Noncitrated Whole Blood Is Optimal for Evaluation of Postinjury Coagulopathy With Point-of-Care Rapid Thrombelastography

被引:50
作者
Kashuk, Jeffry L. [1 ]
Moore, Ernest E.
Le, Tuan [2 ]
Lawrence, Jerry
Pezold, Michael
Johnson, Jeffrey L.
Cothren, Clay C.
Biffl, Walter L.
Barnett, Carlton
Sabel, Allison [3 ,4 ]
机构
[1] Univ Colorado, Sch Med, Denver Hlth Med Ctr, Dept Surg, Denver, CO 80204 USA
[2] Univ Colorado, Denver Hlth Med Ctr, Dept Lab Med, Denver, CO 80204 USA
[3] Univ Colorado, Denver Hlth Med Ctr, Dept Patient Safety & Qual, Denver, CO 80204 USA
[4] Univ Colorado, Denver Hlth Med Ctr, Dept Biostat & Informat, Denver, CO 80204 USA
关键词
thrombelastography; trauma; coagulopathy; goal directed therapy; thrombin release; hypocoagulability; citrate; whole blood; DAMAGE CONTROL RESUSCITATION; FRESH-FROZEN PLASMA; THROMBIN GENERATION; CITRATE STORAGE; TRAUMA; THROMBOELASTOGRAPHY; TRANSFUSIONS;
D O I
10.1016/j.jss.2009.03.046
中图分类号
R61 [外科手术学];
学科分类号
摘要
Introduction. Progressive postinjury coagulopathy has become the fundamental rationale for damage control surgery, and the decision to abort operative intervention must occur prior to overt laboratory confirmation of coagulopathy. Current coagulation testing is most commonly performed for monitoring anticoagulation therapy, the results are delayed, and the applicability of these tests in the trauma setting is questionable. Point-of-care (POC) rapid thrombelastography (r-TEG) provides real time analysis of thrombostatic function, which may allow for accurate, goal directed therapy. The test differs from standard thrombelastography (TEG) because the clotting process and subsequent analysis is accelerated by the addition of tissue factor to the whole blood sample, but is limited by the requirement that the analysis be performed within 4 min of blood draw to prevent clot formation. Consequently, citrated specimens have been proposed to obviate this time limitation. We hypothesized that the speed of r-TEG analysis following tissue factor addition to citrated blood might compromise accurate determinations compared with noncitrated whole blood. Additionally, we sought to compare the use of r-TEG with conventional coagulation tests in analysis of postinjury coagulopathy. Methods. We conducted a retrospective study of severely injured patients entered into our trauma database between January and June 2008 who were at risk for postinjury coagulopathy. Patients needed simultaneous conventional coagulation (INR, fibrinogen, platelet count) and r-TEG specimens with either fresh or citrated whole blood for inclusion in the study. K-Statistics were used to determine the agreement between the tests in predicting hypocoagulability. McNemar's chi(2) tests were used to compare theoretical blood product administration between r-TEG and conventional coagulation tests for noncitrated specimens. Therapeutic transfusion triggers were: INR (> 1.5) and r-TEG ACT (> 125 s) for FFP administration; fibrinogen (<133 mg/dL) and alpha-angle (<63 degrees) for cryoprecipitate; and platelet count (<100 K) and maximum amplitude (MA) (< 52 mm) for aphaeresis platelets. Statistical significance was established as P < 0.05 using two-sided tests. Results. Forty-four patients met the inclusion criteria. ic-Values (correlation) were higher in noncitrated versus citrated specimens for all comparisons between conventional and r-TEG tests, indicating better performance of r-TEG with the noncitrated specimens. FFP would have been administered to significantly more patients based on conventional transfusion triggers (61.5% by INR transfusion triggers versus 26.9% by r-TEG-ACT triggers, P = 0.003). There was no statistically significant difference in potential cryoprecipitate or aphaeresis platelet administration. Conclusion. POC r-TEG is superior when performed with uncitrated versus citrated whole blood for evaluation of postinjury coagulation status. As a real time measure of total thrombostatic function, our preliminary data suggest that r-TEG may effectively guide transfusion therapy and result in reduced FFP administration compared with conventional coagulation tests. (C) 2009 Elsevier Inc. All rights reserved.
引用
收藏
页码:133 / 138
页数:6
相关论文
共 23 条
  • [1] The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital
    Borgman, Matthew A.
