Data-driven Development of ROTEM and TEG Algorithms for the Management of Trauma Hemorrhage: A Prospective Observational Multicenter Study

Developing pragmatic data-driven algorithms for management of trauma induced coagulopathy (TIC) during trauma hemorrhage for viscoelastic hemostatic assays (VHAs). Admission data from conventional coagulation tests (CCT), rotational thrombelastometry (ROTEM) and thrombelastography (TEG) were collect...

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Published in:	Annals of surgery Vol. 270; no. 6; p. 1178
Main Authors:	Baksaas-Aasen, Kjersti, Van Dieren, Susan, Balvers, Kirsten, Juffermans, Nicole P, Næss, Pål A, Rourke, Claire, Eaglestone, Simon, Ostrowski, Sisse R, Stensballe, Jakob, Stanworth, Simon, Maegele, Marc, Goslings, J C, Johansson, Pär I, Brohi, Karim, Gaarder, Christine
Format:	Journal Article
Language:	English
Published:	United States 01.12.2019
Subjects:	Adult Algorithms Blood Coagulation Disorders - diagnosis Blood Coagulation Disorders - etiology Blood Coagulation Disorders - therapy Blood Coagulation Tests Female Hemorrhage - etiology Hemorrhage - therapy Humans Male Middle Aged Prospective Studies Sensitivity and Specificity Thrombelastography Wounds and Injuries - complications Wounds and Injuries - therapy
ISSN:	1528-1140, 1528-1140
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Abstract	Developing pragmatic data-driven algorithms for management of trauma induced coagulopathy (TIC) during trauma hemorrhage for viscoelastic hemostatic assays (VHAs). Admission data from conventional coagulation tests (CCT), rotational thrombelastometry (ROTEM) and thrombelastography (TEG) were collected prospectively at 6 European trauma centers during 2008 to 2013. To identify significant VHA parameters capable of detecting TIC (defined as INR > 1.2), hypofibrinogenemia (< 2.0 g/L), and thrombocytopenia (< 100 x10/L), univariate regression models were constructed. Area under the curve (AUC) was calculated, and threshold values for TEG and ROTEM parameters with 70% sensitivity were included in the algorithms. A total of, 2287 adult trauma patients (ROTEM: 2019 and TEG: 968) were enrolled. FIBTEM clot amplitude at 5 minutes (CA5) had the largest AUC and 10 mm detected hypofibrinogenemia with 70% sensitivity. The corresponding value for functional fibrinogen (FF) TEG maximum amplitude (MA) was 19 mm. Thrombocytopenia was similarly detected using the calculated threshold EXTEM-FIBTEM CA5 30 mm. The corresponding rTEG-FF TEG MA was 46 mm. TIC was identified by EXTEM CA5 41 mm, rTEG MA 64 mm (80% sensitivity). For hyperfibrinolysis, we examined the relationship between viscoelastic lysis parameters and clinical outcomes, with resulting threshold values of 85% for EXTEM Li30 and 10% for rTEG Ly30.Based on these analyses, we constructed algorithms for ROTEM, TEG, and CCTs to be used in addition to ratio driven transfusion and tranexamic acid. We describe a systematic approach to define threshold parameters for ROTEM and TEG. These parameters were incorporated into algorithms to support data-driven adjustments of resuscitation with therapeutics, to optimize damage control resuscitation practice in trauma.
