICH patient blood samples to achieve lower hemoglobin concentrations in vitro, we similarly identified that lower hemoglobin concentrations resulted in progressively faster coagulation kinetics and greater clot strength on ROTEM tracings. CONCLUSIONS Lower hemoglobin concentrations have a consistent, measurable impact on ROTEM/TEG testing in ICU admitted patients, which appear to be artifactual. It is possible that patients with low hemoglobin may appear to have normal viscoelastic parameters when, in fact, they have a mild hypocoagulable state. Further work is required to determine if these tests should be corrected for a patient's hemoglobin concentration.
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Affiliation(s)
- David J Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Tiffany R Chang
- Department of Neurology and Neurosurgery, McGovern Medical School at UTHealth, Houston, TX
| | - Aditya Kumar
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Devin Burke
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Glenda Torres
- Department of Neurology and Neurosurgery, McGovern Medical School at UTHealth, Houston, TX
| | - Katherine Xu
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Winni Yang
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Azzurra Cottarelli
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ernest Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Kirk Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO
| | - Angela Velazquez
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Athina Vrosgou
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Shivani Ghoshal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Soojin Park
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Sachin Agarwal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jan Claassen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - E Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Gebhard Wagener
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Richard O Francis
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Eldad Hod
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
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Curry NS, Davenport R, Wong H, Gaarder C, Johansson P, Juffermans NP, Maegele M, Stensballe J, Brohi K, Laffan M, Stanworth SJ. Traumatic coagulopathy in the older patient: analysis of coagulation profiles from the Activation of Coagulation and Inflammation in Trauma-2 (ACIT-2) observational, multicenter study. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:215-226. [PMID: 36700506 DOI: 10.1016/j.jtha.2022.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Most studies describing traumatic coagulopathy have used data from patient cohorts with an average age of between 35 and 45 years. The last 10 years has seen a steep increase in the number of patients admitted with significant injury and bleeding who are older than the age of 65 years. Many coagulation protein levels alter significantly with normal aging, and it is possible that traumatic coagulopathy has a different signature with age. OBJECTIVES The aim of this study was to report the coagulation profiles, including standard and extended laboratory, as well as viscoelastic hemostatic assays, stratified according to age to explore age-related differences in hemostatic capability. METHODS In total, 1576 patients were analyzed from 6 European level 1 trauma centers. RESULTS As age increased, there was evidence of higher fibrinogen, greater thrombin generation, greater clotting factor consumption, and greater activation of fibrinolysis. Despite this, shock and severe injury led to the same pattern of changes within age groups: lower procoagulant factors (including fibrinogen), increased fibrinolysis, and higher levels of activated protein C. Thromboelastography and rotational thromboelastometry tests detected traumatic coagulopathy with prolongation of R/clotting time and reductions in clot amplitudes in each age cohort. Advancing age strongly correlated with higher fibrinogen levels and greater fibrinolysis. CONCLUSION Age-related coagulation changes are evident in injured patients. Broadly, similar patterns of coagulation abnormalities are seen across age groups following severe injury/shock, but thresholds for single clotting factors differ. Age-related differences may need to be considered when clinical treatments (eg, transfusion therapy) are indicated.
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Affiliation(s)
- Nicola S Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom.
| | - Ross Davenport
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Henna Wong
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | | | - Pär Johansson
- Department of Anesthesiology and Trauma Center, and Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Maegele
- Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - Jakob Stensballe
- Department of Anesthesiology and Trauma Center, and Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karim Brohi
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mike Laffan
- Imperial College and Hammersmith Hospital, London, United Kingdom
| | - Simon J Stanworth
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom; NHS Blood and Transplant, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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30
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Matkovic E, Lindholm PF. Role of Viscoelastic and Conventional Coagulation Tests for Management of Blood Product Replacement in the Bleeding Patient. Semin Thromb Hemost 2022; 48:785-795. [PMID: 36174609 DOI: 10.1055/s-0042-1756192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
An important aim of viscoelastic testing (VET) is to implement transfusion algorithms based on coagulation test results to help reduce transfusion rates and improve patient outcomes. Establishing a rapid diagnosis and providing timely treatment of coagulopathy is the cornerstone of management of severely bleeding patients in trauma, postpartum hemorrhage, and major surgery. As the nature of acute bleeding and trauma leads to an unstable and tenuous physiologic state, conventional coagulation tests (CCTs) are too slow to diagnose, manage, and also course correct any hemostatic abnormalities that accompany an acute critical illness. Viscoelastic point-of-care tests strongly correlate with results from standard laboratory tests but are designed to enable clinicians to make timely, informed bleeding management decisions when time to intervene is critical. These assays provide an individualized and goal-oriented approach to patient blood management and are increasingly becoming involved in transfusion algorithms. The scope of this review aims to evaluate the current literature on VETs and their impact on actionable outputs in clinical decision making and their relationship to CCT.
