Rotational thromboelastometry thresholds for patients at risk for massive transfusion

Abstract

Background Goal-directed hemostatic resuscitation based on thrombelastography has a survival benefit compared to conventional coagulation assays. While thrombelastography transfusion thresholds for patients at risk for massive transfusion (MT) have been defined, similar cutoffs do not exist for the other commonly used viscoelastic assay, rotational thromboelastometry (ROTEM). The purpose of this study was to develop ROTEM blood product thresholds in patients at risk for MT. Methods ROTEM was assessed in trauma activation patients admitted from 2010 to 2016 (n = 222). Receiver operating characteristic curve analyses were performed to test the predictive performance of ROTEM measurements in patients requiring MT. The Youden Index defined optimal thresholds for ROTEM-based resuscitation. Results Patients who required MT (n = 37, 17%) were more severely injured. EXTEM clotting time (CT) was longer in patients with MT compared to non-MT (87 versus 64 s, P < 0.0001). EXTEM angle was shallower in MT patients compared to non-MT (54° versus 69°, P < 0.0001). Clot amplitude after 10 min (CA10) was less in MT compared to non-MT patients (30.5 versus 50 mm, P < 0.0001). Clot lysis index 60 min (CLI60) was lower in patients who had MT than non-MT (47 versus 94%, P = 0.0006). EXTEM CT yielded an area under the receiver operating characteristic curve (AUROC) = 0.7116 and a cut point of >78.5 s. EXTEM angle had an AUROC = 0.865 and a cut point of <64.5°. EXTEM CA10 had an AUROC = 0.858, with a cut point of <40.5 mm. CLI60 had an AUROC = 0.6788 with a cut point at <74%. Conclusions We have identified ROTEM thresholds for transfusion of blood components in severely injured patients requiring an MT. Based on our analysis, we propose plasma transfusion for EXTEM CT > 78.5 s, fibrinogen for angle <64.5°, platelet transfusion for CA10 < 40.5 mm, and antifibrinolytics for CLI60 < 74%.

Trauma-induced coagulopathy

“…Goal-directed resuscitation targets the patient's specific coagulation phenotype, with the objective of achieving a balanced coagulation profile without excessive blood component use, an approach that has been associated with the best outcome 280 . The choice of specific haemostatic adjuncts (including plasma, cryo precipitate or fibrinogen, platelets and TXA) can be directed with algorithms based on VHAs or equivalent haemostatic assays [281][282][283] (fig. 6).…”

Whole Blood, Fixed Ratio, or Goal-Directed Blood Component Therapy for the Initial Resuscitation of Severely Hemorrhaging Trauma Patients: A Narrative Review

“…They state: “The [VET] used at each study site was determined by existing familiarity with a specific device appliance and to ensure a balanced use of the devices across the study” [ 99 ]. This is of importance due to the heterogeneity of thresholds for administering BCT [ 100 , 101 ]. Finally, a problem consistent with many studies regarding the treatment and diagnosis of patients with severe bleeding and trauma is the definition of MT as 10 units PRBCs in 24 h. This may explain the low incidence of TIC in the iTACTIC study considering that the most effective time for intervention to reverse the pathophysiology of TIC is the first few hours after injury.…”

Viscoelastic monitoring in trauma resuscitation

“…Below, we provide a summary of previously published TEG (Table 3) and ROTEM (Table 4) directed transfusion strategies. In general, smaller cohorts have been used to derive TEG, 122 rTEG, 123 citrated kaolin (CK) TEG, 124 and adult 125 and pediatric 126 EXTEM optimized thresholds for resuscitation. The remaining publications describe retrospective or prospective cohort studies, and the abundance of transfusion triggers for both TEG 39,60,70,[127][128][129][130][131][132][133][134][135][136] and ROTEM [137][138][139][140][141][142][143][144][145][146] platforms are derived from expert opinion rather than data-driven thresholds.…”