-
1.
Effect of Benson's relaxation technique versus music intervention on physiological parameters and stress of children with thalassemia during blood transfusions: A randomized controlled trial
Badr, E. A., Ibrahim, H., Saleh, S. E.
Journal of pediatric nursing. 2023
-
-
-
-
Editor's Choice
Abstract
BACKGROUND Children with thalassemia are generally dependent on blood transfusions and face a lot of stress and alteration in their physiological parameters through the procedure. AIM: This study aimed to investigate the effect of Benson's relaxation technique versus music intervention on physiological parameters and stress of children with thalassemia during blood transfusions. DESIGN A randomized, controlled trial with three parallel groups. METHODS One hundred and twenty preschool-age children with thalassemia who underwent blood transfusions were randomly assigned to three groups. Children of the control group received only routine hospital care through blood transfusions. Music intervention group children listened to recorded Mozart's music and children of Benson's relaxation group received relaxation intervention before and during the blood transfusions. Outcome measures were physiological parameters and behavioral distress levels. SETTING Hematology outpatient clinic of the Children's University Hospital at El-Shatby in Alexandria from October 2022 to February 2023. RESULTS The mean total score of children's behavioral responses to stress before the blood transfusions procedure was 19.32 ± 4.08, 14.20 ± 0.93, and 16.92 ± 4.74 in the control, music, and Benson groups, respectively. Beyond that, there was a decline in their physiological parameters and behavioral stress response during and after procedure among groups of study (P = 0.005 & <0.001, respectively). CONCLUSION Music and Benson's relaxation interventions had a helpful effect on stabilizing the physiological parameters and reducing behavioral distress levels in children with thalassemia undergoing blood transfusions. PRACTICE IMPLICATIONS This study directs paediatric nurses to apply Benson's relaxation and music interventions for children with thalassemia to enhance their responses.
PICO Summary
Population
Preschool-age children with thalassemia who underwent blood transfusions (n= 120).
Intervention
Benson’s relaxation technique intervention (n= 40).
Comparison
Mozart's music intervention (n= 40); routine hospital care (n= 40).
Outcome
The mean total score of children's behavioral responses to stress before the blood transfusions procedure was 19.32 ± 4.08, 14.20 ± 0.93, and 16.92 ± 4.74 in the control, music, and Benson groups, respectively. Beyond that, there was a decline in their physiological parameters and behavioral stress response during and after procedure among groups of study.
-
2.
Evaluating the costs and consequences of computerized clinical decision support systems in hospitals: a scoping review and recommendations for future practice
White NM, Carter HE, Kularatna S, Borg DN, Brain DC, Tariq A, Abell B, Blythe R, McPhail SM
Journal of the American Medical Informatics Association : JAMIA. 2023
-
-
-
Free full text
-
-
Editor's Choice
Abstract
OBJECTIVE Sustainable investment in computerized decision support systems (CDSS) requires robust evaluation of their economic impacts compared with current clinical workflows. We reviewed current approaches used to evaluate the costs and consequences of CDSS in hospital settings and presented recommendations to improve the generalizability of future evaluations. MATERIALS AND METHODS A scoping review of peer-reviewed research articles published since 2010. Searches were completed in the PubMed, Ovid Medline, Embase, and Scopus databases (last searched February 14, 2023). All studies reported the costs and consequences of a CDSS-based intervention compared with current hospital workflows. Findings were summarized using narrative synthesis. Individual studies were further appraised against the Consolidated Health Economic Evaluation and Reporting (CHEERS) 2022 checklist. RESULTS Twenty-nine studies published since 2010 were included. Studies evaluated CDSS for adverse event surveillance (5 studies), antimicrobial stewardship (4 studies), blood product management (8 studies), laboratory testing (7 studies), and medication safety (5 studies). All studies evaluated costs from a hospital perspective but varied based on the valuation of resources affected by CDSS implementation, and the measurement of consequences. We recommend future studies follow guidance from the CHEERS checklist; use study designs that adjust for confounders; consider both the costs of CDSS implementation and adherence; evaluate consequences that are directly or indirectly affected by CDSS-initiated behavior change; examine the impacts of uncertainty and differences in outcomes across patient subgroups. DISCUSSION AND CONCLUSION Improving consistency in the conduct and reporting of evaluations will enable detailed comparisons between promising initiatives, and their subsequent uptake by decision-makers.
