Viscoelastic Testing in Trauma

Mathijs R. Wirtz; Holger M. Baumann; J. Henriëtte Klinkspoor; J. Carel Goslings; Nicole P. Juffermans

doi:10.1055/s-0037-1598057

Seminars in Thrombosis and Hemostasis, Table of Contents

Semin Thromb Hemost 2017; 43(04): 375-385
DOI: 10.1055/s-0037-1598057

Review Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Viscoelastic Testing in Trauma

Mathijs R. Wirtz

¹Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands

²Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands

,

Holger M. Baumann

³Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands

,

J. Henriëtte Klinkspoor

⁴Laboratory for General Clinical Chemistry, Academic Medical Center, Amsterdam, The Netherlands

,

J. Carel Goslings

¹Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands

,

Nicole P. Juffermans

²Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands

› Author Affiliations

Abstract

Traumatic-induced coagulopathy (TIC) is a complex condition which develops both as a response to trauma as well as to clinical care interventions. Accurate and timely diagnostics are necessary to enable therapy aimed at correction of TIC. Viscoelastic hemostatic assays (VHA) are increasingly recognized for their potential to diagnose TIC as well as for guidance of treatment. This narrative review focuses on the evidence of the use of VHAs to diagnose TIC, to monitor efficacy of treatment of TIC during bleeding and to prognosticate outcome. Pitfalls of the use of VHA are also discussed.

