Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA.
Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.
Neurocrit Care. 2021 Dec;35(3):738-746. doi: 10.1007/s12028-021-01217-0. Epub 2021 Apr 12.
Coagulopathy in traumatic brain injury (TBI) is associated with increased risk of poor outcomes, but accurate prediction of clinically significant progressive hemorrhagic injury (PHI) in patients with severe TBI remains a challenge. Thromboelastography (TEG) is a real-time test of whole blood coagulation that provides dynamic information about global hemostasis. This study aimed to identify differences in TEG values between patients with severe TBI who did or did not experience clinically significant PHI.
This was a single-center retrospective cohort study of adult patients with severe TBI. Patients were eligible for inclusion if initial Glasgow coma scale (GCS) was ≤ 8 and baseline head computed tomography (CT) imaging and TEG were available. Exclusion criteria included receipt of hemostatic agents prior to TEG. PHI was defined as bleeding expansion on CT within 24 h associated with 2-point drop in GCS, neurosurgical intervention, or mortality within 24 h. The primary endpoint was TEG value differences between patients with and without PHI. Secondary endpoints included differences in conventional coagulation tests (CCTs) between groups.
Of the 526 patients evaluated, 141 met inclusion criteria. The most common reason for exclusion was lack of baseline TEG and receipt of reversal product prior to TEG. Sixty-four patients experienced PHI in the first 24 h after presentation. K time (2.03 min vs. 1.33 min, P = 0.035) and alpha angle (65° vs. 69°, P = 0.015) were found to be significantly different in patients experiencing PHI. R time (5.25 min vs. 4.71 min), maximum amplitude (61 mm vs. 63 mm), and clot lysis at 30 min after maximum clot strength (3.5% vs. 1.7%) were not significantly different between groups. Of the CCTs, only activated partial thromboplastin time (30.3 s vs. 27.6 s, P = 0.014) was found to be different in patients with PHI.
Prolonged K time and narrower alpha angle were found to be associated with developing clinically significant PHI in patients with severe TBI. Despite differences detected in alpha angle, median values in both groups were within normal reference ranges. These abnormalities may reflect pathologic hypoactivity of fibrinogen, and further study is warranted to evaluate TEG-guided cryoprecipitate administration in this patient population.
创伤性脑损伤（TBI）患者的凝血功能障碍与不良预后风险增加相关，但准确预测严重 TBI 患者临床显著进展性出血性损伤（PHI）仍然是一个挑战。血栓弹性描记术（TEG）是一种实时全血凝血检测，可提供关于整体止血的动态信息。本研究旨在确定 TEG 值在发生和未发生临床显著 PHI 的严重 TBI 患者之间的差异。
这是一项单中心回顾性队列研究，纳入了严重 TBI 的成年患者。如果初始格拉斯哥昏迷量表（GCS）评分≤8，且有基线头部 CT 成像和 TEG 可用，则患者符合纳入标准。排除标准包括在 TEG 之前接受止血剂。PHI 定义为在 24 小时内 CT 上的出血扩展，伴有 GCS 下降 2 分、神经外科干预或 24 小时内死亡。主要终点是 PHI 患者和非 PHI 患者之间的 TEG 值差异。次要终点包括两组之间常规凝血检测（CCTs）的差异。
在评估的 526 名患者中，有 141 名符合纳入标准。排除的最常见原因是缺乏基线 TEG 和在 TEG 之前接受逆转产品。64 名患者在出现后 24 小时内发生 PHI。在发生 PHI 的患者中，K 时间（2.03 分钟比 1.33 分钟，P=0.035）和 alpha 角（65°比 69°，P=0.015）明显不同。R 时间（5.25 分钟比 4.71 分钟）、最大振幅（61 毫米比 63 毫米）和最大凝血强度后 30 分钟的血凝块溶解（3.5%比 1.7%）在两组之间无显著差异。在 CCT 中，仅活化部分凝血活酶时间（30.3 秒比 27.6 秒，P=0.014）在发生 PHI 的患者中存在差异。
在严重 TBI 患者中，K 时间延长和 alpha 角变窄与发生临床显著 PHI 相关。尽管在 alpha 角检测到差异，但两组的中位数均在正常参考范围内。这些异常可能反映纤维蛋白原的病理性低活性，需要进一步研究来评估 TEG 指导下在该患者人群中使用冷沉淀。
