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Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies.

ABSTRACT: Fibrinogen and prothrombin have been suggested to become rate limiting in trauma associated coagulopathy. Administration of fibrinogen is now recommended, however, the importance of prothrombin to patient outcome is unknown.We have utilized two trauma patient databases (database 1 n?=?358 and database 2 n?=?331) to investigate the relationship of plasma prothrombin concentration on clinical outcome and coagulation status. Database 1 has been used to assess the relationship of plasma prothrombin to administered packed red blood cells (PRBC), clinical outcome and coagulation biomarkers (Prothrombin Time (PT), ROTEM EXTEM Coagulation Time (CT) and Maximum Clot Firmness (MCF)). ROC analyses have been performed to investigate the ability of admission coagulation biomarkers to predict low prothrombin concentration (database 1), massive transfusion and 24 h mortality (database 1 and 2). The importance of prothrombin was further investigated in vitro by PT and ROTEM assays in the presence of a prothrombin neutralizing monoclonal antibody and following step-wise dilution.Patients who survived the first 24 h had higher admission prothrombin levels compared to those who died (94 vs.67 IU/dL). Patients with lower transfusion requirements within the first 24 h (?10 units of PRBCs) also had higher admission prothrombin levels compared to patients with massive transfusion demands (>10 units of PRBCs) (95 vs.62 IU/dL). Admission PT, in comparison to admission ROTEM EXTEM CT and MCF, was found to be a better predictor of prothrombin concentration <60 IU/dL (AUC 0.94 in database 1), of massive transfusion (AUC 0.92 and 0.81 in database 1 and 2 respectively) and 24 h mortality (AUC 0.90 and 0.78 in database 1 and 2, respectively). In vitro experiments supported a critical role for prothrombin in coagulation and demonstrated that PT and ROTEM EXTEM CT are sensitive methods to measure low prothrombin concentration.Our analyses suggest that prothrombin concentration at admission is predictive of mortality and transfusion and indicates that prothrombin and fibrinogen are rate limiting in coagulopathy.Admission PT is predictive of low prothrombin concentration and clinical outcome. PT could therefore be used as a surrogate for prothrombin concentration and further evaluation of point-of-care devices for faster PT analysis is warranted.

SUBMITTER: Balendran CA

PROVIDER: S-EPMC5348885 | biostudies-other | 2017 Mar

REPOSITORIES: biostudies-other

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Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies.

Balendran Clare A CA Lövgren Ann A Hansson Kenny M KM Nelander Karin K Olsson Marita M Johansson Karin J KJ Brohi Karim K Fries Dietmar D Berggren Anders A

Scandinavian journal of trauma, resuscitation and emergency medicine 20170314 1

<h4>Background</h4>Fibrinogen and prothrombin have been suggested to become rate limiting in trauma associated coagulopathy. Administration of fibrinogen is now recommended, however, the importance of prothrombin to patient outcome is unknown.<h4>Methods</h4>We have utilized two trauma patient databases (database 1 n = 358 and database 2 n = 331) to investigate the relationship of plasma prothrombin concentration on clinical outcome and coagulation status. Database 1 has been used to assess the ...[more]

PMID: 28292321

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Project description:Rapid response teams (RRTs) attend severely ill general ward patients whose average 30-day mortality is near 30%. A major part of RRT patients are over 75 years old, but there are no studies on the characteristics and outcome of this geriatric RRT population. We compared the characteristics and outcome of geriatric RRT sub-population with the RRT patients <75 years old. We further investigated, whether the accumulation of risk factors (RFs) for mortality among the general RRT population predicts a tenuous outcome among the geriatric sub-population.Prospective three-year observational cohort study of adult RRT patients in Tampere University Hospital, Finland. After identifying independent RFs for 30-day mortality among RRT patients with multivariate logistic regression, we further studied the impact of the accumulation of these RFs among geriatric RRT patients who had no limitations of medical treatment.A total of 1372 patients were reviewed 1722 times. Geriatric patients (n = 449, 33%), when compared to non-geriatric patients, had higher 30-day (33% vs. 21%, respectively; p < 0.001) and one-year (54% vs. 35%, respectively; p < 0.001) mortality rates. Among the general RRT population, positive RRT criteria as measured by RRT during the review, high comorbidity index, age ≥ 75 years, non-elective hospital admission, medical reason for admission and afferent limb failure were identified as independent RFs for 30-day mortality and classified as feasible to obtain during a routine RRT review. The observed rates of these RFs among the geriatric RRT patients substantially affected their 30-day mortality (e.g. no RFs: 5.3%; one RF: 14%; two RFs: 27%; three RFs: 38%; four RFs: 52%; five RFs: 38%).One-third of patients reviewed by RRT were ≥75 years old, and age statistics were comparable to previous RRT studies suggesting that this is the case globally. Outcome of geriatric RRT patients is poorer as compared with RRT patients <75 years. However, the outcome is substantially affected by the accruement (or lack) of RFs generally increasing the mortality of RRT patients. Considering these factors during a geriatric RRT review may aid with the decision to either escalate or de-escalate care.

Dataset Information

Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies.

Publications

Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies.

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