A normal platelet count may not be enough: the impact of admission platelet count on mortality and transfusion in severely injured trauma patients

Lisa M Brown, Mariah S Call, M Margaret Knudson, Mitchell J Cohen, Trauma Outcomes Group, J B Holcomb, C E Wade, K J Brasel, G Vercruysse, J MacLeod, R P Dutton, J R Hess, J C Duchesne, N E McSwain, P Muskat, J Johannigamn, H M Cryer, A Tillou, J F Pittet, M A De Moya, M A Schreiber, B Tieu, S Brundage, L M Napolitano, M Brunsvold, M Brunsvold, G Beilman, A B Peitzman, M S Zenait, J Sperry, L Alarcon, M A Croce, J P Minei, R Kozar, E A Gonzalez, R M Stewart, S M Cohn, J E Mickalek, E M Bulger, B A Cotton, T C Nunez, R Ivatury, J W Meredith, P Miller, G J Pomper, B Marin, Lisa M Brown, Mariah S Call, M Margaret Knudson, Mitchell J Cohen, Trauma Outcomes Group, J B Holcomb, C E Wade, K J Brasel, G Vercruysse, J MacLeod, R P Dutton, J R Hess, J C Duchesne, N E McSwain, P Muskat, J Johannigamn, H M Cryer, A Tillou, J F Pittet, M A De Moya, M A Schreiber, B Tieu, S Brundage, L M Napolitano, M Brunsvold, M Brunsvold, G Beilman, A B Peitzman, M S Zenait, J Sperry, L Alarcon, M A Croce, J P Minei, R Kozar, E A Gonzalez, R M Stewart, S M Cohn, J E Mickalek, E M Bulger, B A Cotton, T C Nunez, R Ivatury, J W Meredith, P Miller, G J Pomper, B Marin

Abstract

Background: Platelets play a central role in hemostasis after trauma. However, the platelet count of most trauma patients does not fall below the normal range (100-450 × 10(9)/L), and as a result, admission platelet count has not been adequately investigated as a predictor of outcome. The purpose of this study was to examine the relationship between admission platelet count and outcomes after trauma.

Methods: A retrospective cohort study of 389 massively transfused trauma patients. Regression methods and the Kruskal-Wallis test were used to test the association between admission platelet count and 24-hour mortality and units of packed red blood cells (PRBCs) transfused.

Results: For every 50 × 10(9)/L increase in admission platelet count, the odds of death decreased 17% at 6 hours (p = 0.03; 95% confidence interval [CI], 0.70-0.99) and 14% at 24 hours (p = 0.02; 95% CI, 0.75-0.98). The probability of death at 24 hours decreased with increasing platelet count. For every 50 × 10(9)/L increase in platelet count, patients received 0.7 fewer units of blood within the first 6 hours (p = 0.01; 95% CI, -1.3 to -0.14) and one less unit of blood within the first 24 hours (p = 0.002; 95% CI, -1.6 to -0.36). The mean number of units of PRBCs transfused within the first 6 hours and 24 hours decreased with increasing platelet count.

Conclusions: Admission platelet count was inversely correlated with 24-hour mortality and transfusion of PRBCs. A normal platelet count may be insufficient after severe trauma, and as a result, these patients may benefit from a lower platelet transfusion threshold. Future studies of platelet number and function after injury are needed.

Figures

Figure 1. Probability of Death at 24…
Figure 1. Probability of Death at 24 Hours by Admission Platelet Count
Unadjusted logistic regression model includes admission platelet count. Adjusted logistic regression model includes admission platelet count, Injury Severity Score, Glasgow Coma Score, and admission base deficit.
Figure 2. Platelet Count by Injury Severity…
Figure 2. Platelet Count by Injury Severity Score and Admission Base Deficit Categories
chi-squared test p=0.01
Figure 3. Association Between Admission Platelet Count…
Figure 3. Association Between Admission Platelet Count and Admission INR and Admission Platelet Count and Admission PTT

References

    1. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248:447–458.
    1. Spinella PC, Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. 2009
    1. Como JJ, Dutton RP, Scalea TM, et al. Blood transfusion rates in the care of acute trauma. Transfusion. 2004;44:809–813.
    1. Cinat ME, Wallace WC, Nastanski F, et al. Improved survival following massive transfusion in patients who have undergone trauma. Arch Surg. 1999;134:964–968. discussion 968-970.
    1. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63:805–813.
    1. Sperry JL, Ochoa JB, Gunn SR, et al. An FFP:PRBC transfusion ratio >/=1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma. 2008;65:986–993.
    1. Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007;62:112–119.
    1. Davenport RA, Brohi K. Coagulopathy in trauma patients: importance of thrombocyte function? Curr Opin Anaesthesiol. 2009;22:261–266.
    1. Jacoby RC, Owings JT, Holmes J, et al. Platelet activation and function after trauma. J Trauma. 2001;51:639–647.
    1. Boldt J, Menges T, Wollbruck M, et al. Platelet function in critically ill patients. Chest. 1994;106:899–903.
    1. Hess JR, Lindell AL, Stansbury LG, et al. The prevalence of abnormal results of conventional coagulation tests on admission to a trauma center. Transfusion. 2009;49:34–39.
    1. Asensio J, Trunkey D. Current Therapy of Trauma and Surgical Critical Care. Philadelphia: Mosby Elsevier; 2008.
    1. Lustenberger T, Talving P, Kobayashi L, et al. Early Coagulopathy After Isolated Severe Traumatic Brain Injury: Relationship With Hypoperfusion Challenged. J Trauma
    1. Larson CR, White CE, Spinella PC, et al. Association of shock, coagulopathy, and initial vital signs with massive transfusion in combat casualties. J Trauma. 69(1):S26–32.
    1. Bilello JF, Davis JW, Lemaster D, et al. Prehospital Hypotension in Blunt Trauma: Identifying the “Crump Factor”. J Trauma. 2009
    1. Cosgriff N, Moore EE, Sauaia A, et al. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma. 1997;42:857–861. discussion 861-852.
    1. Ketchum L, Hess JR, Hiippala S. Indications for early fresh frozen plasma, cryoprecipitate, and platelet transfusion in trauma. J Trauma. 2006;60:S51–58.
    1. Stainsby D, MacLennan S, Thomas D, et al. Guidelines on the management of massive blood loss. Br J Haematol. 2006;135:634–641.
    1. Van Beek JG, Mushkudiani NA, Steyerberg EW, et al. Prognostic value of admission laboratory parameters in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24:315–328.
    1. Johansson PI, Stensballe J, Rosenberg I, et al. Proactive administration of platelets and plasma for patients with a ruptured abdominal aortic aneurysm: evaluating a change in transfusion practice. Transfusion. 2007;47:593–598.
    1. Marumo M, Suehiro A, Kakishita E, et al. Extracellular pH affects platelet aggregation associated with modulation of store-operated Ca(2+) entry. Thromb Res. 2001;104:353–360.
    1. Valeri CR, Feingold H, Cassidy G, et al. Hypothermia-induced reversible platelet dysfunction. Ann Surg. 1987;205:175–181.
    1. Niles SE, McLaughlin DF, Perkins JG, et al. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma. 2008;64:1459–1463. discussion 1463-1455.
    1. Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma. 2003;54:1127–1130.
    1. Bowbrick VA, Mikhailidis DP, Stansby G. Influence of platelet count and activity on thromboelastography parameters. Platelets. 2003;14:219–224.
    1. Oshita K, Az-ma T, Osawa Y, et al. Quantitative measurement of thromboelastography as a function of platelet count. Anesth Analg. 1999;89:296–299.

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다