Admission rapid thrombelastography delivers real-time "actionable" data in pediatric trauma

Viscoelastic hemostatic assays in the management of the pediatric trauma patient

Viscoelastic hemostatic assays (VHA), such as TEG and ROTEM, are whole blood tests that depict functional coagulation both numerically and graphically. The development of rapid VHA technology, which allows for the first data points to result within minutes of test initiation, has increased the utility of these tests in the treatment of trauma patients. Both adult and pediatric centers have integrated VHAs into trauma resuscitation and transfusion protocols. Literature regarding the use of VHAs for injured children is limited. Here, we discuss the mechanics and interpretation of VHAs as well as the use of VHAs in data-driven resuscitation of pediatric trauma patients. Novel research on fibrinolysis states after injury as well as hypercoagulable state diagnosed with VHAs are presented.

When children become adults and adults become most hypercoagulable after trauma: An assessment of admission hypercoagulability by rapid thrombelastography and venous thromboembolic risk

BACKGROUND

Thrombelastography (TEG) maximal amplitude (mA) has also been shown to reflect hypercoagulability and increased venous thromboembolism (VTE) risk in adult trauma patients. Based on these previous works, we sought to identify when children become adults with respect to TEG mA values and whether this correlated with VTE risk.

METHODS

We evaluated all trauma patients admitted from January 2010 to December 2013 who were highest-level activations. Age was evaluated as a continuous variable, followed by a categorical evaluation. TEG mA values were evaluated as continuous and dichotomous (hypercoagulable, mA ≥ 65 mm). Logistic regression was then constructed controlling for age categories, sex, and injury severity to assess the association with TEG mA values and VTE risk.

RESULTS

A total of 7,194 Level 1 trauma patients were admitted during this time frame (819 were <18 years of age). The likelihood of mA equal to or greater than 65 mm remained at 35% to 37% through age 30 years with significant increases observed at ages 31 years to 35 years (45%) and 46 years to 50 years (49%), both p < 0.01. When controlling for injury severity, race, and sex, logistic regression demonstrated that every 5-year increase in age (after age 30 years) was associated with a 16% increased likelihood of hypercoagulability at admission. Beginning with age 1 year, VTE risk remained at 1.5% or less until age 13 years where it increased to 2.3%, increasing again at age 15 years to 5.1%. Two additional significant increases were identified between ages 31 years and 35 years (5.5%) as well as 46 years and 50 years (7.6%), both p < 0.001. Logistic regression demonstrated a 3.4-fold increased risk for VTE among those aged 31 years to 50 years compared with those who are younger than 30 years. The same model noted a 2.3-fold increased risk compared with those who are older than 50 years.

CONCLUSION

Beginning at age 13 years, children transition toward adult hypercoagulability, as evidenced by elevated TEG mA values and VTE risk. However, the greatest VTE risk (and highest likelihood of hypercoagulable mA) is among those adults 31 years to 50 years of age.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients

BACKGROUND

Severely injured pediatric trauma patients often present to hospital with early coagulopathy and metabolic acidosis. These derangements are associated with poor outcomes, but it is unclear to what degree they predict transfusion of packed red blood cells (pRBC).

METHODS

We retrospectively identified pediatric trauma patients from a level 1 trauma center from 2006 to 2013. Inclusion criteria were age less than 18years, Injury Severity Score greater than 12, and pRBC transfusion within 24h of admission.

RESULTS

We identified 96 pediatric trauma patients who underwent pRBC transfusion within 24h of presentation to hospital. On admission, 43% of these patients had one or more signs of coagulopathy, and 81% had metabolic acidosis. Size of pRBC transfusion in the first 24h ranged from 3 to 177mL/kg (mean 29mL/kg), and nineteen patients (20%) underwent massive transfusion (>40ml/kg in 24h). Univariate analysis indicated that size of pRBC transfusion was associated with initial base excess (r=0.46), international normalized ratio (r=0.35), partial thromboplastin time (r=0.41), fibrinogen (r=0.46), and BIG score (Base deficit, INR, Glasgow Coma Scale (GCS), r=0.36). Platelet count, age, GCS, and direct versus referred presentation were not predictive. Multivariable linear regression confirmed that coagulopathy and metabolic acidosis remained predictive after adjusting for direct versus referred presentation (R(2)=0.30).

