Persistent Fibrinolysis Shutdown Is Associated with Increased Mortality in Severely Injured Trauma Patients

Jonathan P. Meizoso, Charles A. Karcutskie, Juliet J. Ray, Nicholas Namias, Carl I Schulman, Kenneth G Proctor

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Abstract

Background Acute fibrinolysis shutdown is associated with early mortality after trauma; however, no previous studies have investigated the incidence of persistent fibrinolysis or its association with mortality. We tested the hypothesis that persistent fibrinolysis shutdown is associated with mortality in critically ill trauma patients. Study Design Thromboelastography was performed on ICU admission in 181 adult trauma patients and at 1 week in a subset of 78 patients. Fibrinolysis shutdown was defined as LY30 ≤ 0.8% and was considered transient if resolved by 1 week postinjury or persistent if not. Logistic regression adjusted for age, sex, hemodynamics, and Injury Severity Score (ISS). Results Median age was 52 years, 88% were male, and median ISS was 27, with 56% transient fibrinolysis shutdown, 44% persistent fibrinolysis shutdown and 12% mortality. Median LY30 was 0.23% (interquartile range [IQR] 0% to 1.20%) at admission and 0.10% (IQR 0% to 2.05%) at 1 week. Transient shutdown more often occurred after head injury (p = 0.019); persistent shutdown was more often associated with penetrating injury (29% vs 9%; p = 0.020), lower LY30 at ICU admission (0.10% vs 1.15%; p < 0.0001) and at 1 week (0% vs 1.68%; p < 0.0001), and higher mortality (21% vs 5%; p = 0.036). Persistent fibrinolysis shutdown was associated with admission LY30 (odds ratio [OR] 0.05; 95% CI 0.01 to 0.34; p = 0.002) and transfusion of packed RBCs (OR 0.81; 95% CI 0.68 to 0.97; p = 0.021) and platelets (OR 2.81; 95% CI 1.16 to 6.84; p = 0.022); moreover, it was an independent predictor of mortality (OR 8.48; 95% CI 1.35 to 53.18; p = 0.022). Conclusions Persistent fibrinolysis shutdown is associated with late mortality after trauma. A high index of suspicion should be maintained, especially in patients with penetrating injury, reduced LY30 on admission, and/or receiving blood product transfusion. Judicious use of tranexamic acid is advised in this cohort.

Original languageEnglish (US)
Pages (from-to)575-582
Number of pages8
JournalJournal of the American College of Surgeons
Volume224
Issue number4
DOIs
StatePublished - Apr 1 2017

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Fibrinolysis
Mortality
Wounds and Injuries
Odds Ratio
Injury Severity Score
Thrombelastography
Tranexamic Acid
Craniocerebral Trauma
Critical Illness
Blood Transfusion
Blood Platelets
Logistic Models
Hemodynamics
Incidence

ASJC Scopus subject areas

  • Surgery

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Persistent Fibrinolysis Shutdown Is Associated with Increased Mortality in Severely Injured Trauma Patients. / Meizoso, Jonathan P.; Karcutskie, Charles A.; Ray, Juliet J.; Namias, Nicholas; Schulman, Carl I; Proctor, Kenneth G.

In: Journal of the American College of Surgeons, Vol. 224, No. 4, 01.04.2017, p. 575-582.

Research output: Contribution to journalArticle

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title = "Persistent Fibrinolysis Shutdown Is Associated with Increased Mortality in Severely Injured Trauma Patients",
abstract = "Background Acute fibrinolysis shutdown is associated with early mortality after trauma; however, no previous studies have investigated the incidence of persistent fibrinolysis or its association with mortality. We tested the hypothesis that persistent fibrinolysis shutdown is associated with mortality in critically ill trauma patients. Study Design Thromboelastography was performed on ICU admission in 181 adult trauma patients and at 1 week in a subset of 78 patients. Fibrinolysis shutdown was defined as LY30 ≤ 0.8{\%} and was considered transient if resolved by 1 week postinjury or persistent if not. Logistic regression adjusted for age, sex, hemodynamics, and Injury Severity Score (ISS). Results Median age was 52 years, 88{\%} were male, and median ISS was 27, with 56{\%} transient fibrinolysis shutdown, 44{\%} persistent fibrinolysis shutdown and 12{\%} mortality. Median LY30 was 0.23{\%} (interquartile range [IQR] 0{\%} to 1.20{\%}) at admission and 0.10{\%} (IQR 0{\%} to 2.05{\%}) at 1 week. Transient shutdown more often occurred after head injury (p = 0.019); persistent shutdown was more often associated with penetrating injury (29{\%} vs 9{\%}; p = 0.020), lower LY30 at ICU admission (0.10{\%} vs 1.15{\%}; p < 0.0001) and at 1 week (0{\%} vs 1.68{\%}; p < 0.0001), and higher mortality (21{\%} vs 5{\%}; p = 0.036). Persistent fibrinolysis shutdown was associated with admission LY30 (odds ratio [OR] 0.05; 95{\%} CI 0.01 to 0.34; p = 0.002) and transfusion of packed RBCs (OR 0.81; 95{\%} CI 0.68 to 0.97; p = 0.021) and platelets (OR 2.81; 95{\%} CI 1.16 to 6.84; p = 0.022); moreover, it was an independent predictor of mortality (OR 8.48; 95{\%} CI 1.35 to 53.18; p = 0.022). Conclusions Persistent fibrinolysis shutdown is associated with late mortality after trauma. A high index of suspicion should be maintained, especially in patients with penetrating injury, reduced LY30 on admission, and/or receiving blood product transfusion. Judicious use of tranexamic acid is advised in this cohort.",
author = "Meizoso, {Jonathan P.} and Karcutskie, {Charles A.} and Ray, {Juliet J.} and Nicholas Namias and Schulman, {Carl I} and Proctor, {Kenneth G}",
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T1 - Persistent Fibrinolysis Shutdown Is Associated with Increased Mortality in Severely Injured Trauma Patients

