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

Tongporn  Wannatoop; Janejira  Kittivorapart; Kulvara  Kittisares; Warit  Werawatakul; Theera  Ruchutrakool; Parichart  Permpikul; Sunanta  Chobpluk

doi:10.33192/Smj.2022.36

Authors

Tongporn Wannatoop Division of Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
Janejira Kittivorapart Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
Kulvara Kittisares Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
Warit Werawatakul Division of Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
Theera Ruchutrakool Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
Parichart Permpikul Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
Sunanta Chobpluk Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok

DOI:

https://doi.org/10.33192/Smj.2022.36

Keywords:

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

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.

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