PICO Summary
Population
Patients in hospital settings – including those receiving inpatient, emergency, or ambulatory care (29 studies).
Intervention
Computerized decision support systems (CDSS) based intervention.
Comparison
Current hospital workflows.
Outcome
Studies evaluated CDSS for adverse event surveillance (5 studies), antimicrobial stewardship (4 studies), blood product management (8 studies), laboratory testing (7 studies), and medication safety (5 studies). All studies evaluated costs from a hospital perspective but varied based on the valuation of resources affected by CDSS implementation, and the measurement of consequences.
-
3.
Comparison of quantitative and calculated postpartum blood loss after vaginal delivery
Madar, H., Sentilhes, L., Goffinet, F., Bonnet, M. P., Rozenberg, P., Deneux-Tharaux, C.
American journal of obstetrics & gynecology MFM. 2023;:101065
-
-
-
Full text
-
Editor's Choice
Abstract
BACKGROUND Because there is no consensual method of assessing postpartum blood loss, the comparability and relevance of the postpartum hemorrhage-related literature is questionable. Quantitative blood loss assessment using a volumetric technique with a graduated collector bag has been proposed to overcome limitations of intervention-based outcomes but remains partly subjective and potentially biased by amniotic fluid or missed out-of-bag losses. Calculated blood loss based on laboratory parameters has been published and used as an objective method expected to reflect total blood loss, but few studies have compared quantitative with calculated blood loss. OBJECTIVE This study aimed to compare the distribution of postpartum blood loss after vaginal delivery assessed by two methods - quantitative and calculated blood loss - and the incidence of abnormal blood loss with each method. STUDY DESIGN The data came from the merged database of 3 multicenter, randomized controlled trials, all testing different interventions to prevent postpartum blood loss in individuals with a singleton live fetus ≥ 35 weeks, born vaginally. All 3 trials measured blood loss volume by using a graduated collector bag. Hematocrit was measured in the eighth or ninth month of gestation and on day 2 postpartum. The two primary outcomes were: quantitative blood loss defined by the total volume of blood loss measured in a graduated collector bag, and calculated blood loss mathematically defined from the peripartum hematocrit change (estimated blood volume × [(antepartum hematocrit - postpartum hematocrit)/antepartum hematocrit], where estimated blood volume (mL) = booking weight (kg) × 85). We modelled the association between positive quantitative blood loss and positive calculated blood loss with polynomial regression and calculated the Spearman correlation coefficient. RESULTS Among the 8341 individuals included in this analysis, the median quantitative blood loss (100 mL, interquartile range 50-275) was significantly lower than the median calculated blood loss (260 mL, interquartile range 0-630) (P<.05). The incidence of abnormal blood loss was lower with quantitative blood loss than calculated blood loss for blood loss ≥ 500 mL, ≥ 1000 mL and ≥ 2000 mL, respectively, it was 9.6% (799/8341) vs 32.3% (2691/8341), 2.1% (176/8341) vs 11.5% (959/8341), and 0.1% (10/8341) vs 1.4% (117/8341); (P<.05). Quantitative blood loss and calculated blood loss were significantly but moderately correlated (Spearman coefficient=0.44; P<.05). The association between them was not linear, and their difference tended to increase with blood loss. Negative calculated blood loss values occurred in 23% (1958/8341) of individuals; among them, more than 99% (1939/1958) had quantitative blood loss ≤ 500 mL. CONCLUSION Quantitative and calculated blood loss were significantly but moderately correlated after vaginal delivery. However, clinicians should be aware that quantitative blood loss is lower than calculated blood loss, with a difference that tended to rise as blood loss increased.