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Affiliation(s)
- Eduard Matkovic
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul F Lindholm
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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31
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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Sloos PH, Vulliamy P, van 't Veer C, Gupta AS, Neal MD, Brohi K, Juffermans NP, Kleinveld DJB. Platelet dysfunction after trauma: From mechanisms to targeted treatment. Transfusion 2022; 62 Suppl 1:S281-S300. [PMID: 35748694 PMCID: PMC9546174 DOI: 10.1111/trf.16971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Pieter H. Sloos
- Department of Intensive Care Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Cornelis van 't Veer
- Center for Experimental and Molecular Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Anirban Sen Gupta
- Department of Biomedical EngineeringCase Western Reserve UniversityClevelandOhioUSA
| | - Matthew D. Neal
- Pittsburgh Trauma and Transfusion Medicine Research Center and Division of Trauma and Acute Care SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Intensive Care MedicineOLVG HospitalAmsterdamThe Netherlands
| | - Derek J. B. Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Intensive Care MedicineErasmus MCRotterdamThe Netherlands
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Metcalf RA, Cohn CS, Allen ES, Bakhtary S, Gniadek T, Gupta G, Harm S, Haspel R, Hess A, Jacobson J, Lokhandwala PM, Murphy C, Poston J, Prochaska MT, Raval JS, Saifee NH, Salazar E, Shan H, Zantek N, Pagano MB. Current advances in transfusion medicine 2021: A critical review of selected topics by the AABB Clinical Transfusion Medicine Committee. Transfusion 2022; 62:1435-1445. [PMID: 35713186 DOI: 10.1111/trf.16944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Each year the AABB Clinical Transfusion Medicine Committee (CTMC) procures a synopsis highlighting new, important, and clinically relevant studies in the field of transfusion medicine (TM). This has been made available as a publication in Transfusion since 2018. METHODS CTMC members reviewed and identified original manuscripts covering TM-related topics published electronically (ahead-of-print) or in print from December 2020 to December 2021. Selection of publications was discussed at committee meetings and chosen based on perceived relevance and originality. Next, committee members worked in pairs to create a synopsis of each topic, which was then reviewed by additional committee members. The first and senior authors assembled the final manuscript. Although this synopsis is extensive, it is not exhaustive, and some articles may have been excluded or missed. RESULTS The following topics are included: blood products; convalescent plasma; donor collections and testing; hemoglobinopathies; immunohematology and genomics; hemostasis; patient blood management; pediatrics; therapeutic apheresis; and cell therapy. CONCLUSIONS This synopsis highlights and summarizes recent key developments in TM and may be useful for educational purposes.
