From the Guidelines
An elevated TEG-CKH-R in a patient with a subdural hematoma indicates a need for careful management to prevent thrombotic complications, and according to the most recent guidelines, such as those from the Association of Anaesthetists 1, the focus should be on optimizing coagulation parameters to minimize this risk. When interpreting TEG results, it's crucial to consider the specific thresholds that may indicate the need for intervention, such as those suggested for fibrinogen replacement, platelet transfusion, or fresh frozen plasma administration, as outlined in guidelines like the Association of Anaesthetists' recommendations 1. Key points to consider in managing a patient with an elevated TEG-CKH-R include:
- The potential for hypercoagulability and its implications for thrombotic risk
- The importance of prophylactic measures, such as anticoagulation or mechanical prophylaxis, in preventing complications
- The need for regular monitoring of coagulation parameters, including repeat TEG testing, to guide management decisions
- The balance between preventing thrombosis and avoiding interventions that could exacerbate bleeding risk, which is particularly delicate in neurosurgical patients. Given the complexity of managing coagulation in patients with subdural hematoma, it is essential to follow the most recent and highest-quality guidelines, such as those provided by the Association of Anaesthetists 1, to ensure that care is evidence-based and optimized for the best possible outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Elevated TEG-CKH-R in Subdural Hematoma
- An elevated TEG-CKH-R (thromboelastography) result indicates a coagulopathy, which can be a significant concern in patients with subdural hematoma 2, 3, 4.
- Coagulopathy can lead to increased bleeding and hematoma expansion, making timely correction crucial to prevent further complications 2, 3.
- Studies have shown that coagulopathy is independently associated with in-hospital death in patients with acute subdural hematoma 4.
- The use of therapies such as fresh frozen plasma, vitamin K, and recombinant activated factor VIIa can help correct coagulopathy and achieve hemodynamic stability 2, 3.
Management of Coagulopathy in Subdural Hematoma
- The management of coagulopathy in patients with subdural hematoma requires a multidisciplinary approach, involving neurosurgeons, emergency department physicians, pharmacists, hematologists, and intensivists 2.
- Surgical evacuation of the hematoma may be necessary, and the use of tranexamic acid has been suggested as a potential treatment for chronic subdural hematoma 5.
- However, the optimal treatment for subdural hematoma remains unclear, and further research is needed to determine the best course of action 5, 6.
Risk Factors and Outcomes
- Patients with hematologic malignancies and subdural hematoma pose a unique challenge due to intrinsic coagulopathy, platelet dysfunction, and immunosuppression 6.
- Increased age, low hemoglobin levels, and low platelet levels are associated with increased risk of mortality in patients with subdural hematoma 6.
- The 30-day reoperation rate was 35% in the surgical cohort, highlighting the need for careful consideration of surgical intervention 6.