PICO Summary
Population
Patients who gave birth vaginally, participating in the TRACOR, CYTOCINON, and TRAAP randomised controlled trials (RCTs) in several French maternity units (n= 8,341).
Intervention
This study aimed to compare the distribution of postpartum blood assessed by two methods - quantitative and calculated blood loss - and the incidence of abnormal blood loss with each method.
Comparison
Outcome
The data came from 3 RCTs testing different interventions to prevent postpartum blood loss. All 3 trials measured blood loss volume by using a graduated collector bag. The authors modelled the association between positive quantitative blood loss and positive calculated blood loss with polynomial regression and calculated the Spearman correlation coefficient. The median quantitative blood loss (100 mL, IQR= 50, 275) was significantly lower than the median calculated blood loss (260 mL, IQR= 0, 630). The incidence of abnormal blood loss was lower with quantitative blood loss than calculated blood loss. Quantitative blood loss and calculated blood loss were significantly but moderately correlated (Spearman coefficient= 0.44). The association between them was not linear, and their difference tended to increase with blood loss. Negative calculated blood loss values occurred in 23% (1,958/8,341) of individuals; among them, more than 99% (1,939/1,958) had quantitative blood loss ≤ 500 mL.
-
4.
Small-Volume Blood Collection Tubes to Reduce Transfusions in Intensive Care: The STRATUS Randomized Clinical Trial
Siegal, D. M., Belley-Côté, E. P., Lee, S. F., Hill, S., D'Aragon, F., Zarychanski, R., Rochwerg, B., Chassé, M., Binnie, A., Honarmand, K., et al
Jama. 2023
-
-
-
-
Editor's Choice
Abstract
IMPORTANCE Blood collection for laboratory testing in intensive care unit (ICU) patients is a modifiable contributor to anemia and red blood cell (RBC) transfusion. Most blood withdrawn is not required for analysis and is discarded. OBJECTIVE To determine whether transitioning from standard-volume to small-volume vacuum tubes for blood collection in ICUs reduces RBC transfusion without compromising laboratory testing procedures. DESIGN, SETTING, AND PARTICIPANTS Stepped-wedge cluster randomized trial in 25 adult medical-surgical ICUs in Canada (February 5, 2019 to January21, 2021). INTERVENTIONS ICUs were randomized to transition from standard-volume (n = 10 940) to small-volume tubes (n = 10 261) for laboratory testing. MAIN OUTCOMES AND MEASURES The primary outcome was RBC transfusion (units per patient per ICU stay). Secondary outcomes were patients receiving at least 1 RBC transfusion, hemoglobin decrease during ICU stay (adjusted for RBC transfusion), specimens with insufficient volume for testing, length of stay in the ICU and hospital, and mortality in the ICU and hospital. The primary analysis included patients admitted for 48 hours or more, excluding those admitted during a 5.5-month COVID-19-related trial hiatus. RESULTS In the primary analysis of 21 201 patients (mean age, 63.5 years; 39.9% female), which excluded 6210 patients admitted during the early COVID-19 pandemic, there was no significant difference in RBC units per patient per ICU stay (relative risk [RR], 0.91 [95% CI, 0.79 to 1.05]; P = .19; absolute reduction of 7.24 RBC units/100 patients per ICU stay [95% CI, -3.28 to 19.44]). In a prespecified secondary analysis (n = 27 411 patients), RBC units per patient per ICU stay decreased after transition from standard-volume to small-volume tubes (RR, 0.88 [95% CI, 0.77 to 1.00]; P = .04; absolute reduction of 9.84 RBC units/100 patients per ICU stay [95% CI, 0.24 to 20.76]). Median decrease in transfusion-adjusted hemoglobin was not statistically different in the primary population (mean difference, 0.10 g/dL [95% CI, -0.04 to 0.23]) and lower in the secondary population (mean difference, 0.17 g/dL [95% CI, 0.05 to 0.29]). Specimens with insufficient quantity for analysis were rare (≤0.03%) before and after transition. CONCLUSIONS AND RELEVANCE Use of small-volume blood collection tubes in the ICU may decrease RBC transfusions without affecting laboratory analysis. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03578419.
