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Severely injured trauma patients with admission hyperfibrinolysis

Is there a role of tranexamic acid? Findings from the PROPPR trial

Khan, Muhammad, MD; Jehan, Faisal, MD; Bulger, Eileen M., MD; O'Keeffe, Terence, MD; Holcomb, John B., MD; Wade, Charles E., PhD; Schreiber, Martin A., MD; Joseph, Bellal, MD on behalf of the PROPPR Study Group

Journal of Trauma and Acute Care Surgery: November 2018 - Volume 85 - Issue 5 - p 851–857
doi: 10.1097/TA.0000000000002022
2018 WTA PODIUM PAPER
Editor's Choice

INTRODUCTION Administration of tranexamic acid (TXA) in coagulopathy of trauma gained popularity after the CRASH-2 trial. The aim of our analysis was to analyze the role of TXA in severely injured trauma patients with admission hyperfibrinolysis.

METHODS We reviewed the prospectively collected Pragmatic, Randomized Optimal Platelet and Plasma Ratios database. We included patients with admission hyperfibrinolysis (Ly30 >3%) on thromboelastography. Patients were stratified into two groups (TXA and No-TXA) and were matched in 1:2 ratio using propensity score matching for demographics, admission vitals, and injury severity. Primary outcome measures were 6-, 12-, and 24-hour and 30-day mortality; 24-hour transfusion requirements; time to achieve hemostasis; and rebleeding after hemostasis requiring intervention. Secondary outcome measures were thrombotic complications.

RESULTS We analyzed 680 patients. Of those, 118 had admission hyperfibrinolysis, and 93 patients (TXA: 31 patients; No-TXA: 62 patients) were matched. Matched groups were similar in age (p = 0.33), gender (p = 0.84), race (p = 0.81), emergency department (ED) Glasgow Coma Scale (p = 0.34), ED systolic blood pressure (p = 0.28), ED heart rate (p = 0.43), mechanism of injury (p = 0.45), head Abbreviated Injury Scale score (p = 0.68), injury severity score (p = 0.56), and blood products ratio (p = 0.44). Patients who received TXA had a lower 6-hour mortality rate (34% vs. 13%, p = 0.04) and higher 24-hour transfusion of plasma (15 vs. 10 units, p = 0.03) compared with the No-TXA group. However, there was no difference in 12-hour (p = 0.24), 24-hour (p = 0.25), and 30-day mortality (p = 0.82). Similarly, there was no difference in 24-hour transfusion of RBC (p = 0.11) or platelets (p = 0.13), time to achieve hemostasis (p = 0.65), rebleeding requiring intervention (p = 0.13), and thrombotic complications (p = 0.98).

CONCLUSION Tranexamic acid was associated with increased 6-hour survival but does not improve long-term outcomes in severely injured trauma patients with hemorrhage who develop hyperfibrinolysis. Moreover, TXA administration was not associated with thrombotic complications. Further randomized clinical trials will identify the subset of trauma patients who may benefit from TXA.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery (M.K., F.J., T.O., B.J.), College of Medicine, University of Arizona, Tucson, Arizona; Division of Trauma and Critical Care, Department of Surgery (E.M.B.), School of Medicine, University of Washington, Seattle, Washington; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (J.B.H., C.E.W.), Medical School, University of Texas Health Science Center, Houston, Texas; and Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery (M.A.S.), School of Medicine, Oregon Health & Science University, Portland, Oregon.

The Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial was sponsored by the US National Heart, Lung, and Blood Institute (U01HL077863), the US Department of Defense, and Defence Research and Development Canada in partnership with the Canadian Institutes of Health Research, Institute of Circulatory and Respiratory Health (CRR-120612).

Oral presentation at the 48th Annual Meeting of Western Trauma Association; February 25 to March 2, 2018; British Columbia, Canada.

Address for reprints: Bellal Joseph, MD, Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N Campbell Ave, Room 5411, PO Box 245063, Tucson, AZ 85727; email: bjoseph@surgery.arizona.edu.

© 2018 Lippincott Williams & Wilkins, Inc.