The effects of alcohol on coagulation in trauma patients

Howard, Benjamin M.; Kornblith, Lucy Z.; Redick, Brittney J.; Vilardi, Ryan F.; Balhotra, Kimen S.; Crane, Jeremy M; Forde, Melissa R.; Nelson, Mary F.; Callcut, Rachael A.; Cohen, Mitchell J.

doi:10.1097/ta.0000000000000357

Cited by 25 publications

(31 citation statements)

References 27 publications

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“…While we were unable to evaluate definitions employing PTT, platelet count, or fibrinogen level, these parameters alone are insensitive for clinically significant coagulopathy and unlikely to markedly improve an INR-based definition (9, 26, 53-55). Viscoelastic assays' speed, ability to simulate in vivo clotting, and utility for mechanistic studies of acute coagulopathy make them attractive (14), but data linking specific functional abnormalities detected by these tests to trauma outcomes are too limited to base ATC diagnosis on this technology (56-58). An INR-based definition of ATC offers a reproducible, laboratory-based definition with low institutional and geographic variability, facilitating future clinical and translational research studies and ATC intervention trials.…”

Section: Discussionmentioning

confidence: 99%

An International Normalized Ratio–Based Definition of Acute Traumatic Coagulopathy Is Associated With Mortality, Venous Thromboembolism, and Multiple Organ Failure After Injury

Peltan

Vusse

Maier

et al. 2015

Critical Care Medicine

114

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Objective Acute traumatic coagulopathy (ATC) is associated with adverse outcomes including death. Previous studies examining ATC's relationship with mortality are limited by inconsistent criteria for syndrome diagnosis, inadequate control of confounding and single-center designs. In this study, we validated the admission international normalized ratio (INR) as an independent risk factor for death and other adverse outcomes after trauma and compared two common INR-based definitions for ATC. Design Multicenter prospective observational study. Setting Nine level I trauma centers in the United States. Patients 1,031 blunt trauma patients with hemorrhagic shock. Interventions None. Measurements and Main Results INR exhibited a positive adjusted association with all-cause in-hospital mortality, hemorrhagic shock-associated in-hospital mortality, venous thromboembolism, and multiple organ failure. ATC affected 50% of subjects if defined as an INR >1.2 and 21% of subjects if defined by INR >1.5. After adjustment for potential confounders, ATC defined as an INR >1.5 was significantly associated with all-cause death (OR 1.88, p<0.001), hemorrhagic shock-associated death (OR 2.44, p=0.001), venous thromboembolism (1.73, p<0.001), and multiple organ failure (OR 1.38, p=0.02). ATC defined as an INR >1.2 was not associated with an increased risk for the studied outcomes. Conclusions Elevated INR on hospital admission is a risk factor for mortality and morbidity after severe trauma. Our results confirm this association in a prospectively-assembled multicenter cohort of severely injured patients. Defining ATC using an INR >1.5 but not an INR >1.2 identified a clinically-meaningful subset of trauma patients who, adjusting for confounding factors, suffered more adverse outcomes. Targeting future therapies for ATC to patients with an INR >1.5 may yield greater returns than using a lower INR threshold.

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Section: Discussionmentioning

confidence: 99%

An International Normalized Ratio–Based Definition of Acute Traumatic Coagulopathy Is Associated With Mortality, Venous Thromboembolism, and Multiple Organ Failure After Injury

Peltan

Vusse

Maier

et al. 2015

Critical Care Medicine

114

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“…Trials will be complicated by the fact that VM diagnosis cannot be used on patients who have received antifibrinolytics because fibrinolysis is blocked. There are also questions around the effects of alcohol on VM parameters, possibly acting on platelets, which is particularly important given that the majority of trauma patients arriving in emergency departments in some countries have measurable blood alcohol levels . However, some groups are generally enthusiastic about the routine use of VM testing , and VMs certainly will continue to be a research tool that can be used to investigate the kinetics of coagulation and fibrinolysis in whole blood.…”

