Good morning, everyone, and welcome to the November 15th CCAA webinar. My name is Juliane Young, and I'm going to be your moderator today. I have the pleasure of introducing Dr. Howard Pryor, who is my amazing trauma medical director. So I hope that that disclaimer out there. So Dr. Pryor is the trauma medical director here at Texas Children's Hospital and an associate professor of surgery at Baylor College of Medicine. Prior to joining the Texas Children's Hospital family, he was the associate trauma medical director and director of surgical critical care at Le Bonheur Children's Hospital in Memphis, Tennessee. Dr. Pryor completed his service in the United States Navy as a commander after holding positions such as the deputy director of surgical services at Walter Reed National Military Medical Center and director of surgical services on the USNS Comfort CBO, which is a thousand bed hospital. He has experience with supporting combat missions, civilian assistance missions, and was a part of the disaster response to culture we saw following Hurricane Maria. His training includes a general surgery residency at George Washington University, pediatric surgery fellowship at Johns Hopkins Hospital and trauma surgical critical care training at Shock Trauma in Baltimore, Maryland. Today, he will be discussing the benefits of viscoelastic testing in the management of pediatric trauma. Thank you very much, Dr. Pryor. And you can go ahead with your presentation. Oh, just one housekeeping. I'm sorry. You're going to be doing questions at the end. So please, if you have any questions throughout the presentation, you can put it in the chat or in the Q&A section, and then we'll address all questions at the end of the session. Thank you. Oh, thank you, Leanne, for that kind introduction. She's actually the person who makes everything happen around here. I'm just kind of trying to hang on. I let's see if I can get this to advance. There we go. I have nothing to disclose. However, I will be discussing some commercially available products that are used to evaluate blood clotting through viscoelastic testing. And I will use their product names occasionally. I've worked at institutions that use both of these widely recognized platforms. One is called TAG thromboelastography. The other is called Rotem. We'll talk a little bit about how they're the same and how they're different. But more importantly, I'm going to try to focus on the value of viscoelastic testing specifically. Being a surgeon trained in pediatric surgery, trauma and critical care, I consider transfusion therapy to be an essential tool in my clinical toolbox. And I've identified these four objectives for this talk. Although I will say, as I was reviewing the survey data from the TCA membership about issues and interests they had in TAG for children, the last objective is going to be a little bit more about discussion and a little bit less about presentation of data, because I felt the trauma interest and need was greater. And I'm happy to answer some questions about use of viscoelastic testing and ECMO at the end, for sure. So starting off, here's the traditional coagulation cascade, this wonderful picture. I think everyone has nightmares going back to all of their professional training about seeing this. Oh, my Lord. There's some interesting things to note here. This was a fantastic feat of science to figure this all out. And it's very interesting to see how these complex interactions occur. But if you really pay attention, there's something profoundly missing here for clotting. This is a coagulation cascade, but it's not a clot cascade because platelets and their interactivity with fibrin stranding is not represented here in any way. And as a matter of fact, it actually represents in no way the actual formation of a clot. This just shows you how you get fibrinogen polymerized to fibrin. And that's where this whole process stops. When you then categorize these steps into from the traditional coagulation cascade into the traditional coagulation studies, you can see that they focus exclusively on the plasma soluble enzymes responsible for the polymerization of fibrinogen into fibrin. And these studies were developed with intention to monitor medically induced anticoagulation before the development of platelet agents for preventing clotting. So they don't assess the functional aspects of a generated clot actually really honestly at all. And they're they're very helpful in defining very specific factor defects, and there's all kinds of ways that a hematologist can use these studies to be useful in the care of patients. But when it comes to trauma induced coagulopathy, they kind of actually fall short in terms of things you need. You may benefit by knowing. And I'll show you what I mean by that in a minute. Here we have just one kind of example of when people realized that platelets were ignored and the interactivity between platelets and fibrin stranding in a clot were ignored in these studies. They started evaluating all kinds of mechanical properties of clots, which on the one hand, doesn't seem maybe that interesting to the average person, but to mechanically oriented scientists and hematologists, they started to find some really interesting things out. And this is just a representative sample of how they were testing mechanical loads on a clot and how the clot responded when it was pressed and pushed and how things varied and variety of things like that. The point, however, being that after evaluating this for a while, there was a critically relevant development of viscoelastic testing, which, by the way, has actually been around for quite a while, but has recently had a kind of an invigorated interest because it has a lot of applications to things that we now do that are much more complicated, like trauma care at a much higher level than we used to do