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Leveraging Turbidity and Thromboelastography for Complementary Clot Characterization
Published on: June 4, 2020
Admission maximum amplitude-reaction time ratio: Association between thromboelastography values predicts poor outcome
Elissa Abou Khalil1, Barbara A Gaines, Katrina M Morgan
1From the Department of Surgery (E.A.K., K.M.M., C.M.L.), Division of Trauma and General Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine; and Department of Surgery (B.A.G.), Division of Pediatric General and Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Insights
The maximum amplitude-reaction time (MA-R) ratio, a measure of coagulation, predicts worse outcomes in pediatric trauma patients. A low MA-R ratio independently indicates higher mortality and transfusion needs in children.
Area of Science:
- Pediatric Trauma Care
- Coagulation Monitoring
- Thromboelastography
Background:
- Thromboelastography (TEG)-derived maximum amplitude-reaction time (MA-R) ratio is linked to adverse outcomes in adults.
- The prognostic value of the MA-R ratio in pediatric trauma patients remains unstudied.
Purpose of the Study:
- To investigate the association between the MA-R ratio and outcomes in pediatric trauma patients.
- To determine if the MA-R ratio can serve as a prognostic tool in this population.
Main Methods:
- Retrospective cohort study of children (<18 years) with admission TEG assays (2016-2020).
- MA-R ratio calculated and stratified into quartiles.
- Logistic regression analysis adjusted for injury severity, age, mechanism, shock, and Glasgow Coma Scale.
Main Results:
- A low MA-R ratio quartile was associated with increased mortality (15% vs. 4%) and transfusion needs (26% vs. 12%).
- The MA-R ratio was an independent predictor of in-hospital mortality (OR 4.4) and 24-hour transfusion requirement (OR 2.0).
- No association found between MA-R ratio and venous thromboembolic events.
Conclusions:
- The MA-R ratio is an independent predictor of poor outcomes in pediatric trauma, despite normal individual TEG values.
- The MA-R ratio may be a valuable prognostic tool for pediatric trauma patients.
- Further validation studies are recommended.
Introduction:
Thromboelastography (TEG)-derived maximum amplitude-reaction time (MA-R) ratio that accounts for both hypocoagulable and hypercoagulable changes in coagulation is associated with poor outcomes in adults. The relationship between these TEG values and outcomes has not been studied in children.
Methods:
In a retrospective cohort study, a level I pediatric trauma center database was queried for children younger than 18 years who had a TEG assay on admission between 2016 and 2020. Demographics, injury characteristics, and admission TEG values were recorded. The MA-R ratio was calculated and divided into quartiles. Main outcomes included mortality, transfusion within 24 hours of admission, and thromboembolism. A logistic regression model was generated adjusting for age, Injury Severity Score, injury mechanism, admission shock, and Glasgow Coma Scale.
Results:
In total, 657 children were included, of which 70% were male and 75% had blunt mechanism injury. The median (interquartile range) age was 11 (4-14) years, the median (interquartile range) Injury Severity Score was10 (5-22), and in-hospital mortality was 7% (n = 45). Of these patients, 17% (n = 112) required transfusion. Most R and MA values were within normal limits. On unadjusted analysis, the lowest MA-R ratio quartile was associated with increased mortality (15% vs. 4%, 5%, and 4%, respectively; p < 0.001) and increased transfusion need (26% vs. 12%, 16%, and 13%, respectively; p = 0.002) compared with higher quartiles. In the logistic regression models, a low MA-R ratio was independently associated with increased in-hospital mortality (odds ratio [95% confidence interval], 4.4 [1.9-10.2]) and increased need for transfusion within 24 hours of admission (odds ratio [95% confidence interval], 2.0 [1.2-3.4]) compared with higher MA-R ratio. There was no association between MA-R ratio and venous thromboembolic events (venous thromboembolic event rate by quartile: 4%, 2%, 1%, and 3%).
Conclusion:
Although individual admission TEG values are not commonly substantially deranged in injured children, the MA-R ratio is an independent predictor of poor outcome. Maximum amplitude-reaction time ratio may be a useful prognostic tool in pediatric trauma; validation is necessary.
Level Of Evidence:
Therapeutic/Care Management; Level III.
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