Implementation of ROTEM-guided hemostatic resuscitation and evolution of transfusion practices: a 15-year population-level analysis in a Level I trauma center

Abstract Background Hemostatic resuscitation guided by viscoelastic testing has changed the management of trauma-induced coagulopathy. We evaluated changes in blood products transfusion and procoagulant use after implementation of rotational thromboelastometry (ROTEM)-guided coagulation management in patients with severe trauma. Methods 15-year retrospective population-level analysis (2009–2023) of patients with severe trauma admitted to a Level I trauma center. Three periods were defined according to major changes in coagulation management: pre ROTEM (‘Reference’ period), ROTEM-guided management (‘ROTEM’ period) and ROTEM-guided management with tranexamic acid (‘ROTEM + tranexamic acid’ period). Quarterly incidences of blood products transfusion (red blood cells [RBC], platelets, fresh frozen plasma [FFP]), procoagulant products use (fibrinogen concentrate [FC], prothrombin complex concentrate [PCC]) and mortality were compared. Results Among 4,205 patients, 48% had an Injury Severity Score ≥ 15. ROTEM was performed in 92% of the most severely injured. The incidence of RBC transfusion decreased by 27% during the ‘ROTEM’ period (incidence rate ratio [IRR], 0.73; 95% confidence interval [CI], 0.64–0.84) and by 35% during ‘ROTEM + tranexamic acid’ period (IRR, 0.65; 95% CI 0.54–0.78). FFP transfusion also decreased over time. FC use increased by 50% during the ‘ROTEM’ period (IRR, 1.50; 95% CI, 1.11–2.05) and by 153% during the ‘ROTEM + tranexamic acid’ period (IRR, 2.53; 95% CI, 1.83–3.53). The proportion of patients requiring massive transfusion decreased from 19% to 4% during these periods. Incidence of 24-hours and ICU mortality were similar. Conclusion ROTEM-guided coagulation management was associated with reduced RBC and FFP transfusion and increased FC use, without change in mortality.