Tissue plasminogen activator challenge thrombelastography is the most accurate assay in predicting the need for massive transfusion in hypotensive trauma patients - 22/11/23

Doi : 10.1016/j.amjsurg.2023.05.033

Jessie G. Jiang ^a, Hunter B. Moore ^b,^⁎ , Ernest E. Moore ^b,^c, Fredric Pieracci ^b,^c, Angela Sauaia ^d
^a University of Colorado School of Medicine, CU Anschutz Fitzsimons Building, 13001 East 17th Place, C290, Aurora, CO, 80045, USA
^b University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
^c Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, 777 Bannock St, Denver, CO, 80204, USA
^d University of Colorado Denver School of Public Health, Department of Health Systems, Management and Policy, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA

^∗Corresponding author. 12631 E 17th Ave C302, Aurora, CO, 80045, USA.12631 E 17th Ave C302AuroraCO80045USA

Abstract

Background

Tissue plasminogen activator (tPA) added to thrombelastography (TEG) detects hyperfibrinolysis by measuring clot lysis at 30 min (tPA-challenge-TEG). We hypothesize that tPA-challenge-TEG is a better predictor of massive transfusion (MT) than existing strategies in trauma patients with hypotension.

Methods

Trauma activation patients (TAP, 2014–2020) with 1) systolic blood pressure <90 mmHg (early) or 2) those who arrived normotensive but developed hypotension within 1H postinjury (delayed) were analyzed. MT was defined as >10 RBC U/6H postinjury or death within 6H after ≥1 RBC unit. Area under the receiver operating characteristics curves were used to compare predictive performance. Youden index determined optimal cutoffs.

Results

tPA-challenge-TEG was the best predictor of MT in the early hypotension subgroup (N = 212) with positive (PPV) and negative predictive values (NPV) of 75.0%, and 77.6%, respectively. tPA-challenge-TEG was a better predictor of MT than all but TASH (PPV = 65.0%, NPV = 93.3%) in the delayed hypotension group (N = 125).

Conclusions

The tPA-challenge-TEG is the most accurate predictor of MT in trauma patients arriving hypotensive and offers early recognition of MT in patients with delayed hypotension.

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Highlights

•	tPA-challenge TEG LY30 predicts massive transfusion in hypotensive patients.
•	tPA-TEG LY30 predicts massive transfusion in delayed traumatic hemorrhagic shock.
•	75% of patients with tPA-challenge-TEG LY30 > 60.6% will require massive transfusion.

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Keywords : Massive transfusion, Hypotension, Hemorrhagic shock, Resuscitation, Coagulopathy, Thrombelastography