VHA-guided resuscitation and post-24-hour survival in traumatic hemorrhage: a propensity- matched retrospective...

Traumatic hemorrhage is the predominant preventable cause of mortality in severe trauma cases. Timely and efficacious hemostatic resuscitation is crucial for the management of severe traumatic hemorrhages. This study aimed to evaluate the association between implementation of viscoelastic hemostatic assay (VHA)/TEG-guided hemostatic resuscitation and clinical outcomes among transfused traumatic hemorrhage patients who survived at least 24 h after emergency department arrival in China.

We conducted a retrospective, single-center before-after cohort study of trauma patients admitted to the emergency department of a tertiary trauma center from January 2012 to December 2021. Patients admitted from 2012 to 2016 were managed using a conventional coagulation assay (CCA)-guided strategy, whereas patients admitted from 2017 to 2021 were managed using a VHA/TEG-guided strategy. Because the analysis required complete 24-h coagulation and transfusion-response data, the primary cohort was defined as transfused traumatic hemorrhage patients who survived at least 24 h after emergency department arrival. Propensity score matching was used to reduce baseline imbalance. The primary outcome was post-24-h in-hospital mortality.

A total of 154 patients who survived at least 24 h were included after propensity score matching, with 77 patients in each group. Post-24-h in-hospital death occurred in 21 of 77 patients in the CCA-guided group and 9 of 77 patients in the VHA-guided group. Kaplan-Meier analysis showed improved post-24-h in-hospital survival in the VHA-guided group (log-rank P = 0.015). In multivariable Cox regression adjusting for age, ISS, APACHE II score, admission shock index, and baseline PT, VHA-guided resuscitation was associated with a lower hazard of post-24-h in-hospital death (adjusted HR 0.37, 95% CI 0.16-0.84, P = 0.018). The VHA-guided group exhibited reduced plasma utilization and greater fibrinogen-directed replacement compared with the CCA-guided group.

Among transfused traumatic hemorrhage patients who survived at least 24 h, VHA-guided hemostatic resuscitation was associated with improved post-24-h in-hospital survival, reduced plasma exposure, greater fibrinogen-directed replacement, and improved PT correction. This study cannot determine whether VHA-guided resuscitation improves survival during the initial 24 h, when early hemorrhagic mortality is highest. Because of the retrospective before-after design, survivorship bias, and residual confounding, these findings should be interpreted as hypothesis-generating.