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Affiliation(s)
- Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth S Allen
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Thomas Gniadek
- Department of Pathology, NorthShore University Health System, Chicago, Illinois, USA
| | - Gaurav Gupta
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sarah Harm
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont, USA
| | - Richard Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Aaron Hess
- Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin, USA
| | - Jessica Jacobson
- Department of Pathology, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Colin Murphy
- Department of Pathology, University of Maryland, Baltimore, Maryland, USA
| | - Jacqueline Poston
- Department of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Micah T Prochaska
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Eric Salazar
- Department of Pathology, UT Health San Antonio, San Antonio, Texas, USA
| | - Hua Shan
- Department of Pathology, Stanford University, Palo Alto, California, USA
| | - Nichole Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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The coagulopathy underlying rotational thromboelastometry derangements in trauma patients: a prospective observational multicenter study. Anesthesiology 2022; 137:232-242. [PMID: 35544678 DOI: 10.1097/aln.0000000000004268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Viscoelastic hemostatic assays such as rotational thromboelastometry (ROTEM®) are used to guide treatment of trauma induced coagulopathy. We hypothesized that ROTEM derangements reflect specific coagulation factor deficiencies after trauma. METHODS Secondary analysis of a prospective cohort study in six European trauma centers in patients presenting with full trauma team activation. Patients with dilutional coagulopathy and patients on anticoagulants were excluded. Blood was drawn on arrival for measurement of ROTEM®, coagulation factor levels and markers of fibrinolysis. ROTEM® cut-off values to define hypocoagulability were: EXTEM clotting time (CT) >80s, EXTEM clot amplitude after 5 minutes (CA5) <40mm, EXTEM lysis at 30 minutes (Li30) <85%, FIBTEM clot amplitude after 5 minutes (CA5) <10mm and FIBTEM lysis at 30 minutes (Li30) <85%. Based on these, patients were divided into 7 deranged ROTEM® profiles and compared to the reference group (ROTEM® values within reference range). The primary endpoint was coagulation factors levels and fibrinolysis. RESULTS Of 1828 patients, 40% had ROTEM® derangements 40.0%, most often consisting of a combined decrease in EXTEM and FIBTEM CA5, that was present in 217 (11.9%) patients. While an isolated EXTEM CT>80s had no impact on mortality, all other ROTEM® derangements were associated with increased mortality. Also, coagulation factor levels in this group were similar to patients with a normal ROTEM®. Of coagulation factors, decrease was most apparent for fibrinogen (with a nadir of 0.78 g/L) and for factor V levels (with a nadir of 22.8%). In addition, increased fibrinolysis can be present when LI30 is normal but EXTEM and FIBTEM CA5 is decreased. CONCLUSION Coagulation factor levels and mortality in the group with an isolated clotting time prolongation is similar to patients with a normal ROTEM ®. Other ROTEM ® derangements are associated with mortality and reflect a depletion of fibrinogen and factor V. Increased fibrinolysis can be present when lysis after 30 minutes is normal.
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Richards JE, Fedeles BT. Coagulation Management in Trauma: Do We Need a Viscoelastic Hemostatic Assay? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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36
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Heubner L, Mirus M, Vicent O, Güldner A, Tiebel O, Beyer-Westendorf J, Fries D, Spieth PM. Point of care coagulation management in anesthesiology and critical care. Minerva Anestesiol 2022; 88:615-628. [PMID: 35416466 DOI: 10.23736/s0375-9393.22.16380-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Point of care (POC) devices are increasingly used in the ICU and in anesthesia. Besides POC-devices for blood gas analysis, several devices are available for coagulation measurements. Although basic principles for thromboelastographic measurements are not novel, some promising developments were made during the last decade improving both user-friendliness and measurement reliability. For instance, POC measurements of activated clotting time (ACT) for heparin monitoring is still regarded as standard-of-care in cardiac interventions and surgery. In the field of anesthesia and intensive care medicine, POC-devices for thromboelastographic and platelet aggregation measurements are widely used. Their impact in case of bleeding and patient blood management for cardiothoracic and trauma surgery is well known. Moreover, there are promising concepts for anticoagulation monitoring including new oral anticoagulant drugs. Coagulation POC-devices may also identify patients at specific risk for thromboembolic events quickly. On the other hand, benefits of POC-devices need to be balanced against limitations, which include technical restrictions and operator related errors, mainly affecting reproducibility and interpretation of results. Therefore, it is recommendable to consider results of POC-coagulation testing in comparison to standard laboratory tests (SLT). Nevertheless, in urgent or emergency situations POC results enable fast decision making to optimize patient care.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany. -
| | - Martin Mirus
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Vicent
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Peter M Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
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Vigneshwar NG, Moore EE, Moore HB, Cotton BA, Holcomb JB, Cohen MJ, Sauaia A. Precision Medicine: Clinical Tolerance to Hyperfibrinolysis Differs by Shock and Injury Severity. Ann Surg 2022; 275:e605-e607. [PMID: 33214445 PMCID: PMC8589450 DOI: 10.1097/sla.0000000000004548] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The definition of hyperfibrinolysis based on thrombelastogram LY30 measurements should vary with trauma patient characteristics, i.e., as anatomic injury or shock severity increase, the ability to tolerate even mild degrees of fibrinolysis is markedly reduced. This trend is independent of institutional practice patterns. The management of hyperfibrinolysis, particularly with anti-fibrinolytics administration, should be interpreted in the context of injury severity/shock and managed on an individual patient basis.
