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Citation
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Leeper CM, Kutcher M, Nasr I, McKenna C, Billiar T, Neal MD, Sperry J, Gaines BA. J. Trauma Acute Care Surg. 2016; 81(1): 34-41. |
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Affiliation
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C.M.L., M.K., T.B., M.D.N., J.S. - Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh PA C.M.L., C.M., B.A.G. - Children's Hospital of Pittsburgh of UPMC I.N. - Division of Pediatric Surgery, The Johns Hopkins Hospital, Baltimore MD. |
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Abstract
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BACKGROUND: While our understanding of acute traumatic coagulopathy (ATC) in adults is advancing, the pediatric literature on ATC is limited. Children have a unique injury profile and physiologic response to trauma, however the impact of this phenomenon on ATC has not been fully elucidated.
METHODS: We performed a retrospective review of our trauma registry from 2005-2014. Level 1 trauma patients age 0-17 requiring admission to the intensive care unit were included. Variables included admission vital signs and laboratory studies, product transfusion, injuries, and mortality. Youden index was utilized to determine optimum cutoff point for admission INR as predictor of mortality. Logistic regression modeling was utilized to determine independent predictors of mortality adjusting for hypotension, hypothermia, acidosis, injury severity, hemorrhage and head injury. Chi-square tests were performed evaluating for association between mortality and 24-hour INR, and between transfusion and INR correction.
RESULTS: 776 patients were analyzed: 29.2% (n=227) had admission INR≥1.3 and 13.3% (n=103) with admission INR≥1.5. Youden index demonstrated optimum cutoff of INR≥1.3 to distinguish survivors and non-survivors. Overall mortality rate was 11.1% (n=86). Elevated INR was independently associated with mortality (OR 3.77, p<0.001) after controlling for other predictors in regression modeling. Death was also associated with elevated INR at 24 hours and worsening INR trend over time. Patients who received plasma were equally likely to normalize their INR compared to those who were not transfused (p=NS).
FINDINGS were consistent across age groups.
CONCLUSIONS: INR likely serves as a marker of systemic dysregulation rather than a treatment target in ATC. Elevated admission INR, elevated INR at 24 hours, and overall trend in INR strongly predict mortality in a diverse pediatric trauma population; however, product transfusion did not influence the INR trend or clinical outcome. Further research is warranted to evaluate potential upstream mediators of ATC and targets for intervention in pediatric trauma patients. LEVEL OF EVIDENCE: III, prognostic and epidemiological.
Language: en |