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Monitoring the Coagulation Status of Trauma Patients with Viscoelastic Devices Yuichiro Sakamoto*, Hiroyuki Koami and Toru Miike

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Monitoring the Coagulation Status of Trauma Patients with Viscoelastic Devices Yuichiro Sakamoto*, Hiroyuki Koami and Toru Miike Sakamoto et al. Journal of Intensive Care (2017) 5:7 DOI 10.1186/s40560-016-0198-4 REVIEW Open Access Monitoring the coagulation status of trauma patients with viscoelastic devices Yuichiro Sakamoto*, Hiroyuki Koami and Toru Miike Abstract Coagulopathy is a physiological response to massive bleeding that frequently occurs after severe trauma and is an independent predictive factor for mortality. Therefore, it is very important to grasp the coagulation status of patients with severe trauma quickly and accurately in order to establish the therapeutic strategy. Judging from the description in the European guidelines, the importance of viscoelastic devices in understanding the disease condition of patients with traumatic coagulopathy has been widely recognized in Europe. In the USA, the ACS TQIP Massive Transfusion in Trauma Guidelines proposed by the American College of Surgeons in 2013 presented the test results obtained by the viscoelastic devices, TEG® 5000 and ROTEM®, as the standard for transfusion or injection of blood plasma, cryoprecipitate, platelet concentrate, or anti-fibrinolytic agents in the treatment strategy for traumatic coagulopathy and hemorrhagic shock. However, some studies have reported limitations of these viscoelastic devices. A review in the Cochrane Library published in 2015 pointed out the presence of biases in the abovementioned reports in trauma patients and the absence of a quality study in this field thus far. A quality study on the relationship between traumatic coagulopathy and viscoelastic devices is needed. Background of hemorrhagic shock that accounts for 90% of incidents Two of the major causes of coagulopathy in trauma of traumatic shock. Since coagulation abnormality which patients are coagulopathy secondary to hemorrhagic is a physiological response to massive bleeding frequently shock due to massive bleeding and coagulopathy due to occurs after severe trauma and is an independent pre- severe head injury [1]. The release of tissue factor from dictive factor for mortality, it is very important to grasp the damaged brain tissue is postulated as the cause of the coagulation status of the patient quickly and accur- coagulopathy due to severe head injury. The fundamen- ately in order to establish the therapeutic strategy [1, 5]. tal treatment for shock due to bleeding is treatment to It has been recognized that trauma patients are more achieve hemostasis, but fluid infusion and blood trans- likely to die from intraoperative metabolic failure than fusion for long periods of time under insufficient from a failure to complete operative repairs. Damage hemostasis may lead to the derangement of hemostasis control surgery (DCS) is surgery that is designed to re- and the impairment of hemostasis due to hypothermia store normal physiology prior to normal anatomy in crit- [2–4]. Therefore, it is important to achieve hemostasis ically ill patients. DCS is important for the treatment of quickly without missing the timing in which the patient trauma because the development of coagulopathy due to is able to cope with physiological changes in the early radical hemostasis is fatal [5, 6]. DCS is a therapeutic stage of massive bleeding such as tachycardia, wetness, concept in which hemostasis is achieved in as short a and coldness in the extremities, and anxiety, rather time as possible, physiological function is normalized by than cope with hypotension that is a physiological postoperative intensive care, and then injury repair is response to massive bleeding. It is also important to completed by planned reoperation if necessary [7]. perform blood transfusion quickly and appropriately as For this purpose, the status and degree of coagulopathy well as obtain immediate hemostasis for the treatment must be determined quickly with objective indicators. For example, it is possible that continuation of a surgical operation in a patient with a defect in coagulability fails * Correspondence: [email protected] to save the life of the patient because of uncontrollable Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga 849-8501, Japan bleeding. To avoid such a situation, the criteria known © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sakamoto et al. Journal of Intensive Care (2017) 5:7 Page 2 of 11 as the trauma triad of death (deadly triad) consisting of used as a common viscoelastic device. A new device has hypothermia, metabolic acidosis, and coagulopathy have been developed in Japan, and it has a completely different been proposed for the introduction