AbstractList	Developing pragmatic data-driven algorithms for management of trauma induced coagulopathy (TIC) during trauma hemorrhage for viscoelastic hemostatic assays (VHAs). Admission data from conventional coagulation tests (CCT), rotational thrombelastometry (ROTEM) and thrombelastography (TEG) were collected prospectively at 6 European trauma centers during 2008 to 2013. To identify significant VHA parameters capable of detecting TIC (defined as INR > 1.2), hypofibrinogenemia (< 2.0 g/L), and thrombocytopenia (< 100 x10/L), univariate regression models were constructed. Area under the curve (AUC) was calculated, and threshold values for TEG and ROTEM parameters with 70% sensitivity were included in the algorithms. A total of, 2287 adult trauma patients (ROTEM: 2019 and TEG: 968) were enrolled. FIBTEM clot amplitude at 5 minutes (CA5) had the largest AUC and 10 mm detected hypofibrinogenemia with 70% sensitivity. The corresponding value for functional fibrinogen (FF) TEG maximum amplitude (MA) was 19 mm. Thrombocytopenia was similarly detected using the calculated threshold EXTEM-FIBTEM CA5 30 mm. The corresponding rTEG-FF TEG MA was 46 mm. TIC was identified by EXTEM CA5 41 mm, rTEG MA 64 mm (80% sensitivity). For hyperfibrinolysis, we examined the relationship between viscoelastic lysis parameters and clinical outcomes, with resulting threshold values of 85% for EXTEM Li30 and 10% for rTEG Ly30.Based on these analyses, we constructed algorithms for ROTEM, TEG, and CCTs to be used in addition to ratio driven transfusion and tranexamic acid. We describe a systematic approach to define threshold parameters for ROTEM and TEG. These parameters were incorporated into algorithms to support data-driven adjustments of resuscitation with therapeutics, to optimize damage control resuscitation practice in trauma. Developing pragmatic data-driven algorithms for management of trauma induced coagulopathy (TIC) during trauma hemorrhage for viscoelastic hemostatic assays (VHAs).OBJECTIVEDeveloping pragmatic data-driven algorithms for management of trauma induced coagulopathy (TIC) during trauma hemorrhage for viscoelastic hemostatic assays (VHAs).Admission data from conventional coagulation tests (CCT), rotational thrombelastometry (ROTEM) and thrombelastography (TEG) were collected prospectively at 6 European trauma centers during 2008 to 2013.BACKGROUNDAdmission data from conventional coagulation tests (CCT), rotational thrombelastometry (ROTEM) and thrombelastography (TEG) were collected prospectively at 6 European trauma centers during 2008 to 2013.To identify significant VHA parameters capable of detecting TIC (defined as INR > 1.2), hypofibrinogenemia (< 2.0 g/L), and thrombocytopenia (< 100 x10/L), univariate regression models were constructed. Area under the curve (AUC) was calculated, and threshold values for TEG and ROTEM parameters with 70% sensitivity were included in the algorithms.METHODSTo identify significant VHA parameters capable of detecting TIC (defined as INR > 1.2), hypofibrinogenemia (< 2.0 g/L), and thrombocytopenia (< 100 x10/L), univariate regression models were constructed. Area under the curve (AUC) was calculated, and threshold values for TEG and ROTEM parameters with 70% sensitivity were included in the algorithms.A total of, 2287 adult trauma patients (ROTEM: 2019 and TEG: 968) were enrolled. FIBTEM clot amplitude at 5 minutes (CA5) had the largest AUC and 10 mm detected hypofibrinogenemia with 70% sensitivity. The corresponding value for functional fibrinogen (FF) TEG maximum amplitude (MA) was 19 mm. Thrombocytopenia was similarly detected using the calculated threshold EXTEM-FIBTEM CA5 30 mm. The corresponding rTEG-FF TEG MA was 46 mm. TIC was identified by EXTEM CA5 41 mm, rTEG MA 64 mm (80% sensitivity). For hyperfibrinolysis, we examined the relationship between viscoelastic lysis parameters and clinical outcomes, with resulting threshold values of 85% for EXTEM Li30 and 10% for rTEG Ly30.Based on these analyses, we constructed algorithms for ROTEM, TEG, and CCTs to be used in addition to ratio driven transfusion and tranexamic acid.RESULTSA total of, 2287 adult trauma patients (ROTEM: 2019 and TEG: 968) were enrolled. FIBTEM clot amplitude at 5 minutes (CA5) had the largest AUC and 10 mm detected hypofibrinogenemia with 70% sensitivity. The corresponding value for functional fibrinogen (FF) TEG maximum amplitude (MA) was 19 mm. Thrombocytopenia was similarly detected using the calculated threshold EXTEM-FIBTEM CA5 30 mm. The corresponding rTEG-FF TEG MA was 46 mm. TIC was identified by EXTEM CA5 41 mm, rTEG MA 64 mm (80% sensitivity). For hyperfibrinolysis, we examined the relationship between viscoelastic lysis parameters and clinical outcomes, with resulting threshold values of 85% for EXTEM Li30 and 10% for rTEG Ly30.Based on these analyses, we constructed algorithms for ROTEM, TEG, and CCTs to be used in addition to ratio driven transfusion and tranexamic acid.We describe a systematic approach to define threshold parameters for ROTEM and TEG. These parameters were incorporated into algorithms to support data-driven adjustments of resuscitation with therapeutics, to optimize damage control resuscitation practice in trauma.CONCLUSIONSWe describe a systematic approach to define threshold parameters for ROTEM and TEG. These parameters were incorporated into algorithms to support data-driven adjustments of resuscitation with therapeutics, to optimize damage control resuscitation practice in trauma.
