Platelet adenosine diphosphate receptor inhibition provides no advantage in predicting need for platelet transfusion or massive transfusion

doi:10.1016/j.surg.2017.07.022

Surgery

Volume 162, Issue 6, December 2017, Pages 1286-1294

Presented at the 12th Annual Academic Surgical Congress, Las Vegas, NV, February 7–9, 2017.

https://doi.org/10.1016/j.surg.2017.07.022 Get rights and content

Background

Thrombelastography platelet mapping is a useful assay to assess antiplatelet therapy. Inhibited response to the adenosine diphosphate receptor on platelets occurs early after injury, but recent work suggests this alteration occurs even with minor trauma. However, the utility of thrombelastography platelet mapping, specifically the percent of adenosine diphosphate receptor inhibition, in predicting outcomes and guiding platelet transfusion in trauma-induced coagulopathy remains unknown We assessed the role of percent of adenosine diphosphate-inhibition in predicting survival, requirement for massive transfusion or platelet transfusion in patients at risk for trauma-induced coagulopathy.

Methods

Thrombelastography platelet mapping was assessed in 303 trauma activation patients from 2014–2016 and in 89 healthy volunteers. Percent of adenosine diphosphate-inhibition is presented as median and interquartile range. We compared the area under the receiver operating characteristic curve of percent of adenosine diphosphate-inhibition, platelet count, and rapid thrombelastography maximum amplitude for in-hospital mortality, massive transfusion (>10 red blood cells or death/6 hours), and platelet transfusion (>0 platelet units or death/6 hour).

Results

Overall, 35 (11.5%) patient died, 27 (8.9%) required massive transfusion and 46, platelet transfusions (15.2%). Median percent of adenosine diphosphate-inhibition was 42.5% (interquartile range: 22.4–69.1%), compared with 4.3 % (interquartile range: 0–13.5%) in healthy volunteers (P < .0001). Patients that died, had a massive transfusion, or platelet transfusion had higher percent of adenosine diphosphate-inhibition than those that did not (P < .05 for all). However, percent of adenosine diphosphate-inhibition did not add significantly to the predictive performance of maximum amplitude or platelet count for any of the 3 outcomes, after adjustment for confounders. Subgroup analyses by severe traumatic brain injury, severe injury and requirement of red blood cells showed similar results.

Conclusion

Adenosine diphosphate receptor inhibition did not add predictive value to predicting mortality, massive transfusion, or platelet transfusion. Thus, the role of thrombelastography platelet mapping as a solitary tool to guide platelet transfusions in trauma requires continued refinement.

Section snippets

Study design

This is an analysis of prospectively collected data from our Trauma Activation Protocol from 2014 to 2016 database (TAP database), which includes patients who met criteria for the highest level of trauma team activation at Denver Health Medical Center, an American College of Surgeons verified and Colorado state certified Level 1 trauma center affiliated with the University of Colorado Denver. The Colorado Multiple Institutional Review Board approved all studies included in the TAP database. We

Patient characteristics

Of 436 consecutive trauma activation patients enrolled in our trauma activation database from 2014 to 2016, 303 (69.5%) had %ADP-INH measured within 1 hour of injury. Table I depicts the characteristics and injury severity for all patients and stratified by the 3 major outcomes (in-hospital death, massive transfusion, platelet transfusion). Overall, these were severely injured patients with a median NISS of 17 and base deficit-6 mEq/L. Mortality was 11.6%, massive transfusion was required in

Discussion

The purpose of this study was to assess whether platelet ADP receptor dysfunction, measured by TEG-PM, adds additional information in determining the need for massive transfusion, platelet transfusion or predicts mortality. This study confirmed that platelet dysfunction, as measured by %ADP-INH, occurs early after trauma and is associated with mortality, massive transfusion, or platelet transfusion. However, %ADP-INH was not a better predictor of these outcomes than platelet count, rTEG MA or

References (23)

