Harrison Hannah B, Smith William Zachary, Salhanick Marc A, Higgins Russell A, Ortiz Alfonso, Olson John D, Schwacha Martin G, Harrison Chantal R, Aydelotte Jayson D, Stewart Ronald M, Dent Daniel L
Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
Am J Surg. 2014 Dec;208(6):1078-82; discussion 1082. doi: 10.1016/j.amjsurg.2014.09.012. Epub 2014 Sep 28.
Traumatic hemothorax (HTX) has been demonstrated to predictably contain low fibrinogen, low hematocrit, and low platelet counts. When analyzed on its own, shed HTX demonstrates coagulopathy. However, when mixed with normal pooled plasma (NPP) at physiologically relevant dilutions, HTX demonstrates accelerated coagulation. We hypothesize that when HTX is mixed with a patient's own plasma, the mixture will demonstrate hypercoagulability. The accelerated coagulation of this mixture would have important implications for the autotransfusion of HTX as a method of resuscitating a trauma patient.
Adult trauma patients from whom greater than 140 mL of HTX was evacuated within 1 hour of tube thoracostomy were included. HTX was sampled at 1 hour after evacuation, and a portion of the sample was centrifuged and stored as frozen plasma for later analysis. The remainder of the sample was analyzed (coagulation, hematology, electrolytes), and values were compared with concurrent venous values extracted via chart review. A citrate tube containing the patient's venous blood was additionally spun down and frozen for subsequent mixing study analysis. Coagulation was further evaluated by mixing serial dilutions of the previously frozen HTX with NPP. Additionally, the previously frozen HTX was mixed in serial dilutions with the previously frozen sample of patient plasma (PTP).
Subjects (10) were enrolled based on inclusion criteria and collection of a discarded venous sample. In HTX samples analyzed alone, no thrombus was formed in any coagulation test (activated partial thromboplastin time [aPTT] > 180). The median aPTT value of PTP alone was 25.5. In 1-hour specimens mixed at a clinically relevant dilution of 1:4, HTX mixed with NPP had a mediana PTT value of 26.0, whereas HTX mixed with PTP had a median aPTT value of 21.7. Thus, the mixture of HTX + PTP demonstrated a statistically significantly lower aPTT than the mixture of HTX + NPP (P = 0.01). Additionally, the mixture of HTX and PTP shows a statistically significantly lower aPTT value than PTP alone (P = 0.03), indicating a hypercoagulable state.
HTX demonstrates coagulopathy when analyzed independently, but is hypercoagulable when mixed with NPP or PTP. Furthermore, mixing studies show a statistically significantly lower aPTT when HTX is mixed with PTP versus HTX mixed with NPP. Thus, autotransfusion of HTX would likely produce a hypercoagulable state in vivo, and should not be used in place of other blood products to resuscitate a trauma patient. The autotransfusion of HTX may, however, be of use in a resource-limited environment where other blood products are not available.
创伤性血胸（HTX）已被证明可预测地含有低纤维蛋白原、低血细胞比容和低血小板计数。单独分析时，流出的HTX表现出凝血病。然而，当以生理相关稀释度与正常混合血浆（NPP）混合时，HTX表现出加速凝血。我们假设，当HTX与患者自身血浆混合时，混合物将表现出高凝状态。这种混合物的加速凝血对于将HTX自体输血作为创伤患者复苏方法具有重要意义。
纳入在胸腔闭式引流术后1小时内引出超过140 mL HTX的成年创伤患者。在引出后1小时采集HTX样本，将一部分样本离心并作为冷冻血浆储存以备后续分析。对样本的其余部分进行分析（凝血、血液学、电解质），并将值与通过图表回顾提取的同期静脉值进行比较。另外，将含有患者静脉血的枸橼酸盐管离心并冷冻，用于后续混合研究分析。通过将先前冷冻的HTX与NPP的系列稀释液混合来进一步评估凝血情况。此外，将先前冷冻的HTX与先前冷冻的患者血浆（PTP）样本进行系列稀释混合。
根据纳入标准和采集废弃静脉样本纳入了10名受试者。在单独分析的HTX样本中，任何凝血试验（活化部分凝血活酶时间[aPTT]>180）均未形成血栓。单独PTP的中位aPTT值为25.5。在以1:4的临床相关稀释度混合的1小时标本中，HTX与NPP混合的中位aPTT值为26.0，而HTX与PTP混合的中位aPTT值为21.7。因此，HTX + PTP混合物的aPTT在统计学上显著低于HTX + NPP混合物（P = 0.01）。此外，HTX和PTP的混合物的aPTT值在统计学上显著低于单独的PTP（P = 0.03），表明处于高凝状态。
单独分析时HTX表现出凝血病，但与NPP或PTP混合时具有高凝性。此外，混合研究表明，与HTX与NPP混合相比，HTX与PTP混合时aPTT在统计学上显著更低。因此，HTX自体输血在体内可能会产生高凝状态，不应代替其他血液制品用于创伤患者的复苏。然而，在没有其他血液制品的资源有限环境中，HTX自体输血可能有用。