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Affiliation(s)
- Navin G Vigneshwar
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Hunter B Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Bryan A Cotton
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - John B Holcomb
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Mitchell J Cohen
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Angela Sauaia
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Health Systems, Management and Policy, University of Colorado School of Public Health, Aurora, Colorado
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Dias JD, Butwick AJ, Hartmann J, Waters JH. Viscoelastic haemostatic point-of-care assays in the management of postpartum haemorrhage: a narrative review. Anaesthesia 2022; 77:700-711. [PMID: 35194779 DOI: 10.1111/anae.15662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 01/29/2023]
Abstract
Viscoelastic haemostatic assays provide rapid testing at the bed-side that identify all phases of haemostasis, from initial fibrin formation to clot lysis. In obstetric patients, altered haemostasis is common as pregnancy is associated with coagulation changes that may contribute to bleeding events such as postpartum haemorrhage, as well as thrombosis events. In this narrative review, we examine the potential clinical utility of viscoelastic haemostatic assays in postpartum haemorrhage and consider the current recommendations for their use in obstetric patients. We discuss the clinical benefits associated with the use of viscoelastic haemostatic assays due to the provision of (near) real-time readouts with a short turnaround, coupled with the identification of coagulation defects such as hypofibrinogenaemia. The use of viscoelastic haemostatic assay-guided algorithms may be beneficial to diagnose coagulopathy, predict postpartum haemorrhage, reduce transfusion requirements and monitor fibrinolysis in women with obstetric haemorrhage. Further studies are required to assess whether viscoelastic haemostatic assay-guided treatment improves clinical outcomes, and to confirm the utility of prepartum viscoelastic haemostatic assay measurements for identifying patients at risk of postpartum haemorrhage.
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Affiliation(s)
- J D Dias
- Haemonetics Corporation, Boston, MA, USA
| | - A J Butwick
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA
| | - J Hartmann
- Haemonetics Corporation, Boston, MA, USA
| | - J H Waters
- Department of Anesthesiology and Bioengineering, University of Pittsburgh and McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
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39
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Pavoni V, Gianesello L, Pazzi M, Dattolo P, Prisco D. Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests. J Clin Monit Comput 2022; 36:55-69. [PMID: 34264472 PMCID: PMC8280589 DOI: 10.1007/s10877-021-00744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.
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Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Largo Palagi, 1, 50139, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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40
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Lier H, Fries D. Emergency Blood Transfusion for Trauma and Perioperative Resuscitation: Standard of Care. Transfus Med Hemother 2022; 48:366-376. [PMID: 35082568 DOI: 10.1159/000519696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Uncontrolled and massive bleeding with derangement of coagulation is a major challenge in the management of both surgical and seriously injured patients. The underlying mechanism of trauma-induced or -associated coagulopathy is tissue injury in the presence of shock and acidosis provoking endothelial damage, activation of inflammation, and coagulation disbalancing. Furthermore, the combination of ongoing blood loss and consumption of blood components that are essential for effective coagulation worsens uncontrolled hemorrhage. Additionally, therapeutic actions, such as resuscitation with replacement fluids or allogeneic blood products, can further aggravate coagulopathy. Of the coagulation factors essential to the clotting process, fibrinogen is the first to be consumed to critical levels during acute bleeding and current evidence suggests that normalizing fibrinogen levels in bleeding patients improves clot formation and clot strength, thereby controlling hemorrhage. Three different therapeutic approaches are discussed controversially. Whole blood transfusion is used especially in the military scenario and is also becoming more and more popular in the civilian world, although it is accompanied by a strong lack of evidence and severe safety issues. Transfusion of allogeneic blood concentrates in fixed ratios without any targets has been investigated extensively with disappointing results. Individualized and target-controlled coagulation management based on point-of-care diagnostics with respect to the huge heterogeneity of massive bleeding situations is an alternative and advanced approach to managing coagulopathy associated with massive bleeding in the trauma as well as the perioperative setting.
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Affiliation(s)
- Heiko Lier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic for Anesthesiology and Intensive Care Medicine, Cologne, Germany
| | - Dietmar Fries
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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41
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Lantry JH, Mason P, Logsdon MG, Bunch CM, Peck EE, Moore EE, Moore HB, Neal MD, Thomas SG, Khan RZ, Gillespie L, Florance C, Korzan J, Preuss FR, Mason D, Saleh T, Marsee MK, Vande Lune S, Ayoub Q, Fries D, Walsh MM. Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center. J Clin Med 2022; 11:356. [PMID: 35054050 PMCID: PMC8778082 DOI: 10.3390/jcm11020356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 12/18/2022] Open
Abstract
Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy-especially in austere or challenging environments-is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.
