Background
Previous investigators have demonstrated that postinjury thrombocytosis is associated
with an increase in thromboembolic (TE) risk. Increased rates of thrombocytosis have
been found specifically in patients after splenectomy for trauma. We hypothesized
that patients undergoing splenectomy (1) would demonstrate a more hypercoagulable
profile during their hospital stay and (2) that this hypercoagulable state would be
associated with increased TE events.
Methods
This was a 14-month, prospective, observational trial evaluating serial rapid thrombelastography
(rTEG) at 3 American College of Surgeons−verified, level 1 trauma centers. Inclusion
criteria were highest-level trauma activation and arrival within 6 hours of injury.
Exclusion criteria were <18 years of age, incarcerated, and burns>20% total body surface
area. Serial rTEG (activated clotting time, k-time, α-angle, MA, lysis) and traditional
coagulation testing (prothrombin time, partial thromboplastin time, fibrinogen and
platelet count) were obtained at admission and then at 3, 6, 12, 24, 48, 72, 96, and
120 hours. Thromboembolic complications were defined as the development of deep-vein
thrombosis, pulmonary embolism, acute myocardial infarction, or ischemic stroke during
hospitalization. Patients were stratified into splenectomy versus nonsplenectomy cohorts.
Univariate analysis was then conducted followed by longitudinal analysis using generalized
estimating equations to evaluate the effects of time, splenectomy, and group-time
interactions on changes in rTEG and traditional coagulation testing. We used an adjusted
generalized estimating equation model to control for age, sex, ISS, admission blood
pressure, base deficit, and hemoglobin.
Results
A total of 1,242 patients were enrolled; 795 had serial rTEG data. Of these, 605 had
serial values >24 hours and made up the study population. Splenectomy patients were
younger, more hypotensive, and in shock on arrival. Although there was no difference
in 24-hour or 30-day mortality, splenectomy patients were more likely to develop TE
events. Using the GEE model, we found that α-angle and MA in splenectomy patients
were lesser (more hypocoagulable) within the first 6 hours; however, they became substantially
greater (more hypercoagulable) at 48, 72, 96, and 120 hours; all P < .05. In addition, platelet counts were greater in the splenectomy group beginning
at 72 hours and continuing through 120 hours; P < .05.
Conclusion
This multicenter, prospective study demonstrates that patients undergoing splenectomy
have a more hypercoagulable state than other trauma patients. This hypercoagulable
state (identified by greater α-angle and mA values) begins at approximately 48 hours
after injury and continues through at least day 5. Moreover, this hypercoagulable
state is associated with increased risk of TE complications.
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Article info
Publication history
Published online: July 21, 2015
Accepted:
June 13,
2015
Footnotes
This work was supported, in part, by a research grant from Haemonetics Corporation (Braintree, MA).
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
