Increased risk of fibrinolysis shutdown among severely injured trauma patients receiving tranexamic acid

Meizoso, Jonathan P.; Dudaryk, Roman; Mulder, Michelle B.; Ray, Juliet J.; Karcutskie, Charles A.; Eidelson, Sarah A.; Namias, Nicholas; Schulman, Carl I.; Proctor, Kenneth G.

doi:10.1097/ta.0000000000001792

Cited by 65 publications

(63 citation statements)

References 24 publications

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“…Excluded from the study were 36 of 202 liver recipients for whom baseline TEG was not recorded. Patients were stratified into 3 fibrinolysis phenotypes according to the percent of clot lysis 30 minutes after maximal amplitude (LY30) on baseline TEG: FS (LY30, 0%‐0.80%), physiologic fibrinolysis (LY30, 0.81%‐2.99%), and hyperfibrinolysis (LY30, ≥3.00%) . Preoperatively instituted renal replacement therapy (RRT) was continued intraoperatively and postoperatively.…”

Section: Methodsmentioning

confidence: 99%

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Fibrinolysis Shutdown Is Associated With Thrombotic and Hemorrhagic Complications and Poorer Outcomes After Liver Transplantation

et al. 2019

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Detrimental consequences of hypofibrinolysis, also known as fibrinolysis shutdown (FS), have recently arisen, and its significance in liver transplantation (LT) remains unknown. To fill this gap, this retrospective study included 166 adults who received transplants between 2016 and 2018 for whom baseline thromboelastography was available. On the basis of percent of clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: FS, physiologic fibrinolysis, and hyperfibrinolysis. FS occurred in 71.7% of recipients, followed by physiologic fibrinolysis in 19.9% and hyperfibrinolysis in 8.4%. Intraoperative and postoperative venous thrombosis events occurred exclusively in recipients with the FS phenotype. Intraoperative thrombosis occurred with an overall incidence of 4.8% and was associated with 25.0% in-hospital mortality. Incidence of postoperative venous thrombosis within the first month was deep venous thrombosis/pulmonary embolism (PE; 4.8%) and portal vein thrombosis/ hepatic vein thrombosis (1.8%). Massive transfusion of ≥20 units packed red blood cells was required in 11.8% of recipients with FS compared with none in the other 2 phenotype groups (P = 0.01). Multivariate analysis identified 2 pretransplant risk factors for FS: platelet count and nonalcoholic steatohepatitis/cryptogenic cirrhosis. Recursive partitioning identified a critical platelet cutoff value of 50 × 10 9 /L to be associated with FS phenotype. The hyperfibrinolysis phenotype was associated with the lowest 1-year survival (85.7%), followed by FS (95.0%) and physiologic fibrinolysis (97.0%). Infection/multisystem organ failure was the predominant cause of death; in the FS group, 1 patient died of exsanguination, and 1 patient died of massive intraoperative PE. In conclusion, there is a strong association between FS and thrombohemorrhagic complications and poorer outcomes after LT. Liver Transplantation 25 380-387 2019 AASLD.

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Section: Methodsmentioning

confidence: 99%

“…The fragility of the hemostatic balance in patients with cirrhosis becomes particularly apparent when perturbed by surgery . Hyperfibrinolysis was long known to be associated with hemorrhage and increased morbidity and mortality . The prothrombotic tendency of postoperative FS was identified in the 1960s .…”

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confidence: 99%

Fibrinolysis Shutdown Is Associated With Thrombotic and Hemorrhagic Complications and Poorer Outcomes After Liver Transplantation

et al. 2019

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“…In the absence of severe anemia or thrombocytopenia, prolonged Col/Epi assay alone suggests a mild intrinsic or aspirin‐induced platelet dysfunction, while prolongation of both assays suggests a significant intrinsic or potent antiaggregant‐induced (other than aspirin) platelet dysfunction . Based on LY30 (% clot lysis 30 minutes after maximal amplitude) on pre‐incisional TEG (Haemonetics ® ), patients were retrospectively stratified into three fibrinolysis phenotypes: fibrinolytic shutdown (LY30 0%‐0.80%), physiologic fibrinolysis (LY30 0.81%‐2.9%), and hyperfibrinolysis (LY30 > 3) …”

