Panamerican Journal of Trauma, Critical Care & Emergency Surgery

Register      Login

VOLUME 12 , ISSUE 1 ( January-April, 2023 ) > List of Articles


The Other Side of the Coin: Using Rotational Thromboelastometry to Stop or Avoid Blood Transfusions in Trauma Patients

José G Parreira, Sandro Rizoli, Joao Rezende-Neto

Keywords : Blood transfusion, Coagulopathy, Diagnostics, Hemorrhage, Injury, Massive transfusion, Rotational thromboelastometry, Shock, Trauma, Viscoelastic

Citation Information : Parreira JG, Rizoli S, Rezende-Neto J. The Other Side of the Coin: Using Rotational Thromboelastometry to Stop or Avoid Blood Transfusions in Trauma Patients. Panam J Trauma Crit Care Emerg Surg 2023; 12 (1):35-41.

DOI: 10.5005/jp-journals-10030-1413

License: CC BY-NC 4.0

Published Online: 29-04-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Aim: To assess rotational thromboelastometry (ROTEM) as a tool to stop or avoid unnecessary transfusions in trauma patients. Materials and methods: Retrospective analysis in a period of 12 months, including all adult patients with a ROTEM assay upon arrival. In an initial analysis, patients were assigned to one of the two groups—“normal (NL) ROTEM” or “abnormal ROTEM.” The “NL ROTEM” group had all ROTEM parameters within the normal range. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and odds ratio (OR) were calculated, which was repeated in subgroups of patients with ISS ≥ 16 and with systolic blood pressure (SBP) ≤90 mm Hg. In a second analysis, prediction models for the transfusion of each blood product were created by multivariate logistic regression, including all ROTEM parameters and the SBP on hospital admission. The prediction models were analyzed by the area under the receiver operating characteristics curve (AUROC). Results: A total of 793 patients fulfilled the inclusion criteria (80.2% blunt trauma and 73.5% male). NL ROTEM was observed in 604 (76.2%) patients. The NL ROTEM NPV for transfusion of any blood product (BBP), plasma (PLS), platelets (PLT), and >9 units of red blood cells (>9 RBC) were, respectively, 94.7, 98.3, 98.8, and 99.7%. Regarding patients with ISS ≥ 16, the NL ROTEM NPV for BBP, PLS, PLT, and >9 RBC were, respectively, 83.8, 92.5, 96.3, and 98.8%. In the subgroup of patients admitted with SBP ≤ 90 mm Hg, NL ROTEM predicted 93.3% of cases in which massive transfusion did not happen. Considering all patients, the AUC observed for the prediction model of >9 RBC was 0.982. Conclusion: Patients with an NL ROTEM assay at admission had a lower need for blood transfusions in the first 24 hours after trauma, even in subgroups sustaining severe injuries and hemodynamic instability. Clinical significance: The NL ROTEM seems to be a useful tool to avoid transfusions in trauma patients.

