Viscoelastic coagulation testing in bleeding trauma patients: a retrospective analysis and development of a treatment algorithm.

Abstract

Viscoelastic coagulation testing (VET) is a key tool for the early diagnosis and treatment of trauma-induced coagulopathy. However, differences exist between VET technologies. Our aim was to identify viscoelastic test thresholds for the ClotPro® analyser, and propose an approach to establishing a VET algorithm for the early management of trauma patients that aligns with current guidelines. ClotPro® data were collected from trauma patients upon arrival, during surgical care, and throughout their ICU stay. Standard coagulation tests including prothrombin time index <70% or international normalised ratio >1.2, fibrinogen concentration <150 mg dl^-1, and platelet count <50 and <100 G L^-1 were compared with ClotPro® parameters from the extrinsically activated thromboelastometric test (EX-Test) and extrinsically activated test plus cytochalasin and tirofiban (FIB-Test), including clotting time, clot amplitude at 5 and 10 min running time (CA5/CA10), maximum clot firmness, and platelet contribution to clot firmness. On the basis of these data, we developed an algorithm for the early treatment of trauma-induced coagulopathy. We included 375 patients (67.8% male) with a median injury severity score of 16 (interquartile range, 9-27). Receiver operating characteristic curve analysis for detecting an international normalised ratio >1.2 using EX-Test clotting time yielded an area under the receiver operating characteristic curve (AUC) of 0.71. Detection of fibrinogen <150 mg dl^-1 using FIB-Test CA5 showed an AUC of 0.96. Platelet counts <50 and <100 G L^-1 were detected by CA5-derived platelet contribution, with AUCs of 0.93 and 0.94, respectively. These ClotPro® cut-off values allow for early and reliable detection of hypofibrinogenaemia and thrombocytopenia. Only after correction of fibrinogen and platelet deficits should prolonged CT be considered a weak marker for the augmentation of coagulation factors.