From the Literature

 

Published: Jun 2016

Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays.
Gonzalez E, Moore EE, Moore HB, et al.
Ann Surg 2016;263:1051-1059.
Pub Med
NATA rating :

 

REVIEW by:
J. Stensballe

 

NATA REVIEW:
In a pragmatic RCT, Gonzalez and colleagues from Denver, CO, USA, show that resuscitation guided by a viscoelastic haemostatic assay (VHA) improves survival compared to conventional coagulation tests (CCTs) in severely injured bleeders.

VHAs (TEG/ROTEM) compared to CCTs have the advantage of monitoring the functional capabilities of the clot and deliver rapidly available results (<10 min) to guide pro-haemostatic interventions and blood transfusion support in bleeding patients.

Gonzalez and colleagues investigated 111 severely injured bleeders (ISS = 30, arrival SBP 92 mmHg, lactate 6 mmol/L, 8 RBC units transfused at 6 h, 28-day mortality of 28%) and the effect of goal-directed resuscitation using thromboelastography (TEG) as compared with CCTs. Survival improved (19.6% in the TEG group vs. 36.4% in the CCT group; P = 0.049) and plasma and platelet transfusion requirements decreased in the TEG group in the early phase of resuscitation. RBC transfusion remained unaffected.

Volume resuscitation was predominantly done with use of fluids (4 L at 2 h, 8 L at 6 h, 14 L at 24 h). The plasma-to-RBC ratio and the platelet-to-RBC ratio were very low (<0.5 and <0.1, respectively) in the initial phase. Coagulopathy was not better controlled in one group compared to the other.

This is the first RCT of VHA versus CCT in trauma. The main limitations of this RCT are the mode of fluid resuscitation, which has the potential to cause further dilution and coagulopathy, and not applying haemostatic resuscitation according to the PROPPR protocol and tranexamic acid according to CRASH-2 protocol.

Further investigations on VHA in trauma are warranted and studies are ongoing (ClinicalTrials.gov Identifier:NCT02593877), but meanwhile VHA seems to improve survival in bleeding trauma patients, particularly in those receiving fluid resuscitation. This RCT supports the efficacy of VHA compared to CCT in different populations to guide resuscitation.

- Jakob Stensballe