Julia R Coleman1, Ernest E Moore2, Jason M Samuels1, Mitchell J Cohen3, Christopher C Silliman4, Arsen Ghasabyan3, James Chandler3, Saulius Butenas5. 1. Department of Surgery, University of Colorado-Denver, Aurora, CO. 2. Department of Surgery, University of Colorado-Denver, Aurora, CO; Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO. Electronic address: Ernest.moore@dhha.org. 3. Department of Surgery, University of Colorado-Denver, Aurora, CO; Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO. 4. Department of Surgery, University of Colorado-Denver, Aurora, CO; Vitalant Research Institute, Vitalant Denver, Denver, CO. 5. Department of Biochemistry, University of Vermont, Burlington, VT.
Abstract
BACKGROUND: Despite the prevalence of hypocoagulability after injury, the majority of trauma patients paradoxically present with elevated thrombin generation (TG). Although several studies have examined plasma TG post injury, this has not been assessed in whole blood. We hypothesize that whole blood TG is lower in hypocoagulopathy, and TG effectively predicts massive transfusion (MT). STUDY DESIGN: Blood was collected from trauma activation patients at an urban Level I trauma center. Whole blood TG was performed with a prototype point-of-care device. Whole blood TG values in healthy volunteers were compared with trauma patients, and TG values were examined in trauma patients with shock and MT requirement. RESULTS: Overall, 118 patients were included. Compared with healthy volunteers, trauma patients overall presented with more robust TG; however, those arriving in shock (n = 23) had a depressed TG, with significantly lower peak thrombin (88.3 vs 133.0 nM; p = 0.01) and slower maximum rate of TG (27.4 vs 48.3 nM/min; p = 0.04). Patients who required MT (n = 26) had significantly decreased TG, with a longer lag time (median 4.8 vs 3.9 minutes, p = 0.04), decreased peak thrombin (median 71.4 vs 124.2 nM; p = 0.0003), and lower maximum rate of TG (median 15.8 vs 39.4 nM/min; p = 0.01). Area under the receiver operating characteristics (AUROC) analysis revealed lag time (AUROC 0.6), peak thrombin (AUROC 0.7), and maximum rate of TG (AUROC 0.7) predict early MT. CONCLUSIONS: These data challenge the prevailing bias that all trauma patients present with elevated TG and highlight that deficient thrombin contributes to the hypocoagulopathic phenotype of trauma-induced coagulopathy. In addition, whole blood TG predicts MT, suggesting point-of-care whole blood TG can be a useful tool for diagnostic and therapeutic strategies in trauma.
BACKGROUND: Despite the prevalence of hypocoagulability after injury, the majority of trauma patients paradoxically present with elevated thrombin generation (TG). Although several studies have examined plasma TG post injury, this has not been assessed in whole blood. We hypothesize that whole blood TG is lower in hypocoagulopathy, and TG effectively predicts massive transfusion (MT). STUDY DESIGN: Blood was collected from trauma activation patients at an urban Level I trauma center. Whole blood TG was performed with a prototype point-of-care device. Whole blood TG values in healthy volunteers were compared with trauma patients, and TG values were examined in trauma patients with shock and MT requirement. RESULTS: Overall, 118 patients were included. Compared with healthy volunteers, trauma patients overall presented with more robust TG; however, those arriving in shock (n = 23) had a depressed TG, with significantly lower peak thrombin (88.3 vs 133.0 nM; p = 0.01) and slower maximum rate of TG (27.4 vs 48.3 nM/min; p = 0.04). Patients who required MT (n = 26) had significantly decreased TG, with a longer lag time (median 4.8 vs 3.9 minutes, p = 0.04), decreased peak thrombin (median 71.4 vs 124.2 nM; p = 0.0003), and lower maximum rate of TG (median 15.8 vs 39.4 nM/min; p = 0.01). Area under the receiver operating characteristics (AUROC) analysis revealed lag time (AUROC 0.6), peak thrombin (AUROC 0.7), and maximum rate of TG (AUROC 0.7) predict early MT. CONCLUSIONS: These data challenge the prevailing bias that all trauma patients present with elevated TG and highlight that deficient thrombin contributes to the hypocoagulopathic phenotype of trauma-induced coagulopathy. In addition, whole blood TG predicts MT, suggesting point-of-care whole blood TG can be a useful tool for diagnostic and therapeutic strategies in trauma.
Authors: Beth A Bouchard; Thomas Orfeo; Hollis N Keith; Elizabeth M Lavoie; Matthew Gissel; Mark Fung; Kenneth G Mann Journal: J Trauma Acute Care Surg Date: 2018-04 Impact factor: 3.313
Authors: Myung S Park; Grant M Spears; Kent R Bailey; Ailing Xue; Michael J Ferrara; Amy Headlee; Sabtir K Dhillon; Donald H Jenkins; Scott P Zietlow; William S Harmsen; Aneel A Ashrani; John A Heit Journal: J Trauma Acute Care Surg Date: 2017-09 Impact factor: 3.313
Authors: Jessica C Cardenas; Elaheh Rahbar; Matthew J Pommerening; Lisa A Baer; Nena Matijevic; Bryan A Cotton; John B Holcomb; Charles E Wade Journal: J Trauma Acute Care Surg Date: 2014-12 Impact factor: 3.313
Authors: Karim Brohi; Mitchell J Cohen; Michael T Ganter; Michael A Matthay; Robert C Mackersie; Jean-François Pittet Journal: Ann Surg Date: 2007-05 Impact factor: 12.969
Authors: Elaheh Rahbar; Jessica C Cardenas; Gyulnar Baimukanova; Benjamin Usadi; Roberta Bruhn; Shibani Pati; Sisse R Ostrowski; Pär I Johansson; John B Holcomb; Charles E Wade Journal: J Transl Med Date: 2015-04-12 Impact factor: 5.531
Authors: Ernest E Moore; Hunter B Moore; Lucy Z Kornblith; Matthew D Neal; Maureane Hoffman; Nicola J Mutch; Herbert Schöchl; Beverley J Hunt; Angela Sauaia Journal: Nat Rev Dis Primers Date: 2021-04-29 Impact factor: 65.038
Authors: Julia R Coleman; Hiroshi Deguchi; Taichi K Deguchi; Mitchel J Cohen; Ernest E Moore; John H Griffin Journal: J Thromb Haemost Date: 2022-03-20 Impact factor: 16.036