Role of Viscoelastic and Conventional Coagulation Tests for Management of Blood Product Replacement in the Bleeding Patient

Abstract

An important aim of viscoelastic testing (VET) is to implement transfusion algorithms based on coagulation test results to help reduce transfusion rates and improve patient outcomes. Establishing a rapid diagnosis and providing timely treatment of coagulopathy is the cornerstone of management of severely bleeding patients in trauma, postpartum hemorrhage, and major surgery. As the nature of acute bleeding and trauma leads to an unstable and tenuous physiologic state, conventional coagulation tests (CCTs) are too slow to diagnose, manage, and also course correct any hemostatic abnormalities that accompany an acute critical illness. Viscoelastic point-of-care tests strongly correlate with results from standard laboratory tests but are designed to enable clinicians to make timely, informed bleeding management decisions when time to intervene is critical. These assays provide an individualized and goal-oriented approach to patient blood management and are increasingly becoming involved in transfusion algorithms. The scope of this review aims to evaluate the current literature on VETs and their impact on actionable outputs in clinical decision making and their relationship to CCT.

Keywords

viscoelastic testing (VET) - blood transfusions - coagulopathy - conventional coagulation tests (CCTs)

Publication History

Article published online:
29 September 2022

• References

• 1 Hoffman M, Monroe III DM. A cell-based model of hemostasis. Thromb Haemost 2001; 85 (06) 958-965
• 2 Zwaal RF, Schroit AJ. Pathophysiologic implications of membrane phospholipid asymmetry in blood cells. Blood 1997; 89 (04) 1121-1132
• 3 MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma 2003; 55 (01) 39-44
• 4 Rattray DD, O'Connell CM, Baskett TF. Acute disseminated intravascular coagulation in obstetrics: a tertiary centre population review (1980 to 2009). J Obstet Gynaecol Can 2012; 34 (04) 341-347
• 5 Haas T, Spielmann N, Mauch J. et al. Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery. Br J Anaesth 2012; 108 (01) 36-41
• 6 Hincker A, Feit J, Sladen RN, Wagener G. Rotational thromboelastometry predicts thromboembolic complications after major non-cardiac surgery. Crit Care 2014; 18 (05) 549-557
• 7 Gary JL, Schneider PS, Galpin M. et al. Can thrombelastography predict venous thromboembolic events in patients with severe extremity trauma?. J Orthop Trauma 2016; 30 (06) 294-298
• 8 Levrat A, Gros A, Rugeri L. et al. Evaluation of rotation thrombelastography for the diagnosis of hyperfibrinolysis in trauma patients. Br J Anaesth 2008; 100 (06) 792-797
• 9 Davenport R, Manson J, De'Ath H. et al. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med 2011; 39 (12) 2652-2658
• 10 Inaba K, Rizoli S, Veigas PV. et al; Viscoelastic Testing in Trauma Consensus Panel. 2014 Consensus conference on viscoelastic test-based transfusion guidelines for early trauma resuscitation: report of the panel. J Trauma Acute Care Surg 2015; 78 (06) 1220-1229
• 11 Baksaas-Aasen K, Van Dieren S, Balvers K. et al; TACTIC/INTRN collaborators. Data-driven development of ROTEM and TEG algorithms for the management of trauma emorrhage: a prospective observational multicenter study. Ann Surg 2019; 270 (06) 1178-1185
• 12 Moore EE, Moore HB, Kornblith LZ. et al. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7 (01) 30
• 13 Moore EE, Moore HB, Gonzalez E, Sauaia A, Banerjee A, Silliman CC. Rationale for the selective administration of tranexamic acid to inhibit fibrinolysis in the severely injured patient. Transfusion 2016; 56 (Suppl. 02) S110-S114
• 14 Moore HB, Moore EE, Chapman MP. et al. Does tranexamic acid improve clot strength in severely injured patients who have elevated fibrin degradation products and low fibrinolytic activity, measured by thrombelastography?. J Am Coll Surg 2019; 229 (01) 92-101
