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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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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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Peng HT, Nascimento B, Rhind SG, da Luz L, Beckett A. Evaluation of trauma-induced coagulopathy in the fibrinogen in the initial resuscitation of severe trauma trial. Transfusion 2021; 61 Suppl 1:S49-S57. [PMID: 34269460 DOI: 10.1111/trf.16488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Coagulopathic bleeding is frequently present after major trauma. However, trauma-induced coagulopathy (TIC) remains incompletely understood. This laboratory analysis of blood samples derived from our completed trial on fibrinogen in the initial resuscitation of severe trauma (FiiRST) was conducted to evaluate TIC and associated responses to fibrinogen replacement. STUDY DESIGN AND METHODS We conducted a retrospective evaluation of TIC in 45 FiiRST trial patients based on rotational thromboelastometry (ROTEM), international normalized ratio (INR), and biomarkers for hemostasis and endotheliopathy. Whole blood was analyzed by ROTEM. Plasma was analyzed for INR and biomarkers. RESULTS Overall, 19.0% and 30.0% of the FiiRST trial patients were coagulopathic on admission defined by EXTEM maximum clot firmness out of the range of 40-71 mm and INR >1.2, respectively. The FiiRST patients showed lower fibrinogen, factor II and V levels, protein C and antiplasmin activities, higher activated protein C, tissue plasminogen activator, d-dimer, and thrombomodulin concentrations at admission than healthy controls. Most of the biomarkers changed their activities during 48-h hospitalization, but were at abnormal levels even 48-h after admission. The fibrinogen treatment reduced hypofibrinogenemia and increased factor XIII level, but had no significant effects on other biomarkers levels. Limited development of endotheliopathy was indicated by syndean-1, thrombomodulin, and sE-selectin. CONCLUSIONS About 19%-30% of the trauma patients in the FiiRST trial were coagulopathic on hospital admission depending on the definition of TIC. Analyses of the TIC biomarkers demonstrated that hemostasis would not return to normal after 48-h hospitalization, and fibrinogen replacement improved hypofibrinogenemia.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | | | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Luis da Luz
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.,Royal Canadian Medical Services, Ottawa, Ontario, Canada
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Peng HT, Nascimento B, Tien H, Callum J, Rizoli S, Rhind SG, Beckett A. A comparative study of viscoelastic hemostatic assays and conventional coagulation tests in trauma patients receiving fibrinogen concentrate. Clin Chim Acta 2019; 495:253-262. [DOI: 10.1016/j.cca.2019.04.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
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Spasiano A, Matellon C, Orso D, Brussa A, Cafagna M, Marangone A, Dogareschi T, Bove T, Giacomello R, Fontana D, Vetrugno L, Della Rocca G. Functional fibrinogen (FLEV-TEG) versus the Clauss method in an obstetric population: a comparative study. BMC Anesthesiol 2019; 19:90. [PMID: 31153366 PMCID: PMC6545203 DOI: 10.1186/s12871-019-0769-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/24/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Hemostasis is the dynamic equilibrium between coagulation and fibrinolysis. During pregnancy, the balance shifts toward a hypercoagulative state; however placental abruption and abnormal placentations may lead to rapidly evolving coagulopathy characterized by the increased activation of procoagulant pathways. These processes can result in hypofibrinogenemia, with fibrinogen levels dropping to 2 g/L or less and an associated increased risk of post-partum hemorrhage. The aim of the present study was to evaluate the concordance between two methods of functional fibrinogen measurement: the Thromboelastography (TEG) method (also known as FLEV) vs. the Clauss method. Three patient groups were considered: healthy volunteers; non-pathological pregnant patients; and pregnant patients who went on to develop postpartum hemorrhage. METHODS A prospective observational study. Inclusion criteria were: healthy volunteer women of childbearing age, non-pathological pregnant women at term, and pregnant hemorrhagic patients subjected to elective or urgent caesarean section (CS), with blood loss exceeding 1000 mL. Exclusion criteria were age < 18 years, a history of coagulopathy, and treatment with contraceptives, anticoagulants, or antiplatelet agents. RESULTS Bland-Altman plots showed a significant overestimation with the FLEV method in all three patient groups: bias was - 133.36 mg/dL for healthy volunteers (95% IC: - 257.84; - 8.88. Critical difference: 124.48); - 56.30 mg/dL for healthy pregnant patients (95% IC: - 225.53; 112.93. Critical difference: 169.23); and - 159.05 mg/dL for hemorrhagic pregnant patients (95% IC: - 333.24; 15.148. Critical difference: 174.19). Regression analyses detected a linear correlation between FLEV and Clauss for healthy volunteers, healthy pregnant patients, and hemorrhagic pregnant patients (R2 0.27, p value = 0.002; R2 0.31, p value = 0.001; R2 0.35, p value = 0.001, respectively). ANOVA revealed a statistically significant difference in fibrinogen concentration between all three patients groups when assayed using the Clauss method (p value < 0.001 for all the comparisons), but no statistically significant difference between the two patients groups of pregnant women when using the FLEV method. CONCLUSIONS The FLEV method does not provide a valid alternative to the Clauss method due to the problem of fibrinogen overestimation, and for this reason it should not be recommended for the evaluation of patients with an increased risk of hypofibrinogenemia.
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Affiliation(s)
- Alessandra Spasiano
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Carola Matellon
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Daniele Orso
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Alessandro Brussa
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Maria Cafagna
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Anna Marangone
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Teresa Dogareschi
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Roberta Giacomello
- Department of Laboratory Medicine, ASUIUD Hospital of Udine, Udine, Italy
| | - Desrè Fontana
- Postgraduate School of Clinical Pathology and Biochemistry, University of Padua, Padua, Italy
| | - Luigi Vetrugno
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Giorgio Della Rocca
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
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Thromboelastography and Thromboelastometry in Assessment of Fibrinogen Deficiency and Prediction for Transfusion Requirement: A Descriptive Review. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7020539. [PMID: 30596098 PMCID: PMC6286766 DOI: 10.1155/2018/7020539] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/28/2018] [Accepted: 11/06/2018] [Indexed: 12/22/2022]
Abstract
Fibrinogen is crucial for the formation of blood clot and clinical outcomes in major bleeding. Both Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) have been increasingly used to diagnose fibrinogen deficiency and guide fibrinogen transfusion in trauma and surgical bleeding patients. We conducted a comprehensive and comparative review on the technologies and clinical applications of two typical functional fibrinogen assays using TEG (FF TEG) and ROTEM (FIBTEM) for assessment of fibrinogen level and deficiency, and prediction of transfusion requirement. Clot strength and firmness of FF TEG and ROTEM FIBTEM were the most used parameters, and their associations with fibrinogen levels as measured by Clauss method ranged from 0 to 0.9 for FF TEG and 0.27 to 0.94 for FIBTEM. A comparison of the interchangeability and clinical performance of the functional fibrinogen assays using the two systems showed that the results were correlated, but are not interchangeable between the two systems. It appears that ROTEM FIBTEM showed better associations with the Clauss method and more clinical use for monitoring fibrinogen deficiency and predicting transfusion requirements including fibrinogen replacement than FF TEG. TEG and ROTEM functional fibrinogen tests play important roles in the diagnosis of fibrinogen-related coagulopathy and guidance of transfusion requirements. Despite the fact that high-quality evidence is still needed, the two systems are likely to remain popular for the hemostatic management of bleeding patients.
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