PICO Summary
Population
Adult patients in 25 medical-surgical intensive care units (ICU) in Canada (n= 21,201).
Intervention
Small-volume vacuum tubes for blood collection (n= 10,261).
Comparison
Standard-volume vacuum tubes for blood collection (n= 10,940).
Outcome
In the primary analysis of 21,201 patients, which excluded 6,210 patients admitted during the early COVID-19 pandemic, there was no significant difference in red blood cell (RBC) units per patient per ICU stay (relative risk [RR] 0.91; 95% CI [0.79, 1.05]; absolute reduction of 7.24 RBC units/100 patients per ICU stay 95% CI [-3.28, 19.44]). In a prespecified secondary analysis (n= 27,411 patients), RBC units per patient per ICU stay decreased after transition from standard-volume to small-volume tubes (RR 0.88; 95% CI [0.77, 1.00]; absolute reduction of 9.84 RBC units/100 patients per ICU stay 95% CI [0.24, 20.76]). Median decrease in transfusion-adjusted haemoglobin was not statistically different in the primary population (mean difference 0.10 g/dL; 95% CI [-0.04, 0.23]) and lower in the secondary population (mean difference 0.17 g/dL; 95% CI [0.05, 0.29]). Specimens with insufficient quantity for analysis were rare (≤0.03%) before and after transition.
-
5.
Systematic review highlights high risk of bias of clinical prediction models for blood transfusion in patients undergoing elective surgery
Dhiman P, Ma J, Gibbs VN, Rampotas A, Kamal H, Arshad SS, Kirtley S, Doree C, Murphy MF, Collins GS, et al
Journal of clinical epidemiology. 2023
-
-
-
Free full text
-
Editor's Choice
Abstract
BACKGROUND Blood transfusion can be a lifesaving intervention after perioperative blood loss. Many prediction models have been developed to identify patients most likely to require blood transfusion during elective surgery, but it is unclear whether any are suitable for clinical practice. STUDY DESIGN AND SETTING We conducted a systematic review, searching MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, Scopus, and Web of Science databases for studies reporting the development or validation of a blood transfusion prediction model in elective surgery patients between 01/01/2000 to 30/06/2021. We extracted study characteristics, discrimination performance (c-statistics) of final models and data which we used to perform risk of bias assessment using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). RESULTS We reviewed 66 studies (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes. CONCLUSION Most blood transfusion prediction models are at high risk of bias and suffer from poor reporting and methodological quality, which must be addressed before they can be safely used in clinical practice.
PICO Summary
Population
Patients undergoing elective surgery (66 studies).
Intervention
Blood transfusion prediction models used perioperatively.
Comparison
Outcome
This systematic review appraised 120 prediction models developed or validated for predicting blood transfusion in elective surgery (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes.
-
6.
Can a Checklist Facilitate Recognition of a Transfusion-Associated Adverse Event by Prelicensure Nursing Students?
Scott, S. S., Scanlon, M., McKelvey, M., Nathanson, B. H., Andrzejewski, C., Jr.
Nurse educator. 2023
-
-
-
-
Editor's Choice
Abstract
BACKGROUND Early identification of a transfusion-associated adverse event (TAAE) is key to patient safety. Research has indicated that use of a TAAE checklist resulted in greater frequency of TAAE recognition behaviors. PURPOSE To explore whether use of a TAAE checklist resulted in greater frequency of TAAE recognition behaviors among nursing students. METHODS A prospective, randomized controlled study was conducted with 62 nursing students playing the role of a registered nurse in a simulation of a patient exhibiting clinical indicators of a TAAE. Subjects were randomly assigned to have or not have a TAAE checklist. Time to recognition of the TAAE was measured. RESULTS The checklist group (CG) identified TAAEs on average 4 minutes sooner than the non-CG (P < .001). CG subjects were also significantly less likely to miss TAAEs completely. CONCLUSIONS A checklist may improve the safety of transfusions by promoting earlier recognition and treatment of TAAEs.
