Rapid-thrombelastography (r-TEG) thresholds for goal-directed resuscitation of patients at risk for massive transfusion.

Background: Uncontrolled hemorrhage is a leading cause of mortality following trauma accounting for up to 40% of deaths. Massive transfusion protocols (MTPs) offer a proven benefit in resuscitation of these patients. Recently, the superiority of thrombelastography (TEG)-guided resuscitation over strategies guided by conventional clotting assays (CCA) has been established. We seek to determine optimal thresholds for r-TEG driven resuscitation. Methods: R-TEG data were reviewed for 190 patients presenting to our Level 1 Trauma Center from 2010 to 2015. Criteria for inclusion were highest level trauma activation in patients >= 18 years of age with hypotension presumed due to acute blood loss. Exclusion criteria included: isolated gun-shot wound to the head, pregnancy and chronic liver disease. Receiver operating characteristic (ROC) analysis was performed to test the predictive performance of r-TEG for massive transfusion requirement defined by need for 1) >10 units of RBCs total or death in the first six hours or 2) >4 units of RBCs in any hour within the first 6 hours. Cut-point analysis was then performed to determine optimal thresholds for TEG-based resuscitation. Results: ROC analysis of r-TEG yielded areas under the curve (AUC) greater than 70% for all outputs with respect to both transfusion thresholds considered, with exception of activated clotting time (ACT) and lysis at 30 minutes (LY30) for > 4U RBC in any hour in the first 6 hours. Optimal cut-point analysis of the resultant ROC curves was performed and for each value, the most sensitive cut-point was identified, respectively ACT >= 128 sec, angle ([alpha]) = 5%. Conclusions: Through ROC analysis of prospective TEG data, we have identified optimal thresholds to guide hemostatic resuscitation. These thresholds should be validated in a prospective multicenter trial. Level of Evidence: Prognostic, level III (C) 2016 Lippincott Williams & Wilkins, Inc.

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