Diagnosis and Treatment of Trauma-Induced Coagulopathy by Viscoelastography

2020 ◽  
Vol 46 (02) ◽  
pp. 134-146 ◽  
Author(s):  
Jan Hartmann ◽  
Mark Walsh ◽  
Anne Grisoli ◽  
Anthony V. Thomas ◽  
Faisal Shariff ◽  
...  
Keyword(s):  
Trauma Patient ◽  
Clinical Outcomes ◽  
Blood Product ◽  
Blood Component ◽  
Trauma Resuscitation ◽  
Rotational Thromboelastometry ◽  
Trauma Induced Coagulopathy ◽  
Coagulation Tests ◽  
Blood Component Therapy ◽  
Compare And Contrast

AbstractThis article explores the application of viscoelastic tests (VETs) in trauma-induced coagulopathy and trauma resuscitation. We describe the advantages of VETs over conventional coagulation tests in the trauma setting and refer to previous disciplines in which VET use has reduced blood product utilization, guided prohemostatic agents, and improved clinical outcomes such as the mortality of critically bleeding patients. We describe different VETs and provide guidance for blood component therapy and prohemostatic therapy based on specific VET parameters. Because the two most commonly used VET systems, rotational thromboelastometry and thromboelastography, use different activators and have different terminologies, this practical narrative review will directly compare and contrast these two VETs to help the clinician easily interpret either and use the interpretation to determine hemostatic integrity in the bleeding trauma patient. Finally, we anticipate the future of new viscoelastic technologies that can be used in this setting.

scholarly journals The Utilization of Viscoelastic Testing to Guide Blood Component Therapy and Adjunctive Hemostatic Therapy for Postpartum Hemorrhage: A Narrative Review

2019 ◽  
pp. 272-286
Author(s):  
Baumgartner S ◽  
Shariff F ◽  
Vande Lune SA ◽  
Zackariya N ◽  
Grisoli A ◽  
...  
Keyword(s):  
Postpartum Hemorrhage ◽  
Point Of Care ◽  
Narrative Review ◽  
Blood Component ◽  
Clinical Parameters ◽  
Rotational Thromboelastometry ◽  
Coagulation Tests ◽  
Blood Component Therapy ◽  
History Of ◽  
Hemostatic Therapy

This narrative review discusses the history of the pathophysiologic principles and utilization of point-of-care (POC) viscoelastic tests (VETs) in the definition and treatment of postpartum hemorrhage (PPH). This paper addresses the epidemiology of PPH, describes the hemostatic changes that occur in pregnancy and in PPH, and demonstrates the utilization of viscoelastic testing in the identification and treatment of patients with PPH. Additionally, a description of rotational thromboelastometry (ROTEM) and thromboelastography (TEG), the two most commonly used VETs, is detailed in this paper. VETs have only recently been used to guide blood component therapy (BCT) in trauma in the last decade. The recent increased utilization of VETs to guide BCT in PPH is following a similar trend with a delay of ten years. In a similar fashion to the trauma literature, which expanded greatly within this last decade, the literature concerning the use of VETs in PPH has also increased in the last few years. However, because of differing pathophysiologies associated with the coagulopathy of PPH verses traumatic-induced coagulopathy (TIC), utilization of VETs has been more refined and focused on the VETs’ capacity to determine low fibrinogen and to guide the utilization of blood components and prohemostatic agents. The identification and treatment of PPH depends on clinical parameters, conventional coagulation tests (CCTs) including Clauss fibrinogen, and VETs. Successful treatment of PPH will no doubt include utilization of all three strategies with an increasing utilization of VETs in the future.

Is thromboelastography reliable in postpartum coagulopathies? Two case reports and a literature review

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Elif E. Gultekin-Elbir ◽  
J. Peter R. Pelletier ◽  
Kendra R. Sylvester-Armstrong ◽  
Mehmet R. Genc
Keyword(s):  
Case Reports ◽  
Damage Control ◽  
International Normalized Ratio ◽  
Blood Component ◽  
Reference Ranges ◽  
Coagulation Tests ◽  
Maternal Morbidity And Mortality ◽  
Blood Component Therapy ◽  
Intervention Goal

