Thromboelastography Reaction-Time Thresholds for Optimal Prediction of Coagulation Factor Deficiency in Trauma

Authors

Jonathan H. Chow, University of Maryland School of Medicine
Benjamin Fedeles, University of Maryland School of Medicine
Justin E. Richards, University of Maryland School of Medicine
Kenichi A. Tanaka, University of Maryland School of Medicine
Jonathan J. Morrison, University of Maryland School of Medicine
Peter Rock, University of Maryland School of Medicine
Thomas M. Scalea, University of Maryland School of Medicine
Michael A. Mazzeffi, University of Maryland School of Medicine
Anthony T. Trinh
Corinne Renner
Caroline Schlee

Document Type

Journal Article

Publication Date

5-1-2020

Journal

Journal of the American College of Surgeons

Volume

230

Issue

5

DOI

10.1016/j.jamcollsurg.2020.01.033

Abstract

© 2020 American College of Surgeons Background: Coagulopathy is common in multitrauma patients and repletion of procoagulant factor deficiency with fresh frozen plasma (FFP) improves hemostasis. Optimal kaolin-thromboelastography thresholds for FFP transfusion in trauma patients have not been well established. Study Design: Adult trauma patients with an Injury Severity Score ≥15 were included in this retrospective observational cohort study. The primary end point was area under the receiver operating characteristic curve (AUROC) for reaction time (R-time) to detect procoagulant factor deficiency, as reflected by an elevated international normalized ratio (INR) or aPTT. Test characteristics for the optimal R-time threshold calculated in our study were compared against thresholds recommended by the American College of Surgeons for FFP transfusion. Results: Six hundred and ninety-four pairs of thromboelastography and conventional coagulation tests were performed in 550 patients, with 144 patients having additional pairs of tests after the first hour. The R-time was able to detect procoagulant factor deficiency (INR ≥1.5 AUROC 0.80; 95% CI, 0.75 to 0.85; aPTT ≥40 seconds AUROC 0.85; 95% 0.80 to 0.89) and severe procoagulant factor deficiency (INR ≥2.0 AUROC 0.82; 95% CI, 0.73 to 0.99; aPTT ≥60 seconds AUROC 0.89; 95% CI, 0.81 to 0.98) with good accuracy. Optimal thresholds to maximize sensitivity and specificity were 3.9 minutes for detection of INR ≥1.5, 4.1 minutes for detection of aPTT ≥40 seconds, 4.3 minutes for detection of INR ≥2.0, and 4.3 for detection of aPTT ≥60 seconds. Currently recommended R-time thresholds for FFP transfusion had 100% specificity for detecting procoagulant factor deficiency, but low sensitivity (3% to 7%). Conclusions: R-time can detect procoagulant factor deficiency in multitrauma patients with good accuracy, but currently recommended R-time thresholds are highly specific and not sensitive. Use of low-sensitivity thresholds might result in undertreatment of many patients with procoagulant factor deficiency.

APA Citation

Chow, J., Fedeles, B., Richards, J., Tanaka, K., Morrison, J., Rock, P., Scalea, T., Mazzeffi, M., Trinh, A., Renner, C., & Schlee, C. (2020). Thromboelastography Reaction-Time Thresholds for Optimal Prediction of Coagulation Factor Deficiency in Trauma. Journal of the American College of Surgeons, 230 (5). http://dx.doi.org/10.1016/j.jamcollsurg.2020.01.033