Background Failure to achieve primary fascial closure (PFC) after damage control laparotomy is costly and carries great morbidity. We hypothesized that time from the initial laparotomy to the first ...take-back operation would be predictive of successful PFC. Methods Trauma patients managed with open abdominal techniques after damage control laparotomy were prospectively followed at 14 Level 1 trauma centers during a 2-year period. Time to the first take-back was evaluated as a predictor of PFC using hierarchical multivariate logistic regression analysis. Results A total of 499 patients underwent damage control laparotomy and were included in this analysis. PFC was achieved in 327 (65.5%) patients. Median time to the first take-back operation was 36 hours (interquartile range 24–48). After we adjusted for patient demographics, resuscitation volumes, and operative characteristics, increasing time to the first take-back was associated with a decreased likelihood of PFC. Specifically, each hour delay in return to the operating room (24 hours after initial laparotomy) was associated with a 1.1% decrease in the odds of PFC (odds ratio 0.989; 95% confidence interval 0.978–0.999; P = .045). In addition, there was a trend towards increased intra-abdominal complications in patients returning after 48 hours (odds ratio 1.80; 95% confidence interval 1.00–3.25; P = .05). Conclusion Data from this prospective, multicenter study demonstrate that delays in returning to the operating room after damage control laparotomy are associated with reductions in PFC. These findings suggest that emphasis should be placed on returning to the operating room within 24 hours after the initial laparotomy if possible (and no later than 48 hours).
Background Previous investigators have demonstrated that postinjury thrombocytosis is associated with an increase in thromboembolic (TE) risk. Increased rates of thrombocytosis have been found ...specifically in patients after splenectomy for trauma. We hypothesized that patients undergoing splenectomy (1) would demonstrate a more hypercoagulable profile during their hospital stay and (2) that this hypercoagulable state would be associated with increased TE events. Methods This was a 14-month, prospective, observational trial evaluating serial rapid thrombelastography (rTEG) at 3 American College of Surgeons−verified, level 1 trauma centers. Inclusion criteria were highest-level trauma activation and arrival within 6 hours of injury. Exclusion criteria were <18 years of age, incarcerated, and burns>20% total body surface area. Serial rTEG (activated clotting time, k-time, α-angle, MA, lysis) and traditional coagulation testing (prothrombin time, partial thromboplastin time, fibrinogen and platelet count) were obtained at admission and then at 3, 6, 12, 24, 48, 72, 96, and 120 hours. Thromboembolic complications were defined as the development of deep-vein thrombosis, pulmonary embolism, acute myocardial infarction, or ischemic stroke during hospitalization. Patients were stratified into splenectomy versus nonsplenectomy cohorts. Univariate analysis was then conducted followed by longitudinal analysis using generalized estimating equations to evaluate the effects of time, splenectomy, and group-time interactions on changes in rTEG and traditional coagulation testing. We used an adjusted generalized estimating equation model to control for age, sex, ISS, admission blood pressure, base deficit, and hemoglobin. Results A total of 1,242 patients were enrolled; 795 had serial rTEG data. Of these, 605 had serial values >24 hours and made up the study population. Splenectomy patients were younger, more hypotensive, and in shock on arrival. Although there was no difference in 24-hour or 30-day mortality, splenectomy patients were more likely to develop TE events. Using the GEE model, we found that α-angle and MA in splenectomy patients were lesser (more hypocoagulable) within the first 6 hours; however, they became substantially greater (more hypercoagulable) at 48, 72, 96, and 120 hours; all P < .05. In addition, platelet counts were greater in the splenectomy group beginning at 72 hours and continuing through 120 hours; P < .05. Conclusion This multicenter, prospective study demonstrates that patients undergoing splenectomy have a more hypercoagulable state than other trauma patients. This hypercoagulable state (identified by greater α-angle and mA values) begins at approximately 48 hours after injury and continues through at least day 5. Moreover, this hypercoagulable state is associated with increased risk of TE complications.