CONCLUSIONS

Early coagulopathy and metabolic acidosis predict size of pRBC transfusion among pediatric trauma patients. Further research is needed to develop massive transfusion protocols and guidelines for activation.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Noncardiac Challenges in the Cardiac ICU: Feeding, Growth and Gastrointestinal Complications, Anticoagulation, and Analgesia

Outcomes following cardiac intensive care unit (CICU) admission are influenced by many factors including initial cardiac diagnosis, surgical complexity, and burden of critical illness. Additionally, the presence of noncardiac issues may have a significant impact on outcomes and the patient experience during and following an intensive care unit stay. This review focuses on three common noncardiac areas which impact outcomes and patient experience in and beyond the CICU: feeding and growth, pain and analgesia, and anticoagulation. Growth failure and feeding dysfunction are commonly encountered in infants requiring cardiac surgery and have been associated with worse surgical and developmental outcomes. Recent studies most notably in the single ventricle population have demonstrated improved weight gain and outcomes when feeding protocols are implemented. Children undergoing cardiac surgery may experience both acute and chronic pain. Emerging research is investigating the impact of sedatives and analgesics on neurodevelopmental outcomes and quality of life. Improved pain scores and standardized management of pain and withdrawal may improve the patient experience and outcomes. Effective anticoagulation is a critical component of perioperative care but may be complicated by inflammation, multiorgan dysfunction, and patient factors. Advances in monitoring of anticoagulation and emerging therapies are reviewed.

Assessment of hemostatic changes in a model of acute hemorrhage in dogs

OBJECTIVE

To evaluate hemostatic changes following experimental acute hemorrhage in dogs using traditional coagulation tests (eg, platelet count, prothrombin time [PT], and activated partial thromboplastin time [aPTT]), kaolin-activated thromboelastography (TEG), and whole blood multiple electrode impedance platelet aggregometry.

DESIGN

Prospective study.

SETTING

Research laboratory.

ANIMALS

Five Beagles.

INTERVENTIONS

Dogs were anesthetized prior to obtaining blood samples for baseline PCV, total plasma protein (TPP), arterial blood-gas, platelet count, PT, aPTT, TEG, fibrinogen, and aggregometry. Blood was obtained at 4 additional time points, following 20% blood volume loss, 40% blood volume loss, 60 minutes of sustained hypotension, and after autologous blood transfusion. In addition, heart rate and direct arterial blood pressure were measured at each time point.

MEASUREMENTS AND MAIN RESULTS

Significant decreases were noted for PCV (P = 0.048), TPP (P < 0.0001), and arterial blood pressures (P < 0.0001) over time. Platelet count did not change significantly (P = 0.879), but platelet function was decreased following hemorrhage when arachidonic acid (P = 0.004) and ADP (P = 0.008) were used as agonists. The TEG variables R (P = 0.030), MA (P = 0.043), and G (P = 0.037) were significantly, albeit mildly, changed following hemorrhage. Significant prolongations in PT (P < 0.0001) and aPTT (P = 0.041), and decreases in fibrinogen concentration (P = 0.002) were also seen.

CONCLUSION

Platelet dysfunction occurred following hemorrhage in this model, despite a stable platelet count. Additionally, significant changes associated with hemorrhage were documented in aPTT, fibrinogen, and MA. Platelet function testing in dogs with naturally occurring hemorrhage warrants further investigation.

Thromboelastography predictive of death in trauma patients

OBJECTIVES

To determine if thromboelastography (TEG) is predictive of patient outcomes following traumatic injury.