Keywords

trauma - VHA - coagulopathy - treatment algorithm

Full Text

References

References
1 Lozano R, Naghavi M, Foreman K. , et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380 (9859): 2095-2128
2 Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003; 54 (06) 1127-1130
3 Maegele M, Lefering R, Yucel N. , et al; AG Polytrauma of the German Trauma Society (DGU). Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 2007; 38 (03) 298-304
4 Frith D, Goslings JC, Gaarder C. , et al. Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations. J Thromb Haemost 2010; 8 (09) 1919-1925
5 Cohen MJ, Kutcher M, Redick B. , et al; PROMMTT Study Group. Clinical and mechanistic drivers of acute traumatic coagulopathy. J Trauma Acute Care Surg 2013; 75 (1, suppl 1): S40-S47
6 Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 2007; 13 (06) 680-685
7 Cotton BA, Faz G, Hatch QM. , et al. Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma 2011; 71 (02) 407-414 , discussion 414–417
8 Haas T, Fries D, Tanaka KA, Asmis L, Curry NS, Schöchl H. Usefulness of standard plasma coagulation tests in the management of perioperative coagulopathic bleeding: is there any evidence?. Br J Anaesth 2015; 114 (02) 217-224
9 Rugeri L, Levrat A, David JS. , et al. Diagnosis of early coagulation abnormalities in trauma patients by rotation thrombelastography. J Thromb Haemost 2007; 5 (02) 289-295
10 Deppe AC, Weber C, Zimmermann J. , et al. Point-of-care thromboelastography/thromboelastometry-based coagulation management in cardiac surgery: a meta-analysis of 8332 patients. J Surg Res 2016; 203 (02) 424-433
11 Holcomb JB, Spinella PC. Optimal use of blood in trauma patients. Biologicals 2010; 38 (01) 72-77
12 Hartert H. Blutgerinnungsstudien mit der thrombelastographie, einem neuen Untersuchungsverfahren. Klin Wochenschr 1948; 26 (37-38): 577-583
13 Kang YG, Martin DJ, Marquez J. , et al. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg 1985; 64 (09) 888-896
14 Klein AA, Arnold P, Bingham RM. , et al. AAGBI guidelines: the use of blood components and their alternatives 2016. Anaesthesia 2016; 71 (07) 829-842
15 Cohen MJ, Christie SA. New understandings of post injury coagulation and resuscitation. Int J Surg 2016; 33 (Pt B): 242-245
16 Kaufmann CR, Dwyer KM, Crews JD, Dols SJ, Trask AL. Usefulness of thrombelastography in assessment of trauma patient coagulation. J Trauma 1997; 42 (04) 716-720 , discussion 720–722
17 Solomon C, Traintinger S, Ziegler B. , et al. Platelet function following trauma. A multiple electrode aggregometry study. Thromb Haemost 2011; 106 (02) 322-330
18 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
19 Davenport R. Pathogenesis of acute traumatic coagulopathy. Transfusion 2013; 53 (Suppl 1): 23S-27S
20 Hunt H, Stanworth S, Curry N. , et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev 2015; (02) CD010438
21 Woolley T, Midwinter M, Spencer P, Watts S, Doran C, Kirkman E. Utility of interim ROTEM(®) values of clot strength, A5 and A10, in predicting final assessment of coagulation status in severely injured battle patients. Injury 2013; 44 (05) 593-599
22 Hagemo JS, Christiaans SC, Stanworth SJ. , et al. Detection of acute traumatic coagulopathy and massive transfusion requirements by means of rotational thromboelastometry: an international prospective validation study. Crit Care 2015; 19: 97
23 Doran CM, Woolley T, Midwinter MJ. Feasibility of using rotational thromboelastometry to assess coagulation status of combat casualties in a deployed setting. J Trauma 2010; 69 (Suppl 1): S40-S48
24 Nascimento B, Al Mahoos M, Callum J. , et al. Vitamin K-dependent coagulation factor deficiency in trauma: a comparative analysis between international normalized ratio and thromboelastography. Transfusion 2012; 52 (01) 7-13
25 Rizoli SB, Scarpelini S, Callum J. , et al. Clotting factor deficiency in early trauma-associated coagulopathy. J Trauma 2011; 71 (5, suppl 1): S427-S434
26 Wohlauer MV, Moore EE, Thomas S. , et al. Early platelet dysfunction: an unrecognized role in the acute coagulopathy of trauma. J Am Coll Surg 2012; 214 (05) 739-746
