Impact on Blood Product Utilization with Thromboelastography Guided Resuscitation for Gastrointestinal Hemorrhage

Abstract

Background Thromboelastography (TEG) can guide transfusion therapy in trauma and has been associated with decreased transfusion requirements. This population differs from the medical population where the most common bleeding source is gastrointestinal hemorrhage (GIB). The utility of TEG in patients with acute GIB is not well described. We sought to assess whether the use of TEG impacts blood product utilization in patients with medical GIB. Methods A retrospective study looking at all adult patients admitted with a primary diagnosis of GIB to the George Washington University Intensive Care Unit (ICU) between 01/01/2017 to 12/31/2019. The primary intervention was the use of TEG to guide blood product resuscitation in addition to standard of care (TEG arm) versus standard of care alone (non-TEG arm). Results The primary outcome was the total number of blood products utilized. Patients in the TEG arm used more blood products compared to the non-TEG arm (9.10 vs 3.60, p < 0.001). There was no difference in secondary endpoints except for an increased requirement for mechanical ventilation within the TEG arm (26.2% vs 13.4%, p = 0.018). Conclusions The use of TEG to guide resuscitation in patients with acute GIB may be associated with increased blood product utilization without any clinical benefit to patient-centered outcomes.

A Retrospective Study Comparing the Effect of Conventional Coagulation Parameters Vs. Thromboelastography-Guided Blood Product Utilization in Patients With Major Gastrointestinal Bleeding

“…On the contrary, a retrospective study with a total of 225 patients with all causes of major GIB noted that TEG-guided transfusion led to increased blood product utilization without any clinical benefits in terms of ICU LOS, respiratory failure, use of renal replacement therapy and mortality rate [11]. In comparison to the RCTs that included cirrhotic patients with variceal and non-variceal bleeding, the retrospective study included patients with all causes of major GIB: patient's requiring vasopressor use, prior antiplatelets and anticoagulant agents use and septic patients with higher sequential organ failure assessment (SOFA) scores who were critically ill [9][10][11]. In this retrospective study, TEG patients were noted to be more critically ill than non-TEG patients noted by higher shock index, higher rate of vasopressor utilization, and higher SOFA scores on admission, which might have confounded the primary outcome of blood product utilization [11].…”

“…TEG-Guided Blood Product Use in GIB J Clin Med Res. 2023;15 (10)(11):431-437 The use of TEG has been expanding to the non-trauma medical patient population; however, there is less evidence in the literature to suggest a role for TEG in resuscitating major GIB in MICU patients. There have been two RCTs reported in GIB patients.…”

“…In both trials, the TEG-guided transfusion strategy led to a significantly lower use of blood components without compromising hemostasis and with no increase in mortality [9,10]. On the contrary, a retrospective study with a total of 225 patients with all causes of major GIB noted that TEG-guided transfusion led to increased blood product utilization without any clinical benefits in terms of ICU LOS, respiratory failure, use of renal replacement therapy and mortality rate [11]. In comparison to the RCTs that included cirrhotic patients with variceal and non-variceal bleeding, the retrospective study included patients with all causes of major GIB: patient's requiring vasopressor use, prior antiplatelets and anticoagulant agents use and septic patients with higher sequential organ failure assessment (SOFA) scores who were critically ill [9][10][11].…”

“…In comparison to the RCTs that included cirrhotic patients with variceal and non-variceal bleeding, the retrospective study included patients with all causes of major GIB: patient's requiring vasopressor use, prior antiplatelets and anticoagulant agents use and septic patients with higher sequential organ failure assessment (SOFA) scores who were critically ill [9][10][11]. In this retrospective study, TEG patients were noted to be more critically ill than non-TEG patients noted by higher shock index, higher rate of vasopressor utilization, and higher SOFA scores on admission, which might have confounded the primary outcome of blood product utilization [11]. Hence, we aimed in our study to look at all causes of GIB and to match our cohorts to elucidate if there is any overall benefit from TEG-guided blood transfusion resuscitation.…”

“…The clinical use of TEG has been expanding, and past studies have demonstrated decreased blood product utilization with the use of TEG in patients with specific etiologies of major GIB, such as cirrhosis patients with non-variceal and variceal bleeding [9,10]. However, in non-cirrhotic patients with major GIB, there is less evidence described in the literature; till now, only one retrospective study demonstrated increased blood product utilization without any clinical benefit [11]. We conducted this retrospective study to compare the effect of TEG-guided blood product utilization in patients with major GIB with all etiologies, including cirrhosis admitted in the medical intensive care unit (MICU).…”