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Affiliation(s)
- James H. Lantry
- Department of Medicine Critical Care Services, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA;
| | - Phillip Mason
- Department of Critical Care Medicine, San Antonio Military Medical Center, Fort Sam Houston, San Antonio, TX 78234, USA;
| | - Matthew G. Logsdon
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Connor M. Bunch
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Ethan E. Peck
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health and University of Colorado Health Sciences Center, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health and University of Colorado Health Sciences Center, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Matthew D. Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA;
| | - Rashid Z. Khan
- Department of Hematology, Michiana Hematology Oncology, Mishawaka, IN 46545, USA;
| | - Laura Gillespie
- Department of Quality Assurance and Performance Improvement, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Charles Florance
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Josh Korzan
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Fletcher R. Preuss
- Department of Orthopaedic Surgery, UCLA Santa Monica Medical Center and Orthopaedic Institute, Santa Monica, CA 90404, USA;
| | - Dan Mason
- Department of Medical Science and Devices, Haemonetics Corporation, Braintree, MA 02184, USA;
| | - Tarek Saleh
- Department of Critical Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Mathew K. Marsee
- Department of Graduate Medical Education, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA;
| | - Stefani Vande Lune
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA;
| | | | - Dietmar Fries
- Department of Surgical and General Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Mark M. Walsh
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
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42
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Blaine KP, Dudaryk R. Pro-Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma. Anesth Analg 2022; 134:21-31. [PMID: 34908543 DOI: 10.1213/ane.0000000000005709] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.
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Affiliation(s)
- Kevin P Blaine
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Health System/Ryder Trauma Center, Miami, Florida
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43
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Willis J, Carroll C, Planz V, Galgano SJ. Thromboelastography: a review for radiologists and implications on periprocedural bleeding risk. Abdom Radiol (NY) 2022; 47:2697-2703. [PMID: 35567618 PMCID: PMC9107068 DOI: 10.1007/s00261-022-03539-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/18/2023]
Abstract
Thromboelastography (TEG) and rotational thromboelastometry are emerging technologies that are gaining increasing acceptance in the medical field to evaluate the coagulation status of patients on an individual level by assessing dynamic clot formation. TEG has been proven to reduce blood product use as well as improve patient outcomes in a variety of medical settings, including trauma and surgery due to the expediated nature of the test as well as the ability to determine specific deficiencies present in whole blood that are otherwise undetectable with traditional coagulation studies. Currently, no guidelines or recommendations are in place for the utilization of TEG in interventional or diagnostic radiology although access to TEG has become increasingly common in recent years. This manuscript presents a review of prior literature on the technical aspects of TEG as well as its use in various fields and explains the normal TEG-tracing parameters. Common hemodynamic abnormalities and their effect on the TEG tracing are illustrated, and the appropriate treatments for each abnormality are briefly mentioned. TEG has the potential to be a useful tool for determining the hemodynamic state of patients in both interventional and diagnostic radiology, and further research is needed to determine the value of these tests in the periprocedural setting.
