Utility of thromboelastography to guide blood product transfusion in surgical settings.

Selby R. “TEG talk”: expanding clinical roles for thromboelastography and rotational thromboelastometry. Hematology Am Soc Hematol Educ Program. 2020 Dec 4;2020(1): 67-75.

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“Viscoelastic assays (VEAs) that include thromboelastography and rotational thromboelastometry add value to the investigation of coagulopathies and goal-directed management of bleeding by providing a complete picture of clot formation, strength, and lysis in whole blood that includes the contribution of platelets, fibrinogen, and coagulation factors. Conventional coagulation assays have several limitations, such as their lack of correlation with bleeding and hypercoagulability; their inability to reflect the contribution of platelets, factor XIII, and plasmin during clot formation and lysis; and their slow turnaround times. VEA-guided transfusion algorithms may reduce allogeneic blood exposure during and after cardiac surgery and in the emergency management of trauma-induced coagulopathy and hemorrhage. However, the popularity of VEAs for other indications is driven largely by extrapolation of evidence from cardiac surgery, by the drawbacks of conventional coagulation assays, and by institution-specific preferences. Robust diagnostic studies validating and standardizing diagnostic cutoffs for VEA parameters and randomized trials comparing VEA-guided algorithms with standard care on clinical outcomes are urgently needed. Lack of such studies represents the biggest barrier to defining the role and impact of VEA in clinical care.”

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The balanced resuscitation approach

“Balanced resuscitation minimizes coagulopathy through permissive hypotension, restrictive crystalloid use, and high ratios of plasma and platelet to red blood cell transfusion.” (Cantle, 2017, p. 999)

Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015 Feb 3;313(5):471-82.

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“Exsanguination, the predominant cause of death within the first 24 hours, was decreased in the 1:1:1 group (9.2%) vs the 1:1:2 group (14.6%) (difference, −5.4% [95% CI, −10.4% to −0.5%], P = .03); the median time to death due to exsanguination was 106 minutes interquartile range [IQR], 54 to 198 minutes) and 96 minutes (IQR, 43 to 194 minutes), respectively. From 24 hours through 30 days, the numbers of additional all-cause deaths were similar (32 for the 1:1:1 group vs 31 for the 1:1:2 group). Over 30 days, deaths due to exsanguination occurred in 10.7% of patients in the 1:1:1 group vs 14.7% in the 1:1:2 group, whereas deaths due to traumatic brain injury were 8.1% vs 10.3%, respectively. Additional causes of death were infrequent and are shown in Table 3. More patients achieved anatomic hemostasis in the 1:1:1 group (86.1% vs 78.1% in the 1:1:2 group, P = .006) with a median time of 105 minutes (IQR, 64 to 179 minutes) vs 100 minutes (IQR, 56 to 181 minutes), respectively (P = .44) in those who achieved anatomic hemostasis (Table 2).” (Holcomb, 2015, p. 475)

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