METHODS

A retrospective review of 131 patients with pelvic trauma admitted to a Level II trauma center was conducted over four years from 1 January 2009 to 31 December 2012. Patients were identified retrospectively from a prospectively collected database of acute pelvic trauma (n = 372). Eligible patients were identified from billing/coding data as having fractures of the acetabulum, iliac wing or sacral alae. Patients with incomplete TEG data were excluded (n = 241), as were patients with pathological fractures. TEG clotting variables and traditional clotting variables were recorded.

RESULTS

Evaluation of TEG data revealed 41 patients with abnormal clotting times (TEG R). TEG R > 6 was an independent risk factor for death (OR, 16; 95%CI 5.4-53; P = 0.0001). The death rate was 52% in patients with TEG R values ≥6 (n = 13/25). There was no significant association between traditional clotting markers and death rate.

CONCLUSIONS

TEG reaction time value, representing the time of initial clot formation, was the only hematologic marker predictive of mortality in patients with pelvic trauma. Delay in reaction time was associated with a significantly increased death rate, independent of injury severity. The death rate association was not observed with traditional markers of clotting. Future prospective studies may be warranted to determine the presentation and significance of TEG abnormalities when resuscitating patients with orthopaedic trauma.

Prevalence and impact of admission hyperfibrinolysis in severely injured pediatric trauma patients

INTRODUCTION

Hyperfibrinolysis (HF) on admission is associated with increased mortality in adult patients with trauma. Several studies have demonstrated that 9% of severely injured adults present to the emergency department (ED) with HF. Our aim was to (1) define HF in pediatric patients and develop a relevant cut-point for therapeutic intervention (if any); (2) identify the prevalence of HF in severely injured pediatric patients; and (3) determine whether HF on admission is as lethal a phenomenon as it is in adults.

METHODS

After approval from the institutional review board (Committee for the Protection of Human Subjects), we identified all pediatric trauma admissions (patients ≤17 years old) who met highest-level trauma activation criteria between January 2010 and December 2013. Fibrinolysis rates were determined with LY-30 by rapid thrombelastography, which represents the percent decrease of the maximal clot amplitude (fibrinolysis) 30 minutes after such amplitude is achieved. HF was defined a priori as an initial LY-30 inflection point that translated to a doubling of mortality. Two previous studies in adults demonstrated an inflection point of ≥3% where mortality doubled from 9 to 20%. We began by identifying a relevant inflection point to define HF and its prevalence, followed by univariate analysis to compare HF and non-HF patients. Finally, a purposeful logistic regression model was developed to evaluate clinically relevant predictors of mortality in severely injured pediatric patients.

RESULTS

A total of 819 patients met study criteria. LY-30 values were plotted against mortality. A distinct inflection point was noted at ≥3%, where mortality doubled from 6 to 14%. Of note, mortality continued to increase as the amount of lysis increased, with a 100% mortality demonstrated at a LY-30 ≥30% (compared with 77% in adults). Using LY-30 ≥3%, we stratified patients into HF (n = 197) and non-HF (n = 622) groups, with prevalence on admission of 24%. With the exception of HF patients being younger (median age 11 vs 15 years; P < .001), there were no differences in demographics, scene vitals, or Injury Severity Scores between the groups. On arrival to the ED, HF patients had a lesser systolic blood pressure (median 118 vs 124 mm Hg) and lesser hemoglobin (median 12.2 vs 12.7 g/dL); both P < .001). Controlling for age, arrival vital signs, admission hemoglobin, and Injury Severity Score, we found that logistic regression identified admission LY30 ≥3% (odds ratio 6.2, 95% confidence interval 2.47-16.27) as an independent predictor of mortality.

CONCLUSION

Similar to adults, admission HF appears to reach a critical threshold at a LY30 ≥3% in pediatric patients. Admission HF in pediatric patients occurs more frequently than in adults (24 vs 9%) but is associated similarly with a substantial increase in mortality (6-14%). When controlling for additional factors, we found that admission LY-30 ≥3% has an odds ratio of 6.2 (P < .001) for mortality among severely injured pediatric patients. HF on admission may serve to identify rapidly those injured children and adolescents likely to benefit from hemostatic resuscitation efforts and to guide antifibrinolytic therapy.

