Postinjury Coagulopathy Management Goal Directed Resuscitation via POC Thrombelastography

Department of Surgery, Denver Health Medical Center, University of Colorado Denver, CO, USA.
Annals of surgery (Impact Factor: 8.33). 03/2010; 251(4):604-14. DOI: 10.1097/SLA.0b013e3181d3599c
Source: PubMed


Progressive postinjury coagulopathy remains the fundamental rationale for damage control surgery, but the decision to abort operative intervention must occur before laboratory confirmation of coagulopathy. Current massive transfusion protocols have embraced pre-emptive resuscitation strategies emphasizing administration of packed red blood cells, fresh frozen plasma, and platelets in ratios approximating 1:1:1 during the first 24 hours postinjury, based on US military retrospective experience and recent noncontrolled civilian data. This policy, termed "damage control resuscitation" assumes that patients presenting with life threatening hemorrhage at risk for postinjury coagulopathy should receive component therapy in rations approximating those found in whole blood during the first 24 hours. While we concur with the concept of pre-emptive coagulation factor replacement, and initially suggested this in 1982, we remain concerned for the continued unbridled administration of fresh frozen plasma and platelets without objective evidence of their specific requirement. A major limitation of current massive transfusion protocols is the lack of real time assessment of coagulation function to guide evolving blood component requirements. Existing laboratory coagulation testing was originally designed for evaluation of hemophilia and subsequently used for monitoring anticoagulation therapy. Consequently, the applicability of these tests in the trauma setting has never been proven and the time required to conduct these assays is incompatible with prompt correction of the coagulopathy in the trauma setting. This review examines the current approach to postinjury coagulopathy, including identification of patients at risk, resuscitation strategies, design and implementation of institutional massive transfusion protocols, and the potential benefits of goal-directed therapy by real time assessment of coagulation function via point of care rapid thromboelastography.

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    • "This entails the early and aggressive use of hemostatic products combined with red blood cells as the primary resuscitation fluids in order to avoid rapid deterioration into the “bloody vicious cycle” and the classic “lethal triad” of hypothermia, acidosis and coagulopathy [42]. Two very distinct paradigms of hemostatic resuscitation have currently emerged: the damage control resuscitation (DCR) model, which uses pre-emptive administration of empiric ratios of blood and hemostatic products to approximate whole blood, often according to an established institutional “massive transfusion protocol” [43-47]; and goal-directed hemostatic resuscitation approaches (also often protocol-based), which generally use point-of-care viscoelastic monitoring (Figure 3) combined with the prompt administration of hemostatic concentrates [24,26,27,34]. Regardless, it is highly likely that the patient with massive hemorrhage who arrives to the ICU under-resuscitated with a coagulopathy has been managed according to some sort of hemostatic resuscitation approach which should be continued in the ICU until it is clear that hemostasis has been achieved. "
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    ABSTRACT: Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 09/2012; 20(1):68. DOI:10.1186/1757-7241-20-68 · 2.03 Impact Factor
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    • "Both tests provide the potential to supersede CCT in the diagnosis of TIC because they provide real-time assessment of clot physiology from initial activation, subsequent achievement of tensile strength, and eventual resolution/degradation via a graphical tracing of fibrin polymerization and clot strength. Beyond the early diagnosis of TIC via point-of-care assessment, perhaps the most promising future for TEG®/ROTEM® technology is the additional potential benefit of early goal-directed therapy, with the objective to optimize and possibly reduce blood product utilization [9]. "
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    ABSTRACT: Thromboelastography and thromboelastometry represent viscoelastic diagnostic methodologies with promising application to diseases of altered coagulation. Their use in trauma-induced coagulopathy as a means of assessing the real-time status of the patient's functional coagulation profile in addition to its impact on effective and appropriate use of blood product support has been gaining acceptance among trauma surgeons, anesthesiologists, and transfusion medicine specialists. However, the ability of viscoelastic testing to augment or supplant conventional coagulation testing for the diagnosis and management of trauma-induced coagulopathy remains controversial. Many of these issues pertain to the differences in methodology, instrumentation, logic, accessibility, ease of use, operator variability, and the method's relationship to patient care, blood product use, cost, and conventional testing algorithms.
    Critical care (London, England) 12/2011; 15(6):1021. DOI:10.1186/cc10569 · 4.48 Impact Factor
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    • "Thromboelastography (TEG™) and rotational thromboelastometry (ROTEM™) add a direct display of clot strength and subsequent clot lysis not observed with traditional laboratory testing [43-45]. Experience in trauma patients has identified specific parameters of TEG™ and ROTEM™ that can be used as a guide to blood component treatment [41,46-48]. In trauma patients, however, results correlated poorly (r2 = 0.22 to 0.28) with those obtained using traditional laboratory tests [49]. "
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    ABSTRACT: In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.
    Critical care (London, England) 12/2011; 15(6):242. DOI:10.1186/cc10498 · 4.48 Impact Factor
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