ROTEM significantly optimizes transfusion practices for damage control resuscitation in combat casualties.

BACKGROUND: Up to 40% of combat casualties with a truncal injury die of massive hemorrhage before reaching a surgeon. This hemorrhage can be prevented with damage control resuscitation (DCR) methods, which are focused on replacing shed whole blood (WB) by empirically transfusing blood components in a 1:1:1:1 ratio of platelets:plasma:erythrocytes:cryoprecipitate (PLT:FFP:RBC:CRYO). Measurement of hemostatic function with thromboelastometry (ROTEM) may allow optimization of the type and quantity of blood products transfused. Our hypothesis was that incorporating ROTEM measurements into DCR methods at the US Role 3 hospital at Bagram Airfield, Afghanistan (BAF) would change the standard transfusion ratios of 1:1:1:1 to a product mix tailored specifically for the combat causality.

METHODS: This retrospective study collected data from the Department of Defense (DOD) Trauma Registry to compare transfusion practices and outcomes before and after ROTEM deployment to BAF. Over the course of six months, 134 trauma patients received a transfusion (pre-ROTEM) and 85 received a transfusion and underwent ROTEM testing (post-ROTEM). Trauma teams received instruction on ROTEM use and interpretation, with no provision of a specific transfusion protocol, to supplement their clinical judgment and practice.

RESULTS: The pre and post groups were not significantly different in terms of mortality, massive transfusion protocol activation, mean injury severity score, or coagulation measurements. Despite the difference in size, each group received an equal total number of transfusions. However, the post-ROTEM group received a significant increase in platelets and cryoprecipitate transfusions ratios, 4x and 2x, respectively.

CONCLUSIONS: The introduction of ROTEM significantly improved adherence to DCR practices. The transfusion differences suggest that aggressive DCR without thromboelastometry data may result in reduced hemostatic support and underestimate the need for platelets and cryoprecipitate. Thus, future controlled trials should include ROTEM-guided coagulation management in trauma resuscitation.

LEVEL OF EVIDENCE: Diagnostic Test Level 3.