Transfusion therapy in paediatric trauma patients: a review of the literature

Haemorrhage is a leading cause of death in paediatric trauma patients. Predefined massive transfusion protocols (MTP) have the potential to significantly reduce mortality by treating haemorrhagic shock and coagulopathy, in adhering to the principles of haemostatic resuscitation with rapid administration of balanced ratios of packed red blood cells (RBC), fresh frozen plasma (FFP) and platelets (PLT).

Because of their substantial physiological reserve, initial vital signs may not be good predictors of early haemorrhage in paediatric patients. Determining the triggers for MTP activation in paediatric trauma patients is challenging, and the optimal blood product ratio that will increase survival in massively bleeding paediatric trauma patients has yet to be determined. To date, only a few small descriptive studies and case reports have investigated the use of predefined MTP in paediatric trauma patients.

MTP with increased FFP or PLT to RBC ratios combined with viscoelastic haemostatic assay (VHA) guided haemostatic resuscitation have not yet been tested in paediatric populations but based on results from adult trauma patients, this therapeutic approach seems promising.

Considering the high prevalence of early coagulopathy in paediatric trauma patients, immediate identification and implementation of VHA-directed treatment of traumatic coagulopathy could ensure faster haemostasis and thereby, potentially, reduce bleeding as well as the total transfusion requirements and further improve outcome in paediatric trauma patients. Prospective randomized trials investigating this therapeutic approach in paediatric trauma patients are highly warranted.

The influence of cardiopulmonary bypass priming without FFP on postoperative coagulation and recovery in pediatric patients with cyanotic congenital heart disease

Transfusion guidelines have been produced for the evidence-based use of fresh frozen plasma (FFP). However, the inappropriate use of FFP is still a worldwide problem, especially in the prophylactic settings. In the present study, 100 cyanotic pediatric patients (age 6 months to 3 years) undergoing cardiac surgery with cardiopulmonary bypass (CPB) were randomized to receive either 10-20 ml/kg FFP (FFP group, n = 50) or 10-20 ml/kg 4 % succinylated gelatin (Gelofusine, GEL group, n = 50) in the priming solution. Rapid thromboelastography (r-TEG) was measured before skin incision and 15 min after heparin neutralization. Postoperative renal and hepatic function, mediastinal chest tube drainage, transfusion requirements, and recovery time were observed. The relationships between hematologic and demographic data and postoperative bleeding volume were also analyzed. The results showed that there were significantly elevated levels of fibrinogen (r-TEG parameters: fibrinogen contribution to maximal amplitude (MAf) and fibrinogen level (FLEV)) in the FFP group compared to the GEL group. The postoperative blood loss, total transfusion requirements, and recovery time were not significantly different between the two groups, indicating that there were no obvious clinical benefits of using FFP in the priming. The maximal amplitude (MA) of r-TEG measured after heparin neutralization was correlated with the 6-h postoperative bleeding volume. In addition, preoperative fibrinogen level rather than FFP priming was an independent predictor of postoperative blood loss.

CONCLUSION

Prophylactic use of FFP in the priming solution does not have obvious clinical benefits in cyanotic congenital heart disease (CCHD) patients. Gelofusine, an artificial colloid, is a safe and effective substitute of FFP in the priming solution. Furthermore, r-TEG can be used as a "real-time" assessment tool to evaluate postoperative bleeding and guide transfusion after cardiac surgery in pediatric patients.

Plasma colloid osmotic pressure is an early indicator of injury and hemorrhagic shock

OBJECTIVE

Hemorrhagic shock is the leading cause of traumatic deaths; many could be potentially prevented with appropriate resuscitation. However, to initiate resuscitation, one must identify patients with hemorrhagic shock early. In this article, we determined the associations between plasma colloid osmotic pressure (COP) and clinical outcomes in severely injured trauma patients.

METHODS

Plasma samples were collected from 104 trauma patients upon admission to the emergency department and 10 healthy volunteers to serve as control subjects. Plasma osmolality, COP, and serum protein were measured and correlated to clinical data. Thrombelastography and impedance aggregometry were performed to assess coagulopathy. Commercial enzyme-linked immunosorbent assays were used to quantify syndecan 1.

