Citrated Kaolin Thrombelastography (TEG) Thresholds for Goal-Directed Therapy in Injured Patients Receiving Massive Transfusion

Introduction Goal-directed hemostatic resuscitation based on thrombelastography (TEG) has a survival benefit compared to conventional coagulation assays such as INR, aPTT, fibrinogen level, and platelet count. While TEG-based transfusion thresholds for patients at risk for massive transfusion (MT) have been defined using rapid TEG (rTEG), cutoffs have not been defined for TEG using other activators such as kaolin. The purpose of this study was to develop thresholds for blood product transfusion using citrated kaolin TEG (CK-TEG) in patients at risk for MT. Methods CK-TEG was assessed in trauma activation patients at two level-one trauma centers admitted between 2010-2017. ROC curve analyses were performed to test the predictive performance of CK-TEG measurements in patients requiring MT, defined as >10 units of RBC or death within the first 6 hours. The Youden Index defined optimal thresholds for CK-TEG-based resuscitation. Results Of the 825 trauma activations, 671 (81.3%) were male, 419 (50.8%) suffered a blunt injury, and 62 (7.5%) received a MT. Patients who had a MT were more severely injured, had signs of more pronounced shock, and more abnormal coagulation assays. CK-TEG R-Time was longer (4.9vs4.4 min, p=0.0084), Angle was lower (66.2vs70.3 degrees, p4.45 min. Angle had an AUROC=0.6931, and a 4 cut point of4.55%. Conclusions We have identified CK-TEG thresholds that can guide MT in trauma. We propose plasma transfusion for R-time > 4.45 min, fibrinogen products for an angle 4.55%. Level of Evidence Therapeutic study, level V Study Type Prognostic and Therapeutic Corresponding Author: Ernest E Moore, MD, Email: ernest.moore@dhha.org Phone: 303-724-2685 Fax: 303-720-2682, Mailing Address: 655 Bannock Street Denver, CO 80203 Author Contact Information: Gregory Stettler: gregory.stettler@ucdenver.edu Joshua Sumislawski: joshua.sumislawski@ucdenver.edu Ernest E Moore: ernest.moore@dhha.org Geoffrey R Nunns: Geoffrey.nunns@ucdenver.edu Lucy Z Kornblith: Lucy.Kornblith@ucsf.edu Amanda S Conroy: Amanda.Conroy@ucsf.edu Rachael A Callcut: Rachael.Callcut@ucsf.edu Christopher C Silliman: christopher.silliman@ucdenver.edu Anirban Banerjee: anirban.banerjee@ucdenver.edu Mitchell J Cohen: mitchell.cohen@ucdenver.edu Angela Sauaia: angela.sauaia@ucdenver.edu Disclosure: Research reported in this publication was supported in part by the National Institute of General Medical Sciences grants: T32-GM008315 and P50-GM49222, the National Heart Lung and Blood Institute UM1-HL120877, the Department of Defense USAMRAA, W81XWH-12-2-0028, and W911QY-15-C-0044, in addition to the National Institute of Environmental Health Sciences K01ES026834. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Heart, Lung, and Blood institute, or the Department of Defense. Additional research support provided by Haemonetics with shared intellectual property. © 2018 Lippincott Williams & Wilkins, Inc.

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