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Affiliation(s)
- Joseph Willis
- grid.265892.20000000106344187University of Alabama at Birmingham School of Medicine, Birmingham, AL USA
| | - Caleb Carroll
- grid.265892.20000000106344187University of Alabama at Birmingham School of Medicine, Birmingham, AL USA
| | - Virginia Planz
- grid.412807.80000 0004 1936 9916Department of Radiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Samuel J. Galgano
- grid.265892.20000000106344187Department of Radiology, University of Alabama at Birmingham, Birmingham, AL USA
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David JS, Lambert A, Taverna XJ, Incagnoli P, Geay-Baillat MO, Vassal O, Friggeri A, Inaba K. Which injured patients with moderate fibrinogen deficit need fibrinogen supplementation? Scand J Trauma Resusc Emerg Med 2021; 29:174. [PMID: 34952618 PMCID: PMC8709958 DOI: 10.1186/s13049-021-00988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background In severely injured patients, fibrinogen supplementation is recommended when fibrinogenemia is < 1.5 g L−1, but some teams have suggested to use higher thresholds (fibrinogenemia < 2.0 g L−1 or FIBTEM clot amplitude at 5 min (A5) values < 11 mm). The goal of this study was to specify in patients with a moderate fibrinogen deficit (MFD) whether some admission characteristics would be associated with fibrinogen administration at 24 h. Methods Prospective analysis of retrospectively collected data from a trauma registry (01/2011–12/2019). MFD-C was defined by a fibrinogenemia 1.51–1.99 g L−1 or the corresponding FIBTEM-A5 values (MFD-A5) that were determined from linear regression and ROC curve analysis. Administration of fibrinogen were described according to the following admission parameters: shock index (SI) > 1, hemoglobin level < 110 g L−1 (HemoCue®), and base deficit > 5 mEq L−1. Data are expressed as count (%), median [IQR]. Results 1076 patients were included in the study and 266 (27%) had MFD-C, among them, 122/266 (46%) received fibrinogen. Patients with MFD-C who received fibrinogen were more severely injured (ISS: 27 [19–36] vs. 24 [17–29]) and had more impaired vital signs (base deficit: 5.4 [3.6–7.8] vs. 3.8 [2.0–6.0]). Linear regression analysis found a positive correlation between fibrinogen level and FIBTEM-A5 (r: 0.805). For a fibrinogen level < 1.5 g L−1 and < 2.0 g L−1, FIBTEM-A5 thresholds were 6 mm (sensitivity 85%, specificity 83%, AUC: 0.934) and 9 mm (sensitivity 84%, specificity 69%, AUC: 0.874), respectively. MFD-A5 values (185 (27%) patients) were defined as a FIBTEM-A5 between 7 and 9 mm. More than 50% of MFD-C patients presenting a SI > 1, a hemoglobin level < 110 g L−1, or a base deficit > 5.0 mEq L−1 received fibrinogen. The relative risk [95% CI] for fibrinogen administration (SI > 1) were 1.39 [1.06–1.82] for MFD-C, and 2.17 [1.48–3.19] for MFD-A5. Results were not modified after adjustment on the ISS. Conclusions We have shown in this study an association between shock parameters and fibrinogen administration. Further studies are needed to determine how these parameters may be used to guide fibrinogen administration in trauma patients with MFD.
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Affiliation(s)
- Jean-Stephane David
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France. .,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France. .,Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France. .,Service d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, 69495, Pierre Bénite cedex, France.
| | - Aline Lambert
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Xavier-Jean Taverna
- Service d'anesthésie-réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, 69008, Lyon, France
| | - Pascal Incagnoli
- Service des Urgences - SAMU, Hôpital Universitaire de Dijon, Dijon, France
| | - Marie-Odile Geay-Baillat
- Laboratoire d'Hémostase, Hôpital Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France
| | - Olivia Vassal
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Arnaud Friggeri
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Kenji Inaba
- Division of Trauma and Critical Care, Department of Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
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45
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Brill JB, Brenner M, Duchesne J, Roberts D, Ferrada P, Horer T, Kauvar D, Khan M, Kirkpatrick A, Ordonez C, Perreira B, Priouzram A, Cotton BA. The Role of TEG and ROTEM in Damage Control Resuscitation. Shock 2021; 56:52-61. [PMID: 33769424 PMCID: PMC8601668 DOI: 10.1097/shk.0000000000001686] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/05/2019] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.