RESULTS

Plasma COP was significantly reduced in trauma patients compared to control subjects 17.7 ± 2.6 vs. 20.7 ± 2.1 mmHg (P < 0.05) and strongly correlated to serum protein values (R = 0.7). We divided our cohort into low (COP ≤16.5 mmHg) and normal (COP >16.5 mmHg) subgroups, illustrating significantly higher Injury Severity Score scores in patients with low COP (21 vs. 10, P = 0.007), despite no differences in vital signs. Patients with low COP received more red blood cells, plasma, and platelets (4 vs. 0 total units, P = 0.0005) within 24 h of admission. Syndecan 1 levels were significantly higher (184 vs. 52 ng/mL, P = 0.027) in patients with low COP.

CONCLUSIONS

Reduced plasma COP and serum protein in trauma patients are indicative of injury severity. In the absence of significant alterations in vital signs, plasma COP levels were associated with increased requirements for blood products and increased syndecan 1 shedding. We believe that plasma COP provides new insight in guiding resuscitation.

Massive transfusion in paediatric and adolescent trauma patients: incidence, patient profile, and outcomes prior to a massive transfusion protocol

OBJECTIVES

The purpose of this study was to quantify the incidence, patient profile, and outcomes associated with massive transfusion in paediatric trauma patients prior to establishing a massive transfusion protocol.

METHODS

We performed a retrospective review of paediatric trauma patients treated at London Heath Sciences Centre between January 1, 2006, and December 31, 2011. Inclusion criteria were Injury Severity Score (ISS) greater than 12 and age less than 18 years.

RESULTS

435 patients met the inclusion criteria. Three hundred and fifty-six (82%) did not receive packed red blood cells in the first 24h, 66 (15%) received a non-massive transfusion (<40mL/kg), and 13 (3%) received a massive transfusion (>40mL/kg). Coagulopathy of any kind was more common in massive transfusion (11/13; 85%) than non-massive (32/66; 49%) (p=0.037). Hyperkalemia (18% versus 23%; p=0.98) and hypocalcemia (41% versus 46%; p=1.00) were similar in both groups. Of the 13 massively transfused patients, 9 had multisystem injuries due to a motor vehicle collision, 3 had non-accidental head injuries requiring surgical evacuation, and 1 had multiple stab wounds. In the absence of a massive transfusion protocol, only 8 of the 13 patients received both fresh frozen plasma and platelets in the first 24h. Massive transfusion occurred in patients from across the age spectrum and was associated with severe injuries (mean ISS=33), a higher incidence of severe head injuries (92%), longer hospital stay (mean=36 days), and increased mortality (38%).

CONCLUSIONS

This study is the first to describe the incidence, complications, and outcomes associated with massive transfusion in paediatric trauma patients prior to a massive transfusion protocol. Massive transfusion occurred in 3% of patients and was associated with coagulopathy and poor outcomes. Protocols are needed to ensure that resuscitation occurs in a coordinated fashion and that patients are given appropriate amounts of fresh frozen plasma, platelets, and cryoprecipitate.

Clinical applicability of rapid thrombelastography and functional fibrinogen thrombelastography to adult liver transplantation

