Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate

Abstract

Introduction: The appropriate strategy for trauma-induced coagulopathy management is under debate. We report the treatment of major trauma using mainly coagulation factor concentrates.

Methods: This retrospective analysis included trauma patients who received >or= 5 units of red blood cell concentrate within 24 hours. Coagulation management was guided by thromboelastometry (ROTEM). Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after fibrinogen concentrate administration was an indication for platelet concentrate. The observed mortality was compared with the mortality predicted by the trauma injury severity score (TRISS) and by the revised injury severity classification (RISC) score.

Results: Of 131 patients included, 128 received fibrinogen concentrate as first-line therapy, 98 additionally received PCC, while 3 patients with recent coumarin intake received only PCC. Twelve patients received FFP and 29 received platelet concentrate. The observed mortality was 24.4%, lower than the TRISS mortality of 33.7% (P = 0.032) and the RISC mortality of 28.7% (P > 0.05). After excluding 17 patients with traumatic brain injury, the difference in mortality was 14% observed versus 27.8% predicted by TRISS (P = 0.0018) and 24.3% predicted by RISC (P = 0.014).

Conclusions: ROTEM-guided haemostatic therapy, with fibrinogen concentrate as first-line haemostatic therapy and additional PCC, was goal-directed and fast. A favourable survival rate was observed. Prospective, randomized trials to investigate this therapeutic alternative further appear warranted.

Figure 1

The ROTEM^® analyses: EXTEM^® test (extrinsically activated test) and FibTEM^® test (fibrin clot obtained by platelet inhibition with cytochalasin D). The clotting time (CT (seconds)) represents the time from the start of the test until a clot firmness of 2 mm is detected; maximum clot firmness (MCF (mm)) represents the total amplitude of the clot.

Figure 2

Comparison of the observed mortality with the mortality predicted by the trauma injury severity score (TRISS) and by the revised injury severity classification (RISC) score. A sub-analysis that excluded patients who died of untreatable brain oedema caused by severe brain injury was also performed.

Figure 3

Perioperative changes in plasma fibrinogen concentration. Measurements were performed on admission to the emergency room (ER), on arrival at the intensive care unit (ICU), 24 hours after admission to the ER, on the third and the seventh postoperative days. The hatched area shows the normal physiological range of plasma fibrinogen concentration. The boxes represent the interquartile range, the lines represent the mean, and the whiskers extend to 95% confidence interval for the mean. The circles represent outside values, larger that the upper quartile plus 1.5 times the interquartile range, and the squares represent far out values, larger that the upper quartile plus three times the interquartile range.