• 15 Rourke C, Curry N, Khan S. et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost 2012; 10 (07) 1342-1351
• 16 McQuilten ZK, Wood EM, Bailey M, Cameron PA, Cooper DJ. Fibrinogen is an independent predictor of mortality in major trauma patients: a five-year statewide cohort study. Injury 2017; 48 (05) 1074-1081
• 17 Pezold M, Moore EE, Wohlauer M. et al. Viscoelastic clot strength predicts coagulation-related mortality within 15 minutes. Surgery 2012; 151 (01) 48-54
• 18 Engström M, Schött U, Romner B, Reinstrup P. Acidosis impairs the coagulation: a thromboelastographic study. J Trauma 2006; 61 (03) 624-628
• 19 Moore HB, Moore EE, Gonzalez E. et al. Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance to antifibrinolytic therapy. J Trauma Acute Care Surg 2014; 77 (06) 811-817 , discussion 817
• 20 Moore HB, Moore EE, Liras IN. et al. Acute fibrinolysis shutdown after injury occurs frequently and increases mortality: a multicenter evaluation of 2,540 severely injured patients. J Am Coll Surg 2016; 222 (04) 347-355
• 21 Stettler GR, Moore EE, Moore HB. et al. Redefining postinjury fibrinolysis phenotypes using two viscoelastic assays. J Trauma Acute Care Surg 2019; 86 (04) 679-685
• 22 Gonzalez E, Moore EE, Moore HB. 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 (06) 1051-1059
• 23 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 (06) 984-994
• 24 Johansson PI, Sørensen AM, Larsen CF. et al. Low hemorrhage-related mortality in trauma patients in a level I trauma center employing transfusion packages and early thromboelastography-directed hemostatic resuscitation with plasma and platelets. Transfusion 2013; 53 (12) 3088-3099
• 25 Afshari A, Wikkelsø A, Brok J, Møller AM, Wetterslev J. Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev 2011; (03) CD007871
• 26 Juffermans NP, Wirtz MR, Balvers K. et al; TACTIC partners. Towards patient-specific management of trauma hemorrhage: the effect of resuscitation therapy on parameters of thromboelastometry. J Thromb Haemost 2019; 17 (03) 441-448
• 27 Liew-Spilger AE, Sorg NR, Brenner TJ. et al. Viscoelastic hemostatic assays for postpartum hemorrhage. J Clin Med 2021; 10 (17) 3946
• 28 Görlinger K, Pérez-Ferrer A, Dirkmann D. et al. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019; 72 (04) 297-322
• 29 Abdul-Kadir R, McLintock C, Ducloy A-S. et al. Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion 2014; 54 (07) 1756-1768
• 30 Frigo MG, Agostini V, Brizzi A, Ragusa A, Svelato A. Practical approach to transfusion management of post-partum haemorrhage. Transfus Med 2021; 31 (01) 11-15
• 31 Chen C-H, Lee K-C, Hsieh Y-J. Amniotic fluid embolism complicated with pulmonary embolism during cesarean section: management with TEE and ROTEM^® . Asian J Anesthesiol 2017; 55 (04) 93-94
• 32 Truong HT, Browning RM. Anaphylaxis-induced hyperfibrinolysis in pregnancy. Int J Obstet Anesth 2015; 24 (02) 180-184
• 33 Gayet-Ageron A, Prieto-Merino D, Ker K, Shakur H, Ageron FX, Roberts I. Antifibrinolytic Trials Collaboration. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet 2018; 391 (10116): 125-132
• 34 Fawole B, Qureshi Z, Abdulkadir A. et al; WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389 (10084): 2105-2116
• 35 Hurwich M, Zimmer D, Guerra E. et al. A case of successful thromboelastographic guided resuscitation after postpartum hemorrhage and cardiac arrest. J Extra Corpor Technol 2016; 48 (04) 194-197
• 36 Loughran JA, Kitchen TL, Sindhakar S, Ashraf M, Awad M, Kealaher EJ. Rotational thromboelastometry (ROTEM®)-guided diagnosis and management of amniotic fluid embolism. Int J Obstet Anesth 2019; 38: 127-130
• 37 Collins PW, Lilley G, Bruynseels D. et al. Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study. Blood 2014; 124 (11) 1727-1736
• 38 Spasiano A, Matellon C, Orso D. et al. Functional fibrinogen (FLEV-TEG) versus the Clauss method in an obstetric population: a comparative study. BMC Anesthesiol 2019; 19 (01) 90-90