of DCS [7]. In actual principle of measurement from that of conventional clinical practice, body temperature and acid-base equilib- point-of-care (POC) devices to assess coagulation and rium can be quickly measured. However, measurement of hemostatic function. This device is the Total Thrombus- prothrombin time (PT) that is commonly used as the indi- Formation Analysis System (T-TAS®) whose measurement cator of coagulability requires more than 60 min before principle will be explained elsewhere in this article. the result is obtained [8]. In addition, it has been said that As for the principle of measurement by POC devices, these indicators reflect the early stage of the coagulation the TEG®5000 and ROTEM® delta optically measure process and that the amount of thrombin produced in this changes in mechanical impedance to a sensor pin gener- period is only 4% of the total prothrombin [9]. Further- ated by clotting-induced change in elasticity of whole more, the PT and activated partial thromboplastin time blood in a cuvette after the addition of a coagulation ac- (APTT) do not necessarily reflect the in vivo status of celerant [14, 15]. coagulability such as the influence of platelets, because the tests are carried out by adding a blood clotting acceler- ROTEM system ant to plasma separated from whole blood. The activated In the ROTEM® system, the results are displayed in a clotting time (ACT) that uses whole blood may not reflect graph in which the horizontal axis is time (min) and the the in vivo status of coagulability either, because the test vertical axis is clot amplitude (mm) which represents the also only reflects the early stage of coagulation similar to firmness of the clot (Fig. 1). Various parameters can be PT and APTT [10]. We review the principles of measure- measured with the ROTEM® system such as the duration ment by viscoelastic devices and guidelines for the treat- from the start of measurement to the beginning of clot- ment of traumatic coagulopathy. ting time, duration from the start of clotting to the time when the clot amplitude representing clot firmness Principle of measurement by viscoelastic devices reaches 20 mm (clot formation time, CFT) and its angle TEG5000 system (α angle), the clot amplitude every 5 min after the begin- The Thrombelastograph (TEG®) is a device that measures ning of clotting (A 5–30) and its maximum (maximum the change in viscoelasticity of whole blood without separ- clot firmness, MCF), the lysis index at 30, 45, and ating out the plasma. The TEG was developed based on a 60 min after the beginning of clotting (LI 30, 45, and concept reported by Hartert in 1948 [11]. The TEG® was 60), and the maximum lysis index (ML) which can be reported as the most rapid available test for providing monitored in real time. The results in a normal healthy reliable information on coagulopathy in patients with person are shown in Fig. 2, and the results in representa- multiple injuries [12]. Since the usefulness of the TEG® for tive patients with a clotting abnormality are shown in monitoring coagulability during liver transplantation sur- Fig. 3. In clinical practice, we observe complicated find- gery was reported in 1985 [13], this instrument has been ings in quite a lot of patients with some types of coagu- widely used in clinical settings. In addition to the TEG®, lation abnormalities. Case 1 was an 80-year-old woman the rotational thromboelastometer (ROTEM®) has been who complained of vertigo (Fig. 4). She was referred to Fig. 1 An example of results obtained using the ROTEM system. In the ROTEM® system, the results are displayed in a graph in which the horizontal axis is time (min) and the vertical axis is clot amplitude (mm) based on the firmness of the clot. Various parameters can be measured in real time such as clotting time (CT), clot formation time (CFT), the amplitude at 5 min (A5), maximum clot firmness (MCF), maximum lysis (ML), and lysis index at 30 min (LI30) Sakamoto et al. Journal of Intensive Care (2017) 5:7 Page 3 of 11 Fig. 2 The results in ROTEM in a normal healthy person our hospital because of suspicion of cerebral bleeding. linkage; arachidonic acid (AA) and adenosine diphosphate Her past medical history showed that she underwent (ADP) that activate the respective receptor on platelets; artificial blood vessel replacement surgery for thoracoab- and a platelet aggregation inhibitor, abciximab [14]. The dominal aortic aneurysm 8 years previously, and she had TEG®5000 system allows us to conduct six different tests chronic hepatitis C, liver cirrhosis (Child-Pugh class B), by using different combinations of these reagents. Kaolin and chronic atrial fibrillation. On admission to our TEG is the basic test in TEG® and measures the clotting emergency department (ED), her consciousness was alert activity of the intrinsic pathway.
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