Goal-directed Coagulation Management of Major Trauma Patients Using Thromboelastometry (ROTEM)-guided Administration of Fibrinogen Concentrate and Prothrombin Complex Concentrate

Overview

Journal Crit Care

Specialty Critical Care

Date 2010 Apr 9

PMID 20374650

Citations 177

Authors

Herbert Schochl

Ulrike Nienaber

Georg Hofer

Wolfgang Voelckel

Csilla Jambor

Gisela Scharbert

Sibylle Kozek-Langenecker

Cristina Solomon

Affiliations

Soon will be listed here.

Abstract

Introduction: The appropriate strategy for trauma-induced coagulopathy management is under debate. We report the treatment of major trauma using mainly coagulation factor concentrates.

Methods: This retrospective analysis included trauma patients who received >or= 5 units of red blood cell concentrate within 24 hours. Coagulation management was guided by thromboelastometry (ROTEM). Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after fibrinogen concentrate administration was an indication for platelet concentrate. The observed mortality was compared with the mortality predicted by the trauma injury severity score (TRISS) and by the revised injury severity classification (RISC) score.

Results: Of 131 patients included, 128 received fibrinogen concentrate as first-line therapy, 98 additionally received PCC, while 3 patients with recent coumarin intake received only PCC. Twelve patients received FFP and 29 received platelet concentrate. The observed mortality was 24.4%, lower than the TRISS mortality of 33.7% (P = 0.032) and the RISC mortality of 28.7% (P > 0.05). After excluding 17 patients with traumatic brain injury, the difference in mortality was 14% observed versus 27.8% predicted by TRISS (P = 0.0018) and 24.3% predicted by RISC (P = 0.014).

Conclusions: ROTEM-guided haemostatic therapy, with fibrinogen concentrate as first-line haemostatic therapy and additional PCC, was goal-directed and fast. A favourable survival rate was observed. Prospective, randomized trials to investigate this therapeutic alternative further appear warranted.

Citing Articles

A comprehensive review of massive transfusion and major hemorrhage protocols: origins, core principles and practical implementation.

Marinho D, Brunetta D, Carlos L, Carvalho L, Miranda J Braz J Anesthesiol. 2024; 75(2):844583.

PMID: 39730103 PMC: 11808514. DOI: 10.1016/j.bjane.2024.844583.

Four-factor Prothrombin Complex Concentrate Use for Bleeding Management in Adult Trauma.

Mora L, Maegele M, Grottke O, Koster A, Stein P, Levy J Anesthesiology. 2024; 142(2):351-363.

PMID: 39476104 PMC: 11723492. DOI: 10.1097/ALN.0000000000005230.

Synergistic effects of rivaroxaban and hypothermia or acidosis on coagulation initiation measured with ROTEM: a prospective observational study.

Sunnersjo L, Ymen I, Schott U, Hillarp A, Unden J, Kander T Thromb J. 2024; 22(1):91.

PMID: 39425155 PMC: 11488277. DOI: 10.1186/s12959-024-00661-0.

Early Point-of-Care Thromboelastometry Reduces Mortality in Patients with Severe Trauma and Risk of Transfusion: An Analysis Based on the TraumaRegister DGU.

Beyersdorf C, Bieler D, Lefering R, Imach S, Hackenberg L, Schiffner E J Clin Med. 2024; 13(14).

PMID: 39064098 PMC: 11277494. DOI: 10.3390/jcm13144059.

Tailoring transfusion strategy using thromboelastogram in goal-directed massive transfusion: Impact on transfusion requirements and clinical outcomes.

Prethika P, Mohan G, Shastry S, Balakrishnan J Asian J Transfus Sci. 2024; 18(1):7-15.

PMID: 39036674 PMC: 11259345. DOI: 10.4103/ajts.ajts_56_23.

References

Danes A, Cuenca L, Bueno S, Mendarte Barrenechea L, Ronsano J . Efficacy and tolerability of human fibrinogen concentrate administration to patients with acquired fibrinogen deficiency and active or in high-risk severe bleeding. Vox Sang. 2008; 94(3):221-226. DOI: 10.1111/j.1423-0410.2007.01024.x. View

Dara S, Rana R, Afessa B, Moore S, Gajic O . Fresh frozen plasma transfusion in critically ill medical patients with coagulopathy. Crit Care Med. 2005; 33(11):2667-71. DOI: 10.1097/01.ccm.0000186745.53059.f0. View

Nielsen V, Levy J . Fibrinogen and bleeding: old molecule--new ideas. Anesth Analg. 2007; 105(4):902-3. DOI: 10.1213/01.ane.0000286775.33975.6e. View

