Methodology: 4/5
Usefulness: 3.5/5

Baksaas-Aasen K, et al. Intensive Care Med. 2020 Oct 13. doi: 10.1007/s00134-020-06266-1. 

Question and Methods: Pragmatic, European, multi-center RCT comparing outcomes in trauma patients who received empiric massive transfusion protocols (MTPs) augmented either by viscoelastic hemostatic assays (VHAs) or conventional coagulation test (CCT)-guided intervention.
Findings: Primary outcome – at 24h, no difference in the proportion of patients who were alive and free of massive transfusion between groups. No differences in any secondary outcomes. In the pre-specified subgroup with TBI, mortality benefit at 28d in the VHA-guided group
Limitations: Less coagulopathy than expected, lower observed vs predicted effect size in primary outcome – possibly under-powered. Empiric administration of 1:1:1 blood products in both arms and the lack of a sequential VHA algorithm might have masked benefits. No comment on surgical sources of bleeding and if these were corrected.

Interpretation: First larger-scale RCT comparing VHA (both TEG and ROTEM) to CCT-guided MTP. Study findings suggest that all-comers do not benefit from VHA-guided MTPs though limitations dampen this statement. Future study should test a stepwise VHA protocol and identify injury types that may benefit from a VHA-guided approach, e.g. severe TBI.

By: Dr.  Richard Hoang

Hans Rosenberg
Dr. Rosenberg is an emergency physician at the Ottawa Hospital, assistant professor at the University of Ottawa, and Director of the Digital Scholarship and Knowledge Dissemination Program.