AbstractPostpartum hemorrhage (PPH) is an underestimated problem in labor and delivery units and remains a leading cause of maternal morbidity and mortality worldwide. Managing PPH starts with immediate recognition and intervention. Goal-directed massive transfusion protocol can be achieved by properly monitoring the maternal coagulation profile during severe obstetric hemorrhage. Conventional coagulation tests (prothrombin time, activated partial thromboplastin time, international normalized ratio, fibrinogen analysis, platelet count) have long turnaround times (occasionally >60 min and provide little information about the in vivo condition of hemostasis) compared to viscoelastic tests (VETs) (available results within 10–30 min). The outcome in actively hemorrhaging patients can be optimized by VETs, including thromboelastography (TEG), rotational thromboelastometry and Sonoclot, providing more individualized blood component therapy compared to traditional 1:1:1 ‘damage control resuscitation’ ratios of blood transfusion strategy. The main limitations of the efficacy of VETs include, but are not limited to, the lack of validation, not having well-established reference ranges for each patient group, results affected by fluid resuscitation regimes and consistent operator proficiency. Although there is limited data with the use of VETs in obstetric patients, the value of VETs is supported by guidelines with increasing evidence. This article will demonstrate two obstetric cases to evaluate the reliability of the TEG in the management of postpartum coagulopathies. The lesson we took from our two cases is presented.

scholarly journals Quality Assessment of Established and Emerging Blood Components for Transfusion

2016 ◽  
Vol 2016 ◽  
pp. 1-28 ◽  
Author(s):  
Jason P. Acker ◽  
Denese C. Marks ◽  
William P. Sheffield
Keyword(s):  
Whole Blood ◽  
Blood Product ◽  
Standard Of Care ◽  
Blood Component ◽  
Industrialized Countries ◽  
Platelet Concentrates ◽  
Donor Blood ◽  
Additional Manufacturing ◽  
Blood Component Therapy ◽  
Nonstandard Conditions

Blood is donated either as whole blood, with subsequent component processing, or through the use of apheresis devices that extract one or more components and return the rest of the donation to the donor. Blood component therapy supplanted whole blood transfusion in industrialized countries in the middle of the twentieth century and remains the standard of care for the majority of patients receiving a transfusion. Traditionally, blood has been processed into three main blood products: red blood cell concentrates; platelet concentrates; and transfusable plasma. Ensuring that these products are of high quality and that they deliver their intended benefits to patients throughout their shelf-life is a complex task. Further complexity has been added with the development of products stored under nonstandard conditions or subjected to additional manufacturing steps (e.g., cryopreserved platelets, irradiated red cells, and lyophilized plasma). Here we review established and emerging methodologies for assessing blood product quality and address controversies and uncertainties in this thriving and active field of investigation.

The Role of Thromboelastography in Directing Blood Product Usage in Infant Open Heart Surgery

2009 ◽  
Vol 4 (5) ◽  
pp. 282-290 ◽  
Author(s):  
Eric N. Mendeloff ◽  
George F. Glenn ◽  
Paul Tavakolian ◽  
Eugene Lin ◽  
Allison Leonard ◽  
...  
Keyword(s):  
Heart Surgery ◽  
Blood Product ◽  
Open Heart Surgery ◽  
Fresh Frozen Plasma ◽  
Blood Component ◽  
Open Heart ◽  
Product Usage ◽  
Blood Component Therapy ◽  
Fresh Frozen

Objective Thromboelastography (TEG) measures the dynamics of clot formation in whole blood and provides data that can guide specific blood component therapy. This study analyzed whether the implementation of TEG affected blood product utilization and overall hemostasis in infants (6 months and younger) undergoing open heart surgery. Methods TEG values measured include R (time to fibrin formation), angle (fibrinogen formation), and MA (platelet function). Blood product usage, TEG values, and operative parameters were collected during surgery on 112 consecutive infants (66 acyanotic) undergoing open heart surgery within the first 6 months of life. Controls consisted of chart data on 70 consecutive patients (57 acyanotic) undergoing the same surgical procedures before implementation of TEG (pre-TEG). Results Using TEG, the pattern of blood product utilization changed. Compared with the pre-TEG era, TEG era patients demonstrated a significant increase in fresh frozen plasma usage intraoperatively (4.74 vs. 1.83 mL/kg; P < 0.001) and reduced postoperative use of platelets (1.69 vs. 3.74 mL/kg; P = 0.006) and cryoprecipitate (0.89 vs. 1.95 mL/kg; P = 0.149). Chest tube drainage was significantly reduced at 1, 2, and 24 hours in the TEG group. TEG angle and MA measurements suggest that fibrinogen and platelets of cyanotic patients are more sensitive to hemodilution than the acyanotic patients. Conclusions TEG allows for proactive, goal-directed blood component therapy with improved postoperative hemostasis in infants undergoing cardiopulmonary bypass.