Background Recent studies suggest there are gender-specific differences in injury response that may be related to coagulation. The objective of this study was to test the hypothesis that rapid ...thrombelastography (rTEG) coagulation profiles differ by gender. Methods Adult trauma patients were prospectively followed at 3 level 1 trauma centers over a 14-month period. rTEG was obtained upon arrival and serially at several time points during the hospital stay. Female patients were stratified into premenopausal (≤50 years) and postmenopausal (>50 years) age groups with age-matched male cohorts. Values were analyzed using a repeated-measures multilevel linear model to evaluate the effect of gender on coagulation. Results A total of 795 patients had serial rTEG data (24% female and 76% male). Compared with age-matched males, premenopausal females were more hypercoagulable by rTEG on admission ( P < .001) and for the first 12 hours after arrival. Gender was an effect modifier for alpha angle ( P = .02) and maximum amplitude ( P = .04). Controlling for Injury Severity Score and mechanism of injury, age-matched males had a >4-fold increased risk of hypercoagulable complications than premenopausal females (odds ratio, 4.7; P = .038). Conclusion This prospective, multicenter study demonstrates that premenopausal females are relatively hypercoagulable compared with age-matched males early after injury. However, this did not translate into higher thromboembolic complications.
Hypercoagulability after energy drink consumption Pommerening, Matthew J., MD; Cardenas, Jessica C., PhD; Radwan, Zayde A., MD ...
The Journal of surgical research,
12/2015, Volume:
199, Issue:
2
Journal Article
Peer reviewed
Abstract Background Energy drink consumption in the United States has more than doubled over the last decade and has been implicated in cardiac arrhythmias, myocardial infarction, and even sudden ...cardiac death. We hypothesized that energy drink consumption may increase the risk of adverse cardiovascular events by increasing platelet aggregation, thereby resulting in a relatively hypercoagulable state and increased risk of thrombosis. Methods Thirty-two healthy volunteers aged 18–40 y were given 16 oz of bottled water or a standardized, sugar-free energy drink on two separate occasions, 1-wk apart. Beverages were consumed after an overnight fast over a 30-min period. Coagulation parameters and platelet function were measured before and 60 min after consumption using thrombelastography and impedance aggregometry. Results No statistically significant differences in coagulation were detected using kaolin or rapid thrombelastography. In addition, no differences in platelet aggregation were detected using ristocetin, collagen, thrombin receptor–activating peptide, or adenosine diphosphate–induced multiple impedance aggregometry. However, compared to water controls, energy drink consumption resulted in a significant increase in platelet aggregation via arachidonic acid–induced activation (area under the aggregation curve, 72.4 U versus 66.3 U; P = 0.018). Conclusions Energy drinks are associated with increased platelet activity via arachidonic acid–induced platelet aggregation within 1 h of consumption. Although larger clinical studies are needed to further address the safety and health concerns of these drinks, the increased platelet response may provide a mechanism by which energy drinks increase the risk of adverse cardiovascular events.
Background Clot lysis values (LY30) determined by rapid thrombelastography (rTEG) predict postinjury transfusion needs and mortality risk. However, the first derivative velocity curve values ...generated by rTEG measuring lysis—maximum rate of lysis (MRL) and total lysis (TL)—have not been evaluated. Although recent data support use of antifibrinolytics in trauma, the population that would benefit remains poorly defined. The purpose of this study was to determine if velocity curves more accurately predict large volume transfusions and early mortality than conventional rTEG values. Study Design Conventional and velocity curve admission rTEG values of adult trauma patients were retrospectively evaluated for their ability to predict early transfusion of RBC and plasma, substantial bleeding, massive transfusion, and mortality. Patient outcomes were compared according to hyperfibrinolysis diagnosed by velocity curve values and the conventional LY30 cutoff. Results There were 1,625 patients included. Clot lysis values predicted early transfusion of RBC (p = 0.003), but not plasma (p = 0.298), within 3 hours of arrival. With respect to velocity curves, MRL and TL predicted both early RBC and plasma transfusion (p < 0.05). All 3 parameters predicted massive transfusion, but only MRL and TL predicted substantial bleeding (odds ratio OR 3.1 and 2.9, respectively). In addition, MRL was a stronger predictor of 24-hour and 30-day mortality (p < 0.001) and was also available earlier after arrival than LY30 (p < 0.001). Conclusions Velocity curve measures of fibrinolysis are stronger predictors of early transfusion of blood components, bleeding, and mortality after trauma compared with conventional rTEG values. In addition, the MRL is more rapidly available after arrival, which may facilitate earlier diagnosis and treatment of clinically significant hyperfibrinolysis.