27 Chambers LA, Chow SJ, Shaffer LE. Frequency and characteristics of coagulopathy in trauma patients treated with a low- or high-plasma-content massive transfusion protocol. Am J Clin Pathol 2011; 136 (03) 364-370
28 Meyer MA, Ostrowski SR, Sørensen AM. , et al. Fibrinogen in trauma, an evaluation of thrombelastography and rotational thromboelastometry fibrinogen assays. J Surg Res 2015; 194 (02) 581-590
29 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
30 Raza I, Davenport R, Rourke C. , et al. The incidence and magnitude of fibrinolytic activation in trauma patients. J Thromb Haemost 2013; 11 (02) 307-314
31 Kashuk JL, Moore EE, Sawyer M. , et al. Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma. Ann Surg 2010; 252 (03) 434-442 , discussion 443–444
32 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
33 Liras IN, Cotton BA, Cardenas JC, Harting MT. Prevalence and impact of admission hyperfibrinolysis in severely injured pediatric trauma patients. Surgery 2015; 158 (03) 812-818
34 Davenport R, Curry N, Manson J. , et al. Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios of 1:2. J Trauma 2011; 70 (01) 90-95 , discussion 95–96
35 Khan S, Brohi K, Chana M. , et al; International Trauma Research Network (INTRN). Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage. J Trauma Acute Care Surg 2014; 76 (03) 561-567 , discussion 567–568
36 Rahbar E, Cardenas JC, Matijevic N. , et al; Early Whole Blood Investigators. Trauma, time, and transfusions: a longitudinal analysis of coagulation markers in severely injured trauma patients receiving modified whole blood or component blood products. Shock 2015; 44 (05) 417-425
37 Yao D, Li Y, Wang J, Yu W, Li N, Li J. Effects of recombinant activated factor VIIa on abdominal trauma patients. Blood Coagul Fibrinolysis 2014; 25 (01) 33-38
38 Ponschab M, Voelckel W, Pavelka M, Schlimp CJ, Schöchl H. Effect of coagulation factor concentrate administration on ROTEM® parameters in major trauma. Scand J Trauma Resusc Emerg Med 2015; 23: 84
39 Maegele M. Coagulation factor concentrate-based therapy for remote damage control resuscitation (RDCR): a reasonable alternative?. Transfusion 2016; 56 (Suppl. 02) S157-S165
40 Innerhofer P, Westermann I, Tauber H. , et al. The exclusive use of coagulation factor concentrates enables reversal of coagulopathy and decreases transfusion rates in patients with major blunt trauma. Injury 2013; 44 (02) 209-216
41 Tauber H, Innerhofer P, Breitkopf R. , et al. Prevalence and impact of abnormal ROTEM(R) assays in severe blunt trauma: results of the ‘Diagnosis and Treatment of Trauma-Induced Coagulopathy (DIA-TRE-TIC) study’. Br J Anaesth 2011; 107 (03) 378-387
42 Schlimp CJ, Voelckel W, Inaba K, Maegele M, Schöchl H. Impact of fibrinogen concentrate alone or with prothrombin complex concentrate (+/- fresh frozen plasma) on plasma fibrinogen level and fibrin-based clot strength (FIBTEM) in major trauma: a retrospective study. Scand J Trauma Resusc Emerg Med 2013; 21: 74
43 Khan S, Davenport R, Raza I. , et al. Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma hemorrhage. Intensive Care Med 2015; 41 (02) 239-247
44 Harr JN, Moore EE, Chin TL. , et al. Postinjury hyperfibrinogenemia compromises efficacy of heparin-based venous thromboembolism prophylaxis. Shock 2014; 41 (01) 33-39
45 Roberts I, Shakur H, Coats T. , et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013; 17 (10) 1-79
46 Van Haren RM, Valle EJ, Thorson CM. , et al. Hypercoagulability and other risk factors in trauma intensive care unit patients with venous thromboembolism. J Trauma Acute Care Surg 2014; 76 (02) 443-449
47 Harvin JA, Peirce CA, Mims MM. , et al. The impact of tranexamic acid on mortality in injured patients with hyperfibrinolysis. J Trauma Acute Care Surg 2015; 78 (05) 905-909 , discussion 909–911
48 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
49 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
