Panamerican Journal of Trauma, Critical Care & Emergency Surgery

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VOLUME 7 , ISSUE 2 ( May-August, 2018 ) > List of Articles


A Comparative Analysis of Functional Fibrinogen Assays using TEG and ROTEM in Trauma Patients Enrolled in the FiiRST Trial

Homer Tien, Henry T Peng, Barto Nascimento, Jeannie Callum, Shawn G Rhind, Andrew Beckett

Keywords : Coagulation tests, Fibrinogen concentrate, Functional fibrinogen, Thrombelastography, Thromboelastometry, Trauma

Citation Information : Tien H, Peng HT, Nascimento B, Callum J, Rhind SG, Beckett A. A Comparative Analysis of Functional Fibrinogen Assays using TEG and ROTEM in Trauma Patients Enrolled in the FiiRST Trial. Panam J Trauma Crit Care Emerg Surg 2018; 7 (2):143-157.

DOI: 10.5005/jp-journals-10030-1217

License: NA

Published Online: 07-08-2018

Copyright Statement:  NA


Introduction: Given the growing use of both thrombelastography (TEG) and rotational thromboelastometry (ROTEM) in trauma and surgery, it is important to determine whether the two are interchangeable, and how comparable they are to Clauss fibrinogen assay and for clinical use. We recently completed a randomized control trial on early fibrinogen in trauma (the Fii RST trial). The object of this analysis was to evaluate the interchangeability and correlations between TEG and ROTEM functional fibrinogen assays in injured trauma patients. Also, we evaluated their correlation with Clauss fibrinogen and compared their potentials for diagnosis of coagulopathy and use in guided fibrinogen administration. Materials and Methods: The Post-hoc analysis of the coagulation data collected as part of the FiiRST trial. It was a comparative analysis of functional fibrinogen assays using TEG and ROTEM in trauma patients screened for hypotension and need for blood transfusion. TEG and ROTEM tests were also compared with Clauss fibrinogen assay and INR as additional analyses of their clinical use. Results: TEG and ROTEM parameter values were correlated but were significantly different, and their agreement fell outside acceptable limits and thus were not interchangeable. TEG maximum amplitude (MA) and ROTEM maximum clot firmness (MCF) showed closest correlations with Clauss fibrinogen concentration, particularly with ROTEM FIBTEM MCF (r = 0.84; p < 0.001). There were discrepancies between TEG and ROTEM in their detection of coagulation abnormalities, hypofibrinogenemia, and hyperfibrinolysis. Conclusion: TEG and ROTEM fibrinogen assay parameters were associated, especially between TEG MA and ROTEM MCF, showing the strongest correlation, but the parameters were not interchangeable. TEG and ROTEM showed varying extents of correlations with Clauss fibrinogen. Overall, ROTEM parameters exhibited better correlations with Clauss fibrinogen than TEG. Different algorithms for TEG and ROTEM need to be developed for diagnosis of coagulopathy and guided fibrinogen administration in trauma.