Unlike kaolin thrombelastography (k-TEG), the clinical utility of rapid thrombelastography (r-TEG) and functional fibrinogen thrombelastography (FF-TEG) has not been tested in liver transplantation (LT). These thrombelastography techniques were simultaneously performed at the time of the skin incision (the baseline) and 30 minutes after graft reperfusion (III + 30) for 27 consecutive adult LT patients. k-TEG and r-TEG parameters [alpha angle (α) and maximum amplitude of the clot (MA)] were compared in addition to the assay time. Estimated FF-TEG fibrinogen levels were compared with plasma fibrinogen measurements. At the baseline, the values of Spearman's correlation coefficient (r) between k-TEG and r-TEG were moderate for α (r = 0.40, P = 0.06) and strong for MA (r = 0.90, P < 0.01). At III + 30, r was 0.46 (P < 0.05) for α and 0.80 (P < 0.01) for MA. The average time required to measure MA via r-TEG was decreased in comparison with k-TEG [from 29.7 to 21.6 minutes at the baseline (a 22% reduction) and from 29.6 to 22.9 minutes at III + 30 (a 23% reduction)]. FF-TEG correlated strongly with the plasma fibrinogen level at the baseline (r = 0.90, P < 0.01); however, FF-TEG overestimated the fibrinogen level at III + 30 (r = 0.58, P = 0.01). In conclusion, in adult LT, r-TEG correlates with k-TEG strongly for MA but only moderately for α. FF-TEG estimates the plasma fibrinogen level well at the baseline; however, it must be interpreted with caution because of its overestimation after graft reperfusion when the plasma fibrinogen level often decreases to less than 100 mg/dL.

Trauma induced hypercoagulablity in pediatric patients

PURPOSE

Coagulation changes in pediatric trauma patients are not well defined. To fill this gap, we tested the hypothesis that trauma evokes a hypercoagulable response.

METHODS

A prospective observational study was conducted in hospitalized patients (age 8months to 14years) admitted for trauma or elective surgery. Informed consent was obtained from the parents and informed assent was obtained in patients 7years of age or older. Coagulation changes were evaluated on fresh whole blood using thromboelastography (TEG) and on stored plasma using assays for special clotting factors.

RESULTS

Forty three patients (22 trauma, median injury severity score =9; and 21 uninjured controls) were evaluated. For trauma vs control, prothrombin time (PT) was higher by about 10% (p<0.001), but activated partial thromboplastin time was not altered. TEG clotting time (R;p=0.005) and fibrin cross-linking were markedly accelerated (K time, alpha angle; p<0.001) relative to the control patients. d-Dimer, Prothrombin Fragment 1+2, and Plasminogen Activator Inhibitor-1 were all elevated, whereas Protein S activity was reduced (all p<0.01). Importantly, a large fraction of TEG values and clotting factor assays in the pediatric control group were outside the published reference ranges for adults.

CONCLUSION

A hypercoagulable state is associated with minor trauma in children. More work is needed to determine the functional significance of these changes and to establish normal pediatric reference ranges.

Tranexamic acid in pediatric trauma: why not?

Trauma is a leading cause of death in pediatrics. Currently, no medical treatment exists to reduce mortality in the setting of pediatric trauma; however, this evidence does exist in adults. Bleeding and coagulopathy after trauma increases mortality in both adults and children. Clinical research has demonstrated a reduction in mortality with early use of tranexamic acid in adult trauma patients in both civilian and military settings. Tranexamic acid used in the perioperative setting safely reduces transfusion requirements in children. This article compares the hematologic response to trauma between children and adults, and explores the potential use of tranexamic acid in pediatric hemorrhagic trauma.

Acute coagulopathy in pediatric trauma

PURPOSE OF REVIEW

To summarize our current understanding of the pathophysiology, diagnosis, and management of acute traumatic coagulopathy in children.

RECENT FINDINGS

Traumatic coagulopathy is a complex process that leads to global dysfunction of the endogenous coagulation system and results in worse outcomes and increased mortality. Although the cause is multifactorial, it is common in severely injured patients and is driven by significant tissue injury and hypoperfusion. Viscoelastic coagulation tests have been established as a rapid and reliable method to assess traumatic coagulopathy. Additionally, massive transfusion protocols have improved outcomes in adults, but limited studies in pediatrics have not shown any difference in mortality.

SUMMARY

Prospective studies are needed to determine how to best diagnose and manage acute traumatic coagulopathy in children.

