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TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients

Tapia, Nicole M. MD; Chang, Alex MD; Norman, Michael MD; Welsh, Francis MD; Scott, Bradford MD; Wall, Matthew J. Jr MD; Mattox, Kenneth L. MD; Suliburk, James MD

Journal of Trauma and Acute Care Surgery: February 2013 - Volume 74 - Issue 2 - p 378–386
doi: 10.1097/TA.0b013e31827e20e0
AAST 2012 PLENARY PAPER
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BACKGROUND For nearly a decade, our center performed thromboelastograms (TEGs) to analyze coagulation profiles, allowing rapid data-driven blood component therapy. After consensus recommendations for massive transfusion protocols (MTPs), we implemented an MTP in October 2009 with 1:1:1 ratio of blood (red blood cells [RBC]), plasma (fresh-frozen plasma [FFP]), and platelets. We hypothesized that TEG-directed resuscitation is equivalent to MTP resuscitation.

METHODS All patients receiving 6 units (U) or more of RBC in the first 24 hours for 21 months before and after MTP initiation in an urban Level I trauma center were examined. Demographics, mechanism of injury (MOI), Injury Severity Score (ISS), 24-hour volume of RBC, FFP, platelets, crystalloid, and 30-day mortality were compared, excluding patients with traumatic brain injuries. Variables were analyzed using Student’s t-test and χ2 or Fisher’s exact test.

RESULTS For the preMTP group, there were 165 patients. In the MTP group, there were 124 patients. There were no significant differences in ISS, age, or sex. PreMTP patients with 6U or more RBC had significantly more penetrating MOI (p = 0.017), whereas preMTP patients with 10U or more RBC had similar MOIs. All patients received less crystalloid after MTP adoption (p < 0.001). There was no difference in volume of blood products or mortality in patients receiving 6U or more RBC. Blunt trauma MTP patients who received 10U or more RBC received more FFP (p = 0.02), with no change in mortality. Penetrating trauma patients who received 10U or more RBC received a similar volume of FFP; however, mortality increased from 54.1% for MTP versus 33.3% preMTP (p = 0.04).

CONCLUSION TEG-directed resuscitation is equivalent to standardized MTP for patients receiving 6U or more RBC and for blunt MOI patients receiving 10U or more RBC. MTP therapy worsened mortality in penetrating MOI patients receiving 10U or more RBC, indicating a continued need for TEG-directed therapy. A 1:1:1 strategy may not be adequate in all patients.

LEVEL OF EVIDENCE Therapeutic study, level IV.

From the Baylor College of Medicine, Houston, Texas.

Submitted: July 31, 2012, Revised: October 26, 2012, Accepted: October 31, 2012.

This study was presented at the 71st annual meeting of the American Association for the Surgery of Trauma, September 12–15, 2012, in Kauai, Hawaii.

Address for reprints: Nicole M. Tapia, MD, One Baylor Plaza, Suite 404D, Houston, TX 77030; email: nmtapia@bcm.edu.

© 2013 Lippincott Williams & Wilkins, Inc.