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  1. Whiting D, DiNardo JA: Teg and rotem: Technology and clinical applications. Am J Hematol 2014;89(2): 228-232.
  2. Gonzalez E, Pieracci FM, Moore EE, Kashuk JL: Coagulation abnormalities in the trauma patient: The role of point-of-care thromboelastography. Semin Thromb Hemost 2010;36(7): 723-737.
  3. Sankarankutty A, Nascimento B, da Luz LT, Rizoli S: TEG® and ROTEM® in trauma: Similar test but different results? World J Emerg Surg 2012;7(Suppl 1): S3.
  4. Inaba K, Rizoli S, Veigas PV, Callum J, Davenport R, Hess J, Maegele M: 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.
  5. Spahn DR, Spahn GH, Stein P. Indications and risks of fibrinogen in surgery and trauma. Presented at: Seminars in Thrombosis and Hemostasis, New York, NY, USA, March 2016.
  6. Görlinger K, Fries D, Dirkmann D, Weber CF, Hanke AA, Schöchl H: Reduction of fresh frozen plasma requirements by perioperative point-of-care coagulation management with early calculated goal-directed therapy. Transfus Med Hemother 2012;39(2): 104-1013.
  7. Karkouti K, Callum J, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC, TACS Investigators: Point-of-care hemostatic testing in cardiac surgeryclinical perspective: A stepped-wedge clustered randomized controlled trial. Circulation 2016;134(16): 1152-1162.
  8. Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, Wohlauer MV, Barnett CC, Bensard DD, Biffl WL: 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.
  9. Kashuk JL, Moore EE, Sawyer M, Wohlauer M, Pezold M, Barnett C, Biffl WL, Burlew CC, Johnson JL, Sauaia A: Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma. Ann Surg 2010;252(3): 434-442.
  10. Schöchl H, Frietsch T, Pavelka M, Jámbor C: Hyperfibrinolysis after major trauma: Differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma Acute Care Surg 2009;67(1): 125-131.
  11. Bolliger D, Seeberger MD, Tanaka KA: Principles and practice of thromboelastography in clinical coagulation management and transfusion practice. Transfus Med Rev 2012;26(1): 1-13.
  12. Schobersberger W, Fries D, Mittermayr M, Innerhofer P, Sumann G, Schobersberger B, Klingler A, Stöllnberger V, Fischbach U, Gunga HC: Changes of biochemical markers and functional tests for clot formation during long-haul flights. Thromb Res 2003;108(1): 19-24.
  13. Enriquez LJ, Shore-Lesserson L: Point-of-care coagulation testing and transfusion algorithms. Br J Anaesth 2009;103(suppl 1): i14-i22.
  14. Solomon C, Sørensen B, Hochleitner G, Kashuk J, Ranucci M, Schöchl H: Comparison of whole blood fibrin-based clot tests in thrombelastography and thromboelastometry. Anesth Analg 2012;114(4): 721-730.
  15. Venema LF, Post WJ, Hendriks HG, Huet RC, De Wolf JT, De Vries AJ: An assessment of clinical interchangeability of TEG® and ROTEM® thromboelastographic variables in cardiac surgical patients. Anesth Analg 2010;111(2): 339-344.
  16. Tomori T, Hupalo D, Teranishi K, Michaud S, Hammett M, Freilich D, McCarron R, Arnaud F: Evaluation of coagulation stages of hemorrhaged swine: Comparison of thromboelastography and rotational elastometry. Blood Coagul Fibrinolysis 2010;21(1): 20-27.
  17. Nielsen V: A comparison of the thrombelastograph and the rotem. Blood Coagul Fibrinolysis 2007;18: 247-252.
  18. Hagemo JS, Næss PA, Johansson P, Windeløv NA, Cohen MJ, Røislien J, Brohi K, Heier HE, Hestnes M, Gaarder C: Evaluation of TEG® and ROTEM® inter-changeability in trauma patients. Injury 2013;44(5): 600-605.
  19. Scharbert G, Auer A, Kozek-Langenecker S: Evaluation of the platelet mapping™ assay on rotational thromboelastometry ROTEM®. Platelets 2009;20(2): 125-130.
  20. Sørensen B, Fenger-Eriksen C, Christiansen K, Larsen OH, Ingerslev J: Evaluation of coagulation kinetics using thromboelastometry-methodologic influence of activator and test medium. Ann Hematol 2010;89(11): 1155-1161.
  21. Kornblith LZ, Kutcher ME, Redick BJ, Calfee CS, Vilardi RF, Cohen MJ: Fibrinogen and platelet contributions to clot formation: Implications for trauma resuscitation and thromboprophylaxis. J Trauma 2014;76(2): 255-263.
  22. Schöchl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, Kozek-Langenecker S, Solomon C: Goaldirected coagulation management of major trauma patients using thromboelastometry (ROTEM®)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Critical Care 2010;14(2): R55.
