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BJA Advance Access originally published online on April 24, 2008
British Journal of Anaesthesia 2008 100(6):792-797; doi:10.1093/bja/aen083
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© The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Evaluation of rotation thrombelastography for the diagnosis of hyperfibrinolysis in trauma patients

A. Levrat2, A. Gros2, L. Rugeri3, K. Inaba4, B. Floccard2, C. Negrier3 and J.-S. David1,*

1 Department of Anesthesiology and Critical Care, Lyon-Sud Hospital, Hospices Civils de Lyon and University Lyon 1, Pierre-Bénite F-69495, France
2 Department of Anesthesiology and Critical Care
3 Division of Haemostasis, Edouard Herriot Hospital, Hospices Civils de Lyon and Université Lyon 1, Lyon F-69437, France
4 Division of Trauma and Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA

* Corresponding author. E-mail: js-david{at}univ-lyon1.fr

Background: Blood loss and uncontrollable bleeding are major factors affecting survival in trauma patients. Because treatment with antifibrinolytic drugs may be effective, early detection of hyperfibrinolysis with rotation thrombelastography (ROTEM®) may be beneficial.

Methods: Eighty-seven trauma patients were included in this prospective observational study. Blood samples were collected at admission. After in vitro activation with tissue factor (EXTEM) and inhibition with aprotinin (APTEM), ROTEM® parameters including maximal clot firmness (MCF) and clot lysis index at 30 min (CLI30) were determined. Hyperfibrinolysis was defined as a euglobulin lysis time (ELT) <90 min. Threshold for ROTEM® parameters were determined with receiver-operating characteristic curves (ROC) analysis according to the ELT results.

Results: ELT was determined in a subgroup of 23 patients. In this group of patients, ROC analysis showed that for a threshold of 18 mm (MCF-EXTEM), 71% (CLI30) and 7% (increase of MCF-APTEM), sensitivity was, respectively, 100%, 75%, and 80% with a specificity of 100%. With the application of these thresholds to the whole trauma cohort, ROTEM® analysis detected hyperfibrinolysis in five patients [6%, 95% confidence interval (CI): 2–13%]. As expected, patients with hyperfibrinolysis were more severely injured (median Injury Severity Score: 75 vs 20, P<0.05), had greater coagulation abnormalities [international normalized ratio (INR): 8.2 vs 1.3, P<0.05; fibrinogen: 0.0 vs 2.2 g litre–1, P<0.05], and a higher mortality rate (100%, CI: 48–100% vs 11% CI: 5–20%, P<0.05).

Conclusions: ROTEM® provided rapid and accurate detection of hyperfibrinolysis in severely injured trauma patients.

Keywords: blood, haemostasis; complications, bleeding; complications, coagulopathy; complications, trauma


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