in 70 years ago, and also extracorporeal therapy. So the two, I wouldn't say the two, but two pretty well recognized names in viscoelastic testing are TAG and ROTEP. These analyzers are very similar in nature, actually, and how they work is modestly different. And I'll point that out. Then they have some proprietary naming schemes that change what results they deliver to you. We'll talk about this very quickly here. On the left here, you can see a TAG system where you take blood at a certain specific volume, you place it in a cup and then hang a pin inside the blood at a specific depth. And then you rotate that cup around the pin at a speed of 4.45 degrees per 10 seconds. And then you allow the blood to clot. There's a variety of ways in which the blood can be clotted. These are all, there's proprietary components to this. They add, they put additives to speed things along. They look at it under normal circumstances. They put heparinases in there. All of that, all of the minutia of that are things that are warranted in a discussion with a lab at an individual institution and the device rep. But the basics are all here. The difference between TAG and Rotem is that in TAG, the cup is spinning and in Rotem, the pin is spinning. And then as the clot forms, it starts to impact on the ability of the pin and cup to spin separately. And when they start beginning to spin together, you start generating a tracing. I will say, we're going to talk about this in more depth, what the result is. I've worked in two, I've worked in institutions that use both of these devices. And for children, I have not personally identified a meaningful difference in performance in the care of trauma care, in the care of trauma patients. TAGs do have some ability to address platelet mapping and platelet function evaluations for patients that are on DOACs that I am that I am not familiar with for Rotem. However, since most children are not on DOACs, it isn't something I've dug into at depth or really pressed a device rep about at length. At any rate, let me give you a picture of what is what's returned as a result. This is a tracing of the viscoelastic test, and it shows both Rotem and TAG parameters on the same picture. And this is a very common tracing. This would be the start of the test. This would be the time to clot formation. And I'll talk about this a little bit more thoroughly. And then these are the results that you get. And I'll tell you about a little bit about what they mean so that we're all speaking the same language before we get into some of the discussions about why these are useful in the care of children or adults or traumas in general. So here again, is that this is a this happens to be a predominantly TAG tracing. So I will and it has all the TAG nomenclature on it. But like I showed in this previous slide, there's an analogous nomenclature piece for each one of these items that we'll talk about that can be. Transferred from TAG to Rotem. So here we go. First up is the R value or the activated clotting time, which most people are familiar with as a as a name. This is the time from when you initiate the test to when clot formation actually begins. And this is an indicator of how the enzymes are functioning to polymerize fibrinogen to fibrin. That tells you that you've got it. That can tell you that you have a clotting factor defect if it is extended. And we'll talk about what to do about this in a minute. Next up is the K time. So the K time is the actual time from when the clot formation is starting to be measured to when it reaches 20 millimeters on the tracing. That's a that happens to be a random standardized distance off the midline so that they can measure other things later on down the line. The K time and the R time, the R time start time and the K time help you determine the alpha angle, which is the rate of clot formation. This is an indicator in several different trauma induced coagulating issues that I'll talk about in a minute. Finally, you have the maximum amplitude, which is the maximum amplitude of the tracing, which is also a proxy indicator for overall clot strength. This is the point where platelets are maximally interacting with fibrin and are forming your clot. And it's at your maximum state of hemostasis. And finally, you have on a tag, you have what's called the lysis 30, the lysis at 30 minutes, which is the percent amplitude reduction or fibrinolytic function, if you will, of the clot at 30 minutes. So this gives you an indication of how stable your clotting function is in the blood at the time you take this test. Here is a nomogram for responses to an abnormal tag. This the reference intervals are general. They would need to be a little bit more precisely determined at your individual institution. These are not like take home labs. You you're just like any other laboratory device. They have to be validated at your site. But it's there's a process for doing that, and it's not very complicated when you have. Elevated R value, there's there's a nomogram for how much FFP would want to respond to, because that indicates driving enzymatic clotting problem when your alpha angle is too low. That indicates that you that cryoprecipitate would would be beneficial to your clotting cascade. And then when your maximum amplitude is low, that means you need platelets and you can determine the various degrees to which you need platelets. Occasionally, DDAVP is indicated in these circumstances. And finally, if you're LY30 is elevated, that suggests that you need a clot stabilizer, Amacar or TXA as examples. These are just general. These are presented as a general ideas so that we're all kind of generally talking on the same page. Here, so that's those are the numbers and the numbers. I will tell you are typically derived and presented after a period of time, and they usually have to reach a formal