P. M. EINERSEN2, M. P. Chapman1, H. B. Moore2, E. Gonzalez2, C. C. Silliman2,3, A. Banerjee1, A. Sauaia1, E. E. Moore1,2 1Denver Health Medical Center,Surgery,Aurora, CO, USA 2University Of Colorado Denver,Surgery,Aurora, CO, USA 3Children’s Hospital Colorado,Pediatric Hematology-Oncology,Aurora, CO, USA
Introduction: Uncontrolled hemorrhage is the leading cause of preventable death from trauma with hemorrhagic shock accounting for approximately 50% of deaths in hospitalized patients. Massive transfusion protocols (MTPs) offer a long-proven benefit in resuscitation of these patients and recently, the superiority of TEG-guided resuscitation over pre-determined component ratio strategies has been established. However, optimal cutoff values for TEG-driven interventions have yet to be identified. We seek to establish optimal thresholds for r-TEG driven resuscitation based on prospective data collected in severely injured patients at risk for trauma-induced coagulopathy.
Methods: R-TEG data was reviewed for patients from 3 randomized, prospective studies conducted at a level 1 trauma center from September 26, 2010 to June 30, 2015. Criteria for inclusion were highest-level trauma activation in patients ≥ 18 years of age with hypotension presumed due to acute blood loss. Patients were excluded if an r-TEG was not sent within one hour of injury, injuries were deemed unsalvageable or in cases of isolated GSW to the head, pregnancy, or liver disease. Receiver operating characteristic (ROC) analysis was performed to test the predictive performance of r-TEG for substantial transfusion requirement, defined ≥ 4 units of RBCs in the first hour of hospitalization. Cut-point analysis, utilizing Youden Index, distance to (0,1) and sensitivity, specificity equality was then performed on these ROC curves to determine optimal thresholds for TEG-based resuscitation.
Results: ROC analysis of r-TEG data from194 patients who met inclusion criteria in one of three concurrent prospective studies yielded areas under the curve (AUC) with respect to substantial transfusion requirement greater than 70% for ACT, α, MA and LY30 (70%, 82%, 80% and 71% respectively). There was considerable overlap in confidence intervals of all AUCs indicating these TEG variables did not differ statistically in their predictive capacity. Optimal cut-point analysis of the resultant ROC curves was performed and for each value, sensitivity, specificity equality determination yielded the most sensitive cut-point, respectively ACT >128 sec, MA <57 mm, α <66 and LY30 >3%.
Conclusion: Through cut-point analysis of prospective TEG data, we have identified optimal thresholds for initiating TEG-based resuscitation for ACT, MA, α and LY30 favoring the more conservative thresholds set forth by sensitivity, specificity equality analysis. These thresholds should be validated in a prospective multicenter trial.