Stettler Gregory R, Moore Ernest E, Nunns Geoffrey R, Chandler Jim, Peltz Erik, Silliman Christopher C, Banerjee Anirban, Sauaia Angela
Department of Surgery, University of Colorado, Aurora, Colorado.
Department of Surgery, Denver Health Medical Center, Denver, Colorado.
J Surg Res. 2018 Aug;228:154-159. doi: 10.1016/j.jss.2018.03.027. Epub 2018 Apr 11.
Goal-directed hemostatic resuscitation based on thrombelastography has a survival benefit compared to conventional coagulation assays. While thrombelastography transfusion thresholds for patients at risk for massive transfusion (MT) have been defined, similar cutoffs do not exist for the other commonly used viscoelastic assay, rotational thromboelastometry (ROTEM). The purpose of this study was to develop ROTEM blood product thresholds in patients at risk for MT.
ROTEM was assessed in trauma activation patients admitted from 2010 to 2016 (n = 222). Receiver operating characteristic curve analyses were performed to test the predictive performance of ROTEM measurements in patients requiring MT. The Youden Index defined optimal thresholds for ROTEM-based resuscitation.
Patients who required MT (n = 37, 17%) were more severely injured. EXTEM clotting time (CT) was longer in patients with MT compared to non-MT (87 versus 64 s, P < 0.0001). EXTEM angle was shallower in MT patients compared to non-MT (54° versus 69°, P < 0.0001). Clot amplitude after 10 min (CA10) was less in MT compared to non-MT patients (30.5 versus 50 mm, P < 0.0001). Clot lysis index 60 min (CLI60) was lower in patients who had MT than non-MT (47 versus 94%, P = 0.0006). EXTEM CT yielded an area under the receiver operating characteristic curve (AUROC) = 0.7116 and a cut point of >78.5 s. EXTEM angle had an AUROC = 0.865 and a cut point of <64.5°. EXTEM CA10 had an AUROC = 0.858, with a cut point of <40.5 mm. CLI60 had an AUROC = 0.6788 with a cut point at <74%.
We have identified ROTEM thresholds for transfusion of blood components in severely injured patients requiring an MT. Based on our analysis, we propose plasma transfusion for EXTEM CT > 78.5 s, fibrinogen for angle <64.5°, platelet transfusion for CA10 < 40.5 mm, and antifibrinolytics for CLI60 < 74%.
与传统凝血检测相比，基于血栓弹力图的目标导向性止血复苏具有生存获益。虽然已确定了大量输血（MT）风险患者的血栓弹力图输血阈值，但其他常用的粘弹性检测方法，即旋转血栓弹力测定法（ROTEM），却没有类似的临界值。本研究的目的是确定MT风险患者的ROTEM血液制品阈值。
对2010年至2016年收治的创伤激活患者（n = 222）进行ROTEM评估。进行受试者操作特征曲线分析，以测试ROTEM测量值对需要MT的患者的预测性能。约登指数确定了基于ROTEM复苏的最佳阈值。
需要MT的患者（n = 37，17%）受伤更严重。与非MT患者相比，MT患者的EXTEM凝血时间（CT）更长（87秒对64秒，P < 0.0001）。与非MT患者相比，MT患者的EXTEM角度更浅（54°对69°，P < 0.0001）。与非MT患者相比，MT患者10分钟后的血凝块幅度（CA10）更小（30.5毫米对50毫米，P < 0.0001）。MT患者的60分钟血凝块溶解指数（CLI60）低于非MT患者（47%对94%，P = 0.0006）。EXTEM CT的受试者操作特征曲线下面积（AUROC）= 0.7116，切点>78.5秒。EXTEM角度的AUROC = 0.865，切点<64.5°。EXTEM CA10的AUROC = 0.858，切点<40.5毫米。CLI60的AUROC = 0.6788，切点<74%。
我们已确定了需要MT的重伤患者输血的ROTEM阈值。基于我们的分析，我们建议当EXTEM CT > 78.5秒时输注血浆，角度<64.5°时输注纤维蛋白原，CA10 < 40.5毫米时输注血小板，CLI60 < 74%时使用抗纤溶药物。