stopping point before they are available to you as a as numbers per se. But many actually both of these companies, Teg and Rotem now have a graphical presentation of the results, and they will accumulate data as it is available to you in real time. So you can get the R value back in under five minutes and you can have the maximum amplitude very frequently. Shortly thereafter, within seven to ten minutes, the final numbers might show up later about the same amount of time as or earlier, but similar time frames for plasma based tests. But if you're looking at the graphical readout, you'll be able to start figuring out what you need to do for the patient long before any of those numbers are formally returned from the laboratory because you can interpret the data for yourself, which I think most most trauma teams find desirable. All right. So here's an example of a normal pattern on a thromboelastogram. This is a normal R value and then a nice, robust clot forms with a good the the alpha angle is good and it's got a nice maximum amplitude. It means you've got good platelets, enzymes. Everything is looking very nice here. You can see that you're having difficulty starting the formation of a clot. And this represents a significant problem with your enzymatic the presence of enzymes for one reason or another. This could be hemophilia. It could be the presence of anticoagulants. It could be that you bled out so much that you're having synthesis problems in your liver, all kinds of variations to this interpretation. But you can guide your resuscitation as soon as you see this developing. You know, right off the bat, you need to start with some FFP. Other things may be required, but this is you should begin administering that as soon as you see a prolonged R time on your graphical result. Now, platelet blockers, which I don't talk about very much, will show you a decreased maximum amplitude. And that will allow you to fish into the patient's medical history and figure out what is the appropriate response to the platelet blocker that they are on. And finally, if you have significant femoral lysis, this would help you determine that you need to actually you'll get a quick you'll start getting a quick answer here. As soon as you reach seven percent, typically they'll return a seven percent reduction in clot. They'll give you a return value, and that will help you determine that you need to apply a clot stabilizer. Here are some other examples of hypercoagulation and then variations of DIC. I don't actually have a representation. I apologize for trauma induced coagulopathy, but it has two stages very similar to this actually. And then some folks talk about this graphical interpretation based on frequently comparing to glassware that most trauma personnel are familiar with. The brandy tumbler, the red wine glass means you need to give FFP. Cryo is required when it's a champagne flute versus a wine glass. And then the upside down martini glass means that you're having significant femoral lysis and that you really need TXA. Test tube says please. So those are some general guidelines. So that's all great. How do we how should we resuscitate critically injured children in hemorrhagic shock? So when a healthy person experiences a serious trauma, they have a high incidence of coagulopathy, typically due to loss of blood specifically. The coagulopathy following trauma increases morbidity and mortality. And we assume that treating coagulopathy following trauma improves morbidity and mortality. We are operating kind of generally from that standpoint. As we look at the options that we have for how we're going to manage that coagulation, excuse me, that coagulopathy and how we're going to respond to it, we want to pursue goals that are metrics we can follow and we want to keep our volumes limited. So the question is, in traumatically injured patients with hemorrhagic shock, does viscoelastic testing guide guided resuscitation confer a benefit? And that's compared to the empiric administration of blood products and also compared to plasma based tests of coagulation. And outcomes of interest, obviously, are mortality first and foremost, but also things like total blood product utilization for both resource purposes and in children because over administration of volume has practical downstream negative consequences as well. So let's look at some of the of the data that's available for adults first to talk about massive transfusion protocols, which is where this all kind of got started. In 2017, EAST made some recommendations after reviewing a large set of literature that massive transfusion protocols or what they sometimes call damage control resuscitation in patients with severe traumatic hemorrhage conferred some benefits, particularly when you had a high target ratio of plasma to RBCs to platelets. And their recommendation was to consider a one-to-one-to-one ratio. This was 2017 East, so about whatever, five years ago. There were additional conditional recommendations for TXA use in certain circumstances. And interestingly, they did also evaluate activated factor VII and found that there was no evidence to support the utilization of activated factor VII in a massive transfusion scenario. A meta-analysis by Kansuji and company in 2020 found that there was a significant reduction in mortality when you implement a massive transfusion protocol in a trauma center for adults. And recommended that all institutions managing acutely injured patients implement a massive transfusion protocol to guide their resuscitation. They also recommended, obviously, further studies to specifically identify which aspects of an MTP really conferred the most benefit. Since you can see here that some of these effects do cross the line between validity and invalidity. A meta-analysis was performed by East in 2020 that did show a decrease in blood