Targeting resuscitation to normalization of coagulating status: Hyper and hypocoagulability after severe injury are both associated with increased mortality

Moore, Hunter B.; Moore, Ernest E.; Liras, Ioannis N.; Wade, Charles E.; Huebner, Benjamin R.; Burlew, Clay Cothren; Pieracci, Fredric M.; Sauaia, Angela; Cotton, Bryan A.

doi:10.1016/j.amjsurg.2017.08.036

Cited by 40 publications

(32 citation statements)

References 31 publications

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“…Finally, thrombosis is a big issue in trauma, orthopedics, and neurosurgery, and overtreatment should definitively be avoided by implementing the 'therapeutic window' concept of ROTEM-guided bleeding management. This also includes the timely start of thromboprophylaxis in the post-operative period [137,172,[176][177][178].…”

Section: In Trauma and Orthopedic Surgerymentioning

confidence: 99%

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Görlinger

Pérez-Ferrer

Dirkmann

et al. 2019

Korean J Anesthesiol

179

138

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Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management ('theranostic' approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient's safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration. Fig. 1. ROTEM trace ('temogram') displaying the clinically most important parameters and their informative value. FDPs: fibrin (ogen) split products. Courtesy of Klaus Görlinger, Germany.

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Section: In Trauma and Orthopedic Surgerymentioning

confidence: 99%

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Görlinger

Pérez-Ferrer

Dirkmann

et al. 2019

Korean J Anesthesiol

179

138

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“…These patient’s data have been used in previous studies to define hypercoagulability in trauma patients using a rapid TEG. 17 However, because native TEG has been reported to be more sensitive for detecting hypercoagulability, we selected to use only a citrated native assay for this study. 18 The cut points for hypercoagulability based on citrated native TEG were as follows: R <10.2 min, angle >59 deg, MA >66 mm, LY30 <0.2%.…”

Section: Methodsmentioning

confidence: 99%

Microfluidics contrasted to thrombelastography: perplexities in defining hypercoagulability

Lawson

Moore

et al. 2018

Journal of Surgical Research

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Background: Elevated clot strength (maximum amplitude [MA]) measured by thrombelastography (TEG) is associated with thrombotic complications. However, it remains unclear how MA translates to thrombotic risks, as this measurement is independent of time, blood flow, and clot degradation. We hypothesize that under flow conditions, increased clot strength correlates to time-dependent measurements of coagulation and resistance to fibrinolysis. Materials and methods: Surgical patients at high risk of thrombotic complications were analyzed with TEG and total thrombus-formation analysis system (T-TAS). TEG hypercoagulability was defined as an r <10.2 min, angle >59, MA >66 or LY30 <0.2% (based off of healthy control data, n = 141). The T-TAS AR and PL chips were used to measure clotting at arterial shear rates. T-TAS measurements include occlusion start time, occlusion time (OT), occlusion speed (OSp), and total clot generation (area under the curve). These measurements were correlated to TEG indices (R time, angle, MA, and LY30). Both T-TAS and TEG assays were challenged with tissue plasminogen activator (t-PA) to assess clot resistance to fibrinolysis. Results: Thirty subjects were analyzed, including five controls. TEG-defined hypercoagulability by MA was detectedin52% of the inflammatory bowel disease/cancer patients; 0%was detected in the controls. There were no TEG measurements that significantly correlated with T-TAS AR and PL chip. However, in the presence of t-PA, T-TAS AR determined OSp to have an inverse relationship with TEG angle (−0.477, P = 0.012) and LY30 (−0.449, P = 0.019), and a positive correlation with R time (0.441 P = 0.021). In hypercoagulability determined by TEG MA, T-TAS PL had a significantly reduced OT (4:07 versus 6:27 min, P = 0.043). In hypercoagulability defined by TEG LY30, T-TAS PL had discordant findings, with a significantly prolonged OT (6:36 versus 4:30 min, P = 0.044) and a slower OSp (10.5 versus 19.0 kPa/min, P = 0.030). Conclusions: Microfluidic coagulation assessment with T-TAS has an overall poor correlation with most TEG measurements in a predominantly hypercoagulable patient population, except in the presence of t-PA. The one anticipated finding was an elevated MA having a shorter time to platelet-mediated microfluidic occlusion, supporting the role of platelets and hypercoagulability. However, hypercoagulability defined by LY30 had opposing results in which a low LY30 was associated with a longer PL time to occlusion and slower OSp. These discordant findings warrant ongoing investigation into the relationship between clot strength and fibrinolysis under different flow conditions.

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“…Early assessment of the clinical status of severely injured patients is of pivotal importance in guiding surgical and intensive care management [1][2][3][4]. Blood transfusions have been associated with acute and long-term complications [5][6][7][8][9]. Most authors agree that the prediction of early mortality is equally important as predicting complications in the later stages.…”

Section: Introductionmentioning

confidence: 99%

How to detect a polytrauma patient at risk of complications: A validation and database analysis of four published scales

et al. 2020

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Introduction Early accurate assessment of the clinical status of severely injured patients is crucial for guiding the surgical treatment strategy. Several scales are available to differentiate between risk categories. They vary between expert recommendations and scores developed on the basis of patient data (level II). We compared four established scoring systems in regard to their predictive abilities for early (e.g., hemorrhage-induced mortality) versus late (Multiple Organ Failure (MOF), sepsis, late death) in-hospital complications. Methods A database from a level I trauma center was used. The inclusion criteria implied an injury severity score (ISS) of �16 points, primary admission, and a complete data set from admission to hospital-day 21. The following four scales were tested: the clinical grading scale (CGS; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mCGS; covers CGS with modifications), the polytrauma grading score (PTGS; covers shock, coagulation, and ISS), and the early appropriate care protocol (EAC; covers acid-base changes). Admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. Statistics Shapiro-Wilk test for normal distribution, Pearson Chi square, odds ratios (OR) for all endpoints, 95% confidence intervals. Fitted, generalized linear models were used for prediction analysis. Krippendorff was used for comparison of CGS and mCGS. Alpha set at 0.05. Results In total, 3668 severely injured patients were included (mean age, 45.8±20 years; mean ISS, 28.2±15.1 points; incidence of pneumonia, 19.0%; incidence of sepsis, 14.9%; death from

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Targeting resuscitation to normalization of coagulating status: Hyper and hypocoagulability after severe injury are both associated with increased mortality

Cited by 40 publications

References 31 publications

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Microfluidics contrasted to thrombelastography: perplexities in defining hypercoagulability

How to detect a polytrauma patient at risk of complications: A validation and database analysis of four published scales

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