1. Massive Transfusions: To TEG or not to TEG (or ROTEM)?
Evy Potochny, DO FASCP
02DEC2017

2. Disclaimer
The views expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.

3. I have no disclosures.

4. Objectives
Understand a Massive Transfusion Protocol (MTP) and its indications
Review literature on “golden” ratios, units transfused, and survivability
Discuss role of viscoelastic testing in MTP

5. Massive Transfusion Indications
Replacement of approximately one blood volume in 24 hours
Roughly 10 units of red cells in 24 hours
Replacing half of an individual’s blood volume in 2-3 hours
Roughly 5-6 units over 2-3 hours
Bleeding at rates of > 150 mL/minute

6. Why Massive Transfusion Protocols (MTPs)?

7. Hemorrhage is the leading cause of death among combat and civilian traumas
Hemorrhage is the leading cause of potentially preventable death during pregnancy/childbirth

8. Uncrossmatched whole blood used in WW I
Robertson LB. The transfusion of whole blood: a suggestion for its more frequent employment in war surgery. Br Med J 1916;2:38-40

9. The ‘70s: the decade the whole blood stopped
1970s: blood centers try to maximize component availability

10. Mogadishu, Somalia 21 yo M attacked by great white shark off Mogadishu
Only 50 units packed red blood cells (pRBCs) on hand
Used all of them
Developed profound coagulopathy
Switched to fresh whole blood (WB)
15 U fresh WB given
Coagulation improved, gained hemostatic control
Hess JR et al. (2011). Massive Transfusion and Transfusion Therapy in Trauma. In P.D. Mintz (ed.), Transfusion Therapy: Clinical Principles and Practice (3rd ed.; pp. 305–321). Bethesda MD: AABB Press.

11. 3 days later, same hospital
130 US casualties during Blackhawk Down
34 surgeries; only 70 units whole blood used
The surgical team credits that to the use of fresh whole blood
Hess JR et al. (2011). Massive Transfusion and Transfusion Therapy in Trauma. In P.D. Mintz (ed.), Transfusion Therapy: Clinical Principles and Practice (3rd ed.; pp. 305–321). Bethesda MD: AABB Press.

12. Why Not Just Use Whole Blood?
Must give type-specific blood due to either red cell or plasma incompatibility
Component therapy designed to minimize infectious disease risks and increase storage times
Why Not Just Use Whole Blood?

13. So we try and approximate whole blood with ratios of components
And the ratio is???

14. Retrospective review 246 Army Combat Support pts
Author
Year
Journal
Design
Conclusions
Borgman
2007
J Trauma
Retrospective review 246 Army Combat Support pts
1:1 to 1.4 plasma:pRBCs associated with improved survival from hemorrhage
Holcomb
2008
Annals of Surgery
467 MT trauma pts Level I centers (16)
Transfusion practices and survival rates for traumas varied. Survival in civilians improved as approached 1:1 plasma:pRBC
2015
JAMA
PROMMT Trial
680 pts. 12 sites.
1:1:1 vs 1:1:2
24h, 30 d survival
ratios < 1:2 were 3 to 4x more likely to die than patients with ratios of 1:1 or higher
Baraniuk
2014
Injury
PROPPR Trial: Optimal Ratios.
Largest randomized in severely bleeding.
No significant 24h and 30 d mortality. More in 1:1:1 achieved hemostasis. -
Borgman 2007: Retrospective review of 246 patients at US army combat support hospital who received >= 10 U rbcs in 24 hours. Divided into 3 groups based on plasma to RBC ratio and compared mortality rates and COD.
Would increased plasma to platelet to rbc ratios decreased early hemorrhagic death and sustain through hospital course? MT = >=10 U RBCs

15. Why Not Just Use Whole Blood?
Must give type-specific blood due to either red cell or plasma incompatibility
Why Not Just Use Whole Blood?

16. Must we? ….vinyl’s back

17. 2016;56;S190–S202

18. Accessed www.militaryblood.dod.mil on 10/27/17

19. Low Titer O Whole Blood
Now used in austere environments where components not readily available

20. Ratios approximating whole blood mitigate Trauma Induced Coagulopathy
While only low % of each coagulation factor are necessary to achieve clotting,
The combination of multiple clotting factors at their minimum functional levels,
Combined with low platelet levels
And fibrinolysis, hypothermia, and acidosis

21. Lethal Triad
Dilutional coagulopathy
Acidosis
Hypothermia

22. Sihler KC et al. Complications of massive transfusion. Chest. 2010

23. Addressing Hyperfibrinolysis
CRASH-2 trial (Lancet. 2010) found that early use of antifibrinolytics like tranexamic acid (TXA) cut mortality in traumas by 9% and reduced bleeding death by 15% vs. placebo

24. Antifibrinolytics and PPH
World Maternal Antifibrinolytic (WOMAN) trial (ongoing), has randomized ~20,000 women comparing whether TXA helps in PPH

25. Volume Transfused and Survivability
Author
Year
Journal
Conclusions
Design
Velmahos
1998
Arch Surg
Volume transfused no bearing on mortality
104 patients; retrospective
Hakala
1999
Injury
204 patients; retrospective
Como
2004
Transfusion
501 patients;
retrospective
Criddle
2005
J Emerg Nurs
46 patients; retrospective
Huber-Wagner
2007
Vox Sang
Correlation with volume; however
No identifiable threshold
1062 patients;

26. When do you stop? The patient survived.
Concern for placenta percreta and 2 prior C/S.
MTP lasted 15 hours.
Transfused 195 RBCs,
155 plasma,
26 apheresis PLTs,
8 cryoprecipitate pools…
estimated 180 L of blood loss
The patient survived.
Hulse M. et al. Massive transfusion in an obstetric emergency. Transfusion :23.