Section: Methodsmentioning

confidence: 99%

Susceptibility‐directed anticoagulation after pancreas transplantation: A single‐center retrospective study

Raveh

Ciancio

Burke

et al. 2019

Clinical Transplantation

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Pancreas transplant achieves consistent long-term euglycemia in type 1 diabetes.Allograft thrombosis (AT) causes the majority of early graft failure. We compared outcomes of four anticoagulation regimens administered to 95 simultaneous kidney-pancreas or isolated pancreas transplanted between 1/1/2015 and 11/20/2018. Early postoperative anticoagulation regimens included the following: none, subcutaneous heparin/aspirin, with or without dextran, and heparin infusion. The regimens were empirically selected based on each surgeon's assessment of hemostasis of the operative field and personal preference. A sonographic-based global scoring system of AT is presented. The 47-month recipients and graft survival were 95% and 86%, respectively. Recipients with or without AT had similar survival. Five and four grafts were lost due to death and AT, respectively. Outcomes of prophylaxis regimens correlated with intensity of anticoagulation. Compared with no anticoagulation, an increase in hemorrhagic complications occurred exclusively with iv heparin. The higher arterial AT score found in regimens lacking antiplatelet therapy highlights the importance of early antiaggregants therapy. Abnormal fibrinolysis was associated with an increase in AT score. Platelet dysfunction, warm ischemia time, and enteric drainage were predictive of AT and, along with other known risk factors, were incorporated into an algorithm that matches intensity of early postoperative anticoagulation to the thrombotic risk.

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“…This haemostatic approach is a key element in the treatment of major trauma patients and recommended by the European Trauma Treatment Guidelines [1]. Frequency of thrombotic complications in trauma patients was reported in 1.1% up to 34.3% [25][26][27]. Our incidence of thromboembolic events was below 10% in both periods and thereby in the lower range.…”

Section: Discussionmentioning

confidence: 82%

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

Stein

Rössler

Braun

et al. 2019

Scand J Trauma Resusc Emerg Med

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Background: A factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines. However, concerns about the thromboembolic risk of this approach are still prevalent. Our study therefore aims to assess if such a haemostatic management is associated with an increased risk for thromboembolic events. Methods: In this retrospective observational study carried out at the University Hospital Zurich we compared two three-year periods before (period 1: 2005-2007) and after (period 2: 2012-2014) implementation of a factor-based coagulation algorithm. We included all adult patients following major trauma primarily admitted to the University Hospital Zurich. Thromboembolic events were defined as a new in-hospital appearance of any peripheral thrombosis, arterial embolism, pulmonary embolism, stroke or myocardial infarction. A logistic regression was performed to investigate the association of thromboembolic events with possible confounders such as age, sex, specific Abbreviated Injury Scale (AIS) subgroups, allogeneic blood products, and the coagulation management. Results: Out of 1138 patients, 772 met the inclusion criteria: 344 patients in period 1 and 428 patients in period 2. Thromboembolic events were present in 25 patients (7.3%) of period 1 and in 42 patients (9.8%) of period 2 (raw OR 1.39, 95% CI 0.83 to 2.33, p = 0.21). Only AIS extremities (adjusted OR 1.26, 95% CI 1.05 to 1.52, p = 0.015) and exposure to allogeneic blood products (adjusted OR 2.39, 95% CI 1.33 to 4.30, p = 0.004) were independently associated with thromboembolic events in the logistic regression, but the factor-based coagulation management was not (adjusted OR 1.60, 95% CI 0.90-2.86, p = 0.11). Conclusion: There is no evidence that a goal-directed, factor-based coagulation management is associated with an increased risk for thromboembolic events following major trauma.

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Increased risk of fibrinolysis shutdown among severely injured trauma patients receiving tranexamic acid

Abstract: Therapeutic, level III.

Cited by 65 publications

References 24 publications

Fibrinolysis Shutdown Is Associated With Thrombotic and Hemorrhagic Complications and Poorer Outcomes After Liver Transplantation

Fibrinolysis Shutdown Is Associated With Thrombotic and Hemorrhagic Complications and Poorer Outcomes After Liver Transplantation

Susceptibility‐directed anticoagulation after pancreas transplantation: A single‐center retrospective study

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

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