Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy

Authors

  • Jeffry L. Kashuk,

    Corresponding author
    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Ernest E. Moore,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Max Wohlauer,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Jeffrey L. Johnson,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Michael Pezold,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Jerry Lawrence,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Walter L. Biffl,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • C. Clay Cothren Burlew,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Carlton Barnett,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Michael Sawyer,

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • Angela Sauaia

    1. From the Department of Surgery and Anesthesia, Denver Health Medical Center at the Rocky Mountain Regional Trauma Center and the Department of Surgery, University of Colorado Denver, School of Medicine, Denver, Colorado.
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  • This project was supported by a seed grant from the University of Colorado Department of Surgery and in part by P50GM049222 and T32GM08315 from the National Institute of General Medical Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIGMS or National Institutes of Health.

  • Presented at the 68th annual meeting of the American Association for the Surgery of Trauma, October 1, 2009, Pittsburgh, PA.

Jeffry L. Kashuk, MD FACS, Trauma, Surgical Critical Care and Acute Care Surgery, St Mary's of Michigan and Midwestern Surgical Associates, 999 S. Washington #2, Saginaw, MI 48602; e-mail: jeffrykashuk@gmail.com.

Abstract

BACKGROUND: Massive transfusion (MTP) protocol design is hindered by lack of accurate assessment of coagulation. Rapid thrombelastography (r-TEG) provides point-of-care (POC) analysis of clot formation. We designed a prospective study to test the hypothesis that integrating TEG into our MTP would facilitate goal-directed therapy and provide equivalent outcomes compared to conventional coagulation testing.

STUDY DESIGN AND METHODS: Thiry-four patients who received more than 6 units of red blood cells (RBCs)/6 hours who were admitted to our Level 1 trauma center after r-TEG implementation (TEG) were compared to 34 patients admitted prior to TEG implementation (Pre-TEG). Data are presented as mean ± SEM.

RESULTS: Emergency department pre-TEG versus TEG shock, and coagulation indices, were not different: systolic blood pressure (94 mmHg vs.101 mmHg), temperature (35.3°C vs. 35.9°C), pH (7.16 vs. 7.11), base deficit (−13.0 vs. −14.7), lactate (6.5 vs. 8.1), international normalized ratio (INR; 1.59 vs. 1.83), and partial thromboplastin time (48.3 vs. 57.9). Although not significant, patients with Injury Severity Score range 26 to 35 were more frequent in the pre-TEG group. Fresh-frozen plasma (FFP) : RBCs, platelets : RBCs, and cryoprecipitate (cryo) : RBC ratios were not significantly different at 6 or 12 hours. INR at 6 hours did not discriminate between survivors and nonsurvivors (p = 0.10), whereas r-TEG “G” value was significantly associated with survival (p = 0.03), as was the maximum rate of thrombin generation (MRTG; mm/min) and total thrombin generation (TG; area under the curve) (p = 0.03 for both). Patients with MRTG of more than 9.2 received significantly less components of RBCs, FFP, and cryo (p = 0.048, p = 0.03, and p = 0.04, respectively).

CONCLUSION: Goal-directed resuscitation via r-TEG appears useful for management of trauma-induced coagulopathy. Further experience with POC monitoring could result in more efficient management leading to a reduction of transfusion requirements.

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