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World Journal of Emergency Surgery

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Open Access 01-12-2022 | Research

Utility of viscoelastic hemostatic assay to guide hemostatic resuscitation in trauma patients: a systematic review

Authors: Zhe Zhu, Yong Yu, Kairui Hong, Mengqin Luo, Yefang Ke

Published in: World Journal of Emergency Surgery | Issue 1/2022

Abstract

Objective

Viscoelastic hemostatic assay (VHA) provides a graphical representation of a clot’s lifespan and reflects the real time of coagulation. It has been used to guide trauma resuscitation; however, evidence of the effectiveness of VHAs is still limited. This systematic review aims to summarize the published evidence to evaluate the VHA-guided strategy in resuscitating trauma patients.

Methods

The PubMed, Embase, and Web of Science databases were searched from their inception to December 13, 2021. Randomized controlled trials (RCTs) or observational studies comparing VHA-guided transfusion to controls in resuscitating trauma patients were included in this systematic review.

Results

Of the 7743 records screened, ten studies, including two RCTs and eight observational studies, met the inclusion criteria. There was great heterogeneity concerning study design, enrollment criterion, VHA device, VHA-guided strategy, and control strategy. Thrombelastography (TEG) was used as a guiding tool for transfusion in eight studies, and rotational thromboelastometry (ROTEM), and TEG or ROTEM were used in the other two studies. The overall risk of bias assessment was severe or mild in RCTs and was severe or moderate in observational studies. The main outcomes reported from the included studies were blood transfusion (n = 10), mortality (n = 10), hospital length of stay (LOS) (n = 7), intensive care unit LOS (n = 7), and cost (n = 4). The effect of the VHA-guided strategy was not always superior to the control. Most of the studies did not find significant differences in the transfusion amount of red blood cells (n = 7), plasma (n = 5), platelet (n = 7), cryoprecipitate/fibrinogen (n = 7), and mortality (n = 8) between the VHA-guided group and control group. Notable, two RCTs showed that the VHA-guided strategy was superior or equal to the conventional coagulation test-guided strategy in reducing mortality, respectively.

Conclusion

Although some studies demonstrated VHA-guided strategy probable benefit in reducing the need for blood transfusion and mortality when resuscitating trauma patients, the evidence is still not robust. The quality of evidence was primarily downgraded by the limited number of included studies and great heterogeneity and severe risk of bias in these. Further studies are strongly recommended.

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Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, et al. Trauma-induced coagulopathy. Nat Rev Dis Primers. 2021;7(1):30. https://doi.org/10.1038/s41572-021-00264-3.CrossRefPubMedPubMedCentral

Curry NS, Davenport R. Transfusion strategies for major haemorrhage in trauma. Br J Haematol. 2019;184(4):508–23. https://doi.org/10.1111/bjh.15737.CrossRefPubMed

Baksaas-Aasen K, Gall L, Eaglestone S, Rourke C, Juffermans NP, Goslings JC, et al. iTACTIC - implementing treatment algorithms for the correction of trauma-induced coagulopathy: study protocol for a multicentre, randomised controlled trial. Trials. 2017;18(1):486. https://doi.org/10.1186/s13063-017-2224-9.CrossRefPubMedPubMedCentral

Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008;65(4):748–54. https://doi.org/10.1097/TA.0b013e3181877a9c.CrossRefPubMed

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805–13. https://doi.org/10.1097/TA.0b013e3181271ba3.CrossRefPubMed

Briggs A, Askari R. Damage control resuscitation. Int J Surg (London, England). 2016;33(Pt B):218–21. https://doi.org/10.1016/j.ijsu.2016.03.064.CrossRef

Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471–82. https://doi.org/10.1001/jama.2015.12.CrossRefPubMedPubMedCentral

Scalea TM, Bochicchio KM, Lumpkins K, Hess JR, Dutton R, Pyle A, et al. Early aggressive use of fresh frozen plasma does not improve outcome in critically injured trauma patients. Ann Surg. 2008;248(4):578–84. https://doi.org/10.1097/SLA.0b013e31818990ed.CrossRefPubMed

Sambasivan CN, Kunio NR, Nair PV, Zink KA, Michalek JE, Holcomb JB, et al. High ratios of plasma and platelets to packed red blood cells do not affect mortality in nonmassively transfused patients. J Trauma. 2011;71(2 Suppl 3):S329–36. https://doi.org/10.1097/TA.0b013e318227edd3.CrossRefPubMed

10.

Nascimento B, Callum J, Tien H, Rubenfeld G, Pinto R, Lin Y, et al. Effect of a fixed-ratio (1:1:1) transfusion protocol versus laboratory-results-guided transfusion in patients with severe trauma: a randomized feasibility trial. CMAJ Can Med Assoc J J l’Assoc Med Can. 2013;185(12):E583-9. https://doi.org/10.1503/cmaj.121986.CrossRef

11.

Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK. Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care. 2014;18(5):518. https://doi.org/10.1186/s13054-014-0518-9.CrossRefPubMedPubMedCentral

12.

Wikkelsø A, Wetterslev J, Møller AM, Afshari A. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst Rev. 2016;2016(8):Cd007871. https://doi.org/10.1002/14651858.CD007871.pub3.CrossRefPubMedCentral

13.

Nystrup KB, Windeløv NA, Thomsen AB, Johansson PI. Reduced clot strength upon admission, evaluated by thrombelastography (TEG), in trauma patients is independently associated with increased 30-day mortality. Scand J Trauma Resusc Emerg Med. 2011;19:52. https://doi.org/10.1186/1757-7241-19-52.CrossRefPubMedPubMedCentral

14.

Kane I, Ong A, Orozco FR, Post ZD, Austin LS, Radcliff KE. Thromboelastography predictive of death in trauma patients. Orthop Surg. 2015;7(1):26–30. https://doi.org/10.1111/os.12158.CrossRefPubMedPubMedCentral

15.

Stettler GR, Sumislawski JJ, Moore EE, Nunns GR, Kornblith LZ, Conroy AS, et al. Citrated kaolin thrombelastography (TEG) thresholds for goal-directed therapy in injured patients receiving massive transfusion. J Trauma Acute Care Surg. 2018;85(4):734–40. https://doi.org/10.1097/ta.0000000000002037.CrossRefPubMedPubMedCentral

16.

Cotton BA, Faz G, Hatch QM, Radwan ZA, Podbielski J, Wade C, et al. Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma. 2011;71(2):407–14. https://doi.org/10.1097/TA.0b013e31821e1bf0 (discussion 14–7).CrossRefPubMed

17.

Brill JB, Badiee J, Zander AL, Wallace JD, Lewis PR, Sise MJ, et al. The rate of deep vein thrombosis doubles in trauma patients with hypercoagulable thromboelastography. J Trauma Acute Care Surg. 2017;83(3):413–9. https://doi.org/10.1097/ta.0000000000001618.CrossRefPubMed

18.

Cotton BA, Minei KM, Radwan ZA, Matijevic N, Pivalizza E, Podbielski J, et al. Admission rapid thrombelastography predicts development of pulmonary embolism in trauma patients. J Trauma Acute Care Surg. 2012;72(6):1470–5. https://doi.org/10.1097/TA.0b013e31824d56ad (discussion 5–7).CrossRefPubMed

19.

Schöchl H, Nienaber U, Maegele M, Hochleitner G, Primavesi F, Steitz B, et al. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care. 2011;15(2):R83. https://doi.org/10.1186/cc10078.CrossRefPubMedPubMedCentral

20.

Cochrane C, Chinna S, Um JY, Dias JD, Hartmann J, Bradley J, et al. Site-of-care viscoelastic assay in major trauma improves outcomes and is cost neutral compared with standard coagulation tests. Diagnostics (Basel, Switzerland). 2020. https://doi.org/10.3390/diagnostics10070486.CrossRef

21.

Campbell D, Wake E, Walters K, Ho D, Keijzers G, Wullschleger M, et al. Implementation of point-of-care ROTEM® into a trauma major haemorrhage protocol: a before and after study. Emerg Med Australas EMA. 2020. https://doi.org/10.1111/1742-6723.13643.CrossRefPubMed

22.

Unruh M, Reyes J, Helmer SD, Haan JM. An evaluation of blood product utilization rates with massive transfusion protocol: Before and after thromboelastography (TEG) use in trauma. Am J Surg. 2019;218(6):1175–80. https://doi.org/10.1016/j.amjsurg.2019.08.027.CrossRefPubMed

23.

Wang H, Robinson RD, Phillips JL, Ryon A, Simpson S, Ford JR, et al. Traumatic abdominal solid organ injury patients might benefit from thromboelastography-guided blood component therapy. J Clin Med Res. 2017;9(5):433–8. https://doi.org/10.14740/jocmr3005w.CrossRefPubMedPubMedCentral

24.

Mohamed M, Majeske K, Sachwani GR, Kennedy K, Salib M, McCann M. The impact of early thromboelastography directed therapy in trauma resuscitation. Scand J Trauma Resusc Emerg Med. 2017;25(1):99. https://doi.org/10.1186/s13049-017-0443-4.CrossRefPubMedPubMedCentral

25.

Yin J, Zhao Z, Li Y, Wang J, Yao D, Zhang S, et al. Goal-directed transfusion protocol via thrombelastography in patients with abdominal trauma: a retrospective study. World J Emerg Surg WJES. 2014;9:28. https://doi.org/10.1186/1749-7922-9-28.CrossRefPubMed

26.

