Tissue plasminogen activator challenge thrombelastography is the most accurate assay in predicting the need for massive transfusion in hypotensive trauma patients

Jessie G Jiang; Hunter B Moore; Ernest E Moore; Fredric Pieracci; Angela Sauaia

doi:10.1016/j.amjsurg.2023.05.033

Tissue plasminogen activator challenge thrombelastography is the most accurate assay in predicting the need for massive transfusion in hypotensive trauma patients

Am J Surg. 2023 Dec;226(6):778-783. doi: 10.1016/j.amjsurg.2023.05.033. Epub 2023 Jun 2.

Authors

Jessie G Jiang¹, Hunter B Moore², Ernest E Moore³, Fredric Pieracci³, Angela Sauaia⁴

Affiliations

¹ University of Colorado School of Medicine, CU Anschutz Fitzsimons Building, 13001 East 17th Place, C290, Aurora, CO, 80045, USA.
² 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. Electronic address: hunter.moore@cuanschutz.edu.
³ 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; Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, 777 Bannock St, Denver, CO, 80204, USA.
⁴ 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.

PMID: 37301646
DOI: 10.1016/j.amjsurg.2023.05.033

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.

Keywords: Coagulopathy; Hemorrhagic shock; Hypotension; Massive transfusion; Resuscitation; Thrombelastography.

MeSH terms

Blood Coagulation Disorders* / diagnosis
Blood Transfusion
Humans
Hypotension* / diagnosis
Hypotension* / etiology
Thrombelastography
Tissue Plasminogen Activator
Wounds and Injuries* / complications
Wounds and Injuries* / therapy

Substances

Tissue Plasminogen Activator