product utilization by trauma centers that guide their resuscitation with Teg or Rotet. And so that is, again, something that's desirable in the pursuit of a resuscitation for children. So that's all great. That was all in adults. What about kids getting massive transfusion protocols? There's really primarily three studies that show the benefits of an MTP in kids. And they demonstrate that those are similar benefits to those found in adults. One of the first ones was Cure Out of Nationwide Children's in 2012 that showed that in a single center, when they reviewed a very small, the patient numbers are very small here, 33 non-massive transfusion versus 22 massive transfusion protocol patients. The massive transfusion protocol patients were more severely injured. They did get more blood products, but they had less thromboembolism, and there was no real difference in mortality, but that was, they believe, confounded by a variety of other issues. So they found some modest benefits from a small number. Another institution, Hendrickson and Company, reviewed their massive transfusion protocol after implementation and found that by comparison, there were no differences in the baseline characteristics of their patients. However, they had an improved plasma to RBC ratio with their massive transfusion protocol plan. And they definitely had a faster time to plasma administration with no difference in mortality, but that also was confounded by variations in severity of illness. And finally, there was another example of a pre and post massive transfusion implementation in a single children's hospital where they looked at how much kids received red blood cells in a massive transfusion setting versus in the first 24 hours. And what they found is that the time, when using a massive transfusion protocol, they decreased the time to plasma and platelet administration. It increased their plasma and platelet to red blood cell ratios significantly, which is all desirable because abnormally applying red blood cells to a child's resuscitation is not definitively helpful. So that's great. We know that in adults, that high and balanced ratios matter and that they improve morbidity and mortality. We wanna see how these relationships hold in children. We're also interested in how we can achieve those same things without excess volume administration. This is where viscoelastic testing can confer some direct benefits. So I wanna talk a little bit about the data behind using viscoelastic testing in adults first, and then talk about how, despite a lot of great data, there's some data that suggests this is clearly applicable to children as well. So first off, I wanna look at a study by Davenport and Company that was a prospective observational trial of 300 patients, where they defined coagulopathy as an acute traumatic coagulopathy was a PT greater than 1.2. Rotem was better at identifying the coagulopathy in trauma better than conventional coagulation studies, both for precision, but also for time to results. There's a Koshokin Company published this article in, I believe this is 2012, that showed based on prospective data collection that MTP defined as six units or greater of bad friend cells within six hours of admission was improved in terms of lower ratio of FFP to RBCs and overall improved mortality when driven by a tag-guided algorithm. As you can see here, demonstrated by their graph as presented for product administration. Their overall mortality improved from 65% to 29%. However, this does still represent a small population and they did have injury severity score differences. In the Journal of Trauma, Cotton and Company from Houston published a prospective evaluation, 272 patients, where they compared conventional coagulation to plasma tests to rapid tag specifically. Rapid tag is one of the variations of tag, but bottom line is a fiscal elastic test. The authors found that these parameters had strong correlation to conventional coagulation tests. However, they returned faster. You typically got your early tag results in five minutes, your late tag results like maximum amplitude and the indication for need of platelets at about 15 minutes, whereas plasma tests resulted in about 48 minutes. And that was a significant finding, the P-value was 0.001. This was well repeated. They were able to guide their transfusions based on the R-values that were returned early in the evaluation and could identify patients that were gonna need significant transfusions as soon as their ACTs were over a certain value. Again, the reference interval all by itself not being critical. So Holcombe and Company looked in the mid-2000s, late 2000s, early 2010s, at the admission tags and using them to evaluate how they might drive resuscitation and what you might be able to figure out from a patient based on an admission tag drawn as a person comes through the door. And what they discovered in this scenario is that the activated clotting time or R-value predicted patients with substantial bleeding and that the alpha angle was better than fibrinogen for predicting when plasma transfusion would be required. The maximum amplitude was greater than platelet count for predicting when platelet transfusions would be required and that they had improved correlations between transfusion shock and headed or injured patients. More importantly, what they discovered, I think it's more important is that at that time with the dollars from those years, the charges for a tag were around $317 versus plasma tests, which would exceed $400. It varied on how much they pursued fibrinogen and some other stuff like that, but the basic studies were more costly than using a tag. So admission plasma testing, they stated, could be outright replaced with some form of viscoelastic testing. They advocated for rapid tag, nevertheless. Gonzales in 2016 did a single center study here that