Harmful or Physiologic: Diagnosing Fibrinolysis Shutdown in a Trauma Cohort With Rotational Thromboelastometry.
Harmful or Physiologic: Diagnosing Fibrinolysis Shutdown in a Trauma Cohort With Rotational Thromboelastometry.
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DOI：
10.1213/ane.0000000000003341
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发表时间：
2018-10
影响因子：
5.7
通讯作者：
Rizoli SB
中科院分区：
文献类型：
--
作者：
Gomez-Builes JC;Acuna SA;Nascimento B;Madotto F;Rizoli SB
尽管其在早期创伤凝血病中的中心作用，但异常纤溶仍然知之甚少。过度的纤维蛋白溶解是已知的死亡原因。最近的血栓弹力图（TEG）研究表明，纤维蛋白溶解减少（或关闭）可能同样有害。考虑到2种不同的粘弹性测定法的广泛使用（不可互换），我们首次提出使用旋转血栓弹性测定法（ROTEM）来定义和表征纤维蛋白溶解停止。严重创伤患者入院ROTEM的回顾性队列研究。通过最大溶解的最佳约登指数值定义最大溶解。纤溶表型为生理性、纤溶亢进和关闭。多变量逻辑回归评估损伤严重度评分与纤溶表型之间的相关性，以及停机表型与死亡率、输血和血栓事件之间的相关性。共纳入550例患者。选择<3.5%的最大溶解来定义关闭。主要表型为生理性（70.7%），其次为停工（25.6%）和纤溶亢进（3.6%）。与生理组相比，经皮穿刺组患者的损伤严重程度评分较高，碱过量较低，需要更多的输血。与酸中毒有关（碱过量：增加1 mEq/L的比值比[OR]，0.93; 95%置信区间[CI]，0.88-0.98; P = .0094）和凝血紊乱的组合，更高的凝块硬度（最大血凝块形成：增加2 mm的OR为1.8; 95% CI为1.5-2.27; P < .0001），纤维蛋白原降低（降低0.5 g/dL的OR，1.47; 95% CI，1.18-1.84; P = 0.0006），血凝块形成动力学较差（凝块形成时间：OR增加5秒，1.25; 95%CI，1.15-1.36; P < .0001）。纤溶停止与死亡率（OR，0.61; 95% CI，0.28-1.33; P = 0.21）、大量输血（OR，2.14; 95% CI，0.79-5.74; P = 0.1308）或血栓形成事件（OR，1.08; 95% CI，0.37-3.15; P = 0.874）无关。与24小时输血量增加相关（OR，2.24; 95% CI，1.24-4.04; P = .007）。尽管损伤负荷更高、休克证据和更大的输血需求，但早期纤溶停止与死亡率无关，这表明它可能代表对危及生命的创伤的适应性生理反应。
Despite its central role in early trauma coagulopathy, abnormal fibrinolysis continues to be poorly understood. Excessive fibrinolysis is a known contributor to mortality. Recent studies with thromboelastography (TEG) suggest decreased fibrinolysis (or shutdown) may be just as harmful. Considering the broad use of 2 different viscoelastic assays, which are not interchangeable, we proposed for the first time to define and characterize fibrinolysis shutdown using rotational thromboelastometry (ROTEM). Retrospective cohort study of severely injured patients with admission ROTEM. Shutdown was defined by the best Youden index value of the maximum lysis. Fibrinolysis phenotypes were physiologic, hyperfibrinolysis, and shutdown. Multivariable logistic regression evaluated association between Injury Severity Score and the fibrinolysis phenotypes, and the association among shutdown phenotype with mortality, blood transfusion, and thrombotic events. Five hundred fifty patients were included. Maximum lysis <3.5% was selected to define shutdown. Predominant phenotype was physiologic (70.7%), followed by shutdown (25.6%) and hyperfibrinolysis (3.6%). Shutdown patients had higher Injury Severity Score, lower base excess, and required more transfusions than physiologic group. Shutdown was associated with acidosis (base excess: odds ratio [OR] for a 1 mEq/L increase, 0.93; 95% confidence interval [CI], 0.88–0.98; P = .0094) and the combination of clotting derangements, higher clot firmness (maximum clot formation: OR for a 2 mm increase, 1.8; 95% CI, 1.5–2.27; P < .0001), lower fibrinogen (OR for a 0.5 g/dL decrease, 1.47; 95% CI, 1.18–1.84; P = .0006), and poor clot formation dynamics (clot formation time: OR for a 5 seconds increase, 1.25; 95% CI, 1.15–1.36; P < .0001). Fibrinolysis shutdown was not independently associated with mortality (OR, 0.61; 95% CI, 0.28–1.33; P = .21), massive transfusion (OR, 2.14; 95% CI, 0.79–5.74; P = .1308), or thrombotic events (OR, 1.08; 95% CI, 0.37–3.15; P = .874). Shutdown was associated with increased 24-hour transfusion (OR, 2.24; 95% CI, 1.24–4.04; P = .007). Despite higher injury burden, evidence of shock, and greater need for blood transfusions, early fibrinolysis shutdown was not associated with mortality, suggesting that it could represent an adaptive physiologic response to life-threatening trauma.