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Affiliation(s)
- Jason B. Brill
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Derek Roberts
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Universidad del Valle, Valle, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Bryan A. Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
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Bell SF, Roberts TCD, Freyer Martins Pereira J, De Lloyd L, Amir Z, James D, Jenkins PV, Collis RE, Collins PW. The sensitivity and specificity of rotational thromboelastometry (ROTEM) to detect coagulopathy during moderate and severe postpartum haemorrhage: a prospective observational study. Int J Obstet Anesth 2021; 49:103238. [PMID: 34840018 DOI: 10.1016/j.ijoa.2021.103238] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/23/2021] [Accepted: 10/31/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Point-of-care viscoelastic haemostatic assays such as rotational thromboelastometry (including ROTEM and TEG) have been used in the management of postpartum haemorrhage (PPH). This study compared results obtained from the automated ROTEM Sigma with laboratory tests of coagulation and platelet count during PPH. METHODS A prospective observational cohort study recruited women with PPH ≥1000 mL (or clinical concern of bleeding). The Fibtem A5, Extem CT and Pltem (Extem A5 - Fibtem A5) results were compared with laboratory tests of fibrinogen, prothrombin time (PT), activated partial thromboplastin time (APTT) and platelet count. RESULTS 521 women were recruited, including 274/277 (98.9%) of women with PPH ≥1500 mL. Fibtem A5 results were matched with laboratory fibrinogen in 552/644 (85.7%) samples. The incidence of abnormal laboratory results was low: fibrinogen ≤2 g/L 23/464 (5.0%), PT or APTT >1.5 × midpoint of reference range 4/464 (0.9%), and platelet count <75 × 109/L 11/477 (2.3%). Area-under- the-receiver operator characteristic curve for Fibtem A5 to detect fibrinogen ≤2 g/L was 0.96 (95% Confidence Intervals (CI) 0.94 to 0.98, P<0.001), with sensitivity and specificity of Fibtem A5 ≤11 mm to detect fibrinogen ≤2 g/L of 0.76 and 0.96. Prolonged Extem CT results improved after treatment of hypofibrinogenaemia alone. Intervention points for platelet and fresh frozen plasma (FFP) transfusion based on ROTEM Sigma parameters could not be established. CONCLUSION During PPH (≥1000 mL or cases of clinical concern about bleeding), ROTEM Sigma Fibtem A5 can detect fibrinogen ≤2 g/L and guide targeted fibrinogen replacement. Laboratory results should continue to be used to guide platelet and FFP transfusion.
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Affiliation(s)
- S F Bell
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK.
| | - T C D Roberts
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - L De Lloyd
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | - Z Amir
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | - D James
- Department of Maternity, Cardiff and Vale University Health Board, Cardiff, UK
| | - P V Jenkins
- Haemostasis and Thrombosis, Cardiff and Vale University Health Board, Cardiff, UK
| | - R E Collis
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | - P W Collins
- School of Medicine, Cardiff University, Cardiff, UK
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47
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Temporal Transitions in Fibrinolysis after Trauma: Adverse Outcome Is Principally Related to Late Hypofibrinolysis. Anesthesiology 2021; 136:148-161. [PMID: 34724559 DOI: 10.1097/aln.0000000000004036] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The relationship between late clinical outcomes after injury and early dynamic changes between fibrinolytic states is not fully understood. The authors hypothesized that temporal transitions in fibrinolysis states using rotational thromboelastometry (ROTEM) would aid stratification of adverse late clinical outcomes and improve understanding of how tranexamic acid modulates the fibrinolytic response and impacts mortality. METHODS The authors conducted a secondary analysis of previously collected data from trauma patients enrolled into an ongoing prospective cohort study (International Standard Randomised Controlled Trial Number [ISRCTN] 12962642) at a major trauma center in the United Kingdom. ROTEM was performed on admission and at 24 h with patients retrospectively grouped into three fibrinolysis categories: tissue factor-activated ROTEM maximum lysis of less than 5% (low); tissue factor-activated ROTEM maximum lysis of 5 to 15% (normal); or tissue factor-activated ROTEM maximum lysis of more than 15% (high). Primary outcomes were multiorgan dysfunction syndrome and 28-day mortality. RESULTS Seven-hundred thirty-one patients were included: 299 (41%) were treated with tranexamic acid and 432 (59%) were untreated. Two different cohorts with low-maximum lysis at 24 h were identified: (1) severe brain injury and (2) admission shock and hemorrhage. Multiple organ dysfunction syndrome was greatest in those with low-maximum lysis on admission and at 24 h, and late mortality was four times higher than in patients who remained normal during the first 24 h (7 of 42 [17%] vs. 9 of 223 [4%]; P = 0.029). Patients that transitioned to or remained in low-maximum lysis had increased odds of organ dysfunction (5.43 [95% CI, 1.43 to 20.61] and 4.85 [95% CI, 1.83 to 12.83], respectively). Tranexamic acid abolished ROTEM hyperfibrinolysis (high) on admission, increased the frequency of persistent low-maximum lysis (67 of 195 [34%]) vs. 8 of 79 [10%]; P = 0.002), and was associated with reduced early mortality (28 of 195 [14%] vs. 23 of 79 [29%]; P = 0.015). No increase in late deaths, regardless of fibrinolysis transition patterns, was observed. CONCLUSIONS Adverse late outcomes are more closely related to 24-h maximum lysis, irrespective of admission levels. Tranexamic acid alters early fibrinolysis transition patterns, but late mortality in patients with low-maximum lysis at 24 h is not increased. EDITOR’S PERSPECTIVE
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Curry N. Fibrinogen Replacement in Haemostatic Resuscitation: Dose, Laboratory Targets and Product Choice. Transfus Med Rev 2021; 35:104-107. [PMID: 34565636 DOI: 10.1016/j.tmrv.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/05/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
Fibrinogen is a key coagulation protein that is necessary for the formation of stable clots. Fibrinogen levels have been reported to be one of the first to fall during major haemorrhage reflecting consumption, dilution and fibrinogenolysis. Its role in acquired major haemorrhage, both in relation to the contribution it plays to the coagulopathy of major bleeding that can exacerbate bleeding and how effective fibrinogen supplementation can be at improving clinical outcomes, has received a great deal of attention over the last 10 - 15 years. This commentary focuses on just three of the more recent publications from the last 5 years that provide some of the evidence behind how we can think about fibrinogen as a haemostatic treatment for acquired major haemorrhage and how we can use the laboratory thresholds to guide therapy.