Tapia NM, Chang A, Norman M, Welsh F, Scott B, Wall MJ Jr, et al. TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients. J Trauma Acute Care Surg. 2013;74(2):378–85. https://doi.org/10.1097/TA.0b013e31827e20e0 (discussion 85–6).CrossRefPubMed

27.

Kashuk JL, Moore EE, Wohlauer M, Johnson JL, Pezold M, Lawrence J, et al. Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy. Transfusion. 2012;52(1):23–33. https://doi.org/10.1111/j.1537-2995.2011.03264.x.CrossRefPubMed

28.

Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2016;263(6):1051–9. https://doi.org/10.1097/sla.0000000000001608.CrossRefPubMed

29.

Baksaas-Aasen K, Gall LS, Stensballe J, Juffermans NP, Curry N, Maegele M, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med. 2021;47(1):49–59. https://doi.org/10.1007/s00134-020-06266-1.CrossRefPubMed

30.

Prat NJ, Meyer AD, Ingalls NK, Trichereau J, DuBose JJ, Cap AP. Rotational thromboelastometry significantly optimizes transfusion practices for damage control resuscitation in combat casualties. J Trauma Acute Care Surg. 2017;83(3):373–80. https://doi.org/10.1097/ta.0000000000001568.CrossRefPubMedPubMedCentral

31.

Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-Cantos F, Ergin MA. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg. 1999;88(2):312–9. https://doi.org/10.1097/00000539-199902000-00016.CrossRefPubMed

32.

Wang SC, Shieh JF, Chang KY, Chu YC, Liu CS, Loong CC, et al. Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transplant Proc. 2010;42(7):2590–3. https://doi.org/10.1016/j.transproceed.2010.05.144.CrossRefPubMed

33.

Dias JD, Sauaia A, Achneck HE, Hartmann J, Moore EE. Thromboelastography-guided therapy improves patient blood management and certain clinical outcomes in elective cardiac and liver surgery and emergency resuscitation: a systematic review and analysis. J Thromb Haemost. 2019;17(6):984–94. https://doi.org/10.1111/jth.14447.CrossRefPubMedPubMedCentral

34.

Bugaev N, Como JJ, Golani G, Freeman JJ, Sawhney JS, Vatsaas CJ, et al. Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management guideline from the Eastern Association for the surgery of trauma. J Trauma Acute Care Surg. 2020;89(6):999–1017. https://doi.org/10.1097/ta.0000000000002944.CrossRefPubMed

35.

Schaden E, Kimberger O, Kraincuk P, Baron DM, Metnitz PG, Kozek-Langenecker S. Perioperative treatment algorithm for bleeding burn patients reduces allogeneic blood product requirements. Br J Anaesth. 2012;109(3):376–81. https://doi.org/10.1093/bja/aes186.CrossRefPubMed

36.

Spinella PC, Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. 2009;23(6):231–40. https://doi.org/10.1016/j.blre.2009.07.003.CrossRefPubMedPubMedCentral

37.

Whiting P, Al M, Westwood M, Ramos IC, Ryder S, Armstrong N, et al. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess (Winchester, England). 2015;19(58):1–228. https://doi.org/10.3310/hta19580.CrossRef

38.

Duque P, Mora L, Levy JH, Schöchl H. Pathophysiological response to trauma-induced coagulopathy: a comprehensive review. Anesth Analg. 2020;130(3):654–64. https://doi.org/10.1213/ane.0000000000004478.CrossRefPubMed

39.

Kozar RA, Peng Z, Zhang R, Holcomb JB, Pati S, Park P, et al. Plasma restoration of endothelial glycocalyx in a rodent model of hemorrhagic shock. Anesth Analg. 2011;112(6):1289–95. https://doi.org/10.1213/ANE.0b013e318210385c.CrossRefPubMedPubMedCentral

40.

Peng Z, Pati S, Potter D, Brown R, Holcomb JB, Grill R, et al. Fresh frozen plasma lessens pulmonary endothelial inflammation and hyperpermeability after hemorrhagic shock and is associated with loss of syndecan 1. Shock (Augusta, Ga). 2013;40(3):195–202. https://doi.org/10.1097/SHK.0b013e31829f91fc.CrossRef

Title: Utility of viscoelastic hemostatic assay to guide hemostatic resuscitation in trauma patients: a systematic review
Authors: Zhe Zhu
Yong Yu
Kairui Hong
Mengqin Luo
Yefang Ke
Publication date: 01-12-2022
Publisher: BioMed Central
Published in: World Journal of Emergency Surgery / Issue 1/2022
Electronic ISSN: 1749-7922
DOI: https://doi.org/10.1186/s13017-022-00454-8

At a glance: The STEP trials

Springer Medicine

Utility of viscoelastic hemostatic assay to guide hemostatic resuscitation in trauma patients: a systematic review

Abstract

Objective

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Objective

Methods

Results

Conclusion

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