    Spinella, Philip C.
    Perkins, Jeremy G.
    Grathwohl, Kurt W.
    Repine, Thomas
    Beekley, Alec C.
    Sebesta, James
    Jenkins, Donald
    Wade, Charles E.
    Holcomb, John B.
    [J]. JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE, 2007, 63 (04): : 805 - 813
  • [2] Citrate storage affects Thrombelastograph® analysis
    Camenzind, V
    Bombeli, T
    Seifert, B
    Jamnicki, M
    Popovic, D
    Pasch, T
    Spahn, DR
    [J]. ANESTHESIOLOGY, 2000, 92 (05) : 1242 - 1249
  • [3] A novel Thrombelastograph® tissue factor/kaolin assay of activated clotting times for monitoring heparin anticoagulation during cardiopulmonary bypass
    Chavez, JJ
    Foley, DE
    Snider, CC
    Howell, JC
    Cohen, E
    Muenchen, RA
    Carroll, RC
    [J]. ANESTHESIA AND ANALGESIA, 2004, 99 (05) : 1290 - 1294
  • [4] Review of current blood transfusions strategies in a mature level I trauma center: Were we wrong for the last 60 years?
    Duchesne, Juan C.
    Hunt, John P.
    Wahl, Georgia
    Marr, Alan B.
    Wang, Yi-Zarn
    Weintraub, Sharon E.
    Wright, Mary J. O.
    McSwain, Norman E., Jr.
    [J]. JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE, 2008, 65 (02): : 272 - 276
  • [5] Mechanisms of disease: Mechanisms of thrombus formation
    Furie, Bruce
    Furie, Barbara C.
    [J]. NEW ENGLAND JOURNAL OF MEDICINE, 2008, 359 (09) : 938 - 949
  • [6] Fresh frozen plasma should be given earlier to patients requiring massive transfusion
    Gonzalez, Ernest A.
    Moore, Frederick A.
    Holcomb, John B.
    Miller, Charles C.
    Kozar, Rosemary A.
    Todd, S. Rob
    Cocanour, Christine S.
    Balldin, Bjorn C.
    McKinley, Bruce A.
    [J]. JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE, 2007, 62 (01): : 112 - 119
  • [7] Optimizing outcomes in damage control resuscitation: Identifying blood product ratios associated with improved survival
    Gunter, Oliver L., Jr.
    Au, Brigham K.
    Isbell, James M.
    Mowery, Nathan T.
    Young, Pampee P.
    Cotton, Bryan A.
    [J]. JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE, 2008, 65 (03): : 527 - 532
  • [8] Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients
    Holcomb, John B.
    Wade, Charles E.
    Michalek, Joel E.
    Chisholm, Gary B.
    Zarzabal, Lee Ann
    Schreiber, Martin A.
    Gonzalez, Ernest A.
    Pomper, Gregory. J.
    Perkins, Jeremy G.
    Spinella, Phillip C.
    Williams, Kari L.
    Park, Myung S.
    [J]. ANNALS OF SURGERY, 2008, 248 (03) : 447 - 456
  • [9] Damage control resuscitation: Directly addressing the early coagulopathy of trauma - Commentary
    Holcomb, John B.
    Jenkins, Don
    Rhee, Peter
    Johannigman, Jay
    Mahoney, Peter
    Mehta, Sumeru
    Cox, E. Darrin
    Gehrke, Michael J.
    Beilman, Greg J.
    Schreiber, Martin
    Flaherty, Stephen F.
    Grathwohl, Kurt W.
    Spinella, Phillip C.
    Perkins, Jeremy G.
    Beekley, Alec C.
    McMullin, Neil R.
    Park, Myung S.
    Gonzalez, Ernest A.
    Wade, Charles E.
    Dubick, Michael A.
    Schwab, William
    Moore, Fred A.
    Champion, Howard R.
    Hoyt, David B.
    Hess, John R.
    [J]. JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE, 2007, 62 (02): : 307 - 310
  • [10] Investigation of the effect of kaolin and tissue factor-activated citrated whole blood, on clot forming variables, as evaluated by thromboelastography
    Johansson, Par I.
    Bochsen, Louise
    Andersen, Soren
    Viuff, Dorthe
    [J]. TRANSFUSION, 2008, 48 (11) : 2377 - 2383