PDF Share
  1. Holcomb JB, Fox EE, Wade CE, et al. The PRrospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. J Trauma Acute Care Surg 2013;75(1 Suppl 1):S1–2. DOI: 10.1097/TA.0B013E3182983876
  2. Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma 2003;54(6):1127–1130. DOI: 10.1097/01.TA.0000069184.82147.06
  3. Maier RV. Scudder oration on trauma. A century of evolution in trauma resuscitation. J Am Coll Surg 2014;219(3):335–345. DOI: 10.1016/J.JAMCOLLSURG.2014.04.011
  4. Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg 2011;254(4):598–605. DOI: 10.1097/SLA.0B013E318230089E
  5. Olldashi F, Kerçi M, Zhurda T, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet 2010;376(9734):23–32. DOI: 10.1016/S0140-6736(10)60835-5
  6. Albrecht V, Schäfer N, Stürmer EK, et al. Practice management of acute trauma haemorrhage and haemostatic disorders across German trauma centres. Eur J Trauma Emerg Surg 2017;43(2):201–214. DOI: 10.1007/S00068-015-0608-7
  7. Etchill E, Sperry J, Zuckerbraun B, et al. The confusion continues: results from an American Association for the Surgery of Trauma survey on massive transfusion practices among United States trauma centers. Transfusion 2016;56(10):2478–2486. DOI: 10.1111/TRF.13755
  8. Gianola S, Castellini G, Biffi A, et al. Accuracy of risk tools to predict critical bleeding in major trauma: a systematic review with meta-analysis. J Trauma Acute Care Surg 2022;92(6):1086–1096. DOI: 10.1097/TA.0000000000003496
  9. Shander A, Fink A, Javidroozi M, et al. Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes. Transfus Med Rev 2011;25(3):232–246. DOI: 10.1016/J.TMRV.2011.02.001
  10. Johnson JL, Moore EE, Kashuk JL, et al. Effect of blood products transfusion on the development of postinjury multiple organ failure. Arch Surg 2010;145(10):973–977. DOI: 10.1001/ARCHSURG.2010.216
  11. Dunbar NM, Olson NJ, Szczepiorkowski ZM, et al. Blood component transfusion and wastage rates in the setting of massive transfusion in three regional trauma centers. Transfusion 2017;57(1):45–52. DOI: 10.1111/TRF.13880
  12. Johansson PI, Stissing T, Bochsen L, et al. Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med 2009;17:45. DOI: 10.1186/1757-7241-17-45
  13. Veigas PV, Callum J, Rizoli S, et al. A systematic review on the rotational thrombelastometry (ROTEM®) values for the diagnosis of coagulopathy, prediction and guidance of blood transfusion and prediction of mortality in trauma patients. Scand J Trauma Resusc Emerg Med 2016;24(1):114. DOI: 10.1186/S13049-016-0308-2
  14. Da Luz LT, Nascimento B, Shankarakutty AK, et al. Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care 2014;18(5):518. DOI: 10.1186/S13054-014-0518-9
  15. Winearls J, Reade M, Miles H, et al. Targeted coagulation management in severe trauma: the controversies and the evidence. Anesth Analg 2016;123(4):910–924. DOI: 10.1213/ANE.0000000000001516
  16. Gonzalez E, Moore EE, Moore HB, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg 2016;263(6):1051–1059. DOI: 10.1097/SLA.0000000000001608
  17. Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019;23(1):98. DOI: 10.1186/S13054-019-2347-3
  18. Bugaev N, Como JJ, Golani G, et al. Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2020;89(6):999–1017. DOI: 10.1097/TA.0000000000002944
  19. Hunt H, Stanworth S, Curry N, et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev 2015;2015(2):CD010438. DOI: 10.1002/14651858.CD010438.PUB2
  20. Inaba K, Rizoli S, Veigas PV, et al. 2014 Consensus conference on viscoelastic test-based transfusion guidelines for early trauma resuscitation: report of the panel. J Trauma Acute Care Surg 2015;78(6):1220–1229. DOI: 10.1097/TA.0000000000000657
  21. Baksaas-Aasen K, Gall LS, Stensballe J, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med 2021;47(1):49–59. DOI: 10.1007/S00134-020-06266-1
  22. Moore EE, Moore HB, Kornblith LZ, et al. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021;7(1):29. DOI: 10.1038/S41572-021-00264-3
  23. Gomez-Builes JC, Acuna SA, Nascimento B, et al. Harmful or physiologic: diagnosing fibrinolysis shutdown in a trauma cohort with rotational thromboelastometry. Anesth Analg 2018;127(4): 840–849. DOI: 10.1213/ANE.0000000000003341
  24. Dujardin RWG, Kleinveld DJB, Gaarder C, et al. Coagulopathy underlying rotational thromboelastometry derangements in trauma patients: a prospective observational multicenter study. Anesthesiology 2022;137(2):232–242. DOI: 10.1097/ALN.0000000000004268
  25. David JS, Friggeri A, Vacheron CH, et al. Is it possible to improve prediction of outcome and blood requirements in the severely injured patients by defining categories of coagulopathy? Eur J Trauma Emerg Surg 2022;48(4):2751–2761. DOI: 10.1007/s00068-022-01882-6
  26. Brill JB, Brenner M, Duchesne J, et al. The Role of TEG and ROTEM in damage control resuscitation. Shock 2021;56(1S):52–61. DOI: 10.1097/SHK.0000000000001686
  27. Riehl K, Lefering R, Maegele M, et al. Is ROTEM diagnostic in trauma care associated with lower mortality rates in bleeding patients?-a retrospective analysis of 7461 patients derived from the TraumaRegister DGU®. J Clin Med 2022;11(20):6150. DOI: 10.3390/jcm11206150
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.