G. R. Stettler1, H. B. Moore1, G. R. Nunns1, J. Chandler2, A. Arsen Ghasabyan2, E. Peltz1, M. J. Cohen2, C. C. Silliman1, A. Banerjee1, A. Sauaia1, E. E. Moore2 1University Of Colorado,Surgery,Aurora, CO, USA 2Denver Health Medical Center,Surgery,Denver, CO, USA
Introduction: Goal directed hemostatic resuscitation based on thrombelastography (TEG) has a survival benefit compared to conventional coagulation assays. While TEG transfusion thresholds for patients at risk for massive transfusion (MT) have been defined, similar cutoffs do not exist for the other commonly used viscoelastic assay; ie, rotational thrombelastometry (ROTEM). The purpose of this study was to develop ROTEM blood product thresholds in patients at risk for MT.
Methods: ROTEM was assessed in trauma activation patients admitted from 2010 to 2016 (n=222). Receiver operating characteristics curve (ROC) analysis was performed to test the predictive performance of ROTEM measurements for blood products in patients requiring MT defined as >10 units of RBCs or death in the first 6 hours. The Youden Index defined optimal thresholds for ROTEM-based resuscitation for each aspect of clot formation and breakdown. Transfusions were guided by TEG and physicians were blinded to ROTEM results.
Results:As anticipated, patients who received a MT (n=37) were sicker with more abnormal physiologic and laboratory values (Table). Prolonged clot initiation is an indication for plasma and reflected by EXTEM CT. EXTEM CT was longer in patients with MT compared to those without (87 vs 64 seconds, p<0.0001). Abnormal dynamics of clot formation is an indication for fibrinogen products and reflected by EXTEM Angle. EXTEM Angle was shallower in MT patients compared to those that did not (54 vs 69 degrees, p<0.0001). Low clot strength is an indication for platelets and reflected by EXTEM CA10. CA10 was less in MT compared to non-MT patients (30.5 vs 50 mm, p<0.0001). Increased fibrinolysis is an indication for antifibrinolytics and reflected by EXTEM CLI60. CLI60 was lower in patients that had MT than those that did not (47 vs 94 percent, p=0.0006). EXTEM CT yielded an area under the ROC curve (AUROC) = 0.7116, and a cut point of >78.5 sec. EXTEM angle had an AUROC = 0.865, and a cut point of <64.5 degrees. EXTEM CA10 had an AUROC = 0.858, with a cut point of <40.5 mm. CLI60 had an AUROC = 0.6788 with a cut point at < 74%.
Conclusion:We have identified ROTEM thresholds to guide hemostatic resuscitation during MT in trauma, and propose plasma transfusion for EXTEM CT >78.5 seconds, fibrinogen products for angle <64.5 degrees, platelet transfusion for CA10 <40.5 mm, and antifibrinolytics for CLI60 <74%.
