TEG in TRAUMA: IS a USELESS WASTE of TIME and MONEY
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1 TEG in TRAUMA: IS a USELESS WASTE of TIME and MONEY Alison Wilson, MD, FACS Professor in Surgery Skewes Family Chair in Trauma Director, Critical Care and Trauma Institute
2 DISCLOSURES No Financial Disclosures Academic Relationships Trained at BCM Dr. Martin Schreiber attending, mentor International Expert in Coagulopathy KING OF COAGULOPATHY Taught me: Rely on DATA, Get the FACTS
3 CONCESSIONS: TEG VERY Hot topic currently Everyone wants one (attempts to tell admin it is required) Quick Functional Assay, clotting and fibrinolysis Assessment of various coagulation steps Very pretty graphs
4 LOGISTICS Capital Expense: $40 K for machine Dedicated Area: vibration interferes, special tables Quality Assurance Testing: frequently Cost of Reagents, labor Maintenance of software: IT investment Issues with integration with EMR: legalities
5 Just the Facts, Ma am TEG/Rotem do nicely detect coagulopathy Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and costeffectiveness analysis Penny Whiting,1* Maiwenn Al,2 Marie Westwoo Isaac Corro Ramos,2 Steve Ryder,1 Nigel Armstrong,1 Kate Misso,1 Janine Ross,1 Johan Severens2 and Jos Kleijnen3
6 TEG/ROTEM are FAST
7 Abnl Values are Associated w MT Rapid Thrombelastography Delivers Real- Time Results That Predict Transfusion Within 1 Hour of Admission Cotton, Bryan A. MD, MPH et al. Journal of Trauma-Injury Infection & Critical Care: August Volume 71 - Issue 2 - pp doi: /TA.0b013e31821e1bf0
8 Today s World Nice to describe things Nice to find associations Nice to have projects to work on But..Is There Evidence to Make this Standard of Care??
9 WHAT DOES THE EXPERT SAY?
10 ALSO IMPORTANT!!!!! What is the Evidence of Impact on Outcomes??
11 OUTCOMES????..Finally, our study is NOT addressing the impact of ROTEM on clinical outcomes.
12 OUTCOMES??? 39 Publications.There was NO Data on Clinical Effectiveness..Clinical Outcomes did NOT differ between groups.. Results suggestive if patient is hypocoagulable predictor of any blood component transfusion
13 OUTCOMES???? 55 Studies: 38 Prospective, cohort; 15 retrospective cohort; 2 before/after; NO Randomized Trials
14 KEY FINDINGS Only 3 studies had LOW Risk of BIAS Std measures diagnostic accuracy inconsistently reported Predictive performance not consistently superior to routine tests TEG/ROTEM based resuscitation was NOT Associated w/ mortality Effects on blood product transfusion, mortality, outcomes remain unproven
15 2015 Summary
16 FINDINGS Concerns about bias in studies Little evidence on Accuracy of results We are unable to offer advice in use in trauma patients We strongly suggest at present these tests be used only for research
17 WHAT WE DO KNOW Bleeding patients need Blood Don t let a test distract you from a Deficiency of Proline Early Replacement based on Physiology is warranted FFP and Plts early are very important
18 DATA TO SUPPORT Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients Holcomb, John B. MD*; Wade, Charles E. PhD*; Michalek, Joel E. PhD ; Chisholm, Gary B. PhD ; Zarzabal, Lee Ann MS ; Schreiber, Martin A. MD ; Gonzalez, Ernest A. MD ; Pomper, Gregory J. MD ; Perkins, Jeremy G. MD ; Spinella, Phillip C. MD**; Williams, Kari L. RN*; Park, Myung S. MD* Annals of Surgery: September Volume Issue 3 - pp
19 RESULTS 30 d survival: w/ high plasma:prbc ( 1:2) compared to low (p.01) 30 d survival: w/ high plt:prbc ( 1:2) P.01 truncal hemorrhage intensive care unit, ventilator, and hospital-free days (P < 0.05)
20 LANDMARK STUDIES Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe TraumaThe PROPPR Randomized Clinical Trial John B. Holcomb, MD 1 ; Barbara C. Tilley, PhD 2 ; Sarah Baraniuk, PhD 2 Martin A. Schreiber, MS 13 ; Deborah M. Stein, MD 12 ; Jordan A. Weinberg Both ratios effective Some advantages of 1:1:1
21 Landmark Articles DAMAGE CONTROL RESUSCITATION IS ASSOCIATED WITH A REDUCTION IN RESUSCITATION VOLUMES AND IMPROVEMENT IN SURVIVAL IN 390 DAMAGE CONTROL LAPAROTOMY PATIENTS Bryan A Cotton, MD, MPH, 1 Neeti Reddy, BS, 1 Quinton M Hatch, MD, 1 Eric LeFebvre, BS, 1 Charles E Wade, PhD, 1 Rosemary A Kozar, MD, PhD, 2 Brijesh S Gill, MD, 2 Rondel Albarado, MD, 2 Michelle K McNutt, MD, 2 and John B Holcomb, MD Annals Surgery Oct 254
22 Results Lethal triad when arrive to ICU (80% vs. 46%, p<0.001) 24-hour survival higher w DCR (88% vs. 97%, p=0.006) and 30-day survival higher with DCR (76% vs. 86%, p=0.03) OR 2.5
23 QUESTION?? WHY WAIT ON ANY TEST (EVEN IF FAST)? Test w NO DATA on Outcome?
24 Repeating History?? Fervor of Adoption Reminds me of Others.
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