50 Tapia NM, Chang A, Norman M. , et al. TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients. J Trauma Acute Care Surg 2013; 74 (02) 378-385 , discussion 385–386
51 Walsh M, Thomas SG, Howard JC. , et al. Blood component therapy in trauma guided with the utilization of the perfusionist and thromboelastography. J Extra Corpor Technol 2011; 43 (03) 162-167
52 Sawyer MM, Myers G, Humphrey J, Chandler M. Trauma and thrombelastography: how changes in the understanding of coagulopathy, testing, and hospital systems have changed one group's practice. Semin Cardiothorac Vasc Anesth 2012; 16 (03) 142-152
53 Pezold M, Moore EE, Wohlauer M. , et al. Viscoelastic clot strength predicts coagulation-related mortality within 15 minutes. Surgery 2012; 151 (01) 48-54
54 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
55 Schöchl H, Schlimp CJ, Voelckel W. Perioperative coagulation management in multiple trauma patients based on viscoelastic test results [in German]. Unfallchirurg 2014; 117 (02) 111-117
56 Schöchl H, Schlimp CJ, Voelckel W. Potential value of pharmacological protocols in trauma. Curr Opin Anaesthesiol 2013; 26 (02) 221-229
57 Schöchl H, Maegele M, Solomon C, Görlinger K, Voelckel W. Early and individualized goal-directed therapy for trauma-induced coagulopathy. Scand J Trauma Resusc Emerg Med 2012; 20: 15
58 Schöchl H, Nienaber U, Maegele M. , et al. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care 2011; 15 (02) R83
59 Schöchl H, Nienaber U, Hofer G. , et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010; 14 (02) R55
60 Kane I, Ong A, Orozco FR, Post ZD, Austin LS, Radcliff KE. Thromboelastography predictive of death in trauma patients. Orthop Surg 2015; 7 (01) 26-30
61 Carroll RC, Craft RM, Langdon RJ. , et al. Early evaluation of acute traumatic coagulopathy by thrombelastography. Transl Res 2009; 154 (01) 34-39
62 Holcomb JB, Minei KM, Scerbo ML. , et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients. Ann Surg 2012; 256 (03) 476-486
63 Kashuk JL, Moore EE, Sawyer M. , et al. Postinjury coagulopathy management: goal directed resuscitation via POC thrombelastography. Ann Surg 2010; 251 (04) 604-614
64 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
65 Kunio NR, Differding JA, Watson KM, Stucke RS, Schreiber MA. Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury. Am J Surg 2012; 203 (05) 584-588
66 Schöchl H, Solomon C, Traintinger S. , et al. Thromboelastometric (ROTEM) findings in patients suffering from isolated severe traumatic brain injury. J Neurotrauma 2011; 28 (10) 2033-2041
67 Windeløv NA, Welling KL, Ostrowski SR, Johansson PI. The prognostic value of thrombelastography in identifying neurosurgical patients with worse prognosis. Blood Coagul Fibrinolysis 2011; 22 (05) 416-419
68 Rowell SE, Barbosa RR, Lennox TC. , et al. Moderate elevations in international normalized ratio should not lead to delays in neurosurgical intervention in patients with traumatic brain injury. J Trauma Acute Care Surg 2014; 77 (06) 846-850 , discussion 851
69 Vogel AM, Radwan ZA, Cox Jr CS, Cotton BA. Admission rapid thrombelastography delivers real-time “actionable” data in pediatric trauma. J Pediatr Surg 2013; 48 (06) 1371-1376
70 Davis PK, Musunuru H, Walsh M. , et al. Platelet dysfunction is an early marker for traumatic brain injury-induced coagulopathy. Neurocrit Care 2013; 18 (02) 201-208
71 Theusinger OM, Wanner GA, Emmert MY. , et al. Hyperfibrinolysis diagnosed by rotational thromboelastometry (ROTEM) is associated with higher mortality in patients with severe trauma. Anesth Analg 2011; 113 (05) 1003-1012
72 Cotton BA, Harvin JA, Kostousouv V. , et al. Hyperfibrinolysis at admission is an uncommon but highly lethal event associated with shock and prehospital fluid administration. J Trauma Acute Care Surg 2012; 73 (02) 365-370 , discussion 370
73 Chapman MP, Moore EE, Ramos CR. , et al. Fibrinolysis greater than 3% is the critical value for initiation of antifibrinolytic therapy. J Trauma Acute Care Surg 2013; 75 (06) 961-967 , discussion 967
74 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