PICO Summary
Population
Nursing students (n= 62).
Intervention
Transfusion-associated adverse event (TAAE) checklist (checklist group (CG) n= 32).
Comparison
No (TAAE) checklist (non-checklist group (non-CG) n= 30).
Outcome
Time to recognition of the TAAE was measured. The checklist group identified TAAEs on average 4 minutes sooner than the non-CG. The NCG identified a TAAE in a mean (SD) of 740 (224) seconds (or 12 minutes and 20 seconds) versus 498 (208) seconds (or 8 minutes and 18 seconds) in the CG. Sixty percent of subjects in the NCG (n= 18) did not identify the TAAE compared with 15.6% of subjects in the CG (n= 5).
-
7.
The Impact of Time to Hemostatic Intervention and Delayed Care for Patients with Traumatic Hemorrhage: A Systematic Review
Lamb T, Tran A, Lampron J, Shorr R, Taljaard M, Vaillancourt C
The journal of trauma and acute care surgery. 2023
-
-
-
-
Editor's Choice
Abstract
BACKGROUND Uncontrolled bleeding is a common cause of preventable mortality in trauma. While intuitive that delays to hemostasis may lead to worse outcomes, the impacts of these delays remain incompletely explored. This systematic review aimed to characterize the extant definitions of delayed hemostatic intervention and to quantify the impacts of delays on clinical outcomes. METHODS We searched EMBASE, MEDLINE, and Web of Science from inception to August 2022. Studies defining "delayed intervention" and those comparing times to intervention among adults presenting to hospital with blunt or penetrating injuries who required major hemostatic intervention were eligible. The co-primary outcomes were mortality and the definition of delay to hemostasis employed. Secondary outcomes included units of packed red blood cells received, length of stay in hospital, and length of stay in intensive care. RESULTS We identified 2,050 studies, with 24 studies including 10,168 patients meeting inclusion criteria. The majority of studies were retrospective observational cohort studies and most were at high risk of bias. A variety of injury patterns and hemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from ten minutes to four hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital. CONCLUSIONS The extant literature is heterogeneous with respect to injuries included, methods of hemostasis employed, and durations of delay examined. While the majority of the included studies demonstrated a statistically significant relationship between time to intervention and mortality, an evidence-informed definition of delayed intervention for bleeding trauma patients at large has not been solidified. Additional, standardized research is needed to establish targets which could reduce morbidity and mortality. LEVEL OF EVIDENCE Level IV, Systematic Review.
PICO Summary
Population
Patients with traumatic haemorrhage (24 studies, n= 10,168).
Intervention
Systematic review to characterize the extant definitions of delayed haemostatic intervention and to quantify the impacts of delays on clinical outcomes.
Comparison
Outcome
The majority of studies were retrospective observational cohort studies and most were at high risk of bias. A variety of injury patterns and haemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from ten minutes to four hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital.
-
8.
Should adding pain, oxygen saturation and physical assessment to vital signs become the new standard of care for detecting blood transfusion reactions?
Roney JK, Whitley BE, Johnston L, Deleon M, Robnett JC
Vox sanguinis. 2022
-
-
-
-
Editor's Choice
Abstract
BACKGROUND AND OBJECTIVES Clinicians sought to ascertain what frequency of vital signs best detects blood transfusion reactions. This review discusses early and delayed blood product transfusion reaction detection through the lens of scientific literature. METHODS A comprehensive appraisal of published literature was conducted using Integrative Research Review methodology through June 2022 not limited to English or research in Cumulative Index to Nursing and Allied Health Literature, Cochrane Library of Systematic Reviews, Medline and PubMed. RESULTS Full-text articles in the final sample included four articles discussing vital signs detecting blood transfusion reactions and four articles reporting the importance of adding physical assessments for early reaction detection. None of the studies provided evidence regarding how often vital signs should be monitored to detect transfusion reactions. No studies included identical screening components for detecting blood product transfusion reactions. Main themes emerged including variations in what was included in vital signs, importance of respiratory assessment, inclusion of physical assessment, nurse documentation and reporting compliance, and patient and family inclusion in transfusion reaction recognition. CONCLUSION Vital sign components varied across reviewed studies. Respiratory rate and pain were not always included in 'vital signs' to identify transfusion reactions. Only low-level data and no clinical trials loosely informing frequency of vital sign monitoring to transfusion reaction detection were found. Respiratory (to include oxygen saturation, lung sounds and respiratory rate) and pain assessment emerged as crucial to acute and delayed transfusion reaction recognition. The disconnect between 'vital signs' and the varied vital sign components reported to detect transfusion reactions in scientific literature requires further exploration.
