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Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management
Nikolay Bugaev1, John J Como, Guy Golani
1From the Division of Trauma and Acute Care Surgery (N.B.), Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Department of Surgery (J.J.C.), MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery A (G.G.), Soroka Medical Center, Beer Sheva, Israel; Department of Surgery (J.J.F.), TCU and UNTHSC School of Medicine, Fort Worth, Texas; Maine Medical Center (J.S.S.), Portland, Maine; Division of Trauma and Critical Care Surgery (C.J.V.), Department of Surgery, Duke University School of Medicine, Durham, North Carolina; University of Florida College of Medicine-Jacksonville (B.K.Y.), Jacksonville, Florida; Case Western University School of Medicine (L.A.K.), Cleveland, Ohio; Division of Trauma, Surgical Critical Care, and Acute Care Surgery (N.M.G.), Department of Surgery, Brody School of Medicine, East Carolina University, Greenville; Weill Cornell University (H.A.A.), Doha, Qatar; Department of Surgery (P.A.P.), College of Medicine, University of Central Florida, Orlando; Division of Trauma and Acute Care Surgery (E.J.M.), Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; 2D Medical Battalion, 2D Marine Logistics Group (Z.W.B.), Camp LeJeune, North Carolina; Department of Surgery (Z.W.B.), Uniformed Services University of the Health Sciences, Bethesda; and Division of Trauma and Critical Care Surgery (G.K.), Department of Surgery, Duke University School of Medicine, Durham, North Carolina.
Background:
Assessment of the immediate need for specific blood product transfusions in acutely bleeding patients is challenging. Clinical assessment and commonly used coagulation tests are inaccurate and time-consuming. The goal of this practice management guideline was to evaluate the role of the viscoelasticity tests, which are thromboelastography (TEG) and rotational thromboelastometry (ROTEM), in the management of acutely bleeding trauma, surgical, and critically ill patients.
Methods:
Systematic review and meta-analyses of manuscripts comparing TEG/ROTEM with non-TEG/ROTEM-guided blood products transfusions strategies were performed. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied to assess the level of evidence and create recommendations for TEG/ROTEM-guided blood product transfusions in adult trauma, surgical, and critically ill patients.
Results:
Using TEG/ROTEM-guided blood transfusions in acutely bleeding trauma, surgical, and critically ill patients was associated with a tendency to fewer blood product transfusions in all populations. Thromboelastography/ROTEM-guided transfusions were associated with a reduced number of additional invasive hemostatic interventions (angioembolic, endoscopic, or surgical) in surgical patients. Thromboelastography/ROTEM-guided transfusions were associated with a reduction in mortality in trauma patients.
Conclusion:
In patients with ongoing hemorrhage and concern for coagulopathy, we conditionally recommend using TEG/ROTEM-guided transfusions, compared with traditional coagulation parameters, to guide blood component transfusions in each of the following three groups: adult trauma patients, adult surgical patients, and adult patients with critical illness.
Level Of Evidence:
Systematic Review/Meta-Analysis, level III.
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