showed that with MTP activation based on physiologic parameters, systemic, excuse me, systolic blood pressure less than 70 or 70 to 90 with a heart rate greater than 108, a penetrating torso injury, an unstable pelvic fracture or a fast suggestive hemorrhage that they could guide a resuscitation with tag and standardize their resuscitation better, generating less hemorrhagic deaths, less early death and improve the morbidity with less blood product use. Here they showed that at the transfusion that at the two hour mark, FFP was more appropriately tailored to use with a tag. They did show that there was no difference in sepsis, acute kidney injury, DVT or pulmonary embolism by guiding their resuscitation with viscoelastic testing. And they demonstrated that their patients had greater ICU free days and greater ventilator free days when they received a tag guided resuscitation. So they had improved survival, less hemorrhagic deaths, less early deaths, improved morbidity and concluded at the end of the road that they used less blood products and they were more appropriately tailored to the patient when guiding their resuscitation with viscoelastic testing. So that all says that that works fantastic in adults. What do we know about how it applies to children and how we should manage our behavior regarding viscoelastic testing in children? These are the principal studies here. And we did a little, Adam Vogel is one of my partners here and he and I sat down and talked about how the risk of bias domains and looked at these studies. And I will readily admit that the pediatric data is less robust because it's much harder to execute these studies since kids generally have lower volumes of massive transfusion protocols compared to adults, which are having them every day. And so it's difficult to build a prospective study at a single institution, much less a multi-institutional group where you can get the kind of data that these other places are getting to convincingly demonstrate the benefits. However, I think we've got some compelling evidence that aligns with what was previously found suggesting that this is still the right thing to do. This first study is a single center retrospective review from like the mid, early 2010s that showed with 86 pediatric patients that were the highest level code activations. Excuse me, that admission are rapid tag values correlated with their plasma studies. And that again, the maximum angle could predict the need for early transfusions and lifesaving interventions with improved outcomes. Another single center trial evaluated admission coagulopathy. So this is an identified concern with children is that if they're seriously injured, they discovered in this study that they will show up with an identifiable hypercoagulability state by viscoelastic testing. And then finally, there's a study from University of Texas here in Houston that showed rapid tag was able to define this coagulopathy and again, demonstrated the association between admission coagulopathy and mortality where 57% had a coagulopathy on admission. So the lethal triad of deaths certainly applied to injured children. And the question becomes, how do we attack this problem in an interventional manner to try to improve outcomes? So Leros and Company looked at the prevalence and impact of this admission hyperephemeralysis in severely injured children. And they emphasized the important role of hyperfibrinolysis and how it might reveal that severely injured children need some form of intervention. In their definition for this study, an LY30 on tag of greater than 3% was considered significant fibrinolysis. And you can see here at the three mark, you start having mortality accelerate. At greater than 30, LY30 of 30%, excuse me, LY30 resulted in 100% mortality. So their contention was that this is a marker that you can use by viscoelastic testing, which you get very quickly, way faster than plasma-based studies that tell you that you should be intervening on behalf of these children with enzymatic support, possibly plot stabilization, because they are entering a phase of potentially unrecoverable coagulopathy. Another single center perspective observational trial, trended fibrinolysis, you're looking at 83 patients over eight years. Again, that's an indicator of how relatively infrequently in children this comes up in the trauma setting. We'll talk about, I will make a small case for other applications of this information. They discovered, this was Barbara Gaines's group in Pittsburgh. They discovered that fibrinolytic shutdown occurred in about 44% of kids and hyperfibrinolysis occurred in 17% of children. And that this finding, then by the way, the LY30 in that scenario for fibrinolysis was less than 0.8 and was associated with mortality of blood transfusions, DVTs, and other disabilities. And hyperfibrinolysis was an LY30 greater than 3% and was associated with mortality in blood transfusions, not surprisingly. And this suggested a value of assessing fibrinolytic function prior to the administration of some of the pharmacologic hemostatic agents, such as TXA during guided resuscitation. And what this really revealed is that something that has been noted in adults as well as that there's kind of the normal physiologic phenotype, some generally kind of near the admission time, then you get fibrinolytic shutdown at one point in the response to trauma and then a hyperfibrinolytic phase at another point. And that just argues for serial evaluation so you can identify where you are in this coagulopathy kind of flip-flop that occurs after traumas. And most importantly, it points out that none of these findings are even findable at all with plasma tests. So again, kind of just back to arguing in general that you're receiving a totally different level of information about hemostasis, clotting, and your ability to keep the patient