Elsevier

Surgery

Volume 158, Issue 3, September 2015, Pages 618-626
Surgery

Trauma/Critical Care
Splenectomy is associated with hypercoagulable thrombelastography values and increased risk of thromboembolism

Presented at the 10th Annual Academic Surgical Congress in Las Vegas, NV, February 3−5, 2015.
https://doi.org/10.1016/j.surg.2015.06.014Get rights and content

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.

Section snippets

Study setting and selection of participants

This was a 14-month prospective, multicenter, observational study in which we examined the coagulation profile of trauma patients using serial thrombelastography values. The study was conducted at 3 American College of Surgeons−verified Level 1 trauma centers: The Texas Trauma Institute at Memorial Hermann Hospital (Houston, TX), San Francisco General Hospital (San Francisco, CA), and Oregon Health & Sciences University (Portland, OR). The Institutional Review Boards for all 3 hospitals and

Patient demographics, injury characteristics, and arrival laboratory and transfusion data

A total of 1,242 patients were enrolled in this multicenter study, in which we examined the coagulation profile of trauma patients by using serial thrombelastography values. A total of 795 patients had more than one rTEG value obtained, and these patients made up the population for all studies resulting from this prospective, observational study. Of these, 605 patients had serial rTEG values obtained after 24 hours and were the focus of the present study. This represents 76% of the overall

Discussion

Hypercoagulability after trauma has been reported in several previous studies; however, the exact mechanisms and significance remain poorly understood. In this multicenter, prospective study, we examined the role of splenectomy for trauma and its effect on coagulation profiles and TE risk over time. We found that patients undergoing splenectomy: 1) developed significantly greater platelet counts beginning at 72 hours; 2) developed more hypercoagulable alpha angle and MA values on rTEG beginning

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    This work was supported, in part, by a research grant from Haemonetics Corporation (Braintree, MA).

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