Monitoring patients at risk of massive transfusion with Thrombelastography or Thromboelastometry: A systematic review

Department of Anesthesiology and Intensive Care, Herlev Hospital, University of Copenhagen, Denmark.
Acta Anaesthesiologica Scandinavica (Impact Factor: 2.32). 11/2011; 55(10):1174-89. DOI: 10.1111/j.1399-6576.2011.02534.x
Source: PubMed


Thrombelastography (TEG) and Thrombelastometry (ROTEM) are viscoelastic whole-blood assays evaluating the haemostatic capacity of blood. These devices are used in algorithms to guide transfusion of haemostatic blood components.
The methods used for this study were systematic reviews with meta-analyses and trial sequential analyses of randomised clinical trials (RCTs) of TEG/ROTEM-based algorithm compared with standard treatment in patients with bleeding. Primary outcome was all-cause mortality. We searched the literature in seven databases (up to 31 October 2010), reference lists, registers of ongoing trials, and contacted authors and experts. We extracted data from included studies related to study methods, interventions, outcomes, bias risk and adverse events using Cochrane methodology. All trials irrespective of blinding or language status were included.
Nine trials involving 776 participants were included. Eight trials involved cardiac surgery with an average blood loss of 390-960  ml, and one trial investigated liver transplantations. One trial was classified as low-risk-of-bias trial. We found two ongoing trials. No impact was identified on mortality, amount of blood transfused, incidence of surgical reinterventions, time to extubation, or length of stay in hospital and intensive care unit. We identified a significant reduction in blood loss favouring the use of TEG/ROTEM {85  ml [95% confidence interval (CI) 29.4-140.7]} and in the proportion of patients receiving freshly frozen plasma and platelets [relative risk 0.39 (95%CI 0.27-0.57)].
There is currently weak evidence to support the use of TEG/ROTEM as a tool to guide transfusion in patients with severe bleeding. Further studies need to address other clinical settings and with larger blood losses.

37 Reads
  • Source
    • "They demonstrated that the coefficient of variation for TEG ranged from 7Á1–39Á9% while for ROTEM it was 7Á0–83Á6%. From the clinical point of view, a Cochrane systematic review of nine RCTs (involving 776 bleeding patients) concluded that TEG or ROTEM significantly reduced blood loss, but there was no impact on mortality, amount of blood transfused or length of stay in hospital and intensive care units (Wikkelsoe et al, 2011). Additionally, the review identified appreciable heterogeneity between trials and a high risk of bias. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Major obstetric haemorrhage (MOH) remains an important medical challenge worldwide, contributing to significant maternal morbidity and mortality. Prompt and appropriate management is essential if we are to improve outcomes and reduce substandard care that may result in adverse consequences. This review describes the current understanding of the pathophysiological aspects of MOH together with the principles of transfusion and haemostatic therapy, with emphasis on a coordinated multidisciplinary approach. We also highlight the current lack of evidence available from randomized controlled trials to inform best practice and the need to prioritize research in this key clinical area.
    British Journal of Haematology 01/2014; 164(2):177-88. DOI:10.1111/bjh.12605 · 4.71 Impact Factor
  • Source
    • "Dealing with rapid changes as frequently occurs in massively bleeding trauma patients, is challenging. In such situations, any delay in obtaining the lab results can lead to inadequate transfusion and increased morbidity and mortality [4]. Thus in trauma, global, functional and immediately available laboratorial evaluation of hemostasis can improve both patient management and outcome. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Transfusion in trauma is often empiric or based on traditional lab tests. Viscoelastic tests such as thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) have been proposed as superior to traditional lab tests. Due to the similarities between the two tests, general opinion seems to consider them equivalent with interchangeable interpretations. However, it is not clear whether the results can be similarly interpreted. This review evaluates the comparability between TEG and ROTEM and performs a descriptive review of the parameters utilized in each test in adult trauma patients. PUBMED database was reviewed using the keywords "thromboelastography" and "compare", between 2000 and 2011. Original studies directly comparing TEG® with ROTEM® in any area were retrieved. To verify the individual test parameter used in studies involving trauma patients, we further performed a review using the keywords "thromboelastography" and "trauma" in the PUBMED database. Only 4 studies directly compared TEG® with ROTEM®. One in liver transplantation found that transfusion practice could differ depending on the device in use. Another in cardiac surgery concluded that all measurements are not completely interchangeable. The third article using commercially available plasma detected clinically significant differences in the results from the two devices. The fourth one was a head-to-head comparison of the technical aspects. The 24 articles reporting the use of viscoelastic tests in trauma patients, presented considerable heterogeneity. Both tests are potentially useful as means to rapidly diagnose coagulopathy, guide transfusion and determine outcome in trauma patients. Differences in the activators utilized in each device limit the direct comparability. Standardization and robust clinical trials comparing the two technologies are needed before these tests can be widely recommended for clinical use in trauma.
    World Journal of Emergency Surgery 08/2012; 7 Suppl 1(Suppl 1):S3. DOI:10.1186/1749-7922-7-S1-S3 · 1.47 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Despite increasing efforts to provide evidence based treatments for our patients, there is still a large gap between our daily practices and the level of evidence. However, even in the face of what appears to be solid evidence, issues such as scientific fraud, heterogeneity of included patients, interventions and settings may weaken our faith in evidence based medicine. It is however important to view published papers with methodological and scientific vigilance and scrutiny to avoid implementation of interventions that may prove to be harmful only when results of better and larger trials appear. In this paper, I will provide a snapshot overview of some of the major publications of the previous year through this periscope in regards to topics such as fluid resuscitation, transfusion and coagulation management and intraoperative awareness.
    Trends in Anaesthesia and Critical Care 04/2012; 2(2):81–85. DOI:10.1016/j.tacc.2012.02.001
Show more