  23. Nascimento B, Callum J, Tien H, Peng H, Rizoli S, Karanicolas P, Alam A, Xiong W, Selby R, Garzon AM : Fibrinogen in the initial resuscitation of severe trauma (FiiRST): A randomized feasibility trial. Br J Anaesth 2016;117(6): 775-782.
  24. Meyer MAS, Ostrowski SR, Sørensen AM, Meyer ASP, Holcomb JB, Wade CE, Johansson PI, Stensballe J: Fibrinogen in trauma, an evaluation of thrombelastography and rotational thromboelastometry fibrinogen assays. J Surg Res 2015;194(2): 581-590.
  25. Schöchl H, Voelckel W, Grassetto A, Schlimp CJ: Practical application of point-of-care coagulation testing to guide treatment decisions in trauma. J Trauma Acute Care Surg 2013;74(6): 1587-1598.
  26. Vig S, Chitolie A, Bevan DH, Halliday A, Dormandy J: Thromboelastography: A reliable test? Blood Coagul Fibrinolysis 2001;12(7): 555-561.
  27. Tanaka KA, Ogawa S, Bolliger D: A primer for clinical use of rotational thromboelastometry. Point of Care 2012;11(2): 77-84.
  28. Anderson L, Quasim I, Steven M, Moise SF, Shelley B, Schraag S, Sinclair A: Interoperator and intraoperator variability of whole blood coagulation assays: A comparison of thromboelastography and rotational thromboelastometry. J Cardiothorac Vasc Anesth 2014;28(6): 1550-1557.
  29. Lang T, Bauters A, Braun S, Potzsch B, von Pape K, Kolde H: Multi-centre investigation on reference ranges for rotem thromboelastometry. Blood Coagul Fibrinolysis 2005;16: 301-310.
  30. Stensballe J, Ostrowski SR, Johansson PI: Viscoelastic guidance of resuscitation. Curr Opin Anaesthesiol 2014;27(2): 212-218.
  31. Johansson PI, Stensballe J, Oliveri R, Wade CE, Ostrowski SR, Holcomb JB: How i treat patients with massive hemorrhage. Blood 2014;124(20): 3052-3058.
  32. Harr JN, Moore EE, Ghasabyan A, Chin TL, Sauaia A, Banerjee A, Silliman CC: Functional fibrinogen assay indicates that fibrinogen is critical in correcting abnormal clot strength following trauma. Shock 2013;39(1): 45-49.
  33. Solomon C, Baryshnikova E, Schlimp CJ, Schöchl H, Asmis LM, Ranucci M: Fibtem plus provides an improved thromboelastometry test for measurement of fibrin-based clot quality in cardiac surgery patients. Anesth Analg 2013;117(5): 1054-1062.
  34. Biolik G, Kokot M, Sznapka M, wiszek A, Ziaja D, Pawlicki K, Ziaja K: Platelet reactivity in thromboelastometry. Revision of the fibtem test: A basic study. Scand J Clin Lab Invest 2017: 1-7.
  35. Tonglet ML, Poplavsky J-L, Seidel L, Minon JM, D'Orio V, Ghuysen A: Thromboelastometry in trauma care: A place in the 2018 belgian health care system? Acta Clin Belg 2018: 1-7.
  36. Ågren A, Wikman AT, Östlund A, Edgren G: TEG® functional fibrinogen analysis may overestimate fibrinogen levels. Anesthesia & Analgesia 2014;118(5): 933-35.
  37. Sachs L. The spearman rank correlation coefficient. Berlin, Hidelberg: Springer; 1997.
  38. Bland JM, Altman DG: Measuring agreement in method comparison studies. Stat Methods Med Res 1999;8(2): 135-160.
  39. Bland JM, Altman DG: Statistical methods for assessing agreement between two methods of clinical measurement. Int J Nurs Stud 2010;47(8): 931-936.
  40. Peng HT, Grodecki R, Rizoli S, Shek PN: A comparative study of tissue factor and kaolin on blood coagulation assays using rotational thromboelastometry and thromboelastography. Blood Coagul Fibrinolysis 2016;27(1): 31-41.
  41. Peng HT, Cameron BA, Rhind SG: Effects of hyperbaric and decompression stress on blood coagulation and fibrinolysis: Comparison of thromboelastography and thromboelastometry. Clin Appl Thromb Hemost 2016;22(4): 327-339.
  42. Rizoli S, Min A, Perez Sanchez A, Shek P, Grodecki R, Veigas P, Peng HT: In trauma, conventional rotem and teg results are not interchangeable but are similar in clinical applicability. Mil Med 2016;181(5S): 117-126.
  43. Aleshnick M, Orfeo T, Brummel-Ziedins K, Gissel M, Mann K: Interchangeability of rotational elastographic instruments and reagents. J Trauma Acute Care Surg 2014;76(1): 107-113.
  44. Schlimp CJ, Solomon C, Hochleitner G, Zipperle J, Redl H, Schöchl H: Thromboelastometric maximum clot firmness in platelet-free plasma is influenced by the assay used. Anesth Analg 2013;117(1): 23-29.