75 Ives C, Inaba K, Branco BC. , et al. Hyperfibrinolysis elicited via thromboelastography predicts mortality in trauma. J Am Coll Surg 2012; 215 (04) 496-502
76 Pommerening MJ, Goodman MD, Farley DL. , et al. Early diagnosis of clinically significant hyperfibrinolysis using thrombelastography velocity curves. J Am Coll Surg 2014; 219 (06) 1157-1166
77 Tarmey NT, Woolley T, Jansen JO. , et al. Evolution of coagulopathy monitoring in military damage-control resuscitation. J Trauma Acute Care Surg 2012; 73 (06) (Suppl. 05) S417-S422
78 Cotton BA, Minei KM, Radwan ZA. , et al. Admission rapid thrombelastography predicts development of pulmonary embolism in trauma patients. J Trauma Acute Care Surg 2012; 72 (06) 1470-1475 , discussion 1475–1477
79 Kashuk JL, Moore EE, Sabel A. , et al. Rapid thrombelastography (r-TEG) identifies hypercoagulability and predicts thromboembolic events in surgical patients. Surgery 2009; 146 (04) 764-772 , discussion 772–774
80 Müller MC, Balvers K, Binnekade JM. , et al. Thromboelastometry and organ failure in trauma patients: a prospective cohort study. Crit Care 2014; 18 (06) 687
81 Chapman BC, Moore EE, Barnett C. , et al. Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation. Am J Surg 2013; 206 (06) 917-922 , discussion 922–923
82 Allen CJ, Murray CR, Meizoso JP. , et al. Coagulation profile changes due to thromboprophylaxis and platelets in trauma patients at high-risk for venous thromboembolism. Am Surg 2015; 81 (07) 663-668
83 Hagemo JS, Næss PA, Johansson P. , et al. Evaluation of TEG(®) and RoTEM(®) inter-changeability in trauma patients. Injury 2013; 44 (05) 600-605
84 Hagemo JS, Gaarder C, Naess PA, Viksmoen Y, Heier HE. Comparing TEG and RoTEM as Point-of-Care devices in trauma patients. Vox Sang 2010; 99: 437
85 Rizoli S, Min A, Sanchez AP. , et al. In trauma, conventional ROTEM and TEG results are not interchangeable but are similar in clinical applicability. Mil Med 2016; 181 , (5 Suppl): 117-126
86 Yeung MC, Tong SY, Tong PY, Cheung BH, Ng JY, Leung GK. Use of viscoelastic haemostatic assay in emergency and elective surgery. Hong Kong medical journal = Xianggang yi xue za zhi / Hong Kong. Acad Med 2015; 21 (01) 45-51
87 Goodman MD, Makley AT, Hanseman DJ, Pritts TA, Robinson BR. All the bang without the bucks: Defining essential point-of-care testing for traumatic coagulopathy. J Trauma Acute Care Surg 2015; 79 (01) 117-124 , discussion 124
88 Lang T, von Depka M. Possibilities and limitations of thrombelastometry/-graphy [in German]. Hamostaseologie 2006; 26 (3, suppl 1): S20-S29
89 Benes J, Zatloukal J, Kletecka J. Viscoelastic methods of blood clotting assessment - a multidisciplinary review. Front Med (Lausanne) 2015; 2: 62
90 Dunham CM, Rabel C, Hileman BM. , et al. TEG® and RapidTEG® are unreliable for detecting warfarin-coagulopathy: a prospective cohort study. Thromb J 2014; 12 (01) 4
91 Watts DD, Trask A, Soeken K, Perdue P, Dols S, Kaufmann C. Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity. J Trauma 1998; 44 (05) 846-854
92 Howard BM, Kornblith LZ, Redick BJ. , et al. The effects of alcohol on coagulation in trauma patients: interpreting thrombelastography with caution. J Trauma Acute Care Surg 2014; 77 (06) 865-871 , discussion 871–872
93 Spoerke N, Underwood S, Differding J. , et al. Effects of ethanol intoxication and gender on blood coagulation. J Trauma 2010; 68 (05) 1106-1111
94 Anderson L, Quasim I, Steven M. , et al. Interoperator and intraoperator variability of whole blood coagulation assays: a comparison of thromboelastography and rotational thromboelastometry. J Cardiothorac Vasc Anesth 2014; 28 (06) 1550-1557
95 Stensballe J, Ostrowski SR, Johansson PI. Viscoelastic guidance of resuscitation. Curr Opin Anaesthesiol 2014; 27 (02) 212-218
96 Mauffrey C, Cuellar DO, Steven 3rd M, Pieracci F. , et al. Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy. Bone Joint J 2014; 96-B (09) 1143-1154
97 Durila M, Malošek M. Rotational thromboelastometry along with thromboelastography plays a critical role in the management of traumatic bleeding. Am J Emerg Med 2014; 32 (03) 288.e1-e3