PICO Summary
Population
Patients receiving a blood product transfusion (8 studies).
Intervention
Systematic review conducted to examine how often vital sign assessment and what physiologic and physical parameters ought to be included to identify blood transfusion reactions in patients.
Comparison
Outcome
Eight studies were included for qualitative synthesis; four articles discussed vital signs detecting blood transfusion reactions and four articles reported the importance of adding physical assessments for early reaction detection. None of the studies provided evidence regarding how often vital signs should be monitored to detect transfusion reactions. No studies included identical screening components for detecting blood product transfusion reactions. Main themes emerged including variations in what was included in vital signs, importance of respiratory assessment, inclusion of physical assessment, nurse documentation and reporting compliance, and patient and family inclusion in transfusion reaction recognition.
-
9.
Rotational thromboelastometry guided blood component use in cirrhotic children undergoing invasive procedures: Randomized Controlled Trial
Maria A, Lal BB, Khanna R, Sood V, Mukund A, Bajpai M, Alam S
Liver international : official journal of the International Association for the Study of the Liver. 2022
-
-
-
-
Editor's Choice
Abstract
BACKGROUND & AIMS This randomized controlled trial (RCT) was conducted with the aim to evaluate the efficacy and safety of using ROTEM-based transfusion strategy in cirrhotic children undergoing invasive procedures. METHODS This was a open-label, RCT which included (i) children under 18 years of age with liver cirrhosis; (ii) INR between 1.5 and 2.5; and/or (iii) platelet count between 20x10(9) /L to 50x10(9) /L (for procedures other than liver biopsy) and between 40x10(9) /L to 60x10(9) /L (for liver biopsy); and (iv) listed for invasive procedures. Stratified randomization was done for children undergoing liver biopsies. Patients randomized to the ROTEM and conventional groups received blood component transfusion using predefined criteria. RESULTS A total of 423 invasive procedures were screened for inclusion of which 60 were randomized (30 in each group with comparable baseline parameters). The volume of total blood components, fresh frozen plasma (FFP) and platelets transfused was significantly lower in ROTEM as compared to conventional group. Only 46.7% of children in ROTEM group received a blood component compared to 100% in conventional group (p<0.001). The requirement of FFP (ROTEM 43.3%, Conventional: 83.3%, p = 0.001) was significantly lower in the patients receiving ROTEM guided transfusions. There was no difference in procedure related bleed and transfusion related complications between the 2 groups. ROTEM was cost effective (p=0.002) despite the additional cost of the test. CONCLUSION ROTEM-based transfusion strategies result in lower blood component transfusion in cirrhotic children undergoing invasive procedures without an increase in risk of procedure-related bleed. ROTEM-guided transfusion strategy is cost-effective.
PICO Summary
Population
Children with liver cirrhosis undergoing invasive procedures (n= 60).
Intervention
ROTEM-based transfusion strategy (n= 30).
Comparison
Conventional coagulation tests-based transfusion strategy (n= 30).
