Thromboelastography Reaction-Time Thresholds for Optimal Prediction of Coagulation Factor Deficiency in Trauma

Chow, Jonathan H.; Fedeles, Benjamin T; Richards, Justin E.; Tanaka, Kenichi A.; Morrison, Jonathan J.; Rock, Peter; Scalea, Thomas M.; Mazzeffi, Michael; Trinh, Anthony T.; Renner, Corinne; Schlee, Caroline S

doi:10.1016/j.jamcollsurg.2020.01.033

Cited by 8 publications

(11 citation statements)

References 32 publications

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“…Optimal CK R-time thresholds for diagnosing an INR over 1.5 and 2.0 were 3.9 and 4.3 min, respectively-these values are in the lower range of manufacturer normal range (4-8 min) for the TEG CK R time and showed <10% specificity. 5 One study showed that 44% of patients with exceptionally severe trauma (Injury Severity Score [ISS] >30) had normal TEG CK findings. 68 Use of VET is now advised for initial evaluation in the current edition of the American College of Surgeons' Advanced Trauma Life Support (ATLS) recommendations.…”

Section: Traumamentioning

confidence: 99%

“…4 It should be noted that VET results correlate with CCT assays, but are not interchangeable. 5 A comparison of strengths and weaknesses of VET and CCT assays is provided in Table 1.…”

Section: Introductionmentioning

confidence: 99%

“…A 2014 National Institute for Health and Care Excellence (NICE) review supported VET use in cardiac surgery and identified decreases in red cell, plasma, and platelet usage when VET methods are used 4 . It should be noted that VET results correlate with CCT assays, but are not interchangeable 5 . A comparison of strengths and weaknesses of VET and CCT assays is provided in Table 1.…”

Section: Introductionmentioning

confidence: 99%

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Viscoelastic testing: Critical appraisal of new methodologies and current literature

Wool

Carll

2023

Int J Lab Hematology

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United States Food and Drug Administration (FDA)‐approved viscoelastic testing (VET) methodologies have significantly changed in the last 10 years, with the availability of cartridge‐based VET. Some of these cartridge‐based methodologies use harmonic resonance‐based clot detection. While VET has always allowed for the evaluation of real‐time clot formation, cartridge‐based VET provides increased ease of use as well as greater portability and robustness of results in out‐of‐laboratory environments. Here we review the use of VET in a variety of clinical contexts, including cardiac surgery, trauma, liver transplant, obstetrics, and hypercoagulable states such as COVID‐19. As of now, high quality randomized trial evidence for new generation VET (TEG 6s, HemoSonics Quantra, ROTEM sigma) is limited. Nevertheless, the use of VET‐guided transfusion algorithms appears to result in reduced blood usage without worsening of patient outcomes. Future work comparing the new generation VET instruments and continuing to validate clinically important cut‐offs will help move the field of point‐of‐care coagulation monitoring forward and increase the quality of transfusion management in bleeding patients.

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Section: Traumamentioning

confidence: 99%

“…4 It should be noted that VET results correlate with CCT assays, but are not interchangeable. 5 A comparison of strengths and weaknesses of VET and CCT assays is provided in Table 1.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Viscoelastic testing: Critical appraisal of new methodologies and current literature

Wool

Carll

2023

Int J Lab Hematology

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“…Thus, kaolin-activated reaction time (R-time) on thrombelastography (TEG 5000; Haemonetics) was shown to be less sensitive than international normalized ratio (INR) to multifactorial coagulation factor deficiencies. Chow et al 34 recently proposed that optimal thresholds for diagnosing an INR>1.5 and >2.0 should be R-time >3.9 minutes and 4.3 minutes, respectively. Indeed, Holcomb et al 35 reported the median R-time (kaolin TEG) of 3.8 minutes in a large prospective study (n = 680) that investigated the optimal ratio of transfusion (plasma: platelet: RBC ratio, 1:1:1 vs 1:1:2).…”

Section: Viscoelastic Coagulation Tests and Fviiimentioning

confidence: 99%

Factor VIII: A Dynamic Modulator of Hemostasis and Thrombosis in Trauma

Tanaka

Terada

Butt

et al. 2023

Anesthesia &Amp; Analgesia

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A trace amount of thrombin cleaves factor VIII (FVIII) into an active form (FVIIIa), which catalyzes FIXa-mediated activation of FX on the activated platelet surface. FVIII rapidly binds to von Willebrand factor (VWF) after secretion and becomes highly concentrated via VWF-platelet interaction at a site of endothelial inflammation or injury. Circulating levels of FVIII and VWF are influenced by age, blood type (nontype O > type O), and metabolic syndromes. In the latter, hypercoagulability is associated with chronic inflammation (known as thrombo-inflammation). In acute stress including trauma, releasable pools of FVIII/VWF are secreted from the Weibel-Palade bodies in the endothelium and then augment local platelet accumulation, thrombin generation, and leukocyte recruitment. Early systemic increases of FVIII/VWF (>200% of normal) levels in trauma result in a lower sensitivity of contact-activated clotting time (activated partial thromboplastin time [aPTT] or viscoelastic coagulation test [VCT]). However, in severely injured patients, multiple serine proteases (FXa plasmin and activated protein C [APC]) are locally activated and may be systemically released. Severity of traumatic injury correlates with prolonged aPTT and elevated activation markers of FXa, plasmin, and APC, culminating in a poor prognosis. In a subset of acute trauma patients, cryoprecipitate that contains fibrinogen, FVIII/VWF, and FXIII is theoretically advantageous over purified fibrinogen concentrate to promote stable clot formation, but comparative efficacy data are lacking. In chronic inflammation or subacute phase of trauma, elevated FVIII/VWF contributes to the pathogenesis of venous thrombosis by enhancing not only thrombin generation but also augmenting inflammatory functions.

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“…First, the authors advocated using contact-activated (intrinsic) VHA clotting time to determine the need for plasma transfusion based on the “rarity of isolated factor VII (FVII) deficiency.” However, kaolin-activated reaction time (R-time) on thromboelastography (TEG) is rarely abnormal in severely traumatized patients due to stress-induced factor VIII (FVIII) elevations and far less sensitive than international normalized ratio (INR) to the multifactorial factor deficiency in trauma. 2 Indeed, Chow et al 3 suggested that optimal R-time thresholds for diagnosing an INR over 1.5 and 2.0 were 3.9 and 4.3 minutes, respectively, based on a retrospective analysis of 694 trauma patients. These values are in the lower range of normal (4–8 minutes) for the assay.…”

Section: To the Editormentioning

confidence: 99%

Viscoelastic Hemostatic Assays—Training the Next Canary for Hemostatic Resuscitation in Trauma

Vandyck

Mazzeffi

Tanaka

2022

Anesthesia &Amp; Analgesia

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Thromboelastography Reaction-Time Thresholds for Optimal Prediction of Coagulation Factor Deficiency in Trauma

Cited by 8 publications

References 32 publications

Viscoelastic testing: Critical appraisal of new methodologies and current literature

Viscoelastic testing: Critical appraisal of new methodologies and current literature

Factor VIII: A Dynamic Modulator of Hemostasis and Thrombosis in Trauma

Viscoelastic Hemostatic Assays—Training the Next Canary for Hemostatic Resuscitation in Trauma

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