Section: Viscoelastic Methodsmentioning

confidence: 99%

Measuring fibrinolysis: from research to routine diagnostic assays

Longstaff

2018

Journal of Thrombosis and Haemostasis

139

123

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SummaryDevelopment and standardization of fibrinolysis methods have progressed more slowly than coagulation testing and routine high‐throughput screening tests for fibrinolysis are still lacking. In laboratory research, a variety of approaches are available and are applied to understand the regulation of fibrinolysis and its contribution to the hemostatic balance. Fibrinolysis in normal blood is slow to develop. For practical purposes plasminogen activators can be added to clotting plasma, or euglobulin prepared to reduce endogenous inhibitors, but results are complicated by these manipulations. Observational studies to identify a ‘fibrinolysis deficit’ have concluded that excess fibrinolysis inhibitors, plasminogen activator inhibitor 1 (PAI‐1) or thrombin‐activatable fibrinolysis inhibitor (TAFI), zymogen or active enzyme, may be associated with an increased risk of thrombosis. However, results are not always consistent and problems of adequate standardization are evident with these inhibitors and also for measurement of fibrin degradation products (D‐dimer). Few methods are available to investigate fibrinolysis under flow, or in whole blood, but viscoelastic methods (VMs) such as ROTEM and TEG do permit the contribution of cells, and importantly platelets, to be explored. VMs are used to diagnose clinical hyperfibrinolysis, which is associated with high mortality. There is a debate on the usefulness of VMs as a point‐of‐care test method, particularly in trauma. Despite the difficulties of many fibrinolysis methods, research on the fibrinolysis system, taking in wider interactions with hemostasis proteins, is progressing so that in future we may have more complete models and better diagnostic methods and therapeutics.

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“…In addition, the accuracy of TEG results can be compromised by patient factors including alcohol, sex, and age. 41,42 Another major drawback in TEG testing is interlaboratory reproducibility. TEG has not yet achieved the level of interlaboratory consistency observed for CCTs, requires manual manipulation and measurement of samples by laboratory personnel, and remains limited by significant time constraints.…”

Section: Discussionmentioning

confidence: 99%

All the bang without the bucks

Goodman

Makley

Hanseman

et al. 2015

Journal of Trauma and Acute Care Surgery

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BACKGROUND Rapid assessment and treatment of coagulopathy reduces postinjury morbidity and mortality. Although thrombelastography (TEG) may be more accurate and efficient than conventional coagulation tests, it requires significant financial and personnel investments. We hypothesized that point-of-care international normalized ratio (POC INR) may provide a rapid and accurate alternative to TEG. METHODS A retrospective review of sequential trauma patients who underwent both POC INR and rapid TEG (r-TEG) testing upon presentation to a Level I trauma center from July 2012 to December 2013 was performed. POC INR was compared with r-TEG values (R value, K time, α angle, maximum amplitude, percent clot lysis in 30 minutes) and transfusion requirements. Vital signs, admission laboratory values, and injury severity were analyzed. POC INR and venous blood gas testing was performed in the emergency department. All results and Pearson correlations noted were significant if p < 0.05. RESULTS We identified 628 trauma patients with concomitant r-TEG and POC INR testing. Median Injury Severity Score (ISS) was 13, 20% arrived in shock (base value < −5), 21% were transfused, and 11% died. POC INR correlated with all r-TEG values, with stronger correlations for patients in shock. POC INR and r-TEG had similar correlations with blood products transfused at 4 hours and 24 hours, but only POC INR predicted substantial bleeding and massive transfusion. POC INR also correlated strongly with standard INR testing. POC INR test duration was less than 1 minute, compared with at least 30 minutes for r-TEG. Total cohort charges for POC INR were estimated at $21,980 versus $396,896 for r-TEG. CONCLUSION POC INR testing is faster and cheaper than r-TEG. In addition, POC INR correlates not only with r-TEG values but also with acute blood product transfusions. POC INR provides a practical alternative for rapid coagulopathy assessment in the trauma patient at institutions that lack TEG capability. LEVEL OF EVIDENCE Diagnostic study, level III. Therapeutic/care management study, level IV.

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The effects of alcohol on coagulation in trauma patients

Abstract: Prognostic and epidemiologic study, level III.

Cited by 25 publications

References 27 publications

An International Normalized Ratio–Based Definition of Acute Traumatic Coagulopathy Is Associated With Mortality, Venous Thromboembolism, and Multiple Organ Failure After Injury

An International Normalized Ratio–Based Definition of Acute Traumatic Coagulopathy Is Associated With Mortality, Venous Thromboembolism, and Multiple Organ Failure After Injury

Measuring fibrinolysis: from research to routine diagnostic assays

All the bang without the bucks

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