Coagulopathy after severe pediatric trauma

Trauma remains the leading cause of morbidity and mortality in the United States among children aged 1 to 21 years. The most common cause of lethality in pediatric trauma is traumatic brain injury. Early coagulopathy has been commonly observed after severe trauma and is usually associated with severe hemorrhage and/or traumatic brain injury. In contrast to adult patients, massive bleeding is less common after pediatric trauma. The classical drivers of trauma-induced coagulopathy include hypothermia, acidosis, hemodilution, and consumption of coagulation factors secondary to local activation of the coagulation system after severe traumatic injury. Furthermore, there is also recent evidence for a distinct mechanism of trauma-induced coagulopathy that involves the activation of the anticoagulant protein C pathway. Whether this new mechanism of posttraumatic coagulopathy plays a role in children is still unknown. The goal of this review is to summarize the current knowledge on the incidence and potential mechanisms of coagulopathy after pediatric trauma and the role of rapid diagnostic tests for early identification of coagulopathy. Finally, we discuss different options for treating coagulopathy after severe pediatric trauma.

Evidence-based use of FFP: the influence of a priming strategy without FFP during CPB on postoperative coagulation and recovery in pediatric patients

Objective:

Although fresh frozen plasma (FFP) is one of the most commonly used hemostatic agents in clinical specialties today, there is little evidence available supporting its administration. Our present study observed the effects of a priming strategy without FFP during cardiopulmonary bypass (CPB) on postoperative coagulation and clinical recovery in pediatric patients, aiming to supply new evidence for evidence-based use of FFP.

Method:

Eighty pediatric patients with congenital heart disease undergoing cardiac surgery with CPB were randomized to receive either 10-20 ml/kg 4% succinylated gelatin (Gelofusine, GEL group, n = 40) or 1-2 units FFP (FFP group, n = 40) in the pump prime. Rapid-thromboelastography (r-TEG) and functional fibrinogen level were measured before skin incision and 15 minutes after heparin reversal. We recorded the volume of chest tube drainage, transfusion requirements and the dosage of pharmacological agents. The ventilation time, ICU length of stay and hospitalization time after surgery were also collected.

Results:

After heparin neutralization, there were significantly elevated levels of fibrinogen in the FFP group, which were manifested by r-TEG parameters MAf and FLEV. No significant differences were observed between the two groups in postoperative bleeding, transfusion requirements and the usage of pharmacological agents. Recovery time was also comparable between the two groups.

Conclusion:

In conclusion, prophylactic use of FFP in the priming solution does not provide clinical benefits as presumed. Artificial colloids, such as Gelofusine, can be used safely and effectively as a substitute for FFP in the pump prime. TEG is an effective assessment tool to evaluate postoperative coagulation function in pediatric patients.

Acute coagulopathy in a porcine venous hemorrhage and ischemia reperfusion model

BACKGROUND

Injury-related coagulopathy is a complex process. We analyzed coagulation in a swine model of shock using rotational thromboelastometry (ROTEM).

METHODS

Forty-eight swine underwent laparotomy, 35% hemorrhage, supraceliac aortic cross-clamp, then reperfusion and resuscitation. ROTEM measurements and standard labs were taken at baseline and 6 hours into resuscitation.

RESULTS

Clot formation time (98 vs 53 seconds, P = .001) and international normalized ratio (1.67 vs 1.01, P < .001) were prolonged after resuscitation. Maximum clot firmness (61 vs 72 mm, P < .001) and fibrinogen levels (94 vs 165, P < .001) declined significantly during resuscitation. Despite decreased fibrinogen levels, there was no significant increase in fibrinolysis as measured by maximum lysis (3.9% vs 3.8%, P = .99).

CONCLUSIONS

ROTEM demonstrated the development of an acute coagulopathy. The most significant impacts on coagulopathy were seen with clot initiation and fibrin polymerization. Clot strength decreased over time, although there was little impact on clot breakdown because of fibrinolysis.

Neonatal hematology

Neonatal hematology is a complex and dynamic process in the pediatric population. Surgeons frequently encounter hematologic issues regarding hemostasis, inflammation, and wound healing. This publication provides a surgeon-directed review of hematopoiesis in the newborn, as well as an overview of the current understanding of their hemostatic profile under normal and pathologic conditions.