Effect of thromboelastography TEG® and rotational thromboelastometry ROTEM® on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic reviewReport as inadecuate




Effect of thromboelastography TEG® and rotational thromboelastometry ROTEM® on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review - Download this document for free, or read online. Document in PDF available to download.

Critical Care

, 18:518

First Online: 27 September 2014Received: 03 November 2013Accepted: 29 August 2014

Abstract

IntroductionThe understanding of coagulopathies in trauma has increased interest in thromboelastography TEG® and thromboelastometry ROTEM®, which promptly evaluate the entire clotting process and may guide blood product therapy. Our objective was to review the evidence for their role in diagnosing early coagulopathies, guiding blood transfusion, and reducing mortality in injured patients.

MethodsWe considered observational studies and randomized controlled trials MEDLINE, EMBASE, and Cochrane databases to February 2014 that examined TEG®-ROTEM® in adult trauma patients. We extracted data on demographics, diagnosis of early coagulopathies, blood transfusion, and mortality. We assessed methodologic quality by using the Newcastle-Ottawa scale NOS for observational studies and QUADAS-2 tool for diagnostic accuracy studies.

ResultsFifty-five studies 12,489 patients met inclusion criteria, including 38 prospective cohort studies, 15 retrospective cohort studies, two before-after studies, and no randomized trials. Methodologic quality was moderate mean NOS score, 6.07; standard deviation, 0.49. With QUADAS-2, only three of 47 studies 6.4% had a low risk of bias in all domains patient selection, index test, reference standard and flow and timing; 37 of 47 studies 78.8% had low concerns regarding applicability. Studies investigated TEG®-ROTEM® for diagnosis of early coagulopathies n = 40 or for associations with blood-product transfusion n = 25 or mortality n = 24. Most n = 52 were single-center studies. Techniques examined included rapid TEG® n =12, ROTEM® n = 18, TEG® n = 23, or both TEG® and rapid TEG® n = 2. Many TEG®-ROTEM® measurements were associated with early coagulopathies, including some hypercoagulability, hyperfibrinolysis, platelet dysfunction not assessed by routine screening coagulation tests. Standard measures of diagnostic accuracy were inconsistently reported. Many abnormalities predicted the need for massive transfusion and death, but predictive performance was not consistently superior to routine tests. One observational study suggested that a ROTEM® -based transfusion algorithm reduced blood-product transfusion, but TEG®-ROTEM®-based resuscitation was not associated with lower mortality in most studies.

ConclusionsLimited evidence from observational data suggest that TEG®-ROTEM® tests diagnose early trauma coagulopathy and may predict blood-product transfusion and mortality in trauma. Effects on blood-product transfusion, mortality, and other patient-important outcomes remain unproven in randomized trials.

AbbreviationsA10Clot amplitude at 10 minutes

A15clot amplitude at 15 minutes

A5clot amplitude at 5 minutes after CT in ROTEM®

AAarachidonic acid

ACTactivated clotting time

ADPadenosine diphosphate

aPTTactivated partial thromboplastin time

ATantithrombin

ATCacute trauma coagulopathy

AUCarea under the curve

BDbase deficit

BEbase excess

BPblood pressure

CFTclot-formation time

CIconfidence interval

CLIclot lysis index residual clot firmness in percentage of MCF at a certain time after CT

CTclotting time

EDemergency department

ELTeuglobulin lysis time

EXTEMextrinsically activated test with tissue factor

F 1 + 2prothrombin fragment 1 + 2

FFfunctional fibrinogen test

FFPfresh frozen plasma

FIBTEMfibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D

Gshear elastic modulus strength 5,000 – MA-100 – MA

HCRhemostatic control resuscitation

HFhyperfibrinolysis

INRinternational normalized ratio

INTEMintrinsically activated test using ellagic acid

IQRinterquartile range

ISSinjury severity score

Kkinetic time time between 2 and 20 mm amplitude achieved in TEG®

LI30lysis index residual clot firmness in percentage of MCF 30 minutes after CT in ROTEM®

LI60lysis index residual clot firmness in percentage of MCF 60 minutes after CT in ROTEM®

LRlogistic regression

LY30percentage decrease in clot amplitude at 30 minutes after MA in TEG®

LY60percentage decrease in clot amplitude at 60 minutes after MA in TEG®

MAmaximal amplitude

MCFmaximal clot firmness

MLmaximal lysis

MODSmultiple organ-dysfunction syndrome

MRTGmaximal rate of thrombin formation

MTmassive transfusion

NOSNewcastle-Ottawa scale

NPVnegative predictive value

ORodds ratio

PCCprothrombin complex concentrate

PEpulmonary embolism

PFprimary fibrinolysis

PFA-100platelet-function analyzer

PLTplatelet concentrate

PMplatelet mapping

POCpoint-of-care

PPVpositive predictive value

PRISMApreferred reporting items for systematic reviews and meta-analyses

PTprothrombin time

QUADASquality assessment of diagnostic accuracy studies

Rreaction time time from starting the test until 2-mm amplitude can be detected in TEG®

RBCred blood cell

RCTrandomized controlled trial

RISCrevised injury severity classification

ROCreceiver operating curve

ROTEM®rotational thromboelastometry

RSCTroutine screening coagulation test

r-TEG®rapid thromboelastography

RTSrevised trauma score

SBPsystolic blood pressure

SDstandard deviation

SIRSsystemic inflammatory response syndrome

TATthrombin-antithrombin complex

TBItraumatic brain injury

TEthromboembolic event

TEG®thromboelastography

TEG® -PMTEG® platelet mapping

TFtissue factor

TGthrombin generation

TNF-αtumor necrosis factor alpha

TRISStrauma injury severity score

α anglerate of clot formation

Electronic supplementary materialThe online version of this article doi:10.1186-s13054-014-0518-9 contains supplementary material, which is available to authorized users.

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Author: Luis Teodoro Da Luz - Bartolomeu Nascimento - Ajith Kumar Shankarakutty - Sandro Rizoli - Neill KJ Adhikari

Source: https://link.springer.com/







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