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A principal component analysis of coagulation after trauma

Kutcher, Matthew E. MD; Ferguson, Adam R. PhD; Cohen, Mitchell J. MD

Journal of Trauma and Acute Care Surgery:
doi: 10.1097/TA.0b013e31828b7fa1
AAST 2012 Plenary Papers
Editor's Choice
Abstract

BACKGROUND: Clotting factor abnormalities underlying acute traumatic coagulopathy are poorly understood, with application of traditional regression techniques confounded by colinearity. We hypothesized that principal components analysis (PCA), a pattern-finding and data reduction technique, would identify clinically predictive patterns in the complex clotting factor milieu after trauma.

METHODS: Plasma was prospectively collected from 163 critically injured trauma patients. Prothrombin; factors V, VII, VIII, IX, X; D-dimer; activated and native protein C; and antithrombin III levels were assayed and subjected to nonlinear PCA to identify principal components (PCs).

RESULTS: Of 163 patients, 19.0% were coagulopathic on admission. PCA identified 3 significant PCs, accounting for 67.5% of overall variance. PC1 identified global clotting factor depletion; PC2 the activation of protein C and fibrinolysis; and PC3 factor VII elevation and VIII depletion. PC1 score correlated with penetrating injury and injury severity, predicting coagulopathy (odds ratio [OR], 4.67; p < 0.001) and mortality (OR, 1.47; p = 0.032). PC2 score correlated with injury severity, acidosis, and shock, and significantly predicted ventilator-associated pneumonia (OR, 1.59; p = 0.008), acute lung injury (OR, 2.24; p < 0.001), multiorgan failure (OR, 1.83; p = 0.002), and mortality (OR, 1.62; p = 0.006) but was not associated with international normalized ratio (INR)–based or partial thromboplastin time (PTT)–based coagulopathy (p > 0.200). PC3 did not significantly predict outcomes.

CONCLUSION: PCA identifies distinct patterns of coagulopathy: depletion coagulopathy predicts mortality and INR/PTT elevation, while fibrinolytic coagulopathy predicts infection, end-organ failure, and mortality, without detectable differences in INR or PTT. While depletion coagulopathy is intuitive, fibrinolytic coagulopathy may be a distinct but often overlapping entity with differential effects on outcomes.

LEVEL OF EVIDENCE: Prognostic study, level III.

Author Information

From the Department of Surgery (M.E.K., M.J.C.), San Francisco General Hospital; and Brain and Spinal Injury Center (BASIC) (A.R.F.), Department of Neurological Surgery, University of California, San Francisco, California.

Submitted: October 8, 2012, Revised: January 29, 2013, Accepted: January 30, 2013.

This study was presented at the annual meeting of the American Association for the Surgery of Trauma, September 12–15, 2012, in Kauai, Hawaii.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site ( www.jtrauma.com).

Address for reprints: Mitchell Jay Cohen, MD, Department of Surgery, Ward 3A San Francisco General Hospital 1001 Potrero Ave, Room 3C-38 San Francisco, CA 94110; email: matthew.kutcher@ucsfmedctr.org.

© 2013 Lippincott Williams & Wilkins, Inc.