stabilized when you're using viscoelastic testing. And finally, there was a multicenter trial that was retrospective that looked at kids under 15 years of age. They had blunt trauma excluding TBIs, we'll talk about that in a minute separately, where they used a Rotem-based protocol and compared that to the historical controls with propensity scoring to the nearest neighbor matching and found that FFP utilization and 24-hour coagulopathy were reduced with resuscitation guided by, again, Rotem viscoelastic testing. Multicenter retrospective study from 2015 to 2018, a little bit more recently, looking at the highest level of trauma activation compared to TAG-guided massive transfusion protocol, excuse me, with TAG without a massive transfusion and found that younger, smaller, and more injured, more shock, and more acidotic kids were found in the massive transfusion group and they had a lower alpha angle, a lower maximum amplitude. And further, the maximum amplitude on admission TAG is a clear predictor that a massive transfusion is going to be likely. And that data, again, I stress is reported usually about 30 minutes earlier than, or is identifiable, I guess I shouldn't say reported, is findable, is viewable about 30 minutes earlier than any plasma test that would be available that might suggest the same thing. Now, one little additional thing here is that there was a retrospective review that was done from 2010 to 2020 out of the Colorado group that looked at changes in viscoelastic abnormalities in abusive versus non-abusive pediatric trauma. So this is inflicted injury versus accidents. And what they were able to demonstrate is that there is a type of hypercoagulable pattern that is interpretable in these children that demonstrate abuse. They're, again, younger, smaller, it's usually a blunt injury. They were shown to have an decreased maximum amplitude and a decreased alpha angle compared to patients that had experienced a accidental trauma. The meanings behind this weren't further evaluation, but again, still an abnormal maximum amplitude on a viscoelastic test was a higher marker of mortality in this patient population as well. So we've covered a lot of territory. This is just one more kind of independent evaluation, very recent, this past January, that showed that thromboelastography and transfusion patterns in severely injured pediatric trauma patients in blunt solid organ injuries had some definable patterns as well. 32% were coagulopathic on admission and their initial evaluation were of the severely injured pediatric trauma patients with blunt solid organ injuries. What their conclusion was, you should use TEG in those scenarios because you can appropriately direct platelet resuscitation, which isn't something you want to, which isn't a resource you want to burn routinely, and that you may actually impact mortality by applying cryoprecipitate as guided by a TEG or a viscoelastic test. So this was a recent survey of the Pediatric Trauma Society membership, and it kind of gives a snapshot of the current practice with a continued reliance amongst trauma, pediatric trauma centers on conventional coagulation testing compared to viscoelastic monitoring. And it seems to represent an opportunity for quality improvement. But I'll make a comment on implementation because implementation in standalone children hospitals can be at best a field of landmines. So let's just, I'll talk about this one study that was published that talked about one center's kind of prospective observational implementation of TEG monitoring and pediatric trauma. But at the end of the road, the bottom line is they found that they didn't try to impact the actual clinical behavior of folks. But at the end of the road, what they discovered is with some modest training, TEGs were primarily being ordered on the most severely injured patients. And then the kids that got TEGs had worse outcomes, but that's probably because their interpretation, let me put it this way, their interpretation was the TEGs were being ordered because the kids were very, very sick and they were hoping to find some additional data, but they were still generally pretty reliant on the old coagulation studies. So one of their statements was that they were not getting coagulation studies on all the patients that they had outlined that they would get them on. And that sometimes that was probably okay, because honestly, in many cases, the kids that they would have included often really weren't sick enough to warrant full application of all this stuff because they just needed it. Their triage criteria was maybe too inclusive. But on the other hand, it might also not be okay because there were some logistics and education and maybe even some misses out there in the world that they might have been able to identify earlier. They found that patients that get any form of conventional coagulation studies are sick, but that their patients were even sicker. So these are kind of cautionary tales that starting a program of this type in a hospital really warrants talking about selecting the right patients, but it also needs to make sure that there is persistent and ongoing supportive education for a significant period of time until lots of people are comfortable with this new technology for evaluating clotting and anticoagulation. So in summary, MTPs have definitely high quality data and kind of poor pediatric data, but definitely stuff that suggests it's the right thing to do. And then TEG versus conventional coagulation tests or plasma-based tests clearly demonstrates that they have similar costs. The initial capital outlay for getting a new machine is in the under $10,000 range. So it is a real expense up front, but the consumables and the protest costs are similar, and in fact, in many cases, less money than the panel of coagulation studies that are done on plasma. They