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Affiliation(s)
- Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, and Oxford University, NIHR BRC Haematology Theme, Oxford, UK.
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49
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Sayce AC, Neal MD, Leeper CM. Viscoelastic monitoring in trauma resuscitation. Transfusion 2021; 60 Suppl 6:S33-S51. [PMID: 33089933 DOI: 10.1111/trf.16074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/13/2020] [Accepted: 06/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic injury results in both physical and physiologic insult. Successful care of the trauma patient depends upon timely correction of both physical and biochemical injury. Trauma-induced coagulopathy is a derangement of hemostasis and thrombosis that develops rapidly and can be fatal if not corrected. Viscoelastic monitoring (VEM) assays have been developed to provide rapid, accurate, and relatively comprehensive depictions of an individual's coagulation profile. VEM are increasingly being integrated into trauma resuscitation guidelines to provide dynamic and individualized guidance to correct coagulopathy. STUDY DESIGN AND METHODS We performed a narrative review of the search terms viscoelastic, thromboelastography, thromboelastometry, TEG, ROTEM, trauma, injury, resuscitation, and coagulopathy using PubMed. Particular focus was directed to articles describing algorithms for management of traumatic coagulopathy based on VEM assay parameters. RESULTS Our search identified 16 papers with VEM-guided resuscitation strategies in adult patients based on TEG, 12 such protocols in adults based on ROTEM, 1 protocol for children based on TEG, and 2 protocols for children based on ROTEM. CONCLUSIONS This review presents evidence to support VEM use to detect traumatic coagulopathy, discusses the role of VEM in trauma resuscitation, provides a summary of proposed treatment algorithms, and discusses pending questions in the field.
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Affiliation(s)
- Andrew C Sayce
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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50
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Johannsen S, Brohi K, Johansson PI, Moore EE, Reinhold AK, Schöchl H, Shepherd JM, Slater B, Stensballe J, Zacharowski K, Meybohm P. Getting hit by the bus around the world - a global perspective on goal directed treatment of massive hemorrhage in trauma. Curr Opin Anaesthesiol 2021; 34:537-543. [PMID: 34074885 DOI: 10.1097/aco.0000000000001025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Major trauma remains one of the leading causes of death worldwide with traumatic brain injury and uncontrolled traumatic bleeding as the main determinants of fatal outcome. Interestingly, the therapeutic approach to trauma-associated bleeding and coagulopathy shows differences between geographic regions, that are reflected in different guidelines and protocols. RECENT FINDINGS This article summarizes main principles in coagulation diagnostics and compares different strategies for treatment of massive hemorrhage after trauma in different regions of the world. How would a bleeding trauma patient be managed if they got hit by the bus in the United States, United Kingdom, Germany, Switzerland, Austria, Denmark, Australia, or in Japan? SUMMARY There are multiple coexistent treatment standards for trauma-induced coagulopathy in different countries and different trauma centers. Most of them initially follow a protocol-based approach and subsequently focus on predefined clinical and laboratory targets.
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Affiliation(s)
- Stephan Johannsen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ernest E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, Colorado, USA
| | - Ann-Kristin Reinhold
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - Joanna M Shepherd
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ben Slater
- Department of Anaesthesia and Acute Pain Medicine, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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