Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy

Abstract

IntroductionThromboelastometry (TEM)-guided haemostatic therapy with fibrinogen concentrate and prothrombin complex concentrate (PCC) in trauma patients may reduce the need for transfusion of red blood cells (RBC) or platelet concentrate, compared with fresh frozen plasma (FFP)-based haemostatic therapy.MethodsThis retrospective analysis compared patients from the Salzburg Trauma Centre (Salzburg, Austria) treated with fibrinogen concentrate and/or PCC, but no FFP (fibrinogen-PCC group, n = 80), and patients from the TraumaRegister DGU receiving ≥ 2 units of FFP, but no fibrinogen concentrate/PCC (FFP group, n = 601). Inclusion criteria were: age 18-70 years, base deficit at admission ≥2 mmol/L, injury severity score (ISS) ≥16, abbreviated injury scale for thorax and/or abdomen and/or extremity ≥3, and for head/neck < 5.ResultsFor haemostatic therapy in the emergency room and during surgery, the FFP group (ISS 35.5 ± 10.5) received a median of 6 units of FFP (range: 2, 51), while the fibrinogen-PCC group (ISS 35.2 ± 12.5) received medians of 6 g of fibrinogen concentrate (range: 0, 15) and 1200 U of PCC (range: 0, 6600). RBC transfusion was avoided in 29% of patients in the fibrinogen-PCC group compared with only 3% in the FFP group (P< 0.001). Transfusion of platelet concentrate was avoided in 91% of patients in the fibrinogen-PCC group, compared with 56% in the FFP group (P< 0.001). Mortality was comparable between groups: 7.5% in the fibrinogen-PCC group and 10.0% in the FFP group (P = 0.69).ConclusionsTEM-guided haemostatic therapy with fibrinogen concentrate and PCC reduced the exposure of trauma patients to allogeneic blood products.

Impact of Implementation of Rotem on Allogenic Blood Transfusions in Trauma Patients Following ICU Admission before and after Study

“…It has been shown retrospectively that the introduction of near patient methods for coagulation testing and goal directed management may lead to a reduction of the transfusion of allogenic blood products [20]. In our present study we could approve these findings for that the prospectively analysed patient group necessitated significantly less blood products.…”

“…However, while in other clinical settings, e.g. cardiac surgical patients some prospective trials on the use of point-of-care devices such as ROTEM® for the coagulation management have been published [29,30], studies in the special setting of trauma patients are exclusively of retrospective nature [18,20,31,32]. Thus, prospective data on these patients are still missing.…”

“…Compared to conventional plasma-based coagulation tests like measurements of prothrombin time (PT/INR), activated partial thrombin time (aPTT) or single coagulation factor assays, ROTEM® measures the viscoelastic properties of the clot and provides information on the speed of coagulation initiation, kinetics of clot growth, clot strength and breakdown [18]. In brief summary, ROTEM® might allow for an early and more target-aimed treatment with the administration of specific hemostatic agents, blood products and coagulation factor concentrates [19,20].…”

Goal-directed therapy in trauma induced coagulopathy and focus on traumatic brain injury

“…Modificato da [20] Herbert Schöchl e il suo gruppo dell' AUVA Trauma Center di Salisburgo hanno ottenuto risultati simili nelle loro ricerche, utilizzando un algoritmo di gestione basato su Point-Of-Care simile a quello presentato finora. In uno studio hanno confrontato una terapia basata su concentrati di fattori della coagulazione e guidata da ROTEM® con la terapia standard basata su FFP.…”

“…Inoltre la trasfusione di RBC è stata evitata solo nel 3% dei pazienti del gruppo FFP, contro circa 1/3 dei pazienti nel gruppo fibrinogeno-PCC. Di conseguenza, gli autori hanno concluso che la terapia emostatica con concentrato di fibrinogeno e PCC guidata da ROTEM® riduce significativamente l' esposizione dei pazienti traumatizzati a emocomponenti allogenici (Figura 5) [20]. Considerando i risultati, gli autori hanno potuto dimostrare che questo approccio sembra essere efficace nel ridurre la mortalità dei pazienti, così come illustrato nella Figura 6 che riporta i dati di mortalità osservati nello studio di Schöchl confrontandoli con alcuni score sviluppati dal German Trauma Register.…”