Which is the most effective strategy: early detection of coagulopathy with thromboelastometry or use of hemostatic factors or both?

Excerpt

In an article in the previous issue of Critical Care, Schöchl and colleagues suggested that, in trauma patients, a hemostatic strategy combining the use of fibrinogen concentrates or prothrombin complex concentrates (PCCs) (or both) guided by thromboelastometry resulted in a reduction of exposure to allogeneic blood products when compared with a strategy using fresh frozen plasma (FFP) guided by standard coagulation assays [1]. The primary concern with this analysis is the comparison of a series of patients treated at a single center with a highly protocolized approach to transfusion against a registry-based cohort of patients from multiple centers with no standardized protocol. Also, several very specific biases introduced into the analysis are of concern. First, the time required to obtain a hemostatic result varied greatly between groups, ranging from less than 15 minutes with the rotation thrombelastography (ROTEM) to usually more than 45 to 60 minutes in the standard group [2]. The timing of coagulation component replacement must be factored into this analysis. The second bias centers around the concentration of fibrinogen delivered: 3 g of fibrinogen (median of 6 units of FFP) in the FFP group versus a median of 6 g in the fibrinogen-PCC group. Previous reports have demonstrated a close relationship between blood loss and fibrinogen level [3, 4]. …