Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM®)-guided administration of fibrinogen concentrate and prothrombin complex concentrate

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Introduction

The appropriate strategy for trauma-induced coagulopathy management is under debate. We report the treatment of major trauma using mainly coagulation factor concentrates.

Methods

This retrospective analysis included trauma patients who received ≥ 5 units of red blood cell concentrate within 24 hours. Coagulation management was guided by thromboelastometry (ROTEM ^®). Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after fibrinogen concentrate administration was an indication for platelet concentrate. The observed mortality was compared with the mortality predicted by the trauma injury severity score (TRISS) and by the revised injury severity classification (RISC) score.

Results

Of 131 patients included, 128 received fibrinogen concentrate as first-line therapy, 98 additionally received PCC, while 3 patients with recent coumarin intake received only PCC. Twelve patients received FFP and 29 received platelet concentrate. The observed mortality was 24.4%, lower than the TRISS mortality of 33.7% ( P = 0.032) and the RISC mortality of 28.7% ( P > 0.05). After excluding 17 patients with traumatic brain injury, the difference in mortality was 14% observed versus 27.8% predicted by TRISS ( P = 0.0018) and 24.3% predicted by RISC ( P = 0.014).

Conclusions

ROTEM ^®-guided haemostatic therapy, with fibrinogen concentrate as first-line haemostatic therapy and additional PCC, was goal-directed and fast. A favourable survival rate was observed. Prospective, randomized trials to investigate this therapeutic alternative further appear warranted.

Related collections

Most cited references 60

Record: found
Abstract: found
Article: not found

The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital.

Matthew Borgman, Philip Spinella, Jeremy Perkins … (2007)

Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units. We performed a retrospective chart review of 246 patients at a US Army combat support hospital, each of who received a massive transfusion (>/=10 units of RBCs in 24 hours). Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion. Mortality rates and the cause of death were compared among groups. For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range, 0:12-1:5), for the medium ratio group, 1:2.5 (interquartile range, 1:3.0-1:2.3), and for the high ratio group, 1:1.4 (interquartile range, 1:1.7-1:1.2) (p < 0.001). Median Injury Severity Score (ISS) was 18 for all groups (interquartile range, 14-25). For low, medium, and high plasma to RBC ratios, overall mortality rates were 65%, 34%, and 19%, (p < 0.001); and hemorrhage mortality rates were 92.5%, 78%, and 37%, respectively, (p < 0.001). Upon logistic regression, plasma to RBC ratio was independently associated with survival (odds ratio 8.6, 95% confidence interval 2.1-35.2). In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.

0 comments Cited 246 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients.

Marc Maegele, Rolf Lefering, Nedim Yücel … (2007)

There is increasing evidence for acute traumatic coagulopathy occurring prior to emergency room (ER) admission but detailed information is lacking. A retrospective analysis using the German Trauma Registry database including 17,200 multiple injured patients was conducted to determine (a) to what extent clinically relevant coagulopathy has already been established upon ER admission, and whether its presence was associated (b) with the amount of intravenous fluids (i.v.) administered pre-clinically, (c) with the magnitude of injury, and (d) with impaired outcome and mortality. Eight thousand seven hundred and twenty-four patients with complete data sets were screened. Coagulopathy upon ER admission as defined by prothrombin time test (Quick's value) 40% of patients with >2000 ml, in >50% with >3000 ml, and in >70% with >4000 ml administered. Ten percentage of patients presented with clotting disorders although pre-clinical resuscitation was limited to 500 ml of i.v. fluids maximum. The mean ISS score in the coagulopathy group was 30 (S.D. 15) versus 21 (S.D. 12) (p<0.001). Twenty-nine percentage of patients with coagulopathy developed multi organ failure (p<0.001). Early in-hospital mortality (<24h) was 13% in patients with coagulopathy (p<0.001) and overall in-hospital mortality totalled 28% (p<0.001). There is a high frequency of established coagulopathy in multiple injury upon ER admission. The presence of early traumatic coagulopathy was associated with the amount of intravenous fluids administered pre-clinically, magnitude of injury, and impaired outcome.

0 comments Cited 170 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices.

Christoph Hofer, Michael Ganter (2008)

Perioperative monitoring of blood coagulation is critical to better understand causes of hemorrhage, to guide hemostatic therapies, and to predict the risk of bleeding during the consecutive anesthetic or surgical procedures. Point-of-care (POC) coagulation monitoring devices assessing the viscoelastic properties of whole blood, i.e., thrombelastography, rotation thrombelastometry, and Sonoclot analysis, may overcome several limitations of routine coagulation tests in the perioperative setting. The advantage of these techniques is that they have the potential to measure the clotting process, starting with fibrin formation and continue through to clot retraction and fibrinolysis at the bedside, with minimal delays. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Viscoelastic POC coagulation devices are increasingly being used in clinical practice, especially in the management of patients undergoing cardiac and liver surgery. Furthermore, they provide useful information in a large variety of clinical scenarios, e.g., massive hemorrhage, assessment of hypo- and hypercoagulable states, guiding pro- and anticoagulant therapies, and in diagnosing of a surgical bleeding. A surgical etiology of bleeding has to be considered when viscoelastic test results are normal. In summary, viscoelastic POC coagulation devices may help identify the cause of bleeding and guide pro- and anticoagulant therapies. To ensure optimal accuracy and performance, standardized procedures for blood sampling and handling, strict quality controls and trained personnel are required.

0 comments Cited 128 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Journal ID (nlm-ta): Crit Care

Title: Critical Care

Publisher: BioMed Central

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Print): 2010

Publication date (Electronic): 7 April 2010

Volume: 14

Issue: 2

Page: R55

Affiliations

[1 ]Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Dr Franz-Rehrl-Platz 5, 5010 Salzburg, Austria

[2 ]Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstrasse 13, A-1200 Vienna, Austria

[3 ]Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne-Merheim Medical Center, Ostmerheimer Strasse 200, 51109 Cologne, Germany

[4 ]Department of Anaesthesiology and Intensive Care, Munich University Hospital, Bavariaring 19, 80336 Munich, Germany

[5 ]Clinical Division B, Department of Anaesthesiology and General Intensive Care, Vienna Medical University, Spitalgasse 23, 1090 Vienna, Austria

[6 ]Department of Anaesthesiology and Intensive Care, Salzburger Landeskliniken SALK, 48 Müllner Hauptstrasse, 5020 Salzburg, Austria

Article

Publisher ID: cc8948

DOI: 10.1186/cc8948

PMC ID: 2887173

PubMed ID: 20374650

SO-VID: b06fff28-acf9-49f7-b93a-0100a8fd6c27

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 17 October 2009

Date revision received : 29 January 2010

Date accepted : 7 April 2010

Comments

Comment on this article

scite_

Cited by 137

See all cited by

Most referenced authors 583

See all reference authors