scholarly journals Viscoelastic Hemostatic Assays for Postpartum Hemorrhage

2021 ◽  
Vol 10 (17) ◽  
pp. 3946
Author(s):  
Alyson E. Liew-Spilger ◽  
Nikki R. Sorg ◽  
Toby J. Brenner ◽  
Jack H. Langford ◽  
Margaret Berquist ◽  
...  
Keyword(s):  
Postpartum Hemorrhage ◽  
Point Of Care ◽  
Blood Component ◽  
Surgical Trauma ◽  
Point Of Care Test ◽  
Coagulation Tests ◽  
Blood Component Therapy ◽  
Acute Fatty Liver ◽  
Correct Technique ◽  
Point Of Care Tests

This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.

scholarly journals Site-Of-Care Viscoelastic Assay in Major Trauma Improves Outcomes and Is Cost Neutral Compared with Standard Coagulation Tests

Diagnostics ◽  
2020 ◽  
Vol 10 (7) ◽  
pp. 486
Author(s):  
Catriona Cochrane ◽  
Shalini Chinna ◽  
Ju Young Um ◽  
Joao D. Dias ◽  
Jan Hartmann ◽  
...  
Keyword(s):  
Blood Product ◽  
Cost Effective ◽  
Blood Products ◽  
Major Hemorrhage ◽  
Patient Demographics ◽  
Trauma Induced Coagulopathy ◽  
Significant Difference ◽  
Coagulation Tests ◽  
One Year ◽  
Level 1 Trauma Center

Major hemorrhage is often associated with trauma-induced coagulopathy. Targeted blood product replacement could achieve faster hemostasis and reduce mortality. This study aimed to investigate whether thromboelastography (TEG®) goal-directed transfusion improved blood utilization, reduced mortality, and was cost effective. Data were prospectively collected in a U.K. level 1 trauma center, in patients with major hemorrhage one year pre- and post-implementation of TEG® 6s Hemostasis Analyzers. Mortality, units of blood products transfused, and costs were compared between groups. Patient demographics in pre-TEG (n = 126) and post-TEG (n = 175) groups were similar. Mortality was significantly lower in the post-TEG group at 24 h (13% vs. 5%; p = 0.006) and at 30 days (25% vs. 11%; p = 0.002), with no difference in the number or ratio of blood products transfused. Cost of blood products transfused was comparable, with the exception of platelets (average £38 higher post-TEG). Blood product wastage was significantly lower in the post-TEG group (1.8 ± 2.1 vs. 1.1 ± 2.0; p = 0.002). No statistically significant difference in cost was observed between the two groups (£753 ± 651 pre-TEG; £830 ± 847 post-TEG; p = 0.41). These results demonstrate TEG 6s-driven resuscitation algorithms are associated with reduced mortality, reduced blood product wastage, and are cost neutral compared to standard coagulation tests.

Viscoelastic Tests as Point-of-Care Tests in the Assessment and Management of Bleeding and Thrombosis in Liver Disease

2020 ◽  
Vol 46 (06) ◽  
pp. 704-715
Author(s):  
Natasha Janko ◽  
Ammar Majeed ◽  
William Kemp ◽  
Stuart K. Roberts
Keyword(s):  
Liver Disease ◽  
Chronic Liver Disease ◽  
Blood Product ◽  
Point Of Care ◽  
Bleeding Risk ◽  
Chronic Liver ◽  
Current Evidence ◽  
Blood Component ◽  
Blood Product Transfusion ◽  
Coagulation Tests

AbstractViscoelastic point-of-care (VET POC) tests provide a global assessment of hemostasis and have an increasing role in the management of bleeding and blood component delivery across several clinical settings. VET POC tests have a rapid turnaround time, provide a better overall picture of hemostasis, predict bleeding more accurately than conventional coagulation tests, and reduce blood component usage and health care costs. Despite commonly having abnormal conventional coagulation tests, most patients with chronic liver disease have a “rebalanced” hemostasis. However, this hemostatic balance is delicate and these patients are predisposed to both bleeding and thromboembolic events. Over recent years, VET POC tests have been increasingly studied for their potential as better functional tests of hemostasis in liver disease patients. This review provides a background on the most common VET POC tests (thromboelastography and rotational thromboelastometry) and discusses the current evidence for these tests in the prediction and management of bleeding and thrombosis in patients with chronic liver disease, and in liver resection and transplant. With the recent publication of several randomized controlled trials, there is growing evidence that VET POC tests may be used to improve bleeding risk assessment and reduce blood product use in liver disease patients outside of the transplant setting. However, consensus is still lacking regarding the VET POC tests' thresholds that should be used to trigger blood product transfusion. VET POC tests also show promise in predicting thrombosis in patients with liver disease, but further research is needed before they can be used to guide anticoagulant therapy.

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