27. And Why Don’t You Train? Duke University Medical Center
PPH identified, MTP activated
2 L&D nurses designated as runners took quickest way to BB to get MTP coolers via elevator
O’Reilly K. Massive transfusion: a question of timing, detail, a golden ratio. CAP Today. Dec Accessed from

28. And Why Don’t You Train? Badges didn’t work in route they tried to use
Had to run back down long hallway, down stairs, adding several minutes to get blood
Fortunately, this was a simulation
O’Reilly K. Massive transfusion: a question of timing, detail, a golden ratio. CAP Today. Dec Accessed from

29. Massive Transfusion: It’s not just the optimal ratio
Communication
Processing
Delivery
(and in my experience, drilling)
are just as essential as the “golden ratio” of
blood products
O’Reilly K. Massive transfusion: a question of timing, detail, a golden ratio. CAP Today. Dec Accessed from

30. Role of Viscoelastic Testing
Stat labs can take too long
Don’t provide much information on coagulation
Lacks in vivo correlation
Doesn’t offer easy ability to guide transfusion

31. Enter: TEG and ROTEM TEG = thromboelastography (cup rotates)
ROTEM = thromboelastometry (rod rotates)
Patient blood into cup and a sensor rode is inserted. With TEG, cup rotates, with ROTEM, rode rorates. Clot forms between the cup and the rod. Change in speed and pattern of change measured and depicted in a graph.

32. Point-of-care tests that provide information on strength and kinetics of clot formation in bleeding patients

33. TEG: an old concept back again
an old test first developed in 1948 and until recently used almost exclusively in open heart and liver transplant procedures—came after a series of revelations about the coagulation process, particularly in trauma. Clinicians already recognized that the classic coagulation cascade model with intrinsic and extrinsic pathways leading to hemostasis—though admittedly complicated—did not fully describe all the factors at work in TIC.

34. The Coagulation Cascade: an in vitro thing
accessed 10/27/17.

35. However, TEG/ROTEM Are not substitutes for PT/INR/aPTT
Require multiple daily calibrations
Require trained personnel to interpret
Initial data fast, but full tracings may take as long as traditional labs

36. TEG/ROTEM studies 1980s: Liver transplants 1990s: Cardiac surgeries
Wang et al. Transfusion. 2010;47:2590
Decreased intraoperative blood transfusion in orthoptic liver transplants
1990s: Cardiac surgeries
Ak et al. J Card Surg. 2009;20:404
No difference in outcomes, blood loss, or RBCs
But decreased use of platelets, FFP, and TXA
And increased cost savings
Wang SC, Shieh JF, Chang KY et al. Thromboelastography -
guided transfusion decreases
intraoperative blood t
transfusion during orthotopic liver transplantation: randomized clinical trial.
Transfusion
2010;47:2590
3. Ak K, Isbir CS, Tetik S, et al. Thromboelastography
based transfusion algorithm reduced blood
product use after elective CABG: a prospective randomized study.
J Card Surg
2009;24:40 4
410.

37. TEG/ROTEM in MTP
Is there a role in the massive transfusion setting too guide goal-directed therapy and/or deactivate?

38. TEG
Accessed from on 10/2717.

39. ROTEM
Accessed from on 10/2717.

40. http://www2. ccasociety. org/newsletters/2017summer/teg-rotem. html
Accessed 27OCT2017

41. http://www2. ccasociety. org/newsletters/2017summer/teg-rotem. html
Accessed 27OCT2017

42. http://www2. ccasociety. org/newsletters/2017summer/teg-rotem. html
Accessed 27OCT2017

43. Normal and abnormal TEG tracings
da Luz et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,21:29

44. Cochrane Review 2015 TEG/ROTEM for trauma-induced coagulopathy
Small number of trials (3) in trauma setting—creating bias
Evidence strongly suggests that at present these tests should only be used for research.
Hunt H, Stanworth S, Curry N, Woolley T, Cooper C, Ukoumunne O, Zhelev Z, Hyde C. Thromboelastography (TEG)
and rotational thromboelastometry (ROTEM) for trauma induced coagul opathy in adult trauma patients with bleeding. Cochrane
Database of Systematic Reviews 2015, Issue 2. Art. No

45. Updated Cochrane Review 2016
Included 17 studies (1493 patients)
Involved trials of elective cardiac surgery following cardiopulmonary bypass
Wikkelso A et al. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database systematic reviews 2016, issue 8.

46. Their Conclusions
Growing evidence that TEG or ROTEM guided transfusions MAY reduce need for blood products and improve morbidity.
Level of evidence LOW
Better studies in the acute setting still needed
Wikkelso A et al. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database systematic reviews 2016, issue 8.

47. My Conclusions
Massive transfusion protocols used to approximate whole blood, offset coagulopathy
1:1:1 ratio important, but so is effective communication and delivery
TEG/ROTEM promising, but lack large RCT data for recommendations for use in acute setting

48. To TEG or not to TEG is still the question. Questions?