• 39 Mallaiah S, Barclay P, Harrod I, Chevannes C, Bhalla A. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia 2015; 70 (02) 166-175
• 40 McNamara H, Kenyon C, Smith R, Mallaiah S, Barclay P. Four years' experience of a ROTEM^® -guided algorithm for treatment of coagulopathy in obstetric haemorrhage. Anaesthesia 2019; 74 (08) 984-991
• 41 Wolberg AS, Meng ZH, Monroe III DM, Hoffman M. A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma 2004; 56 (06) 1221-1228
• 42 Sharma AD, Al-Achi A, Seccombe JF, Hummel R, Preston M, Behrend D. Does incorporation of thromboelastography improve bleeding prediction following adult cardiac surgery?. Blood Coagul Fibrinolysis 2014; 25 (06) 561-570
• 43 Welsby IJ, Jiao K, Ortel TL. et al. The kaolin-activated thrombelastograph predicts bleeding after cardiac surgery. J Cardiothorac Vasc Anesth 2006; 20 (04) 531-535
• 44 Tanaka KA, Bolliger D, Vadlamudi R, Nimmo A. Rotational thromboelastometry (ROTEM)-based coagulation management in cardiac surgery and major trauma. J Cardiothorac Vasc Anesth 2012; 26 (06) 1083-1093
• 45 Görlinger K, Iqbal J, Dirkmann D, Tanaka KA. Whole blood assay: thromboelastometry. In: Teruya J. ed. Management of Bleeding Patients. Basel: Springer Nature Switzerland AG; 2016: 37-64
• 46 Agarwal S, Johnson RI, Shaw M. A comparison of fibrinogen measurement using TEG(®) functional fibrinogen and Clauss in cardiac surgery patients. Int J Lab Hematol 2015; 37 (04) 459-465
• 47 Ranucci M, Baryshnikova E, Crapelli GB, Rahe-Meyer N, Menicanti L, Frigiola A. Surgical Clinical Outcome REsearch (SCORE) Group. Randomized, double-blinded, placebo-controlled trial of fibrinogen concentrate supplementation after complex cardiac surgery. J Am Heart Assoc 2015; 4 (06) e002066
• 48 Collins PW, Solomon C, Sutor K. et al. Theoretical modelling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate. Br J Anaesth 2014; 113 (04) 585-595
• 49 Görlinger K, Shore-Lesserson L, Dirkmann D, Hanke AAMD, Rahe-Meyer N, Tanaka KAMDM. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth 2013; 27 (4, Suppl): S20-S34
• 50 Peng HT, Nascimento B, Beckett A. Thromboelastography and thromboelastometry in assessment of fibrinogen deficiency and prediction for transfusion requirement: a descriptive review. BioMed Res Int 2018; 2018: 7020539-7020524
• 51 Dirkmann D, Görlinger K, Dusse F, Kottenberg E, Peters J. Early thromboelastometric variables reliably predict maximum clot firmness in patients undergoing cardiac surgery: a step towards earlier decision making. Acta Anaesthesiol Scand 2013; 57 (05) 594-603
• 52 Flisberg P, Rundgren M, Engström M. The effects of platelet transfusions evaluated using rotational thromboelastometry. Anesth Analg 2009; 108 (05) 1430-1432
• 53 Kander T, Tanaka KA, Norström E, Persson J, Schött U. The effect and duration of prophylactic platelet transfusions before insertion of a central venous catheter in patients with bone marrow failure evaluated with point-of-care methods and flow cytometry. Anesth Analg 2014; 119 (04) 882-890
• 54 Tripodi A, Primignani M, Chantarangkul V. et al. Global hemostasis tests in patients with cirrhosis before and after prophylactic platelet transfusion. Liver Int 2013; 33 (03) 362-367
• 55 Aoki K, Sugimoto A, Nagasawa A, Saito M, Ohzeki H. Optimization of thromboelastography-guided platelet transfusion in cardiovascular surgery. Gen Thorac Cardiovasc Surg 2012; 60 (07) 411-416
• 56 Ranucci M, Baryshnikova E, Ranucci M, Silvetti S. Surgical and Clinical Outcome Research (SCORE) Group. Fibrinogen levels compensation of thrombocytopenia-induced bleeding following cardiac surgery. Int J Cardiol 2017; 249: 96-100
• 57 Blasi A, Muñoz G, de Soto I. et al. Reliability of thromboelastometry for detecting the safe coagulation threshold in patients taking acenocoumarol after elective heart valve replacement. Thromb Res 2015; 136 (03) 669-672
