Meizoso Jonathan P, Karcutskie Charles A, Ray Juliet J, Namias Nicholas, Schulman Carl I, Proctor Kenneth G
Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
J Am Coll Surg. 2017 Apr;224(4):575-582. doi: 10.1016/j.jamcollsurg.2016.12.018. Epub 2016 Dec 23.
Acute fibrinolysis shutdown is associated with early mortality after trauma; however, no previous studies have investigated the incidence of persistent fibrinolysis or its association with mortality. We tested the hypothesis that persistent fibrinolysis shutdown is associated with mortality in critically ill trauma patients.
Thromboelastography was performed on ICU admission in 181 adult trauma patients and at 1 week in a subset of 78 patients. Fibrinolysis shutdown was defined as LY30 ≤ 0.8% and was considered transient if resolved by 1 week postinjury or persistent if not. Logistic regression adjusted for age, sex, hemodynamics, and Injury Severity Score (ISS).
Median age was 52 years, 88% were male, and median ISS was 27, with 56% transient fibrinolysis shutdown, 44% persistent fibrinolysis shutdown and 12% mortality. Median LY30 was 0.23% (interquartile range [IQR] 0% to 1.20%) at admission and 0.10% (IQR 0% to 2.05%) at 1 week. Transient shutdown more often occurred after head injury (p = 0.019); persistent shutdown was more often associated with penetrating injury (29% vs 9%; p = 0.020), lower LY30 at ICU admission (0.10% vs 1.15%; p < 0.0001) and at 1 week (0% vs 1.68%; p < 0.0001), and higher mortality (21% vs 5%; p = 0.036). Persistent fibrinolysis shutdown was associated with admission LY30 (odds ratio [OR] 0.05; 95% CI 0.01 to 0.34; p = 0.002) and transfusion of packed RBCs (OR 0.81; 95% CI 0.68 to 0.97; p = 0.021) and platelets (OR 2.81; 95% CI 1.16 to 6.84; p = 0.022); moreover, it was an independent predictor of mortality (OR 8.48; 95% CI 1.35 to 53.18; p = 0.022).
Persistent fibrinolysis shutdown is associated with late mortality after trauma. A high index of suspicion should be maintained, especially in patients with penetrating injury, reduced LY30 on admission, and/or receiving blood product transfusion. Judicious use of tranexamic acid is advised in this cohort.
急性纤维蛋白溶解功能关闭与创伤后早期死亡率相关；然而，既往尚无研究调查持续性纤维蛋白溶解的发生率或其与死亡率的关系。我们检验了以下假设：持续性纤维蛋白溶解功能关闭与重症创伤患者的死亡率相关。
对181例成年创伤患者在入住重症监护病房（ICU）时及78例患者亚组在伤后1周进行血栓弹力图检查。纤维蛋白溶解功能关闭定义为LY30≤0.8%，如果在伤后1周内恢复则视为短暂性，否则视为持续性。采用逻辑回归分析对年龄、性别、血流动力学和损伤严重度评分（ISS）进行校正。
中位年龄为52岁，88%为男性，中位ISS为27，其中56%为短暂性纤维蛋白溶解功能关闭，44%为持续性纤维蛋白溶解功能关闭，死亡率为12%。入院时LY30的中位数为0.23%（四分位间距[IQR]为0%至1.20%），1周时为0.10%（IQR为0%至2.05%）。短暂性关闭更常发生于头部损伤后（p = 0.019）；持续性关闭更常与穿透伤相关（29%对9%；p = 0.020），ICU入院时LY30较低（0.10%对1.15%；p < 0.0001）以及1周时较低（0%对1.68%；p < 0.0001），且死亡率较高（21%对5%；p = 0.036）。持续性纤维蛋白溶解功能关闭与入院时LY30（比值比[OR] 0.05；95%置信区间[CI] 0.01至0.34；p = 0.002）、浓缩红细胞输注（OR 0.81；95% CI 0.68至0.97；p = 0.021）和血小板输注（OR 2.81；95% CI 1.16至6.84；p = 0.022）相关；此外，它是死亡率的独立预测因素（OR 8.48；95% CI 1.35至53.18；p = 0.022）。
持续性纤维蛋白溶解功能关闭与创伤后晚期死亡率相关。应保持高度怀疑，尤其是对于穿透伤、入院时LY30降低和/或接受血液制品输注的患者。建议在此类患者中谨慎使用氨甲环酸。