give you more rapid results. The ability to see these data in a graphical format is a significant value and is worth whatever additional amount of software investment might be required to use this information. It delivers you more useful data to guide resuscitation. It's generally looking like it correlates much better with outcomes. There's a lot of high-quality data applied to adults that there's every indication that it is correlative, but it's not well substantiated in the pediatric world, and that there are clear-cut implementation challenges because you really do have to, outside of the trauma teams, the initial trauma team folks, there's a lot of education, familiarization for people that were not recently trained in trauma with TEG as an implemented strategy for managing trauma-induced coagulation. It's something that just lots of people are not that familiar with. I will kind of pause there. I will, the one other thing I will say, this is, here's my motivation for why I do what I do and why I think about what the right, proper way to resuscitate kids are because one of these guys could ever be in any kind of trouble. I would hate to think we didn't have the perfect plan for them if they showed up in my trauma bay. I will, I'll plan to take questions. I think that covers the big stuff that I wanted to touch on. I will talk, I will state for a minute that when people talk about why should we get this system for a standalone children's hospital if trauma is so infrequent, if the trauma that would warrant its use is so infrequent. And I would point out that most standalone children's hospitals also have, or even for that matter, hospitals within hospitals and all of the other variations. If you have an ECMO program, this system, not although I didn't talk about it that much, but this system is absolutely revolutionary for managing your coagulation on extracorporeal therapies as well. Because again, plasma studies do not deliver the full tale. All they give you is a little part of the story. And there's a whole host of ways in which viscoelastic testing can inform your management of anticoagulation. And when you think about it in terms of a laboratory function, as opposed to a just trauma bay item, viscoelastic testing is, it seems like a very sensible inclusion in the panoply of lab tests available for children. So I guess I'll stop sharing there and see what questions I can answer. Thank you, Dr. Pryor. We do have one question in the chat. In two centers, we often don't have as many folks available during NPPs who are free to read and interpret the testing results. Can you talk about who interprets that in the trauma bay while doing NPPs at your current center or previous centers? Sure. That's a good question. The answer to your question, here at Texas Children's, we are blessed with a transfusion medicine service that is omnipresent. It spoils you, to be honest. So I know that that's not a real thing for most places. It's really another one of the outstanding features in this institution. I was pleased to discover when I got here. However, in other places, almost categorically everywhere else, I've had access to the graphical information. And those of us doing the resuscitation interpret right there for ourselves. There's some practice. They have, again, I'm not advocating for one company or another. I will mention that humanetics has a training program that I was required to undertake in the military that teaches you how to identify over and over again. It's really no different in terms of pattern recognition than the kind of pattern recognition requirements for an EKG in advanced cardiac life support. I'm not a cardiologist. I'm not here to tell you the minutiae of all of these different things. But when it comes to advanced cardiac life support, I can recognize the patterns that matter, adequate to keep a person safe until I can get a cardiologist in the mix. Same thing with viscoelastic testing. Once you've done it a few times, you've identified it a few times, and you've been cycled through the simulation a few times, you'll find that it's relatively straightforward. And it's applicable. The results delivered are generally the same, adult versus children. So there's not a lot of, you know, calculating and rethinking that you have to do once you've generally learned the principles. Okay, we have another question. Do you see value or ability with non-trauma centers doing TIC? Can it guide the transfer process or be of value to the trauma center receiving the results? Potentially. I mean, I try to avoid, I mean, I am enthusiastic about TIC, so I will offer that up front. But I'm enthusiastic about it because it's a smart concept. And it gives you more information about the patient you're taking care of than a variety of tests that also take a long time. It kind of varies a little bit based on, I think the answer to that question is a qualified yes, based on how much transferring your institution really is doing to justify the initial outlay. Because the actual consumable costs are not very high. So if it's sensible to install the system and get it up and running, that you'll use it enough for transfers, then I think it's reasonable to do that because you can be giving the child FFP. I think the other thing is, anytime you're going to be engaging in some forms of resuscitation, my observation in children's hospitals nationwide has been there's an over-reliance on packed red blood cells for transfusions. When in fact, many times what you actually need, and we have now guidelines about this that are still not being followed. Many times what you need is actually just simple volume and FFP can confer way more benefits than giving red blood cells. That use of tag, if having a tag around causes that to happen, that's well worth the money in my personal opinion. Okay, we have a couple more