Ferencz Sarah-Ashley E, Davidson Anders J, Howard Jeffrey T, Janak Jud C, Sosnov Jonathan A, Chung Kevin K, Stewart Ian J
Department of Surgery, University of California Davis, 2221 Stockton Boulevard, Sacramento, CA 95817.
Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535.
Mil Med. 2018 Mar 1;183(suppl_1):34-39. doi: 10.1093/milmed/usx173.
Acute traumatic coagulopathy (ATC) is a common condition after traumatic injury and is known to be associated with an increase in morbidity and mortality in trauma patients. ATC has been implicated as a causative factor in both early hemorrhage and late organ failure in this population, yet the pathophysiology remains largely unknown. Additionally, acute kidney injury (AKI) is a common condition among critically injured trauma patients. AKI has been associated with an elevated International Normalized Ratio (INR) and warfarin use, but its development has not been well studied in the setting of ATC. We hypothesized that the presence of ATC influences the development of AKI and may mediate mortality in combat casualties.
Data were obtained from the Department of Defense Trauma Registry, Medical Data Store and Composite Healthcare System, and the Armed Forces Medical Examiner System. A retrospective review was conducted of US service members injured in Iraq or Afghanistan between February 1, 2002 and February 1, 2011, who required ICU level care and survived evacuation out of theater. Exclusions were made for missing data. Cox proportional hazard regression was performed to determine the effect of ATC (a priori defined as first INR > 1.3) on the development of AKI. Further analysis was conducted to determine the influence of these variables on 30-d mortality, and multiple sensitivity analyses were performed to determine the effect of ATC on both AKI and mortality.
A total of 1,288 patients were identified for analysis. ATC was a risk factor for subsequent AKI after adjustment (HR 1.67, 95% CI 1.28-2.18; p < 0.001). However, ATC was not a risk factor for mortality after adjustment in the full model (HR 1.87, 95% CI 0.95-3.65; p = 0.069). On sensitivity analyses exploring alternate definitions of ATC, an INR of 1.2 remained associated with AKI (HR 1.46, 95% CI 1.13-1.88; p = 0.004) and an INR of 1.5 became significant for mortality (HR 1.76, 95% CI 1.32-2.35; p < 0.001).
ATC is independently associated with the development of AKI. Although ATC is associated with mortality in the unadjusted model, it is not significant after adjustment for AKI. This implies that the kidneys may play a role in the adverse outcomes observed after ATC. Increased awareness and monitoring for coagulopathy and the subsequent development of AKI in combat casualty patients may lead to earlier diagnosis and treatment of these conditions, possibly decreasing morbidity and mortality.
急性创伤性凝血病（ATC）是创伤性损伤后常见的病症，已知与创伤患者的发病率和死亡率增加有关。ATC被认为是该人群早期出血和晚期器官衰竭的致病因素，但其病理生理学仍 largely未知。此外，急性肾损伤（AKI）是重伤创伤患者中的常见病症。AKI与国际标准化比值（INR）升高和华法林使用有关，但其在ATC背景下的发展尚未得到充分研究。我们假设ATC的存在会影响AKI的发展，并可能介导战斗伤员的死亡率。
数据来自国防部创伤登记处、医疗数据存储和综合医疗系统以及武装部队法医系统。对2002年2月1日至2011年2月1日期间在伊拉克或阿富汗受伤、需要重症监护病房（ICU）级护理并在撤离战区后存活的美国军人进行回顾性研究。排除缺失数据的情况。进行Cox比例风险回归以确定ATC（预先定义为首次INR>1.3）对AKI发展的影响。进一步分析以确定这些变量对30天死亡率的影响，并进行多次敏感性分析以确定ATC对AKI和死亡率的影响。
共确定1288例患者进行分析。调整后，ATC是随后发生AKI的危险因素（风险比[HR]1.67，95%置信区间[CI]1.28 - 2.18；p<0.001）。然而，在完整模型中调整后，ATC不是死亡率的危险因素（HR 1.87，95%CI 0.95 - 3.65；p = 0.069）。在探索ATC替代定义的敏感性分析中，INR为1.2仍与AKI相关（HR 1.46，95%CI 1.13 - 1.88；p = 0.004），INR为1.5对死亡率具有显著性（HR 1.76，95%CI 1.32 - 2.35；p<0.001）。
ATC与AKI的发展独立相关。虽然在未调整模型中ATC与死亡率相关，但在调整AKI后并不显著。这意味着肾脏可能在ATC后观察到的不良结局中起作用。提高对凝血病以及战斗伤员中随后发生AKI的认识和监测可能会导致这些病症的早期诊断和治疗，可能降低发病率和死亡率。