Outcome
The volume of total blood components, fresh frozen plasma (FFP) and platelets transfused was significantly lower in ROTEM as compared to conventional group. Only 46.7% of children in ROTEM group received a blood component compared to 100% in conventional group. The requirement of FFP (ROTEM: 43.3%, conventional: 83.3%) was significantly lower in the patients receiving ROTEM guided transfusions. There was no difference in procedure related bleed and transfusion related complications between the two groups. ROTEM was cost-effective despite the additional cost of the test.
-
10.
Thrombelastography (TEG(®) 6s) early amplitudes predict maximum amplitude in severely injured trauma patients
Vigstedt M, Baksaas-Aasen K, Henriksen HH, Maegele M, Stanworth S, Juffermans NP, Kolstadbråten KM, Naess PA, Brohi K, Gaarder C, et al
Scandinavian journal of clinical and laboratory investigation. 2022;:1-5
-
-
-
Full text
-
Editor's Choice
Abstract
Severely injured trauma patients are often coagulopathic and early hemostatic resuscitation is essential. Previous studies have revealed linear relationships between thrombelastography (TEG(®)) five- and ten-min amplitudes (A5 and A10), and maximum amplitude (MA), using TEG(®) 5000 technology. We aimed to investigate the performance of A5 and A10 in predicting low MA in severely injured trauma patients and identify optimal cut-off values for hemostatic intervention based on early amplitudes, using the cartridge-based TEG(®) 6s technology. Adult trauma patients with hemorrhagic shock were included in the iTACTIC randomized controlled trial at six European Level I trauma centers between 2016 and 2018. After admission, patients were randomized to hemostatic therapy guided by conventional coagulation tests (CCT) or viscoelastic hemostatic assays (VHA). Patients with available admission-TEG(®) 6s data were included in the analysis, regardless of treatment allocation. Low MA was defined as <55 mm for Kaolin TEG(®) and RapidTEG(®), and <17 mm for TEG(®) functional fibrinogen (FF). One hundred eighty-seven patients were included. Median time to MA was 20 (Kaolin TEG(®)), 21 (RapidTEG(®)) and 12 (TEG(®) FF) min. For Kaolin TEG(®), the optimal Youden index (YI) was at A5 < 36 mm (100/93% sensitivity/specificity) and A10 < 47 mm (100/96% sensitivity/specificity). RapidTEG(®) optimal YI was at A5 < 34 mm (98/92% sensitivity/specificity) and A10 < 45 mm (96/95% sensitivity/specificity). TEG(®) FF optimal YI was at A5 < 12 mm (97/93% sensitivity/specificity) and A10 < 15 mm (97/99% sensitivity/specificity). In summary, we found that TEG(®) 6s early amplitudes were sensitive and specific predictors of MA in severely injured trauma patients. Intervening on early amplitudes can save valuable time in hemostatic resuscitation.
PICO Summary
Population
Adult trauma patients with haemorrhagic shock enrolled in the iTACTIC study at six European trauma centers (n= 187).
Intervention
Haemostatic therapy guided by conventional coagulation tests (CCT).
Comparison
Viscoelastic haemostatic assays (VHA).
Outcome
The study aimed to investigate the performance of A5 and A10 in predicting low maximum amplitude (MA), and to identify optimal cut-off values for haemostatic intervention based on early amplitudes, using the cartridge-based TEG® 6s technology. Patients with available admission-TEG® 6s data were included in the analysis, regardless of treatment allocation. Low MA was defined as <55 mm for Kaolin TEG® and RapidTEG®, and <17 mm for TEG® functional fibrinogen (FF). Median time to MA was 20 (Kaolin TEG®), 21 (RapidTEG®) and 12 (TEG® FF) min. For Kaolin TEG®, the optimal Youden index (YI) was at A5 < 36 mm (100/93% sensitivity/specificity) and A10 < 47 mm (100/96% sensitivity/specificity). RapidTEG® optimal YI was at A5 < 34 mm (98/92% sensitivity/specificity) and A10 < 45 mm (96/95% sensitivity/specificity). TEG® FF optimal YI was at A5 < 12 mm (97/93% sensitivity/specificity) and A10 < 15 mm (97/99% sensitivity/specificity).