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Master of Public Health

Time Course and Outcomes Associated with Transient Versus Persistent Fibrinolytic Phenotypes After Injury: A Nested, Prospective, Multicenter Cohort Study

AUTHORS

Roberts DJ , Kalkwarf KJ , Moore HB , Cohen MJ , Fox EE , Wade CE , Cotton BA , . The journal of trauma and acute care surgery. 2018 10 29; ().

ABSTRACT

BACKGROUND: Temporal changes in fibrinolytic activity after injury and their impact on outcomes remain poorly defined. We conducted a prospective, multicenter cohort study to determine the incidence of fibrinolytic phenotypes after injury and the trajectories and associated outcomes of these phenotypes over time.

METHODS: We included adults that arrived within six-hours of injury to three American, level-1 trauma centers. Clot lysis at 30-minutes (LY-30) was measured at presentation and 3-, 6-, 12-, 24-, 48-, 72-, 96-, and 120-hours. LY-30 was used to categorize patients into the following fibrinolytic phenotypes: fibrinolysis shutdown (SD, LY-30 ≤0.8%), physiologic fibrinolysis (PHYS, LY-30 >0.8% to <3%), or hyperfibrinolysis (HF, LY-30 ≥3%). We used multivariable logistic regression to estimate adjusted odds ratios (ORs) for mortality.

RESULTS: We included 795 adults [median age=38-years and Injury Severity Scale score=21]. In total, 44% presented with SD, 36% with PHYS, and 21% with HF. Mortality was highest among those who presented with HF (20%) followed by SD (10%) and PHYS (7%) (p=0.001). While mortality within the first 24-hours was highest with admission HF (14% vs. 5% SD vs. 4% PHYS; p=0.001), both admission HF (7%) and SD (6%) had higher mortality after 24-hours compared to PHYS (3%) (p=0.04). All patients who presented with HF switched into another phenotype or died within 24-hours. The majority of patients that presented in SD remained in that phenotype, including 71% at 24-hours and 72% at 120-hours. Persistent SD at 24-hours was independently associated with increased mortality after 24-hours (OR=3.20, 95% confidence interval=1.51-6.67).

CONCLUSIONS: Approximately 70% of major trauma patients who present with SD remain in this phenotype up to 120-hours postinjury. In contrast, patients presenting with HF transition into another phenotype or die within 24-hours. While early mortality is highest with the HF phenotype, persistent SD at 24-hours is associated with elevated late mortality.

LEVEL OF EVIDENCE: Level II, Prognostic and Epidemiological Study.

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