Implementation of Viscoelastic Hemostatic Assay-guided Therapy to Evaluate and Manage Trauma-related Bleeding: A Pilot Study from a Level 1 Trauma Center in Bangkok, Thailand

Abstract

Objective: To evaluate the effectiveness of viscoelastic hemostatic assay (VHA)-guided therapy for assessing and managing trauma-related bleeding using a multidisciplinary team approach at a level 1 trauma center. Materials and Methods: This retrospective pilot study included trauma-related hemorrhagic patients who underwent rotational thromboelastometry (ROTEM) during September 2019-May 2020. ROTEM trace results were compared with those of conventional coagulation tests (CCT). Results: Thirteen patients (median age: 29.1 years; male: 76.92%) were included. The median (range) days of ventilator support, ICU length of stay, and hospital length of stay was 4 [0-65], 5 [1-65], and 6 [1-83], respectively. ROTEM-guided therapy was applied 26 times, and was repeated in 7 cases. Of those, four cases were repeated to correct coagulopathy. The median time-to-confirmed hemostasis for ROTEM was substantially shorter than for CCT (92 minutes [70-110] vs. 287 minutes [204-354], respectively). The coagulation results from 26 ROTEM tests were also compared between those requiring and not requiring a massive transfusion protocol (MTP). MTP with ROTEM-guided therapy was activated in 6/13 cases. Following the resuscitation endpoints in traumatic shock, four of those had their median serum lactate levels decreased from 10.9 d/L (2.1-16.8) to 3.9 d/L (1.7-17.7). ROTEM traces detected cases with low fibrinogen that only required cryoprecipitate transfusion, and red blood cell and fresh frozen plasma use was less in ROTEM than in conventional MTP. Conclusion: VHA-guided therapy was shown to effectively facilitate goal-directed hemostatic resuscitation and efficient blood product use during resuscitation, definitive treatment, and postoperative intensive care.

Keywords

• Implementation
• viscoelastic hemostatic assay-guided therapy
• trauma-related bleeding
• rotational thromboelastometry
• trauma-induced coagulopathy