A case of hemothorax due to traumatic bleeding managed effectively by Sonoclot®-guided blood transfusion
© The Author(s) 2016
Received: 11 June 2016
Accepted: 29 July 2016
Published: 2 August 2016
A 71-year-old woman was transported to our hospital due to traumatic bleeding, and an operation was immediately performed for achieving hemostasis. We decided to perform Sonoclot®-guided blood transfusion. When Sonoclot signatures had returned normal values, further bleeding did not occur. We experienced the first case of traumatic bleeding managed effectively by using Sonoclot. We suggest that a Sonoclot analyzer may be useful for the management of severe coagulopathy due to traumatic bleeding like ROTEM and TEG.
KeywordsTraumatic bleeding Conventional blood coagulation test Sonoclot® analyzer
Appropriate management and treatment of fluid and blood transfusion resuscitation for a case of massive bleeding is difficult. The amount and type of transfusion must usually be considered to estimate the degree of surgical site bleeding. Sonoclot® analyzer is a device for point-of-care monitoring of blood coagulation . It can mainly show three signatures : activated coagulation time (SonACT), degree of fibrin formation (clot rate (CR)), and ability of the clot retraction (platelet function (PF)), all of which can be measured within about 20 min . We could manage effectively for a case of hemothorax due to traumatic bleeding by using Sonoclot.
Change in data obtained by conventional tests during the operation
normal <37 s
normal >200 mg/dL
normal >15 × 104/μL
2.6 × 104
7.4 × 104
Changes in three signatures of Sonoclot® analyzer during the operation
normal 100–155 s
Clot rate (CR)
Platelet function (PF)
We experienced a typical case of hemorrhagic shock due to traumatic bleeding, and the first clinical case of traumatic patient managed effectively by using Sonoclot. Appropriate management and treatment of fluid and blood transfusion resuscitation for a case of massive bleeding as in our case is difficult. In the circumstances, severe coagulopathy inevitably occur. The amount and type of blood must be considered for estimating the degree of surgical site bleeding. However, we also think that a useful and appropriate parameter or guideline to support the clinical decision for blood transfusion in a case of massive hemorrhage is necessary. For example, arterial blood gas analysis can be performed quickly. But arterial blood gas analysis is useful as a guide for RBC transfusion. Also, conventional blood coagulation tests for PT-INR, APTT, and fibrinogen usually take much time for the indication of FFP or platelet transfusion.
European guidelines for the management of bleeding following major trauma were published in 2007 . According to the guidelines, point-of care monitoring of blood coagulation such as thrombelastometry might be useful for more accurate targeting of therapy . However, there are no guidelines for the treatment of traumatic bleeding in Japan. Thus, we have to manage and treat massive bleeding based on our own clinical decision. Although it was thought that the viscoelastic device as ROTEM and TEG was useful for trauma patients , no data on clinical effectiveness of Sonoclot for traumatic bleeding was reported. Sonoclot analyzer is always disposed in our operating room. And we found that Sonoclot was useful as a guide for blood transfusion during cardiac surgery and massive bleeding in a clinical situation and in our clinical study (not yet published). Thus, we thought that a Sonoclot analyzer is very useful for management of coagulopathy and used a Sonoclot analyzer in our case. The main benefits of this device are as follows. Firstly, when we use the analyzer, we can evaluate not only blood clotting function as the degree of fibrin gel formation but also platelet function as clot retraction. Secondly, data can be obtained from the Sonoclot analyzer after only 15 to 20 min. Thirdly, Sonoclot analyzer can perform measurements using whole blood. While, the disadvantage of Sonoclot compared to ROTEM is that we cannot evaluate the exact cause for severe coagulopathy, for example, intrinsic factor, extrinsic factor, or fibrinogen. Therefore, when we would like to check an exact cause for it, we should consider using not only Sonoclot but also other device like ROTEM.
By the way, measurements of PT-INR and APTT are performed using blood contained no platelet. Platelet and coagulation factor are greatly related to the intracellular collect blood coagulation system . Therefore, we think that the values of PT-INR and APTT are not an appropriate signature for blood coagulation. In the European guideline mentioned above , it was reported that PT-INR and APTT alone should not be used to guide hemostatic therapy. In fact, conventional blood coagulation tests after the operation showed some coagulopathy. The final SonACT and postoperative APTT were slightly prolonged. According to the past report , the cell-salvaged transfusion may cause coagulopathy. The cell-salvaged blood was transfused 2750 ml during the operation. Although we should consider the amount of cell-salvaged blood, CR and PF of Sonoclot signature was normal and postoperative further bleeding did not occur. Therefore, our results indicate that the value of Sonoclot may be reliable rather than PT-INR and APTT.
We experienced the first case of traumatic bleeding managed effectively by using Sonoclot. Although the further data is necessary, we suggest that the Sonoclot analyzer may be useful for the management of severe coagulopathy due to not only traumatic bleeding but also massive bleeding of emergent situation.
ME managed the case and wrote the manuscript. TH and RA supported the management. MY helped to draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
This is an anonymous case report. Although written informed consent was obtained from the patient for publication of this case report, the ethical committee in our hospital suggested that there is no need for obtaining ethical committee approval.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
- Brandy KR, Meyer RM, Luo X, et al. Evaluation of the coagulation profile among oral and vaginal combined hormonal contraceptive users using sonoclot coagulation analyzer. Clin Appl Thromb Hemost. 2012;18:576–81.View ArticlePubMedGoogle Scholar
- Bischof DB, Ganter MT, Shore-Lesserson L, et al. Viscoelastic blood coagulation measurement with sonoclot predicts postoperative bleeding in cardiac surgery after heparin reversal. J Cardiothorac Vasc Anesth. 2015;29:715–22.View ArticlePubMedGoogle Scholar
- Espinosa A, Stenseth R, Videm V, et al. Comparison of three point-of-care testing devices to detect hemostatic changes in adult elective cardiac surgery: a prospective observational study. BMC Anesthesiol. 2014;14:80.View ArticlePubMedPubMed CentralGoogle Scholar
- Spahn DR, Cerny V, Coats TJ, et al. Management of bleeding following major trauma: a European guideline. Crit Care. 2007;11:R17.View ArticlePubMedPubMed CentralGoogle Scholar
- Rossaint R, Bouillon B, Cerny V, et al. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14:R52.View ArticlePubMedPubMed CentralGoogle Scholar
- Whiting P, Al M, Westwood M, et al. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2015;19:1–228.View ArticleGoogle Scholar
- Monroe DM, Hoffman M. What does it take to make the perfect clot? Arterioscler Thromb Vasc Biol. 2006;26:41–8.View ArticlePubMedGoogle Scholar
- Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth. 2010;105:401–16.View ArticlePubMedGoogle Scholar