Davis E, MacKenzie E, Sacco W, Bain Jr L, Buckman Jr R, Champion H . A new "TRISS-like" probability of survival model for intubated trauma patients. J Trauma. 2003; 55(1):53-61. DOI: 10.1097/01.TA.0000075340.22097.B5. View

Haas T, Fries D, Velik-Salchner C, Oswald E, Innerhofer P . Fibrinogen in craniosynostosis surgery. Anesth Analg. 2008; 106(3):725-31, table of contents. DOI: 10.1213/ane.0b013e318163fb26. View

Rahe-Meyer N, Pichlmaier M, Haverich A, Solomon C, Winterhalter M, Piepenbrock S . Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study. Br J Anaesth. 2009; 102(6):785-92. PMC: 2683341. DOI: 10.1093/bja/aep089. View

Lang T, Johanning K, Metzler H, Piepenbrock S, Solomon C, Rahe-Meyer N . The effects of fibrinogen levels on thromboelastometric variables in the presence of thrombocytopenia. Anesth Analg. 2009; 108(3):751-8. DOI: 10.1213/ane.0b013e3181966675. View

Jackson G, Ashpole K, Yentis S . The TEG vs the ROTEM thromboelastography/thromboelastometry systems. Anaesthesia. 2009; 64(2):212-5. DOI: 10.1111/j.1365-2044.2008.05752.x. View

Rahe-Meyer N, Solomon C, Winterhalter M, Piepenbrock S, Tanaka K, Haverich A . Thromboelastometry-guided administration of fibrinogen concentrate for the treatment of excessive intraoperative bleeding in thoracoabdominal aortic aneurysm surgery. J Thorac Cardiovasc Surg. 2009; 138(3):694-702. DOI: 10.1016/j.jtcvs.2008.11.065. View

10.

Sanson G, Di Bartolomeo S, Nardi G, Albanese P, Diani A, Raffin L . Road traffic accidents with vehicular entrapment: incidence of major injuries and need for advanced life support. Eur J Emerg Med. 2000; 6(4):285-91. DOI: 10.1097/00063110-199912000-00002. View

11.

Chowdary P, Chowdhury P, Saayman A, Paulus U, Findlay G, Collins P . Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol. 2004; 125(1):69-73. DOI: 10.1111/j.1365-2141.2004.04868.x. View

12.

Geeraedts Jr L, Demiral H, Schaap N, Kamphuisen P, Pompe J, Frolke J . 'Blind' transfusion of blood products in exsanguinating trauma patients. Resuscitation. 2007; 73(3):382-8. DOI: 10.1016/j.resuscitation.2006.10.005. View

13.

Sniecinski R, Chen E, Tanaka K . Reduced levels of fibrin (antithrombin I) and antithrombin III underlie coagulopathy following complex cardiac surgery. Blood Coagul Fibrinolysis. 2008; 19(2):178-9. DOI: 10.1097/MBC.0b013e3282f40d4a. View

14.

Velik-Salchner C, Haas T, Innerhofer P, Streif W, Nussbaumer W, Klingler A . The effect of fibrinogen concentrate on thrombocytopenia. J Thromb Haemost. 2007; 5(5):1019-25. DOI: 10.1111/j.1538-7836.2007.02481.x. View

15.

Chaiwat O, Lang J, Vavilala M, Wang J, MacKenzie E, Jurkovich G . Early packed red blood cell transfusion and acute respiratory distress syndrome after trauma. Anesthesiology. 2009; 110(2):351-60. DOI: 10.1097/ALN.0b013e3181948a97. View

16.

Kaufmann C, Dwyer K, Crews J, Dols S, Trask A . Usefulness of thrombelastography in assessment of trauma patient coagulation. J Trauma. 1997; 42(4):716-20; discussion 720-2. DOI: 10.1097/00005373-199704000-00023. View

17.

Bolliger D, Szlam F, Molinaro R, Rahe-Meyer N, Levy J, Tanaka K . Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model. Br J Anaesth. 2009; 102(6):793-9. DOI: 10.1093/bja/aep098. View

18.

Fries D, Innerhofer P, Schobersberger W . Time for changing coagulation management in trauma-related massive bleeding. Curr Opin Anaesthesiol. 2009; 22(2):267-74. DOI: 10.1097/ACO.0b013e32832678d9. View

19.

Plotkin A, Wade C, Jenkins D, Smith K, Noe J, Park M . A reduction in clot formation rate and strength assessed by thrombelastography is indicative of transfusion requirements in patients with penetrating injuries. J Trauma. 2008; 64(2 Suppl):S64-8. DOI: 10.1097/TA.0b013e318160772d. View

20.

Dempfle C, Borggrefe M . Point of care coagulation tests in critically ill patients. Semin Thromb Hemost. 2008; 34(5):445-50. DOI: 10.1055/s-0028-1092874. View