• Gregory R Stettler, Joshua J Sumislawski, Ernest E Moore, Geoffrey R Nunns, Lucy Z Kornblith, Amanda S Conroy, Rachael A Callcut, Christopher C Silliman, Anirban Banerjee, Mitchell J Cohen, and Angela Sauaia.
• From the Department of Surgery (G.R.S., J.J.S., G.R.N., A.S.), University of Colorado, Aurora, Colorado; Department of Surgery (E.E.M., M.J.C.), Denver Health Medical Center, Denver, Colorado; Department of Pediatrics (C.C.S.), University of Colorado, Aurora, Colorado; Bonfils Blood Center (C.C.S.), Denver, Colorado; University of Colorado School of Public Health (A.S.), University of Colorado, Aurora, Colorado; and Department of Surgery (L.Z.K., A.S.C., R.A.C.), Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California.
• J Trauma Acute Care Surg. 2018 Oct 1; 85 (4): 734-740.

IntroductionGoal-directed hemostatic resuscitation based on thrombelastography (TEG) has a survival benefit compared with conventional coagulation assays such as international normalized ratio, activated partial thromboplastin time, fibrinogen level, and platelet count. While TEG-based transfusion thresholds for patients at risk for massive transfusion (MT) have been defined using rapid TEG, cutoffs have not been defined for TEG using other activators such as kaolin. The purpose of this study was to develop thresholds for blood product transfusion using citrated kaolin TEG (CK-TEG) in patients at risk for MT.MethodsCK-TEG was assessed in trauma activation patients at two Level 1 trauma centers admitted between 2010 and 2017. Receiver operating characteristic (ROC) curve analyses were performed to test the predictive performance of CK-TEG measurements in patients requiring MT, defined as >10 units of red blood cells or death within the first 6 hours. The Youden Index defined optimal thresholds for CK-TEG-based resuscitation.ResultsOf the 825 trauma activations, 671 (81.3%) were men, 419 (50.8%) suffered a blunt injury, and 62 (7.5%) received a MT. Patients who had a MT were more severely injured, had signs of more pronounced shock, and more abnormal coagulation assays. CK-TEG R-time was longer (4.9 vs. 4.4 min, p = 0.0084), angle was lower (66.2 vs. 70.3 degrees, p < 0.0001), maximum amplitude was lower in MT (57 vs. 65.5 mm, p < 0.0001), and LY30 was greater (1.8% vs. 1.2%, p = 0.0012) in patients with MT compared with non-MT. To predict MT, R-time yielded an area under the ROC curve (AUROC) = 0.6002 and a cut point of >4.45 min. Angle had an AUROC = 0.6931 and a cut point of <67 degrees. CMA had an AUROC = 0.7425, and a cut point of <60 mm. LY30 had an AUROC = 0.623 with a cut point of >4.55%.ConclusionWe have identified CK-TEG thresholds that can guide MT in trauma. We propose plasma transfusion for R-time >4.45 min, fibrinogen products for an angle <67 degrees, platelet transfusion for MA <60 mm, and antifibrinolytics for LY30 >4.55%.Level Of EvidenceTherapeutic study, level V.

21 keywords...

hide…