Thromboelastometry-guided haemostatic resuscitation in severely injured patients: a propensity score-matched study

Abstract

Background To accelerate the diagnosis and treatment of trauma-induced coagulopathy (TIC), viscoelastic haemostatic assays (VHA) are increasingly used worldwide, although their value is still debated, with a recent randomised trial showing no improvement in outcome. The objective of this retrospective study was to compare 2 cohorts of injured patients in which TIC was managed with either a VHA-based algorithm or a conventional coagulation test (CCT)-based algorithm. Methods Data were retrieved from 2 registries and patients were included in the study if they received at least 1 unit of red blood cell in the first 24 h after admission. A propensity score, including sex, age, blunt vs. penetrating, systolic blood pressure, GCS, ISS and head AIS, admission lactate and PTratio, tranexamic acid administration, was then constructed. Primary outcome was the proportion of subjects who were alive and free of massive transfusion (MT) at 24 h after injury. We also compared the cost for blood products and coagulation factors. Results From 2012 to 2019, 7250 patients were admitted in the 2 trauma centres, and among these 624 were included in the study (CCT group: 380; VHA group: 244). After propensity score matching, 215 patients remained in each study group without any significant difference in demographics, vital signs, injury severity, or laboratory analysis. At 24 h, more patients were alive and free of MT in the VHA group (162 patients, 75%) as compared to the CCT group (112 patients, 52%; p < 0.01) and fewer patients received MT (32 patients, 15% vs. 91 patients, 42%, p < 0.01). However, no significant difference was observed for mortality at 24 h (odds ratio 0.94, 95% CI 0.59–1.51) or survival at day 28 (odds ratio 0.87, 95% CI 0.58–1.29). Overall cost of blood products and coagulation factors was dramatically reduced in the VHA group as compared to the CCT group (median [interquartile range]: 2357 euros [1108–5020] vs. 4092 euros [2510–5916], p < 0.001). Conclusions A VHA-based strategy was associated with an increase of the number of patients alive and free of MT at 24 h together with an important reduction of blood product use and associated costs. However, that did not translate into an improvement in mortality.

Point-of-care, goal-directed management of bleeding in trauma patients

“…Many, although not all, studies have demonstrated that treatment algorithms based on VET resulted in reduced transfusion requirements in TIC [20,29,[81][82][83][84][85][86]. Two studies in trauma patients that compared transfusion requirements before and after implementation of a TEG-guided resuscitation protocol reported significantly lower RBCs and FFP transfusion rates [82,83].…”

“…In a retrospective study, David et al reported that fewer patients treated according to ROTEM test results received massive transfusions compared to patients treated based on SCT results (15% vs. 42%, P < 0.01). No significant difference was observed in mortality rates [86]. 'The reversal of trauma-induced coagulopathy study' (RETIC) included trauma patients with established TIC according to predefined ROTEM criteria (FIBTEM A10 < 9 mm or EXTEM CT > 90 s) [20].…”

Development and validation of the tic score for early detection of traumatic coagulopathy upon hospital admission: a cohort study

“…TIC is associated with impaired outcomes, including an increased likelihood of massive bleeding, multiple organ failure, transfusion, and death in the first hours following hospital admission [ 3 – 5 ]. Early and aggressive resuscitation strategies that aim to directly correct TIC are associated with improved outcomes and decreased blood products administration [ 6 , 7 ], and therefore the early identification and prompt treatment of TIC are essential [ 8 ]. However, in daily practice, the administration of hemostatic resuscitation is often based on clinical judgment, which performs moderately to identify massive hemorrhage [ 9 ], leading to unnecessary blood product administration to patients responsible for potential side effects and wasted blood products [ 10 ].…”