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.
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.
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.
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.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Surgery
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Injuries.N Engl J Med. 2013; 368: 1723-1730
- Increasing trauma deaths in the United States.Ann Surg. 2014; 260: 13-21
- Epidemiology of trauma deaths: a reassessment.J Trauma. 1995; 38: 185-193
- Statewide, population-based, time-series analysis of the frequency and outcome of pulmonary embolus in 318,554 trauma patients.J Trauma. 1997; 42: 90-99
- Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank.Ann Surg. 2004; 240 (discussion 6-8): 490-496
- Risk factors for inpatient venous thromboembolism despite thromboprophylaxis.Thromb Res. 2014; 133: 25-29
- Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group.J Trauma. 2002; 53: 142-164
- Admission rapid thrombelastography predicts development of pulmonary embolism in trauma patients.J Trauma Acute Care Surg. 2012; 72 (discussion 5-7): 1470-1475
- Platelets are dominant contributors to hypercoagulability after injury.J Trauma Acute Care Surg. 2013; 74 (discussion 62-5): 756-762
- Thromboembolic risk of postsplenectomy thrombocytosis.Arch Surg. 1978; 113: 808-809
- Deep venous thrombosis and postsplenectomy thrombocytosis.Arch Surg. 1978; 113: 429-431
- Leukocytosis after posttraumatic splenectomy: a physiologic event or sign of sepsis?.Arch Surg. 2002; 137 (discussion 8-9): 924-928
- Splenectomy leads to a persistent hypercoagulable state after trauma.Am J Surg. 2010; 199: 646-651
- What is the significance of thrombocytosis in patients with trauma?.J Trauma. 2009; 66: 1349-1354
- Hypocoagulability, as evaluated by thrombelastography, at admission to the ICU is associated with increased 30-day mortality.Blood Coagul Fibrinolysis. 2010; 21: 168-174
- The influence of platelets, plasma and red blood cells on functional haemostatic assays.Blood Coagul Fibrinolysis. 2011; 22: 167-175
- Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time.J Trauma. 2009; 67 (discussion 75-6): 266-275
- Usefulness of thrombelastography in assessment of trauma patient coagulation.J Trauma. 1997; 42 (discussion 20-2): 716-720
- Early diagnosis of clinically significant hyperfibrinolysis using thrombelastography velocity curves.J Am Coll Surg. 2014; 219: 1157-1166
- Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission.J Trauma. 2011; 71 (discussion 14-7): 407-414
- Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma.J Trauma. 2000; 49 (discussion 87-9): 177-187
- Changing patterns in the management of splenic trauma: the impact of nonoperative management.Ann Surg. 1998; 227 (discussion 17-9): 708-717
- Nonoperative management of splenic injuries: have we gone too far?.Arch Surg. 2000; 135 (discussion 9-81): 674-679
- Coagulation and splenectomy: an overview.Ann N Y Acad Sci. 2005; 1054: 317-324
- Postsplenectomy thrombocytosis: its association with mesenteric, portal, and/or renal vein thrombosis in patients with myeloproliferative disorders.Arch Surg. 1978; 113: 713-715
- Postsplenectomy reactive thrombocytosis.Proc (Bayl Univ Med Cent). 2009; 22: 9-12
- Postoperative venous thromboembolism rates vary significantly after different types of major abdominal operations.J Gastrointest Surg. 2008; 12: 2015-2022
- Risk of venous thromboembolism in splenectomized patients compared with the general population and appendectomized patients: a 10-year nationwide cohort study.J Thromb Haemost. 2010; 8: 1413-1416
- Generation of tissue factor by patient monocytes: correlation to thromboembolic complications.J Thromb Haemost. 1981; 46: 489-495
- Blood coagulation changes in patients with post-splenectomy persistent thrombocytosis.Chir Ital. 2001; 53 ([in Italian]): 537-542
- Rapid thrombelastography (r-TEG) identifies hypercoagulability and predicts thromboembolic events in surgical patients.Surgery. 2009; 146 (discussion 72-4): 764-772
- Hypercoagulability and other risk factors in trauma intensive care unit patients with venous thromboembolism.J Trauma Acute Care Surg. 2014; 76: 443-449
- Trauma induced hypercoagulablity in pediatric patients.J Pediatr Surg. 2014; 49: 1295-1299
- Does traumatic brain injury increase the risk for venous thromboembolism in polytrauma patients?.J Trauma Acute Care Surg. 2014; 77: 243-250
- Hypercoagulability after injury in premenopausal females: a prospective, multicenter study.Surgery. 2014; 156: 439-447
Published online: July 21, 2015
Accepted: June 13, 2015
This work was supported, in part, by a research grant from Haemonetics Corporation (Braintree, MA).
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.