• 58 Tanaka KA, Bader SO, Görlinger K. Novel approaches in management of perioperative coagulopathy. Curr Opin Anaesthesiol 2014; 27 (01) 72-80
• 59 Baryshnikova E, Di Dedda U, Ranucci M. A comparative study of SEER sonorheometry versus standard coagulation tests, rotational thromboelastometry, and multiple electrode aggregometry in cardiac surgery. J Cardiothorac Vasc Anesth 2019; 33 (06) 1590-1598
• 60 Groves DS, Welsby IJ, Naik BI. et al. Multicenter evaluation of the Quantra QPlus system in adult patients undergoing major surgical procedures. Anesth Analg 2020; 130 (04) 899-909
• 61 Ranucci M, Baryshnikova E. Sensitivity of viscoelastic tests to platelet function. J Clin Med 2020; 9 (01) E189-E198
• 62 Weitzel NS, Weitzel LB, Epperson LE, Karimpour-Ford A, Tran ZV, Seres T. Platelet mapping as part of modified thromboelastography (TEG®) in patients undergoing cardiac surgery and cardiopulmonary bypass. Anaesthesia 2012; 67 (10) 1158-1165
• 63 Karon BS, Tolan NV, Koch CD. et al. Precision and reliability of 5 platelet function tests in healthy volunteers and donors on daily antiplatelet agent therapy. Clin Chem 2014; 60 (12) 1524-1531
• 64 Ichikawa J, Kodaka M, Nishiyama K, Hirasaki Y, Ozaki M, Komori M. Reappearance of circulating heparin in whole blood heparin concentration-based management does not correlate with postoperative bleeding after cardiac surgery. J Cardiothorac Vasc Anesth 2014; 28 (04) 1003-1007
• 65 Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116 (22) 2544-2552
• 66 Serraino GF, Murphy GJ. Routine use of viscoelastic blood tests for diagnosis and treatment of coagulopathic bleeding in cardiac surgery: updated systematic review and meta-analysis. Br J Anaesth 2017; 118 (06) 823-833
• 67 Vlot EA, Rigter S, Noordzij PG. Optimal patient blood management in cardiac surgery using viscoelastic point-of-care testing. Br J Anaesth 2017; 119 (03) 544-545
• 68 Franchini M, Mengoli C, Cruciani M. et al. The use of viscoelastic haemostatic assays in non-cardiac surgical settings: a systematic review and meta-analysis. Blood Transfus 2018; 16 (03) 235-243
• 69 Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med 2011; 365 (02) 147-156
• 70 Ambrosino P, Tarantino L, Di Minno G. et al. The risk of venous thromboembolism in patients with cirrhosis. A systematic review and meta-analysis. Thromb Haemost 2017; 117 (01) 139-148
• 71 Lisman T, Hernandez-Gea V, Magnusson M. et al. The concept of rebalanced hemostasis in patients with liver disease: communication from the ISTH SSC working group on hemostatic management of patients with liver disease. J Thromb Haemost 2021; 19 (04) 1116-1122
• 72 Massicotte L, Beaulieu D, Thibeault L. et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation 2008; 85 (07) 956-962
• 73 Schmidt DE, Chaireti R, Bruzelius M, Holmström M, Antovic J, Ågren A. Correlation of thromboelastography and thrombin generation assays in warfarin-treated patients. Thromb Res 2019; 178: 34-40
• 74 Schneider T, Siegemund T, Siegemund R, Petros S. Thrombin generation and rotational thromboelastometry in the healthy adult population. Hamostaseologie 2015; 35 (02) 181-186
• 75 Thomas KA, Shea SM, Saini A, Muszynski JA, Spinella PC. Correlation between thrombin generation, standard coagulation assays, and viscoelastic assays for hemostatic assessment in critically ill children. J Appl Lab Med 2022; 07 (05) 1108-1119
• 76 Davies NA, Harrison NK, Sabra A. et al. Application of ROTEM to assess hypercoagulability in patients with lung cancer. Thromb Res 2015; 135 (06) 1075-1080
• 77 van Veenendaal N, Scheeren TWL, Meijer K, van der Voort PHJ. Rotational thromboelastometry to assess hypercoagulability in COVID-19 patients. Thromb Res 2020; 196: 379-381
• 78 Schofield N, Sugavanam A, Thompson K, Mallett SV. No increase in blood transfusions during liver transplantation since the withdrawal of aprotinin. Liver Transpl 2014; 20 (05) 584-590
