Leeper Christine M, Neal Matthew D, McKenna Christine J, Gaines Barbara A
*Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA †Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA.
Ann Surg. 2017 Sep;266(3):508-515. doi: 10.1097/SLA.0000000000002355.
To trend fibrinolysis after injury and determine the influence of traumatic brain injury (TBI) and massive transfusion on fibrinolysis status.
Admission fibrinolytic derangement is common in injured children and adults, and is associated with poor outcome. No studies examine fibrinolysis days after injury.
Prospective study of severely injured children at a level 1 pediatric trauma center. Rapid thromboelastography was obtained on admission and daily for up to 7 days. Standard definitions of hyperfibrinolysis (HF; LY30 ≥3), fibrinolysis shutdown (SD; LY30 ≤0.8), and normal (LY30 = 0.9-2.9) were applied. Antifibrinolytic use was documented. Outcomes were death, disability, and thromboembolic complications. Wilcoxon rank-sum and Fisher exact tests were performed. Exploratory subgroups included massively transfused and severe TBI patients.
In all, 83 patients were analyzed with median (interquartile ranges) age 8 (4-12) and Injury Severity Score 22 (13-34), 73.5% blunt mechanism, 47% severe TBI, 20.5% massively transfused. Outcomes were 14.5% mortality, 43.7% disability, and 9.8% deep vein thrombosis. Remaining in or trending to SD was associated with death (P = 0.007), disability (P = 0.012), and deep vein thrombosis (P = 0.048). Median LY30 was lower on post-trauma day (PTD)1 to PTD4 in patients with poor compared with good outcome; median LY30 was lower on PTD1 to PTD3 in TBI patients compared with non-TBI patients. HF without associated shutdown was not related to poor outcome, but extreme HF (LY30 >30%, n = 3) was lethal. Also, 50% of massively transfused patients in hemorrhagic shock demonstrated SD physiology on admission. All with HF (fc31.2%) corrected after hemostatic resuscitation without tranexamic acid.
Fibrinolysis shutdown is common postinjury and predicts poor outcomes. Severe TBI is associated with sustained shutdown. Empiric antifibrinolytics for children should be questioned; thromboelastography-directed selective use should be considered for documented HF.
追踪损伤后的纤溶情况，并确定创伤性脑损伤（TBI）和大量输血对纤溶状态的影响。
入院时纤溶紊乱在受伤儿童和成人中很常见，且与不良预后相关。尚无研究考察损伤后数天的纤溶情况。
对一家一级儿童创伤中心的重伤儿童进行前瞻性研究。入院时及之后每天进行快速血栓弹力图检查，持续7天。采用高纤溶（HF；LY30≥3）、纤溶停止（SD；LY30≤0.8）和正常（LY30 = 0.9 - 2.9）的标准定义。记录抗纤溶药物的使用情况。结局指标为死亡、残疾和血栓栓塞并发症。进行Wilcoxon秩和检验和Fisher精确检验。探索性亚组包括大量输血患者和重度TBI患者。
共分析了83例患者，中位（四分位间距）年龄8（4 - 12）岁，损伤严重度评分22（13 - 34），73.5%为钝性机制损伤，47%为重度TBI，20.5%大量输血。结局为14.5%死亡，43.7%残疾，9.8%发生深静脉血栓形成。持续处于或趋向于SD与死亡（P = 0.007）、残疾（P = 0.012）和深静脉血栓形成（P = 0.048）相关。预后不良患者创伤后第1天（PTD）至第4天的中位LY30低于预后良好患者；TBI患者PTD1至PTD3的中位LY30低于非TBI患者。无相关纤溶停止的HF与不良预后无关，但极重度HF（LY30>30%，n = 3）是致命的。此外，出血性休克中50%的大量输血患者入院时表现为SD生理状态。所有HF患者（占31.2%）在止血复苏且未使用氨甲环酸后纤溶情况得到纠正。
纤溶停止在损伤后很常见，并预示不良预后。重度TBI与持续性纤溶停止相关。儿童经验性使用抗纤溶药物应受到质疑；对于记录有HF的情况，应考虑根据血栓弹力图指导进行选择性使用。
