The impact of early thromboelastography directed therapy in trauma resuscitation

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, Oct 2017

Conventional coagulation tests do not provide an accurate representation of the complex nature of trauma induced coagulopathy. Thrombelastography provides a prompt global overview of all dynamic sequential aspects of trauma induced coagulopathy. The objective of this study was to evaluate the impact of using thrombelastography on blood products utilization, crystalloids utilization, hospital, and intensive care using length of stay, and cost savings. We retrospectively reviewed 134 patients (May of 2012 to February of 2015) meeting Class I trauma activation. Outcome data was compared between two groups: patients prior to thrombelastography implementation (n = 87) and patients with thrombelastography guided trauma resuscitation (n = 47). Blood product usage was compared for three time periods: first 4 h, the next 20 h, and first 24 h. For the first 24 h of treatment, patients with thrombelastography guided trauma resuscitation had lower packed red blood cells (p = 0.0022) and fresh frozen plasma (p = 0.0474), but higher jumbo pack platelets (p = 0.0476) utilization when compared to the patients prior to thrombelastography implementation. There was no statistical significant difference in the utilization of crystalloids for any of the three time intervals. Patients with thrombelastography guided trauma resuscitation had a shorter hospital length of stay (p = 0.0011) and intensive care unit length of stay (p = 0.0059) than the patients prior to thrombelastography implementation. Cost savings in blood products transfusion were most pronounced in patients with penetrating injuries. Using visco-elastic tests to guide blood transfusion was first used for liver transplant patients and then applied to cardiovascular surgery and trauma. Similar to other studies, this study showed using visco-elastic tests for trauma patietns corresponded to an overall reduction in the use of packed red blood cells and fresh frozen plasma during the first 24 hours of resuscitation. In addition, this study showed using visco-elastic tests corresponded to a significant reduction in both hospital and intensive care unit length of stay. This study demonstrates that Thrombelastography guided trauma resuscitation decreases the overall transfusion requirements of packed red blood cells and fresh frozen plasma. However, given the nature of under-recognized jumbo pack platelets dysfunction in the conventional laboratory parameters, jumbo pack platelets utilization is higher when following Thrombelastography directed resuscitation. The utilization of Thrombelastography corresponded to a reduction in hospital length of stay, intensive care unit length of stay and cost of transfused blood products.

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The impact of early thromboelastography directed therapy in trauma resuscitation

Mohamed et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine The impact of early thromboelastography directed therapy in trauma resuscitation Mohamed Mohamed 0 Karl Majeske 1 Gul R. Sachwani 0 Kristin Kennedy 0 Mina Salib 0 Michael McCann 0 0 Hurley Medical Center , One Hurley Plaza, Flint, MI 48503 , USA 1 School of Business Administration, Oakland University , Rochester, MI 48309-4493 , USA Background: Conventional coagulation tests do not provide an accurate representation of the complex nature of trauma induced coagulopathy. Thrombelastography provides a prompt global overview of all dynamic sequential aspects of trauma induced coagulopathy. The objective of this study was to evaluate the impact of using thrombelastography on blood products utilization, crystalloids utilization, hospital, and intensive care using length of stay, and cost savings. Methods: We retrospectively reviewed 134 patients (May of 2012 to February of 2015) meeting Class I trauma activation. Outcome data was compared between two groups: patients prior to thrombelastography implementation (n = 87) and patients with thrombelastography guided trauma resuscitation (n = 47). Blood product usage was compared for three time periods: first 4 h, the next 20 h, and first 24 h. Results: For the first 24 h of treatment, patients with thrombelastography guided trauma resuscitation had lower packed red blood cells (p = 0.0022) and fresh frozen plasma (p = 0.0474), but higher jumbo pack platelets (p = 0.0476) utilization when compared to the patients prior to thrombelastography implementation. There was no statistical significant difference in the utilization of crystalloids for any of the three time intervals. Patients with thrombelastography guided trauma resuscitation had a shorter hospital length of stay (p = 0.0011) and intensive care unit length of stay (p = 0.0059) than the patients prior to thrombelastography implementation. Cost savings in blood products transfusion were most pronounced in patients with penetrating injuries. Discussion: Using visco-elastic tests to guide blood transfusion was first used for liver transplant patients and then applied to cardiovascular surgery and trauma. Similar to other studies, this study showed using viscoelastic tests for trauma patietns corresponded to an overall reduction in the use of packed red blood cells and fresh frozen plasma during the first 24 hours of resuscitation. In addition, this study showed using viscoelastic tests corresponded to a significant reduction in both hospital and intensive care unit length of stay. Conclusion: This study demonstrates that Thrombelastography guided trauma resuscitation decreases the overall transfusion requirements of packed red blood cells and fresh frozen plasma. However, given the nature of under-recognized jumbo pack platelets dysfunction in the conventional laboratory parameters, jumbo pack platelets utilization is higher when following Thrombelastography directed resuscitation. The utilization of Thrombelastography corresponded to a reduction in hospital length of stay, intensive care unit length of stay and cost of transfused blood products. Thrombelastography; Coagulopathy of trauma; Trauma / critical care Background Severe blood loss leading to hemorrhagic shock represents a major factor in trauma related deaths. An intrinsic dysregulation of the coagulation cascade known as trauma induced coagulopathy (TIC) [ 1 ] – contributes to the ongoing hemorrhage. One in every four trauma patients presents to the hospital with established TIC that may lead to a sequence of deleterious events [ 2–4 ]. Effects of TIC include uncontrolled bleeding, massive transfusion, and multi-organ failure. Further, TIC corresponds to having longer intensive care unit (ICU) and hospital length of stay (LOS), as well as a fourfold increase in mortality [ 5 ]. Conventional coagulation tests (CCTs) offer valuable information in monitoring the different aspects of coagulation. However, CCTs have several limitations: (1) they fail to delineate the complex nature of TIC, (2) they are time consuming, and (3) they have questionable value in guiding transfusion requirements [ 6, 7 ]. A systematic review in 2011 suggested that CCTs are insufficient to diagnose TIC [ 8, 9 ]. Thrombelastography (TEG - Heamonetics Corp, Braintree, MA USA) or rotational thromboelastometry (ROTEM - TEM international; GmbH, Munich, Germany) provides an alternative diagnostic modality for TIC that overcomes the aforementioned limitations. And ROTEM are visco-elastic tests offering a prompt global overview of all dynamic sequential aspects of the TIC process by providing data on the speed of coagulation initiation, kinetics of clot growth, clot strength, and its breakdown [ 6, 10 ]. Clinicians have developed massive transfusion protocols (MTP) to prioritize the correction of coagulopathy by delivering blood products in a systematic and coordinated fashion. Moreover, by (...truncated)


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Mohamed Mohamed, Karl Majeske, Gul R. Sachwani, Kristin Kennedy, Mina Salib, Michael McCann. The impact of early thromboelastography directed therapy in trauma resuscitation, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2017, pp. 99, DOI: 10.1186/s13049-017-0443-4