PMID- 29443859
OWN - NLM
STAT- MEDLINE
DCOM- 20190501
LR  - 20190501
IS  - 2163-0763 (Electronic)
IS  - 2163-0755 (Linking)
VI  - 85
IP  - 1
DP  - 2018 Jul
TI  - Overresuscitation with plasma is associated with sustained fibrinolysis shutdown 
      and death in pediatric traumatic brain injury.
PG  - 12-17
LID - 10.1097/TA.0000000000001836 [doi]
AB  - BACKGROUND: Elevated International Normalized Ratio (INR) is a marker of poor 
      outcome but not necessarily bleeding or clinical coagulopathy in injured 
      children. Conversely, children with traumatic brain injury (TBI) tend to be 
      hypercoagulable based on rapid thromboelastography (rTEG) parameters. Many 
      clinicians continue to utilize INR as a treatment target. METHODS: Prospective 
      observational study of severely injured children age < 18 with rTEG on arrival 
      and daily thereafter for up to 7 days. Standard rTEG definitions of 
      hyperfibrinolysis (LY30 >/= 3), fibrinolysis shutdown (SD) (LY30 </= 0.8), and normal 
      (LY30 = 0.9-2.9) were applied. The first 24-hour blood product transfusion 
      volumes were documented. Abbreviated Injury Scale score >/= 3 defined severe TBI. 
      Sustained SD was defined as two consecutive rTEG with SD and no subsequent 
      normalization. Primary outcomes were death and functional disability, based on 
      functional independence measure score assessed at discharge. RESULTS: One hundred 
      one patients were included: median age, 8 years (interquartile range, 4-12 
      years); Injury Severity Score, 25 (16-30); 72% blunt mechanism; 47% severe TBI; 
      16% mortality; 45% discharge disability. Neither total volume nor any single 
      product volume transfused (mL/kg; all p > 0.1) differed between TBI and non-TBI 
      groups. On univariate analysis, transfusion of packed red blood cells (p = 
      0.016), plasma (p < 0.001), and platelets (p = 0.006) were associated with 
      sustained SD; however, in a regression model that included all products (mL/kg) 
      and controlled for severe TBI (head Abbreviated Injury Scale score >/= 3), 
      admission INR, polytrauma, and clinical bleeding, only plasma remained an 
      independent predictor of sustained SD (odds ratio, 1.17; p = 0.031). Patients 
      with both severe TBI and plasma transfusion had 100% sustained SD, 75% mortality, 
      and 100% disability in survivors. Admission INR was elevated in TBI patients, but 
      did not correlate with rTEG activated clotting time (p = NS) and was associated 
      with sustained SD (p = 0.006). CONCLUSION: Plasma transfusion is independently 
      associated with sustained fibrinolysis SD. Severe TBI is also associated with 
      sustained SD; the combined effect of plasma transfusion and severe TBI is 
      associated with extremely poor prognosis. Plasma transfusion should not be 
      targeted to INR thresholds but rather to rTEG activated clotting time and 
      clinical bleeding. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level 
      III.
FAU - Leeper, Christine M
AU  - Leeper CM
AD  - From the Division of General Surgery and Trauma, Department of Surgery (C.M.L., 
      M.D.N., T.R.B., J.L.S.), Division of Pediatric General and Thoracic Surgery, 
      University of Pittsburgh Medical Center; and Children's Hospital of Pittsburgh of 
      UPMC (C.M.L., B.A.G.), Pittsburgh, Pennsylvania.
FAU - Neal, Matthew D
AU  - Neal MD
FAU - Billiar, Timothy R
AU  - Billiar TR
FAU - Sperry, Jason L
AU  - Sperry JL
FAU - Gaines, Barbara A
AU  - Gaines BA
LA  - eng
PT  - Journal Article
PT  - Observational Study
PT  - Research Support, N.I.H., Extramural
PT  - Research Support, Non-U.S. Gov't
PL  - United States
TA  - J Trauma Acute Care Surg
JT  - The journal of trauma and acute care surgery
JID - 101570622
SB  - IM
MH  - Blood Coagulation Disorders/epidemiology/*etiology
MH  - Blood Component Transfusion/*adverse effects/statistics & numerical data
MH  - Brain Injuries, Traumatic/complications/mortality/*therapy
MH  - Child
MH  - Child, Preschool
MH  - Female
MH  - Fibrinolysis/*physiology
MH  - Hospital Mortality
MH  - Humans
MH  - International Normalized Ratio
MH  - Male
MH  - Medical Overuse/*statistics & numerical data
MH  - Plasma
MH  - Prognosis
MH  - Prospective Studies
MH  - Thrombelastography/methods
EDAT- 2018/02/15 06:00
MHDA- 2019/05/02 06:00
CRDT- 2018/02/15 06:00
PHST- 2018/02/15 06:00 [pubmed]
PHST- 2019/05/02 06:00 [medline]
PHST- 2018/02/15 06:00 [entrez]
AID - 10.1097/TA.0000000000001836 [doi]
PST - ppublish
SO  - J Trauma Acute Care Surg. 2018 Jul;85(1):12-17. doi: 10.1097/TA.0000000000001836.