Acute Crit Care.  2018 Aug;33(3):162-169. 10.4266/acc.2018.00199.

Usefulness of Rotational Thromboelastometry as a Mortality Predictor of Hyperfibrinolysis in Patients with Severe Trauma

• Kim JS
• Wang IJ
• Yeom SR
• Cho SJ
• Kim JH
• Seok JP
• Lee SH
• Bae BG
• Min MK

• KMID: 2436328
• DOI: http://doi.org/10.4266/acc.2018.00199

Abstract

BACKGROUND
Hemorrhage is the major cause of traumatic death and the leading cause of preventable death. Hyperfibrinolysis is associated with trauma severity. Viscoelastic hemostatic assays show complete clot formation dynamics. The present study was designed to identify the relationship between hyperfibrinolysis and mortality, metabolic acidosis, and coagulopathy in patients with trauma.
METHODS
Patients with severe trauma (injury severity score [ISS] of 15 or higher) who were assessed using rotational thromboelastometry (ROTEM) were included in the present study from January 2017 to December 2017. Variables were obtained from the Korea Trauma Database or the medical charts of the patients. To identify whether hyperfibrinolysis is an independent predictor of mortality, univariate and multivariate Cox regression analyses were performed.
RESULTS
During the 1-year study period, 190 patients were enrolled. In total, 21 (11.1%) had hyperfibrinolysis according to the ROTEM analysis and 46 (24.2%) died. Patients with hyperfibrinolysis had a higher ISS (P=0.014) and mortality rate (P < 0.001) than did those without hyperfibrinolysis. In multivariate Cox analysis, hyperfibrinolysis (hazard ratio [HR], 4.960; 95% confidence interval [CI], 2.447 to 10.053), age (HR, 1.033; 95% CI, 1.013 to 1.055), lactic acid level (HR, 1.085; 95% CI, 1.003 to 1.173), and ISS (HR, 1.037; 95% CI, 1.004 to 1.071) were independent predictors of mortality.
CONCLUSIONS
Hyperfibrinolysis is associated with increased mortality, worse metabolic acidosis, and severe coagulopathy and is an independent predictor of mortality in patients with trauma.

Keyword

coagulopathy; fibrinolysis; hemorrhage; thromboelastometry; trauma

MeSH Terms

Acidosis
Fibrinolysis
Hemorrhage
Humans
Korea
Lactic Acid
Mortality*
Thrombelastography*
Lactic Acid

Figure

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  Figure 1. The parameters of rotational thromboelastometry. (1) Clotting time (CT): initiation of clotting; (2) clot formation time (CFT): time from clot initiation to a clot firmness of 20 mm; (3) maximum clot firmness (MCF): maximum clot strength; and (4) maximum lysis (ML): reduction of clot firmness after achieving MCF.

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  Figure 2. Hyperfibrinolysis in (A) INTEM, (B) EXTEM, and (C) FIBTEM. (D) The APTEM shows stable clot formation.

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  Figure 3. Patient flow. ISS: injury severity score; ROTEM: rotational thromboelastometry.

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  Figure 4. Kaplan-Meier survival curves showing mortality differences between patients with and without hyperfibrinolysis. P<0.001 by log-rank test.

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