Thromboelastography in Trauma: A 1-Year Institutional Experience

Viscoelastic testing to assess the overall clotting ability of a patient’s whole blood, such as thromboelastography (TEG), has risen in popularity over the past several years due its holistic assessment and rapid turnaround time, most notably in the realm of liver transplants and complex cardiac surgery. In the setting of trauma and assessing the concomitant coagulopathy, the rapid turnaround time and ability to assess for hyperfibrinolytic states had led to it being requested at our institution despite variable result interpretation and lack of reproducibility in previous studies. In response, our institution’s laboratory made this available at our hospital, which includes a large level 1 trauma center serving multiple states, with the aim of reassessing its utility after a 1-year period. Following the first year of use, data that were evaluated included TEG values and conventional laboratory testing temporally associated with the TEG order, including platelet count and fibrinogen level. Retrospective chart review was also performed to determine indication and context of testing, as well as for assessment of resulting interventions. Seventy-three samples from 58 patients were tested during the 1-year period, 30 of whom were admitted for trauma and 20 of whom were evaluated during the critical initial acute resuscitation period. Among the trauma patients, the majority of TEG samples (75.6%) did not demonstrate any abnormality. A primary reason cited by trauma surgeons for the need for TEG was its ability to accurately identify states of hyperfibrinolysis to determine the need for therapeutic agents such as tranexamic acid. In this regard, no evidence of hyperfibrinolysis was identified in any of the trauma patients. In fact, only a single hyperfibrinolytic sample was identified, corresponding to a nontrauma patient who had received a thrombolytic agent (alteplase) prior to TEG testing. Additionally, 75% of acute trauma patients received tranexamic acid, which was nearly always administered prior to the TEG sample being drawn. No evidence of TEG results affecting patient management was identified. As a result of the retrospective review of the data, use of TEG in the trauma population at our institution dramatically declined. We present this institutional review as an example of performing data review to influence test utilization practices.