What is the role of viscoelastography in Intensive Care Unit (ICU) settings?

From the Guidelines

Viscoelastography should be used in the ICU to guide blood product transfusion decisions, particularly in patients with traumatic coagulopathy, as it allows for targeted therapy and may improve outcomes, as shown in the most recent study by Rossaint et al. 1.

Key Points to Consider

• Viscoelastography provides a comprehensive assessment of the entire coagulation process, allowing for targeted therapy with specific blood products.
• The two main types of viscoelastography used are thromboelastography (TEG) and rotational thromboelastometry (ROTEM).
• Viscoelastography is particularly useful in trauma, massive hemorrhage, liver transplantation, cardiac surgery, and obstetric hemorrhage scenarios.
• Interpretation of viscoelastography results focuses on key parameters: clotting time, clot formation time, maximum clot firmness/amplitude, and clot lysis.

Implementation in the ICU

• Establish clear protocols for when to perform viscoelastography testing, typically with active bleeding, coagulopathy concerns, or before invasive procedures in high-risk patients.
• Ensure proper staff training on the use and interpretation of viscoelastography results.
• Develop institution-specific transfusion algorithms based on viscoelastography results to guide blood product transfusion decisions.

Benefits Over Conventional Coagulation Tests

• Viscoelastography provides a more comprehensive assessment of the coagulation process, allowing for targeted therapy with specific blood products.
• Viscoelastography results are available in real-time, allowing for quicker decision-making and potentially improving outcomes.
• The use of viscoelastography may reduce unnecessary blood product use and improve outcomes in critically ill patients with coagulopathy, as suggested by the study by Baksaas-Aasen et al. 1.

Limitations and Future Directions

• Viscoelastography has limitations, including the lack of sensitivity to detect and monitor platelet dysfunction due to antiplatelet drugs.
• More research is required to fully understand the utility of viscoelastography in the ICU and to develop standardized protocols for its use.
• The study by Rossaint et al. 1 highlights the importance of viscoelastography in guiding blood product transfusion decisions, particularly in patients with traumatic coagulopathy, and suggests that it may improve outcomes.

From the Research

Use of Viscoelastography in ICU

• Viscoelastography (VE) is an established method to identify coagulopathies in various disease processes, including those encountered in ICU settings 2.
• Clinical decisions can be made with real-time tracings and quantitative values at the bedside, making VE a valuable tool in critical care 2.
• Viscoelastic testing (VET) provides a rapid and comprehensive picture of whole blood coagulation dynamics and hemostasis, which can be reviewed and evaluated at the point-of-care 3.
• VET has a wide range of potential clinical applications, including treating coagulopathies in liver disease, transplant surgery, critical care, and obstetrical hemorrhage 3.

Benefits of Viscoelastography in ICU

• Reduced mortality, decreased blood product utilization, and prognostication ability make VE an intriguing tool that can be utilized by providers to improve patient care 2.
• VET has been shown to reduce blood product utilization, bleeding, costs, and lengths of stay in massively bleeding patients 4.
• The use of thromboelastography- (TEG®) or thromboelastometry (ROTEM®)-guided algorithms can result in reductions in the frequency of red blood cell and platelet transfusion 5.

Clinical Applications of Viscoelastography

• VE has a role in many emergency medicine patients encountered by clinicians, including those with trauma, anticoagulation reversal, liver disease, acute ischemic stroke, and acquired brain injuries 2.
• VET can be used to diagnose and treat coagulopathic bleeding in cardiac surgery, and its use is recommended by several recent bleeding guidelines 4.
• The utility of VETs has been demonstrated in guiding blood component therapy for patients undergoing liver transplantation, and its scope has expanded to become routinely used for cardiac surgery, obstetrics, and trauma 6.