Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Neurocrit Care. 2023 Apr;38(2):326-334. doi: 10.1007/s12028-022-01562-8. Epub 2022 Jul 28.
Progression of hemorrhagic injury (PHI) in children with traumatic brain injury portends poor outcomes. The association between thromboelastography (TEG), functional coagulation assays, and PHI is not well characterized in children.
This was a retrospective cohort study of children presenting with PHI at a pediatric level I academic trauma center from 2015 to 2020. Inclusion criteria were as follows: age less than 18 years, intracranial hemorrhage on admission head computed tomography scan, and admission rapid TEG assay and conventional coagulation tests. PHI was defined by the following radiographic criteria: any expansion of or new intracranial hemorrhage on subsequent head computed tomography scan. Rapid TEG values included Activated Clotting Time (ACT), alpha angle, maximum amplitude, and lysis at 30 min. Wilcoxon rank-sum test was used to assess baseline differences between groups with PHI and without PHI, including laboratory assays. Univariate analysis was performed to examine the association between variables of interest and PHI. Patients were dichotomized on the basis of this cut point to generate a "low ACT" group and a "high ACT" group. These variables were included in a multivariable logistic regression model to determine independent association with traumatic brain injury progression.
In total, 219 patients met criteria for analysis. In this cohort, the median (interquartile range [IQR]) age = 6 (2-12) years, median (IQR) Injury Severity Score = 21 (11-27), 68% were boys, and 69% sustained blunt injury. The rate of PHI was 25% (54). Median (IQR) time to PHI was 1 (0-4) days. Children with PHI had a higher Injury Severity Score (p < 0.001), lower Glasgow Coma Scale (p < 0.001), greater incidence of shock (p = 0.04), and lower admission hemoglobin (p = 0.02) compared with those without PHI. Children with PHI had a higher International Normalized Ratio (INR) and longer TEG-ACT; other TEG values (alpha angle, maximum amplitude, and lysis at 30 min) were not associated with PHI. In the logistic regression model accounting for other covariates associated with PHI, elevated ACT remained an independent predictor of progression (odds ratio = 2.25, 95% confidence interval 1.09-4.66; p = 0.03; area under the receiver operating characteristic curve = 0.76). After adjusting for confounders, INR fell out of the model and was not an independent predictor of progression (odds ratio = 1.32, 95% confidence interval 0.60-2.93; p = 0.49).
Although INR was elevated in children with PHI and has been associated with poor clinical outcomes, only admission TEG-ACT was independently associated with PHI. Further study is warranted to determine whether TEG-ACT reflects an actionable therapeutic target.
创伤性脑损伤患儿的出血性损伤（PHI）进展预示着不良预后。血栓弹力图（TEG）、功能性凝血检测与儿童 PHI 之间的关联尚未得到很好的描述。
这是一项回顾性队列研究，纳入了 2015 年至 2020 年期间在一家儿科一级学术创伤中心出现 PHI 的儿童。纳入标准如下：年龄小于 18 岁，入院头部 CT 扫描显示颅内出血，入院时快速 TEG 检测和常规凝血检测。PHI 通过以下影像学标准定义：随后头部 CT 扫描中任何颅内出血的扩大或新出现颅内出血。快速 TEG 值包括活化凝血时间（ACT）、α角、最大振幅和 30 分钟时的溶解。Wilcoxon 秩和检验用于评估 PHI 组和无 PHI 组之间的基线差异，包括实验室检测。单变量分析用于检查感兴趣变量与 PHI 之间的关联。根据该切点将患者分为“低 ACT”组和“高 ACT”组。将这些变量纳入多变量逻辑回归模型，以确定与创伤性脑损伤进展的独立关联。
共有 219 名患者符合分析标准。在该队列中，中位（四分位距 [IQR]）年龄为 6（2-12）岁，中位（IQR）损伤严重程度评分（ISS）为 21（11-27），68%为男性，69%为钝器伤。PHI 发生率为 25%（54 例）。PHI 的中位（IQR）时间为 1（0-4）天。与无 PHI 相比，PHI 组的损伤严重程度评分更高（p<0.001），格拉斯哥昏迷评分更低（p<0.001），休克发生率更高（p=0.04），入院时血红蛋白水平更低（p=0.02）。与无 PHI 相比，PHI 患儿的国际标准化比值（INR）更高，TEG-ACT 时间更长；其他 TEG 值（α角、最大振幅和 30 分钟时的溶解）与 PHI 无关。在考虑了与 PHI 相关的其他协变量的逻辑回归模型中，升高的 ACT 仍然是进展的独立预测因子（比值比=2.25，95%置信区间 1.09-4.66；p=0.03；受试者工作特征曲线下面积=0.76）。在调整混杂因素后，INR 不再是模型中的独立预测因子，与进展无关（比值比=1.32，95%置信区间 0.60-2.93；p=0.49）。
尽管 PHI 患儿的 INR 升高且与不良临床结局相关，但只有入院 TEG-ACT 与 PHI 独立相关。需要进一步研究以确定 TEG-ACT 是否反映了可操作的治疗靶点。
