American Society for Clinical Laboratory Science
View all recommendations from this societySeptember 13, 2021
Do not use viscoelastic testing to determine blood product transfusions in trauma patient resuscitation without an established, institutional treatment algorithm in place.
Currently, many trauma patients presenting to emergency departments are resuscitated through blood product transfusions guided by conventional coagulation tests (CCTs) only. Acute care organizations that utilize viscoelastic testing (VET) in conjunction with CCTs do not commonly have treatment algorithms in place to guide blood transfusions in trauma patients, which can result in the overuse of blood products. When assessing the number of hospitals that have institutional massive transfusion protocols (MTP), one study documented that only 9% of surveyed facilities utilize VET in their MTPs.
Several recent studies compared patient outcomes in facilities that incorporate viscoelastic methodologies into their MTPs against those that did not. Mortality and blood product transfusion rates were measured and positive correlations between CCTs in conjunction with VET versus CCTs-only were found. Not only did viscoelastic-guided resuscitation result in higher survival rates and fewer transfused blood products, but also identified those at risk for hyperfibrinolysis, which is a limitation of CCTs. Apart from positive patient outcomes with VET+CCT, another study found that MTP trauma patients guided by VET-only versus CCT-only had no difference in patient outcomes.
When observing the opportunity of replacing CCTs with VET for trauma activations in the Emergency Department, the reviewed literature seems to be inconclusive. A study of 1,974 major trauma activations argues that rapid thromboelastography methods, a form of VET, are better predictors for massive transfusions; however, another study argued that, because VET testing takes longer to perform than CCTs, VET should not be the sole tool to assess coagulopathies in these patients. Ultimately, the inconsistencies in evidence to date do not support one testing approach over the other, but some data does suggest that a combined approach may be beneficial towards patient outcomes – when properly followed.
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How The List Was Created
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George Fritsma, MS, MLS (ASCP), and the late Cindy Johns, MS, MLS (ASCP) hosted a plenary presentation “Enhancing Laboratory Communication to Reduce Extra-analytical Errors” at the ASCLS Clinical Laboratory Educators’ Conference in Boston in February 2017. Their talk referenced the ABIMF Choosing Wisely initiative. Subsequent discussions resulted in the ASCLS Board of Directors appointing a Choosing Wisely task force that evolved to a standing committee. The committee is composed of ASCLS members representing all medical laboratory science disciplines.
The committee collaborated with respective ASCLS Scientific Assemblies in developing and reviewing recommendations, which the Board of Directors reviewed and accepted for publication. The recommendations were subsequently reviewed in collaboration with the ASCP Test Utilization Steering Committee prior to submission.
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American Society for Clinical Laboratory Science (ASCLS) recommendations were developed under the leadership of ASCLS’s Choosing Wisely Committee and the ASCLS president and executive vice president. The Committee examined numerous options based on evidence available through an extensive review of the literature and member proposals. Subject matter experts from the ASCLS Scientific Assemblies reviewed and recommended approval of their respective recommendations, which are subsequently approved by the ASCLS Board of Directors. The recommendations were subsequently reviewed in collaboration with the ASCP Test Utilization Steering Committee prior to submission.
Sources
Baksaas-Aasen K, Gall LS, Stensballe J, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med.
2021;47(1):49-59. doi:10.1007/s00134-020-06266-1
da Luz LT, Nascimento B, Rizoli S. Thrombelastography (TEG®): practical considerations on its clinical use in trauma resuscitation. Scandinavian journal of trauma, resuscitation and emergency
medicine. 2013;21:29-29.
Etchill E, Sperry J, Zuckerbraun B, et al. The confusion continues: results from an American Association for the Surgery of Trauma survey on massive transfusion practices among United States
trauma centers. Transfusion. 2016;56(10):2478-2486.
Gonzalez E, Moore EE, Moore HB, et al. Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to
Conventional Coagulation Assays. Annals of surgery. 2016;263(6):1051-1059.
Holcomb JB, Minei KM, Scerbo ML, et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive
trauma patients. Annals of surgery. 2012;256(3):476-486.
Shen L, Tabaie S, Ivascu N. Viscoelastic testing inside and beyond the operating room. J Thorac Dis. 2017;9(Suppl 4):S299-S308. doi:10.21037/jtd.2017.03.85
Taylor JR, 3rd, Fox EE, Holcomb JB, et al. The hyperfibrinolytic phenotype is the most lethal and resource intense presentation of fibrinolysis in massive transfusion patients. The journal of
trauma and acute care surgery. 2018;84(1):25-30.
