Thrombotic thrombocytopenic purpura after blunt traumatic liver injury

Therapeutic plasma exchange is feasible and tolerable in severely injured patients with trauma-induced coagulopathy

Objectives

Trauma-induced coagulopathy (TIC) occurs in a subset of severely injured trauma patients. Despite having achieved surgical hemostasis, these individuals can have persistent bleeding, clotting, or both in conjunction with deranged coagulation parameters and typically require transfusion support with plasma, platelets, and/or cryoprecipitate. Due to the multifactorial nature of TIC, targeted interventions usually do not have significant clinical benefits. Therapeutic plasma exchange (TPE) is a non-specific modality of removing and replacing a patient's plasma in a euvolemic manner that can temporarily normalize coagulation parameters and remove deleterious substances, and may be beneficial in such patients with TIC.

Methods

In a prospective case series, TPE was performed in severely injured trauma patients diagnosed with TIC and transfusion requirement. These individuals all underwent a series of at least 3 TPE procedures performed once daily with plasma as the exclusive replacement fluid. Demographic, injury, laboratory, TPE, and outcome data were collected and analyzed.

Results

In total, 7 patients received 23 TPE procedures. All patients had marked improvements in routine coagulation parameters, platelet counts, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activities, inflammatory markers including interleukin-6 concentrations, and organ system injuries after completion of their TPE treatments. All-cause mortality rates at 1 day, 7 days, and 30 days were 0%, 0%, and 43%, respectively, and all patients for whom TPE was initiated within 24 hours after injury survived to the 30-day timepoint. Surgical, critical care, and apheresis nursing personnel who were surveyed were universally positive about the utilization of TPE in this patient population. These procedures were tolerated well with the most common adverse event being laboratory-diagnosed hypocalcemia.

Conclusion

TPE is feasible and tolerable in severely injured trauma patients with TIC. However, many questions remain regarding the application of TPE for these critically ill patients including identification of the optimal injured population, ideal time of treatment initiation, appropriate treatment intensity, and concurrent use of adjunctive treatments.

Level of evidence

Level V.

Risk factors of trauma-induced thrombotic microangiopathy-like syndrome: A retrospective analysis

Patients with trauma may develop thrombocytopenia. We encountered cases wherein patients experienced symptoms resembling thrombotic microangiopathies (TMAs) following severe trauma. As the condition of these patients did not meet the diagnostic criteria of thrombotic thrombocytopenic purpura and there was no mention of trauma among the several causes of TMAs, it was termed as "trauma-induced thrombotic microangiopathy-like syndrome" (t-TMAS). In this study, we aimed to analyze the risk factors that may affect the incidence of t-TMAS in patients with severe trauma. This retrospective study was conducted in the trauma intensive care unit at the Kyungpook National University Hospital between January 2018 and December 2019. The medical records of 1164 of the 1392 enrolled participants were analyzed. To assess the risk factors of t-TMAS, we analyzed age, sex, mechanism of trauma, abbreviated injury scale (AIS) score, injury severity score (ISS), hematological examination, and red blood cell volume transfused in 24 hours. Among the 1164 patients, 20 (1.7%) were diagnosed with t-TMAS. The univariate analysis revealed higher age, ISS, and myoglobin, lactate, creatine kinase-myocardial band (on admission), creatine phosphokinase, lactate dehydrogenase (LDH), and lactate (day 2) levels in the t-TMAS group than in the non-t-TMAS group. The red blood cell volume transfused in 24 hours was higher in the t-TMAS group than in the non-t-TMAS group. t-TMAS was more common in patients with injuries in the chest, abdomen, and pelvis (AIS score ≥3) than in those with head injuries (AIS score ≥3) alone. The higher the sum of AIS scores of the chest, abdomen, and pelvis injuries, the higher the incidence of t-TMAS. Multivariate analysis revealed age, ISS, and LDH level (day 2) to be independent predictors of t-TMAS. Trauma surgeons should consider the possibility of t-TMAS if thrombocytopenia persists without any evidence of bleeding, particularly among older patients with multiple severe torso injuries who have high LDH levels on day 2. Early diagnosis and treatment of t-TMAS could improve patients' prognosis.

Post-traumatic thrombotic microangiopathy: What trauma surgeons need to know?

Thrombotic microangiopathy (TMA) is characterized by systemic microvascular thrombosis, target organ injury, anemia and thrombocytopenia. Thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome and Shiga toxin E-coli-related hemolytic uremic syndrome are the three common forms of TMAs. Traditionally, TMA is encountered during pregnancy/postpartum period, malignant hypertension, systemic infections, malignancies, autoimmune disorders, etc. Recently, the patients presenting with trauma have been reported to suffer from TMA. TMA carries a high morbidity and mortality, and demands a prompt recognition and early intervention to limit the target organ injury. Because trauma surgeons are the first line of defense for patients presenting with trauma, the prompt recognition of TMA for these experts is critically important. Early treatment of post-traumatic TMA can help improve the patient outcomes, if the diagnosis is made early. The treatment of TMA is also different from acute blood loss anemia namely in that plasmapheresis is recommended rather than platelet transfusion. This article familiarizes trauma surgeons with TMA encountered in the context of trauma. Besides, it provides a simplified approach to establishing the diagnosis of TMA. Because trauma patients can require multiple transfusions, the development of disseminated intravascular coagulation must be considered. Therefore, the article also provides different features of disseminated intravascular coagulation and TMA. Finally, the article suggests practical points that can be readily applied to the management of these patients.

Post-traumatic thrombotic microangiopathy following pelvic fracture treated with transcatheter arterial embolization: a case report

Background

Thrombotic microangiopathy is caused by various conditions, but few cases secondary to trauma have been reported. We present the rare case of a patient with thrombotic microangiopathy-induced high-impact trauma with hemorrhagic shock.

Case presentation

An 86-year-old Japanese woman was transferred to our hospital after a traffic accident. A whole-body computed tomography scan revealed pelvic fractures with massive extravasation. She received a blood transfusion and emergency angiographic embolization. On post-traumatic day 1, she showed unexplained severe hemolysis, thrombocytopenia, and renal failure despite her stable condition. Disseminated intravascular coagulation was excluded because her activated partial thromboplastin time and prothrombin time-international normalized ratio were normal. Her fragmented red blood cell concentration was 28.8%. We suspected clinical thrombotic thrombocytopenic purpura and started plasma exchange. She recovered fully after the plasma exchange and was discharged on day 31. We eventually diagnosed thrombotic microangiopathy because her ADAMTS13 activity was not reduced.

Conclusions

It is important to recognize the possibility that thrombotic microangiopathy may occur after severe trauma. In the critical care setting, unexplained thrombocytopenia and hemolytic anemia should be investigated to eliminate the possibility of thrombotic microangiopathy. Early plasma exchange may help to prevent unfortunate outcomes in patients with thrombotic microangiopathy following trauma.