Studies on the Role of Intravascular Coagulation in Irreversible Hemorrhagic Shock

The American Journal of Surgery

Liras

et al. 2017

Introduction The prevalence and impact of hypercoagulability(hypo) in severely injured patients early after injury remains unclear. We hypothesize that the predominant phenotype of postinjury coagulopathy is hypercoagulability(hyper) and it is associated with increased mortality. Material and Methods Blood samples from 141 healthy volunteers assayed with thrombelastography(TEG) were used to identify thresholds of hypo and hypercoagulability(above 95th/below the 5thpercentile) in four TEG indices. These cutoffs were subsequently evaluated in severely injured trauma patients(ISS>15) from two level 1 trauma centers. Results 2,540 patients with a median ISS of 25 were analyzed. Normal TEG was present in 36% of patients. Hyper was found in 38% of patients, with mixed(11%) and hypo(15%) being less common. Compared to normal coagulation patients and after controlling for age, sex, blood pressure, and injury hyper(0.013), mixed(p<0.001) and hypo(p<0.001) were all independent predictors of mortality. Conclusion These data support the ongoing need for goal directed resuscitation in trauma patients, it appears the optimal resuscitation strategy should be targeted towards normalization of coagulation status as both early hyper and hypocoagulability are associated with increased mortality.

Section: Discussionmentioning

confidence: 67%

Targeting resuscitation to normalization of coagulating status: Hyper and hypocoagulability after severe injury are both associated with increased mortality

The American Journal of Surgery

Liras

et al. 2017

“…The protective role of fibrinolysis has been proven in animal models in the 1960’s. Hardaway demonstrated that irreversible shock was associated with impaired fibrinolysis (15), a process that could be reversed by increasing fibrinolysis (16). …”

Section: Discussionmentioning

confidence: 99%

Tranexamic acid is associated with increased mortality in patients with physiological fibrinolysis

Journal of Surgical Research

Huebner

et al. 2017

Introduction Tranexamic acid (TXA) administration following trauma has not been proven to improve survival in the US. Trauma patients present to the hospital with a spectrum of fibrinolytic activity, in which a physiologic levels of fibrinolysis are associated with the lowest mortality. We hypothesize that trauma patients who present to the hospital with physiologic levels of fibrinolysis will have increased mortality if they receive TXA. Material and Methods Severely injured trauma patients followed prospectively from 2014 to 2016 we included in the analysis. The patient’s first thrombelastography (TEG) was used to stratify patients into fibrinolysis phenotypes which included fibrinolysis shutdown, physiologic fibrinolysis, and systemic hyperfibrinolysis. The primary outcome was in hospital mortality. Results 232 patients were analyzed (11% received TXA) with an overall mortality rate of 20%. TXA administration was associated with a higher new injury severity score (NISS 49 vs 28 p=0.001) massive transfusion rate (69% vs 12% p<0.001) and mortality (52% vs 17% p<0.001). Hyperfibrinolysis and shutdown had higher mortality rates than physiologic (24% vs 30% vs 14% p=0.050). The effect of TXA within phenotypes, was not significant for shutdown (28% vs 38% p=0.604) but was significant in the physiologic group (11% vs 63% p<0.001) and systemic hyperfibrinolysis (19% vs 55% p=0.023). After adjusting for NISS, TXA remained a significant predictor of mortality for patients with physiologic fibrinolysis (p=0.018). Conclusion There was no clear benefit of receiving TXA in this study, and patients who present to the hospital with physiologic levels of fibrinolysis, who received TXA, had the highest mortality. The role of TXA in mature trauma systems remains unclear, and emerging data supports it may have adverse effects.

“…This brings into question; is this hypocoaguable state pathologic, or physiologic? Over a half century ago, the beneficial effects of hypocoagulability(57) and fibrinolysis(58) were appreciated in animals subjected to near lethal hemorrhagic shock, supporting that trauma coagulopathy is a survival mechanism. However, in the actively bleeding patient it is difficult to ignore a coagulopathy that may be contributing to additional blood loss.…”

Section: Conmentioning

confidence: 99%

Is Coagulopathy an Appropriate Therapeutic Target During Critical Illness Such as Trauma or Sepsis?

Winfield

Aibiki

et al. 2017

Shock

Coagulopathy is a common and vexing clinical problem in critically ill patients. Recently, major advances focused on the treatment of coagulopathy in trauma and sepsis have emerged. However, the targeting of coagulopathy with blood product transfusion and drugs directed at attenuating the physiologic response to these conditions have major potential risk to the patient. Therefore, the identification of coagulopathy as a clinical target is an area of uncertainty and controversy. In order to analyze the state of the science regarding coagulopathy in critical illness, a symposium addressing the problem was organized at the 39th annual meeting of the Shock Society in the summer of 2016. This manuscript synthesizes the viewpoints of the four expert panelists at the debate and presents an overview of the potential positive and negative consequences of targeting coagulopathy in trauma and sepsis.