A. R. Smith1, K. Stephenson1, H. Jensen1, R. Reif1, K. Kalkwarf1, W. Beck1, B. Davis1, A. Bhavaraju1, M. K. Kimbrough1, K. W. Sexton1 1University Of Arkansas for Medical Sciences,Department Of Surgery, Division Of Trauma And Acute Care,Little Rock, AR, USA
Introduction: Hyperfibrinolysis occurs when the balance between activators and inhibitors of fibrinolysis are disturbed. In actively bleeding patients, hyperfibrinolysis is associated with significantly higher morbidity, mortality, and a higher rate of transfusion of blood products. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are whole-blood viscoelastic hemostasis analyzers that are highly sensitive in detecting real-time hyperfibrinolysis in both critically ill non-trauma and trauma patient populations. A previous study showed that a “diamond-shaped” tracing on TEG has been shown to have a 100% positive predictive value for mortality. The purpose of our study is to retrospectively evaluate trauma patients with the “death diamond” pattern on ROTEM to gain further insight into the survivability of this highly lethal phenotype.
Methods: We performed a retrospective review of all trauma patients admitted to the emergency department at our institution between November 2015 and December 2018 who had a ROTEM performed on admission. A total of 848 patients met the aforementioned criteria and were included in this study. Patients were sorted into groups based upon their fibrinolytic phenotype (Clot Retraction, Hyperfibrinolysis, Death Diamond) as determined by their Maximum Lysis ROTEM value. We subsequently compared each phenotype to its relationship with mortality.
Results: Of the 848 patients, 3.3% developed a hyperfibrinolytic state (n=18). Within this subgroup, 27.8% (n=5) of patients developed the “death diamond” phenotype as defined by a Maximum Lysis ROTEM value of 100%. In this subset of patients, the mortality rate was 60% (n=3). In patients that fell into the “Clot Retraction” phenotype, as defined by a Maximum Lysis ROTEM value between 3% and 15%, and “Hyperfibrinolysis” phenotype, as defined by a Maximum Lysis ROTEM greater than 15% and less than 100%, there was a combined 2% mortality rate.
Conclusion: Critically ill non-trauma and trauma patients who display the “death diamond” phenotype on their admission ROTEM are at an increased risk of mortality. However, in our study, the “death diamond” pattern on ROTEM was not associated with a 100% mortality as had been shown in previous studies for TEG. Due to the amount of blood products and other resources required for resuscitation in patients with this fibrinolytic pattern, this tracing on admission may objectively provide criteria to guide resuscitation efforts. Our findings indicate that further exploration is needed to identify criteria and outcomes for the “death diamond” phenotype in ROTEM.