FIBTEM provides early prediction of massive transfusion in trauma

Abstract

IntroductionPrediction of massive transfusion (MT) among trauma patients is difficult in the early phase of trauma management. Whole-blood thromboelastometry (ROTEM®) tests provide immediate information about the coagulation status of acute bleeding trauma patients. We investigated their value for early prediction of MT.MethodsThis retrospective study included patients admitted to the AUVA Trauma Centre, Salzburg, Austria, with an injury severity score ≥16, from whom blood samples were taken immediately upon admission to the emergency room (ER). ROTEM® analyses (extrinsically-activated test with tissue factor (EXTEM), intrinsically-activated test using ellagic acid (INTEM) and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (FIBTEM) tests) were performed. We divided patients into two groups: massive transfusion (MT, those who received ≥10 units red blood cell concentrate within 24 hours of admission) and non-MT (those who received 0 to 9 units).ResultsOf 323 patients included in this study (78.9% male; median age 44 years), 78 were included in the MT group and 245 in the non-MT group. The median injury severity score upon admission to the ER was significantly higher in the MT group than in the non-MT group (42 vs 27, P < 0.0001). EXTEM and INTEM clotting time and clot formation time were significantly prolonged and maximum clot firmness (MCF) was significantly lower in the MT group versus the non-MT group (P < 0.0001 for all comparisons). Of patients admitted with FIBTEM MCF 0 to 3 mm, 85% received MT. The best predictive values for MT were provided by hemoglobin and Quick value (area under receiver operating curve: 0.87 for both parameters). Similarly high predictive values were observed for FIBTEM MCF (0.84) and FIBTEM A10 (clot amplitude at 10 minutes; 0.83).ConclusionsFIBTEM A10 and FIBTEM MCF provided similar predictive values for massive transfusion in trauma patients to the most predictive laboratory parameters. Prospective studies are needed to confirm these findings.

Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis

“…Mean Glasgow Coma Scale scores ranged from 11 to 14 but were reported in only six studies. [65][66][67][72][73][74] All studies [64][65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81] performed VE testing on admission. Three studies 64,71,72 evaluated TEG as a whole with a positive result based on a combination of different TEG parameters.…”

“…Fifteen prediction studies [64][65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81] No multivariate analysis ED, emergency department; FAST, focused assessment for the sonography of trauma; ISS, injury sensitivity score; n, number enrolled; NR, not reported; PRBC, packed red blood cell. a Studies reported only as abstracts.…”

“…We included 11 RCTs (13 publications) 35,46-57 evaluating ROTEM and TEG in cardiac surgery patients; as no RCTs evaluating Sonoclot were identified, we also included three prediction studies [58][59][60] that evaluated Sonoclot. We included one ongoing RCT, 61,62 one controlled clinical trial (CCT) 63 and 15 prediction studies (18 publications) [64][65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81] in trauma patients, and two prediction studies 82,83 in women with PPH.…”

Early administration of fibrinogen concentrates improves the short‐term outcomes of severe pelvic fracture patients

“…Hypofibrinogenemia results not only from hemodilution by fluid supplementation to maintain blood pressure, but also from fibrinogenolysis due to hyperfibrinolysis induced by tissue‐type plasminogen activator released from injured endothelial cells 11. In this context, fibrinogen is the key molecule in trauma‐induced coagulopathy to be targeted for supplementation 12. Thus, early correction of hypofibrinogenemia would be a promising approach to prevent deadly coagulopathy and mortality after massive traumatic hemorrhage.…”

Goal-directed therapy in trauma induced coagulopathy and focus on traumatic brain injury

“…Modificata da [11] ficazione del rischio di trasfusione massiva utilizzando i risultati disponibili entro 10 minuti dal tempo di coagulazione (FIBTEM® A10) [11]. Nella Figura 1 sono rappresentati i risultati del FIBTEM test: se la stabilità del coagulo dopo 10 minuti (A10) è maggiore di 8 mm all'ammissione in ospedale, il rischio di necessità di trasfusione massiva è abbastanza basso, pertanto dovrebbe essere evitato un trattamento proemostatico precoce e aggressivo; al contrario, in pazienti con stabilità del coagulo dopo 10 minuti (A10) inferiori a 8 mm o a 4 mm, il rischio di necessità di trasfusione massiva è molto alto: in questi casi il trattamento della coagulopatia dovrebbe essere iniziato precocemente per arrestare l' emorragia il più velocemente possibile (il cosiddetto approccio "Hit hard and early").…”