Serial “death diamond” TEGs are a bedside indicator of futile resuscitation during massive transfusion

Abstract

Serial DDs could serve as rapid check points to gauge the likelihood of success of continued resuscitation. Loudon et al.’s work combined with the use of serial DDs may serve as building blocks toward a trial using VETs to predict continued futile resuscitation.

To the Editor:

Loudon et al. demonstrated that among patients who received transfusion for trauma resuscitation defined as “massive transfusion” (10 to 19 U PRBCs/4 hours), the odds of mortality exceed survival beyond 16 U PRBCs/4 hours. For those defined as “ultramassive transfusion” (≥20 U PRBCs/4 hours) survival approaches zero beyond 36 U PRBCs/4 hours.¹ Loudon and colleagues suggested that trauma surgeons should view efforts as “heroic” beyond 16 U PRBCs/4 hours and “near futile” beyond 36 U PRBCs/4 hours.

They are to be congratulated for providing an objective and reproducible marker for futile resuscitation, particularly during a time of urgent blood bank shortage. As a limitation of their study, they mention that viscoelastic tests (VETs), such as thromboelastography (TEG), were not used. First described in 2015, a characteristic rapid TEG (rTEG) pattern called a “Death Diamond” (DD) correlates strongly with futile resuscitation. Specifically, a DD is defined as a rTEG tracing with a time to maximum amplitude of ≤14 minutes and time from maximum amplitude to total lysis of <30 minutes, which is highly predictive of death (Fig. 1).² Viscoelastic tests enable goal-directed blood product resuscitation and have improved mortality while simultaneously reducing blood component waste, yet there are few VET-based criteria that define futile resuscitation.^2,3

Figure 1.

Schematic of an rTEG DD tracing. It has previously been demonstrated an index DD tracing portends near 100% mortality with TMA ≤14 minutes from the start of the test and TTL <30 minutes from the maximum amplitude. TMA, time to maximum amplitude; TTL, time to total lysis.

Patients with a DD pattern comprised only 2.4% of the original 2015 DD study, yet these patients received nearly four times as many units of blood products (approximately 36 U per patient in <4 hours to death) compared with survivors. Interestingly, the 36 units per patient within 4 hours is the same number of units in 4 hours, which Loudon et al. described as a cutoff defining futile resuscitation. Furthermore, the initial 2015 DD study was refined by a 2022 follow-up study which demonstrated that serial DDs (i.e., the “double death diamond” [DDD]) within 3 hours of arrival predicted 100% mortality in trauma patients receiving massive transfusion.^2,3

Clinical findings, biomarkers, and guidelines to assist the trauma surgeon prognosticate futility of massive transfusion are not well defined. The use of blood pressure, pulse rate, pH, base deficit, lactic acid, fibrinogen, and international normalized ratio are not able to predict futile resuscitation.⁴ This was reinforced by the 2015 DD article, whereby survivors and nonsurvivors demonstrated no statistically significant difference in the index base deficit, pH, or number of units of blood transfused.²

We do not recommend that resuscitation should cease because of a single DD rTEG. However, if serial DD traces are observed following the initial resuscitation, the trauma surgeon's consideration to cease resuscitative efforts seems prudent. Because of the importance of accurately defining these limits such as time scales between serial DD TEGs, further research is clearly needed. In light of recent national blood product shortages, this situation is analogous to the now-accepted restrictions on emergency department resuscitative thoracotomy, which began with the study of parameters that predicted certain death and now are widely accepted guidelines.⁵

Therefore, should the surgeon be confronted with failure to achieve hemostasis as documented by the presence of serial DD rTEG patterns after large volumes of blood products, it would be reasonable to assume that the patient is deteriorating into a state of irreversible hemostatic exhaustion characteristic of early trauma-induced coagulopathy.

Loudon and colleagues' study will prompt other traumatologists to further elucidate the predictive value of the serial DDs as a biomarker for futile resuscitation. Describing a threshold number of PRBC units transfused within 4 hours combined with serial bedside viscoelastic parameters, as well as clinical and laboratory markers of shock (e.g., lactate, base deficit, hyperfibrinolysis), may reduce wastage of blood products through evidence-based stewardship. Most recently, the Suspension of Transfusions and Other Procedures (STOP) criteria have incorporated predictable “cut points” combining markers for shock such as serum lactate and degree of fibrinolysis, which together predict futility of resuscitation with a positive predictive value of 100%. Based on the STOP criteria, the concept of a “futility time out” at selected periods of massive transfusion has been proposed.⁴ Serial DDs may serve as rapid check points to gauge the likelihood of successful continued resuscitation while other STOP data points are collected and analyzed during the hectic moments of providing massive transfusion. Loudon et al.'s work, combined with the use of serial DDs incorporated within the STOP criteria, may serve as building blocks toward a larger randomized trial using adjunctive VETs to define reproducible cut points that predict futile resuscitation. In the future with more studies similar to Loudon and colleagues' analysis, resuscitation practices may be significantly changed while leading to more rational use of scarce blood products.

AUTHORSHIP

E.E.M., H.B.M., and M.M.W. conceptualized the letter. E.E.M., S.G.T., D.W., and M.M.W. contributed to the literature review. E.E.M., H.B.M., S.G.T., M.S.F., S.S., J.R.C., J.B.M., C.M.B., D.W., M.M.W. contributed to the critical writing and revising of the letter.

ACKNOWLEDGMENT

The late Michael Chapman, MD for his foundational work on the “Death Diamond” as a predictor of futile resuscitation.

DISCLOSURE

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

E.E.M. and H.B.M. have received research grants from Haemonetics Corp. This letter to the editor was not funded or supported by any private, governmental, or educational institution.

Ernest E. Moore, MD
Department of Surgery
Ernest E. Moore Shock Trauma Center at Denver Health and University of Colorado
Denver, Colorado
Hunter B. Moore, MD
Department of Transplant Surgery
Denver Health and University of Colorado Health Sciences Center
Denver, Colorado
Scott G. Thomas, MD
Department of Trauma Surgery
Memorial Leighton Trauma Center
Beacon Health System
South Bend, Indiana
Michael S. Farrell, MD
Department of Surgery
Lehigh Valley Health Network
Allentown, Pennsylvania
Sherry Sixta, MD
Department of Trauma Services
Saint Anthony Hospital
Lakewood, Colorado
Julia R. Coleman, MD, MPH
Department of Surgery
Ohio State University
Columbus, Ohio
Joseph B. Miller, MD
Connor M. Bunch, MD
Departments of Emergency Medicine and Internal Medicine
Henry Ford Hospital
Detroit, Michigan
Dan Waxman, MD
Department of Transfusion Medicine Blood Services
Versiti Blood Center of Indiana
Indianapolis, Indiana
Mark M. Walsh, MD
Departments of Emergency Medicine and Internal Medicine
Indiana University School of Medicine
South Bend Campus
South Bend, Indiana