Impact of initial coagulation and fibrinolytic markers on mortality in patients with severe blunt trauma: a multicentre retrospective observational study

Kenta Ishii,Shota Nakao,Kazutaka Kiridume,Tetsuya Matsuoka,Takahiro Kinoshita,Satoshi Fujimi,Atsushi Watanabe,Kazuma Yamakawa

doi:10.1186/s13049-019-0606-6

Kenta Ishii, Shota Nakao + Show 6 more

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https://doi.org/10.1186/s13049-019-0606-6

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Abstract

BackgroundAcute coagulopathy is a well-known predictor of poor outcomes in patients with severe trauma. However, using coagulation and fibrinolytic markers, how one can best predict mortality to find out potential candidates for treatment of coagulopathy remains unclear. This study aimed to determine preferential markers and their optimal cut-off values for mortality prediction.MethodsWe conducted a retrospective observational study of patients with severe blunt trauma (injury severity score ≥ 16) transferred directly from the scene to emergency departments at two trauma centres in Japan from January 2013 to December 2015. We investigated the impact and optimal cut-off values of initial coagulation (platelet counts, fibrinogen and prothrombin time-international normalised ratio) and a fibrinolytic marker (D-dimer) on 28-day mortality via classification and regression tree (CART) analysis. Multivariate logistic regression analysis confirmed the importance of these markers. Receiver operating characteristic curve analyses were used to examine the prediction accuracy for mortality.ResultsTotally 666 patients with severe blunt trauma were analysed. CART analysis revealed that the initial discriminator was fibrinogen (cut-off, 130 mg/dL) and the second discriminator was D-dimer (cut-off, 110 μg/mL in the lower fibrinogen subgroup; 118 μg/mL in the higher fibrinogen subgroup). The 28-day mortality was 90.0% (lower fibrinogen, higher D-dimer), 27.8% (lower fibrinogen, lower D-dimer), 27.7% (higher fibrinogen, higher D-dimer) and 3.4% (higher fibrinogen, lower D-dimer). Multivariate logistic regression demonstrated that fibrinogen levels < 130 mg/dL (adjusted odds ratio [aOR], 9.55; 95% confidence interval [CI], 4.50–22.60) and D-dimer ≥110 μg/mL (aOR, 5.89; 95% CI, 2.78–12.70) were independently associated with 28-day mortality after adjusting for probability of survival by the trauma and injury severity score (TRISS Ps). Compared with the TRISS Ps alone (0.900; 95% CI, 0.870–0.931), TRISS Ps with fibrinogen and D-dimer yielded a significantly higher area under the curve (0.942; 95% CI, 0.920–0.964; p < 0.001).ConclusionsFibrinogen and D-dimer were the principal markers for stratification of mortality in patients with severe blunt trauma. These markers could function as therapeutic targets because they were significant predictors of mortality, independent from severity of injury.

Highlights

Acute coagulopathy is a well-known predictor of poor outcomes in patients with severe trauma
Recent studies have reported that elevated D-dimer, which suggests the existence of hyperfibrinolysis, is a significant predictor of poor outcomes [11,12,13]
In the present study, we investigated the impact of initial coagulation and fibrinolytic markers including platelet counts, prothrombin time-international normalised ratio (PT-INR), fibrinogen and D-dimer on 28-day mortality in patients with severe blunt trauma

Summary

Introduction

Acute coagulopathy is a well-known predictor of poor outcomes in patients with severe trauma. Coagulopathy occurring in early phases of trauma leads to systemic haemorrhage that cannot be controlled using surgical procedures; patients who present with coagulopathy following trauma have an approximately four-fold higher mortality [2,3,4] These patients are considered to require ‘damage control strategy’ including damage control surgery, restrictive fluid administration, massive transfusion and use of antifibrinolytic drugs. Recent studies have reported that elevated D-dimer, which suggests the existence of hyperfibrinolysis, is a significant predictor of poor outcomes [11,12,13] Other than those standard laboratory-based coagulation tests, viscoelastic methods are reportedly effective for rapid assessment of coagulopathy [14, 15]; several systematic reviews indicate limited evidence to support their utility [16, 17]. The European guidelines regarding coagulopathy after trauma still recommend early and repeated monitoring of standard laboratorybased coagulation tests as well as parameters of viscoelastic testing [18]

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