• 79 Shimauchi T, Yamaura K, Higashi M, Abe K, Yoshizumi T, Hoka S. Fibrinolysis in living donor liver transplantation recipients evaluated using thromboelastometry: impact on mortality. Transplant Proc 2017; 49 (09) 2117-2121
• 80 Dirkmann D, Görlinger K, Peters J. Assessment of early thromboelastometric variables from extrinsically activated assays with and without aprotinin for rapid detection of fibrinolysis. Anesth Analg 2014; 119 (03) 533-542
• 81 Kim EH, Song SH, Kim GS, Ko JS, Gwak MS, Lee SK. Evaluation of “flat-line” thromboelastography after reperfusion during liver transplantation. Transplant Proc 2015; 47 (02) 457-459
• 82 De Pietri L, Ragusa F, Deleuterio A, Begliomini B, Serra V. Reduced transfusion during OLT by POC coagulation management and TEG functional fibrinogen: a retrospective observational study. Transplant Direct 2015; 2 (01) e49
• 83 Dötsch TM, Dirkmann D, Bezinover D. et al. Assessment of standard laboratory tests and rotational thromboelastometry for the prediction of postoperative bleeding in liver transplantation. Br J Anaesth 2017; 119 (03) 402-410
• 84 Fayed N, Mourad W, Yassen K, Görlinger K. Preoperative thromboelastometry as a predictor of transfusion requirements during adult living donor liver transplantation. Transfus Med Hemother 2015; 42 (02) 99-108
• 85 Görlinger K, Sakai T, Dirkmann D, Planinsic RM, Saner FH. Bleeding related to liver transplant. In: Teruya J. ed. Management of Bleeding Patients. Basel: Springer Nature Switzerland AG; 2016: 263-280
• 86 Görlinger K, Fries D, Dirkmann D, Weber CF, Hanke AA, Schöchl H. Reduction of fresh frozen plasma requirements by perioperative point-of-care coagulation management with early calculated goal-directed therapy. Transfus Med Hemother 2012; 39 (02) 104-113
• 87 Schumacher C, Eismann H, Sieg L. et al. Use of rotational thromboelastometry in liver transplantation is associated with reduced transfusion requirements. Exp Clin Transplant 2019; 17 (02) 222-230
• 88 Wang SC, Shieh JF, Chang KY. et al. Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transplant Proc 2010; 42 (07) 2590-2593
• 89 Pereboom IT, de Boer MT, Haagsma EB, Hendriks HG, Lisman T, Porte RJ. Platelet transfusion during liver transplantation is associated with increased postoperative mortality due to acute lung injury. Anesth Analg 2009; 108 (04) 1083-1091
• 90 Wang SC, Lin HT, Chang KY. et al. Use of higher thromboelastogram transfusion values is not associated with greater blood loss in liver transplant surgery. Liver Transpl 2012; 18 (10) 1254-1258
• 91 Cacciarelli TV, Keeffe EB, Moore DH. et al. Effect of intraoperative blood transfusion on patient outcome in hepatic transplantation. Arch Surg 1999; 134 (01) 25-29
• 92 Tangcheewinsirikul N, Moonla C, Uaprasert N, Pittayanon R, Rojnuckarin P. Viscoelastometric versus standard coagulation tests to guide periprocedural transfusion in adults with cirrhosis: a meta-analysis of randomized controlled trials. Vox Sang 2022; 117 (04) 553-561
• 93 Kovalic AJ, Khan MA, Malaver D. et al. Thromboelastography versus standard coagulation testing in the assessment and reversal of coagulopathy among cirrhotics: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2020; 32 (03) 291-302
• 94 Shenoy A, Louissaint J, Shannon C, Tapper EB, Lok AS. Viscoelastic testing prior to non-surgical procedures reduces blood product use without increasing bleeding risk in cirrhosis. Dig Dis Sci 2022; (e-pub ahead of print).
• 95 Gurusamy KS, Pissanou T, Pikhart H, Vaughan J, Burroughs AK, Davidson BR. Methods to decrease blood loss and transfusion requirements for liver transplantation. Cochrane Database Syst Rev 2011; 12 (12) CD009052
• 96 Volod O, Bunch CM, Zackariya N. et al. Viscoelastic hemostatic assays: a primer on legacy and new generation devices. J Clin Med 2022; 11 (03) 860
• 97 Haemonetics Corporation. Introducing TEG 6s—White Paper. Accessed February 4, 2022 at: https://pdf.medicalexpo.com/pdf/haemonetics/introducing-teg-6s-white-paper/78504-152619.html