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From the Department of Surgery (A.J.C.), Oregon Health and Sciences University; Trauma and Acute Care Surgical Services (M.C.), St. Charles Health System, Bend; Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery (M.C., M.A.S.), Oregon Health and Sciences University; Division of Pediatric Surgery (K.A., N.A.H., M.A.J.), Doernbecher Children's Hospital, Oregon Health and Sciences University, Portland, OR; Trauma Services (K.D., W.B.L.), Legacy Emanuel Medical Center; Department of Anesthesiology (B.G.M.), Randall Children's Hospital at Legacy Emanuel; and Division of Pediatric Surgery (M.A.J.), Randall Children's Hospital at Legacy Emanuel, Portland, Oregon.
Published: January 2020
AI Article Synopsis
Article Abstract
Background: Trauma-induced coagulopathy seen on rotational thromboelastometry (ROTEM) is associated with poor outcomes in adults; however, this relationship is poorly understood in the pediatric population. We sought to define thresholds for product-specific transfusion and evaluate the prognostic efficacy of ROTEM in injured children.
Methods: Demographics, ROTEM, and clinical outcomes from severely injured children (age, < 18 years) admitted to a Level I trauma center between 2014 and 2018 were retrospectively analyzed. Receiver operating characteristic curves were plotted and Youden indexes were calculated against the endpoint of packed red blood cell transfusion to identify thresholds for intervention. The ROTEM parameters were compared against the clinical outcomes of mortality or disability at discharge.
Results: Ninety subjects were reviewed. Increased tissue factor-triggered extrinsic pathway (EXTEM) clotting time (CT) >84.5 sec (p = 0.049), decreased EXTEM amplitude at 10 minutes (A10) <43.5 mm (p = 0.025), and decreased EXTEM maximal clot firmness (MCF) <64.5 mm (p = 0.026) were associated with need for blood product transfusion. Additionally, EXTEM CT longer than 68.5 seconds was associated with mortality or disability at discharge.
Conclusion: Coagulation dysregulation on thromboelastometry is associated with disability and mortality in children. Based on our findings, we propose ROTEM thresholds: plasma transfusion for EXTEM CT longer than 84.5 seconds, fibrinogen replacement for EXTEM A10 less than 43.5 mm, and platelet transfusion for EXTEM MCF less than 64.5 mm.
Level Of Evidence: Prognostic, Level III; Therapeutic, Level IV.
