R. Uhlich1, P. Hu1, J. Pittet3, M. Shroyer2, P. Bosarge1, J. Kerby1, J. Richter1, R. Russell2 1University Of Alabama at Birmingham,Acute Care Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Anesthesia,Birmingham, Alabama, USA
Introduction:
The endothelial glycocalyx layer (EGL) is an important regulator of endothelial cell (EC) function. Trauma induced damage to the EGL can lead to endothelial dysfunction resulting in increased vascular permeability, coagulopathy, organ dysfunction, and mortality. While these associations have been an increasing area of focus within the adult trauma population, the effect of traumatic injury on the EGL and endothelial function among pediatric patients is less clear. Quantification of circulating levels of Syndecan-1 (Syn-1), an essential proteoglycan of the EGL, has recently been identified as a method to demonstrate the endotheliopathy of trauma. Correlations between increased Syn-1 levels and worse clinical outcomes have been described following traumatic injury in the adult patient. Our study sought to identify pertinent clinical correlations with Syn-1 elevation following severe injury in the pediatric population.
Methods:
We performed a prospective observational study from 2013-2016 at a level 1 pediatric trauma center. Blood samples were obtained upon admission, Syn-1 levels were quantified, and coagulopathy and clinical parameters evaluated. Endotheliopathy was defined as an admission Syn-1 ≥ 40 ng/mL, based on existing literature. Traumatic coagulopathy was defined as an INR >1.5. Skewed variables were log-transformed for inclusion. Clinical data was analyzed with χ2 or Fisher’s exact test and Student’s t-test for categorical and continuous variables, respectively. Logistic regression with relevant covariates was used to evaluate the association between endotheliopathy and coagulopathy.
Results:
A total of 53 patients were identified. Endotheliopathy was identified in 43.4% (23/53) of patients. Those with endotheliopathy were more severely injured (mean injury severity score (ISS): 29.04 ± 18.28 vs 20.70 ± 13.80, p = 0.06), which trended towards significance. Mean admission INR was significantly higher (1.40 ± 0.57 vs 1.13 ± 0.16, p = 0.045) and patients were significantly more likely to have traumatic coagulopathy (26.1% vs 3.4%, p=0.035) and require FFP transfusion within 6 hours (17.4% vs 0%, p = 0.03) compared to patients without endotheliopathy. Endotheliopathy was significantly associated with traumatic coagulopathy in multivariate analysis when adjusting for age and mechanism of injury, but not ISS (Table 1).
Conclusion:
These findings reflect the association between endotheliopathy and coagulopathy following pediatric trauma. Damage to the EGL may play an important role in the development of trauma induced coagulopathy. Thus, maintenance of EGL integrity after injury is a potential therapeutic strategy for preventing coagulopathy in pediatric trauma.
