C. M. Leeper1,2, M. D. Neal2, C. McKenna1, T. Billiar2, B. A. Gaines1 1Children’s Hospital Of Pittsburgh Of UPMC,Pediatric Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh Medical Center,General Surgery,Pittsburgh, PA, USA
Introduction:
Injured children commonly present with acute traumatic coagulopathy (ATC) defined by elevated international normalized ratio (INR). ATC is associated with poor outcome, though these patients usually are not clinically coagulopathic. INR, therefore, is not always a therapeutic target but rather a marker of complex systemic dysregulation. Our goal is to evaluate multiple coagulation parameters that encompass the broader hemostatic system and identify patterns after injury that may be associated with clinical outcomes.
Methods:
We performed principal components analysis (PCA) on prospectively collected data from children with highest trauma activation in our pediatric center from June 2015-June 2016. Admission labs included INR, platelet count and thromboelastography (TEG) parameters (clotting factors (ACT), fibrinogen (K), platelet function (MA) and fibrinolysis (LY30)). Variables were reduced to principal components (PC) and PC scores were generated for each subject for use in logistic regression. Outcomes included mortality, disability (based on functional independence measure score or discharge to rehabilitation facility), venous thromboembolism (VTE; screening ultrasound for high-risk or symptomatic patients), and blood transfusion in the first 24 hours.
Results:
133 subjects were included with median(IQR) age =10(5-13), median(IQR) ISS =17(9-25), 73.5% male, 70.8% blunt trauma. The rate of mortality was 5.6% (n=7), disability was 23.9% (n=28), early blood transfusion was 26.3%(n=35) and VTE was 10.3%(n=11). PCA identified 3 significant PCs accounting for 75.0% of overall variance. PC1 identified clot strength (platelets and fibrinogen); PC2 identified abnormal fibrinolysis, both hyperfibrinolysis and fibrinolysis shutdown (LY30 and INR); and PC3 identified global clotting factor depletion (INR and K). PC1 score was associated with increased mortality (odds ratio [OR] =1.63; p<0.001) and early transfusion (OR 1.36; p=0.002). PC2 score was correlated with ISS (rho 0.4; p<0.001) and associated with VTE (OR 1.84; p=0.034), functional disability (OR 1.66; p=0.017), increased mortality (OR 2.07; p=0.003) and early blood transfusion (OR 2.79; p<0.001). PC3 score was associated with increased mortality (OR 1.92; p=0.007) and early transfusion (OR 1.25; p=0.075).
Conclusion:
PCA detects three distinct patterns of coagulation dysregulation using widely available laboratory parameters: 1) abnormalities in clot strength; 2) abnormalities in fibrinolysis, and 3) clotting factor depletion. All were associated with poor outcomes; however, fibrinolytic dysregulation is associated with more severely injured patients and portends particularly poor outcome including increased mortality, DVT, disability and need for transfusion.