questions and probably just time for a few more. Do you have any recommendations for set timings during resuscitation that you draw and repeat the studies? Since as we resuscitate, we should be seeing changes in values imposed? That's a good question too. My practice is, well, first off, here we draw an admission ROTEM. So that gets you your first one right off the bat. And after we've got my practices, I would send a repeat ROTEM at the second MTP pack, which is, so in our first MTP pack is four units of reds, four units of FFP and then platelets. And then our second one is two units of reds, two units of yellows and cryoprecipitate. So once we've gone through that full cycle, if we are still in an active resuscitation phase, that is when the next ROTEM goes off. If not, I will usually draw it at the two hour mark, just to see if there's some fine tuning that I need to do at the end of the resuscitation. Okay, next question. So the wine glass graphics is relatively simple. Have you thought about making that into a handout or back card or what are your recommendations for making that available to providers, especially for those who don't retrace them very often? Short answer to the question is, yes, there are, actually, I believe both companies will happily provide you with a little ID card. I'm not an ID card, but a, you know, identification card tag that can be carried along with you as a quick reference point, so that you can kind of look at the tracing and figure out where you are. And again, it's a good question, which I also circle back to, once you've done it a few times, the pattern recognition becomes pretty straightforward. It's just that little uncomfortable transition phase, and then it all kind of settles out. And then there's nothing else in the chat, but I do have a couple of questions for you, Medical Director. Okay, so you touched on this briefly. So the first three things, you might start to see something within the first 10 minutes. What's your recommendation for resuscitation products prior to that? I know the answer to this, but can you talk about, you know, what the emergency release products should look like? Yeah, I mean, for paying for your book, again, we're back, this is an issue about trying to get the right volume administration for a child. If you have a major exsanguination event in a baby, any what I, by baby, I mean, any child we would take care of in our hospital, whole blood is your first best effort, because it delivers the plasma-based enzymes for coagulation, it delivers platelets, and it delivers oxygen-carrying capacity in one volume administration. While you're getting, while you're awaiting mechanical control of bleeding and further insight into what specific factors might be missing. So that's my, that's my go-to desire whenever I can get it. And I try to achieve something close to that until I have data with one-to-one-to-one resuscitations when I don't have whole blood available. And then is it your recommendation for centers that do have Teg or Roten to utilize it on all of their highest level activations, on all trauma activations that they see, like is there a- If there's a consider, I think me personally, if there's a consideration for blood transfusion in a child, it should be guided as soon as reasonably possible by viscoelastic testing. The data is, people can argue that the data is not 100% definitive, and that is a true statement that's admitted up front. It's very hard to get there with children in general for most of these things, but the correlative data and the analogous interpretations are convincing enough in my mind that it seems very reasonable to do that. And this will probably be your last question and then something pops up quickly. Okay, so one of your slides, I think it was when you were talking about the adult data, but it talks about the cost savings of utilizing Teg or Roten versus your traditional collaboration studies. Are there studies that can estimate like how many patients it would take to get the cost benefit from the initial upfront investment for the hospital? Because I'm just thinking of centers who are trying to roll this out at their programs and they need administrative buy-in for the initial investment. Is there anything out there that shows how many patients or how many times the utilization would pay for itself? It's a good question. I think I'd have to say the answer to my most recent review of the literature, the answer is no, nothing that has gotten that granular. But as a thought exercise, there was about a $100 difference per test sequence between to the benefit of viscoelastic testing. And if you figure it costs, my most recent estimate for the cost of a machine was around $5,000, between 5,000 and $6,000. So with a $100 cost savings, you've got to do 60 tests and you paid for the machine. Well, I think that's kind of loosely it. I think, and if you have an active ECMO program or you have other scenarios where you would be transfusing children with some regularity like an OR for cancer cases and things of that nature, having a tag in your panel of options gets paid for pretty quickly. Awesome. Thank you so much, Dr. Pryor. As a reminder to all of the attendees, you can fill out the link in the chat that has the evaluation survey so that you can get your CME or CE hours. And then CCAA also provides a variety of online education courses and other webinars that you can get CMEs and CEs for. Dr. Pryor, it's a pleasure. I will see you in five minutes at our next meeting. But thank you so much for presenting. We had a great number of participants. Thank you everybody for joining. Thank you, everyone. I appreciate it.

viscoelastic testing

pediatric trauma

clotting process

coagulopathy

targeted interventions

improved outcomes

blood product utilization

implementing viscoelastic testing

optimal resuscitation