AU - Meizoso, Jonathan P.

AU - Karcutskie, Charles A.

AU - Ray, Juliet J.

AU - Namias, Nicholas

AU - Schulman, Carl I

AU - Proctor, Kenneth G

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N2 - Background Acute fibrinolysis shutdown is associated with early mortality after trauma; however, no previous studies have investigated the incidence of persistent fibrinolysis or its association with mortality. We tested the hypothesis that persistent fibrinolysis shutdown is associated with mortality in critically ill trauma patients. Study Design Thromboelastography was performed on ICU admission in 181 adult trauma patients and at 1 week in a subset of 78 patients. Fibrinolysis shutdown was defined as LY30 ≤ 0.8% and was considered transient if resolved by 1 week postinjury or persistent if not. Logistic regression adjusted for age, sex, hemodynamics, and Injury Severity Score (ISS). Results Median age was 52 years, 88% were male, and median ISS was 27, with 56% transient fibrinolysis shutdown, 44% persistent fibrinolysis shutdown and 12% mortality. Median LY30 was 0.23% (interquartile range [IQR] 0% to 1.20%) at admission and 0.10% (IQR 0% to 2.05%) at 1 week. Transient shutdown more often occurred after head injury (p = 0.019); persistent shutdown was more often associated with penetrating injury (29% vs 9%; p = 0.020), lower LY30 at ICU admission (0.10% vs 1.15%; p < 0.0001) and at 1 week (0% vs 1.68%; p < 0.0001), and higher mortality (21% vs 5%; p = 0.036). Persistent fibrinolysis shutdown was associated with admission LY30 (odds ratio [OR] 0.05; 95% CI 0.01 to 0.34; p = 0.002) and transfusion of packed RBCs (OR 0.81; 95% CI 0.68 to 0.97; p = 0.021) and platelets (OR 2.81; 95% CI 1.16 to 6.84; p = 0.022); moreover, it was an independent predictor of mortality (OR 8.48; 95% CI 1.35 to 53.18; p = 0.022). Conclusions Persistent fibrinolysis shutdown is associated with late mortality after trauma. A high index of suspicion should be maintained, especially in patients with penetrating injury, reduced LY30 on admission, and/or receiving blood product transfusion. Judicious use of tranexamic acid is advised in this cohort.

AB - Background Acute fibrinolysis shutdown is associated with early mortality after trauma; however, no previous studies have investigated the incidence of persistent fibrinolysis or its association with mortality. We tested the hypothesis that persistent fibrinolysis shutdown is associated with mortality in critically ill trauma patients. Study Design Thromboelastography was performed on ICU admission in 181 adult trauma patients and at 1 week in a subset of 78 patients. Fibrinolysis shutdown was defined as LY30 ≤ 0.8% and was considered transient if resolved by 1 week postinjury or persistent if not. Logistic regression adjusted for age, sex, hemodynamics, and Injury Severity Score (ISS). Results Median age was 52 years, 88% were male, and median ISS was 27, with 56% transient fibrinolysis shutdown, 44% persistent fibrinolysis shutdown and 12% mortality. Median LY30 was 0.23% (interquartile range [IQR] 0% to 1.20%) at admission and 0.10% (IQR 0% to 2.05%) at 1 week. Transient shutdown more often occurred after head injury (p = 0.019); persistent shutdown was more often associated with penetrating injury (29% vs 9%; p = 0.020), lower LY30 at ICU admission (0.10% vs 1.15%; p < 0.0001) and at 1 week (0% vs 1.68%; p < 0.0001), and higher mortality (21% vs 5%; p = 0.036). Persistent fibrinolysis shutdown was associated with admission LY30 (odds ratio [OR] 0.05; 95% CI 0.01 to 0.34; p = 0.002) and transfusion of packed RBCs (OR 0.81; 95% CI 0.68 to 0.97; p = 0.021) and platelets (OR 2.81; 95% CI 1.16 to 6.84; p = 0.022); moreover, it was an independent predictor of mortality (OR 8.48; 95% CI 1.35 to 53.18; p = 0.022). Conclusions Persistent fibrinolysis shutdown is associated with late mortality after trauma. A high index of suspicion should be maintained, especially in patients with penetrating injury, reduced LY30 on admission, and/or receiving blood product transfusion. Judicious use of tranexamic acid is advised in this cohort.

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