Author	Næss, Pål A Johansson, Pär I Goslings, J C Baksaas-Aasen, Kjersti Juffermans, Nicole P Balvers, Kirsten Rourke, Claire Stanworth, Simon Eaglestone, Simon Brohi, Karim Maegele, Marc Gaarder, Christine Van Dieren, Susan Ostrowski, Sisse R Stensballe, Jakob
Author_xml	– sequence: 1 givenname: Kjersti surname: Baksaas-Aasen fullname: Baksaas-Aasen, Kjersti organization: Department of Traumatology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway – sequence: 2 givenname: Susan surname: Van Dieren fullname: Van Dieren, Susan organization: Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands – sequence: 3 givenname: Kirsten surname: Balvers fullname: Balvers, Kirsten organization: Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands – sequence: 4 givenname: Nicole P surname: Juffermans fullname: Juffermans, Nicole P organization: Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands – sequence: 5 givenname: Pål A surname: Næss fullname: Næss, Pål A organization: Department of Traumatology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway – sequence: 6 givenname: Claire surname: Rourke fullname: Rourke, Claire organization: Center for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom – sequence: 7 givenname: Simon surname: Eaglestone fullname: Eaglestone, Simon organization: Center for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom – sequence: 8 givenname: Sisse R surname: Ostrowski fullname: Ostrowski, Sisse R organization: Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark – sequence: 9 givenname: Jakob surname: Stensballe fullname: Stensballe, Jakob organization: Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark – sequence: 10 givenname: Simon surname: Stanworth fullname: Stanworth, Simon organization: NHS Blood and Transplant, Oxford University Hospital NHS Trust, John Radcliffe Hospital, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom – sequence: 11 givenname: Marc surname: Maegele fullname: Maegele, Marc organization: Department for Traumatology and Orthopedic Surgery, Cologne- Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany – sequence: 12 givenname: J C surname: Goslings fullname: Goslings, J C organization: Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands – sequence: 13 givenname: Pär I surname: Johansson fullname: Johansson, Pär I organization: Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark – sequence: 14 givenname: Karim surname: Brohi fullname: Brohi, Karim organization: Center for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom – sequence: 15 givenname: Christine surname: Gaarder fullname: Gaarder, Christine organization: Department of Traumatology, Oslo University Hospital, Oslo, Norway
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SubjectTerms	Adult Algorithms Blood Coagulation Disorders - diagnosis Blood Coagulation Disorders - etiology Blood Coagulation Disorders - therapy Blood Coagulation Tests Female Hemorrhage - etiology Hemorrhage - therapy Humans Male Middle Aged Prospective Studies Sensitivity and Specificity Thrombelastography Wounds and Injuries - complications Wounds and Injuries - therapy
Title	Data-driven Development of ROTEM and TEG Algorithms for the Management of Trauma Hemorrhage: A Prospective Observational Multicenter Study
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