  45. Prüller F, Münch A, Preininger A, Raggam Reinhard B, Grinschgl Y, Krumnikl J, Toller W, Metzler H, Mahla E, Mangge H: Comparison of functional fibrinogen (FF/CFF) and fibtem in surgical patients – a retrospective study. Clinical Chemistry and Laboratory Medicine (CCLM) 2016;54(3): 453-458.
  46. Solomon C, Cadamuro J, Ziegler B, Schöchl H, Varvenne M, Sørensen B, Hochleitner G, Rahe-Meyer N: A comparison of fibrinogen measurement methods with fibrin clot elasticity assessed by thromboelastometry, before and after administration of fibrinogen concentrate in cardiac surgery patients. Transfusion (Paris) 2011;51(8): 1695-706.
  47. Schlimp CJ, Solomon C, Ranucci M, Hochleitner G, Redl H, Schochl H: The effectiveness of different functional fibrinogen polymerization assays in eliminating platelet contribution to clot strength in thromboelastometry. Anesth Analg 2014;118(2): 269–276.
  48. Meyer ASP, Meyer MAS, Sørensen AM, Rasmussen LS, Hansen MB, Holcomb JB, Cotton BA, Wade CE, Ostrowski SR, Johansson PI: Thrombelastography and rotational thromboelastometry early amplitudes in 182 trauma patients with clinical suspicion of severe injury. J Trauma Acute Care Surg 2014;76(3): 682-690.
  49. Chitlur M, Sorensen B, Rivard GE, Young G, Ingerslev J, Othman M, Nugent D, Kenet G, Escobar M, Lusher J: Standardization of thromboelastography: A report from the teg-rotem working group. Haemophilia 2011;17(3): 532-537.
  50. Mace H, Lightfoot N, McCluskey S, Selby R, Roy D, Timoumi T, Karkouti K: Validity of thromboelastometry for rapid assessment of fibrinogen levels in heparinized samples during cardiac surgery: A retrospective, singlecenter, observational study. J Cardiothorac Vasc Anesth 2016;30(1): 90-95.
  51. Peng HT, Rhind SG: Thromboelastographic study of psychophysiological stress: A review. Clin Appl Thromb Hemost 2015;21(6): 497-512.
  52. Chang R, Cardenas JC, Wade CE, Holcomb JB: Advances in the understanding of trauma-induced coagulopathy. Blood 2016.
  53. Branco BC, Inaba K, Ives C, Okoye O, Shulman I, David J-S, Schöchl H, Rhee P, Demetriades D: Thromboelastogram evaluation of the impact of hypercoagulability in trauma patients. Shock 2014;41(3): 200-207.
  54. Park MS, Martini WZ, Dubick MA, Salinas J, Butenas S, Kheirabadi BS, Pusateri AE, Vos JA, Guymon CH, Wolf SE: Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time. Journal of Trauma - Injury, Infection and Critical Care 2009;67(2): 266-275.
  55. Doran CM, Woolley T, Midwinter MJ: Feasibility of using rotational thromboelastometry to assess coagulation status of combat casualties in a deployed setting. Journal of Trauma - Injury, Infection and Critical Care 2010;69(Suppl. 1): S40-S48.
  56. Johansson P, Stissing T, Bochsen L, Ostrowski S: Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med 2009;17(1): 45.
  57. Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK: Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: Descriptive systematic review. Critical Care 2014;18(5): 1-26.
  58. Mengoli C, Franchini M, Marano G, Pupella S, Vaglio S, Marietta M, Liumbruno GM: The use of fibrinogen concentrate for the management of trauma-related bleeding: A systematic review and meta-analysis. Blood transfusion 2017;15(4): 318-324.
  59. Levy JH, Welsby I, Goodnough LT: Fibrinogen as a therapeutic target for bleeding: A review of critical levels and replacement therapy. Transfusion (Paris) 2014;54(5): 1389-405.
  60. Spahn D, Spahn G, Stein P. Indications and risks of fibrinogen in surgery and trauma. Semin Thromb Hemost. 2016;42(2):147-154
  61. Abuelkasem E, Lu S, Tanaka K, Planinsic R, Sakai T: Comparison between thrombelastography and thromboelastometry in hyperfibrinolysis detection during adult liver transplantation. Br J Anaesth 2016;116(4): 507-512.
  62. Gall L, Brohi K, Davenport R: Diagnosis and treatment of hyperfibrinolysis in trauma (a European perspective). Semin Thromb Hemost 2017;43: 224-234.
  63. Harr JN, Moore EE, Chin TL, Chapman MP, Ghasabyan A, Stringham JR, Banerjee A, Silliman CC: Viscoelastic hemostatic fibrinogen assays detect fibrinolysis early. European Journal of Trauma and Emergency Surgery 2015;41(1): 49-56.
  64. Cohen MJ, West M: Acute traumatic coagulopathy: From endogenous acute coagulopathy to systemic acquired coagulopathy and back. Journal of trauma and acute care surgery 2011;70(5): S47-S49.
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