Department of Surgery, University of Colorado-Denver, Aurora, CO.
Department of Surgery, University of Colorado-Denver, Aurora, CO; Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO.
J Am Coll Surg. 2021 May;232(5):709-716. doi: 10.1016/j.jamcollsurg.2020.12.058. Epub 2021 Feb 4.
Despite the prevalence of hypocoagulability after injury, the majority of trauma patients paradoxically present with elevated thrombin generation (TG). Although several studies have examined plasma TG post injury, this has not been assessed in whole blood. We hypothesize that whole blood TG is lower in hypocoagulopathy, and TG effectively predicts massive transfusion (MT).
Blood was collected from trauma activation patients at an urban Level I trauma center. Whole blood TG was performed with a prototype point-of-care device. Whole blood TG values in healthy volunteers were compared with trauma patients, and TG values were examined in trauma patients with shock and MT requirement.
Overall, 118 patients were included. Compared with healthy volunteers, trauma patients overall presented with more robust TG; however, those arriving in shock (n = 23) had a depressed TG, with significantly lower peak thrombin (88.3 vs 133.0 nM; p = 0.01) and slower maximum rate of TG (27.4 vs 48.3 nM/min; p = 0.04). Patients who required MT (n = 26) had significantly decreased TG, with a longer lag time (median 4.8 vs 3.9 minutes, p = 0.04), decreased peak thrombin (median 71.4 vs 124.2 nM; p = 0.0003), and lower maximum rate of TG (median 15.8 vs 39.4 nM/min; p = 0.01). Area under the receiver operating characteristics (AUROC) analysis revealed lag time (AUROC 0.6), peak thrombin (AUROC 0.7), and maximum rate of TG (AUROC 0.7) predict early MT.
These data challenge the prevailing bias that all trauma patients present with elevated TG and highlight that deficient thrombin contributes to the hypocoagulopathic phenotype of trauma-induced coagulopathy. In addition, whole blood TG predicts MT, suggesting point-of-care whole blood TG can be a useful tool for diagnostic and therapeutic strategies in trauma.
尽管损伤后普遍存在低凝状态，但大多数创伤患者却表现出升高的凝血酶生成（TG）。尽管有几项研究检查了损伤后的血浆 TG，但尚未在全血中进行评估。我们假设低凝状态下全血 TG 较低，并且 TG 可有效预测大量输血（MT）。
在城市一级创伤中心，从创伤激活患者采集血液。使用原型即时检测设备进行全血 TG 检测。将健康志愿者的全血 TG 值与创伤患者进行比较，并检查有休克和 MT 需求的创伤患者的 TG 值。
总体上，纳入了 118 例患者。与健康志愿者相比，总体上创伤患者的 TG 更活跃；然而，出现休克的患者（n=23）的 TG 降低，峰值凝血酶明显降低（88.3 对 133.0 nM；p=0.01），最大 TG 速率较慢（27.4 对 48.3 nM/min；p=0.04）。需要 MT 的患者（n=26）的 TG 明显降低，延迟时间较长（中位数 4.8 对 3.9 分钟，p=0.04），峰值凝血酶降低（中位数 71.4 对 124.2 nM；p=0.0003），最大 TG 速率降低（中位数 15.8 对 39.4 nM/min；p=0.01）。受试者工作特征（ROC）曲线下面积（AUROC）分析显示，延迟时间（AUROC 0.6）、峰值凝血酶（AUROC 0.7）和最大 TG 速率（AUROC 0.7）可预测早期 MT。
这些数据挑战了普遍存在的偏见，即所有创伤患者均表现出升高的 TG，并强调缺乏凝血酶有助于创伤性凝血病的低凝状态表型。此外，全血 TG 可预测 MT，表明即时检测全血 TG 可为创伤的诊断和治疗策略提供有用的工具。