M.V. Wohlauer et al.
Early platelet dysfunction: an unrecognized role in the acute coagulopathy of trauma
J Am Coll Surg
(2012)
H.B. Moore et al.
Viscoelastic measurements of platelet function, not fibrinogen function, predicts sensitivity to tissue-type plasminogen activator in trauma patients
J Thromb Haemost
(2015)
A.N. Bartels et al.
Platelet adenosine diphosphate inhibition in trauma patients by thromboelastography correlates with paradoxical increase in platelet dense granule content by flow cytometry
Surgery
(2016)
K.J. Clemetson
Platelets and Primary Haemostasis
Thrombosis Res
(2012)
M.I. Baharoglu et al.
Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial
Lancet
(2016)
A. Sauaia et al.
Epidemiology of trauma deaths
J Trauma
(1995)
H.B. Moore et al.
Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown
J Trauma Acute Care Surg
(2014)
J.L. Kashuk et al.
Postinjury coagulopathy management: goal directed resuscitation via POC thrombelastography
Ann Surg
(2010)
J.B. Holcomb et al.
Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial
JAMA
(2015)
E. Gonzalez et al.
Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays
Ann Surg
(2016)

A.R. Hobson et al.

Thrombelastography: current clinical applications and its potential role in interventional cardiology

Platelets

(2006)

Cited by (20)

Trauma-induced coagulopathy: The past, present, and future
2019, Journal of Thrombosis and Haemostasis
Trauma remains a leading cause of death worldwide, and most early preventable deaths in both the civilian and military settings are due to uncontrolled hemorrhage, despite paradigm advances in modern trauma care. Combined tissue injury and shock result in hemostatic failure, which has been identified as a multidimensional molecular, physiologic and clinical disorder termed trauma‐induced coagulopathy (TIC). Understanding the biology of TIC is of utmost importance, as it is often responsible for uncontrolled bleeding, organ failure, thromboembolic complications, and death. Investigations have shown that TIC is characterized by multiple phenotypes of impaired hemostasis due to altered biology in clot formation and breakdown. These coagulopathies are attributable to tissue injury and shock, and encompass underlying endothelial, immune and inflammatory perturbations. Despite the recognition and identification of multiple mechanisms and mediators of TIC, and the development of targeted treatments, the mortality rates and associated morbidities due to hemorrhage after injury remain high. The purpose of this review is to examine the past and present understanding of the multiple distinct but highly integrated pathways implicated in TIC, in order to highlight the current knowledge gaps and future needs in this evolving field, with the aim of reducing morbidity and mortality after injury.
Debunking the lethal triad and delineating damage control surgery
2023, Minerva Surgery
Point-of-care, goal-directed management of bleeding in trauma patients
2023, Current Opinion in Critical Care
Pathophysiology of Trauma-Induced Coagulopathy
2023, Hamostaseologie
Effects of Guideline-Based Correction of Platelet Inhibition on Outcomes in Moderate to Severe Isolated Blunt Traumatic Brain Injury
2022, Neurotrauma Reports
Platelet Transfusion for Trauma Resuscitation
2022, Current Trauma Reports

View all citing articles on Scopus

: Supported in part by the National Institute of General Medical Sciences grants: T32-GM008315 and P50-GM49222, the National Heart Lung and Blood Institute UM1-HL120877, in addition to the Department of Defense USAMRAA and W81XWH-12-2-0028. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Heart, Lung, and Blood institute, or the Department of Defense. Additional research support was provided by Haemonetics with shared intellectual property.

View full text

TraumaPresented at the Academic Surgical Congress 2017Platelet adenosine diphosphate receptor inhibition provides no advantage in predicting need for platelet transfusion or massive transfusion

Background

Methods

Results

Conclusion

Section snippets

Study design

Patient characteristics

Discussion

J Am Coll Surg

J Thromb Haemost

Surgery

Thrombosis Res

Lancet

Epidemiology of trauma deaths

J Trauma

Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown

J Trauma Acute Care Surg

Postinjury coagulopathy management: goal directed resuscitation via POC thrombelastography

Ann Surg

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

JAMA

Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays

Ann Surg

Thrombelastography: current clinical applications and its potential role in interventional cardiology

Platelets

Trauma
Presented at the Academic Surgical Congress 2017
Platelet adenosine diphosphate receptor inhibition provides no advantage in predicting need for platelet transfusion or massive transfusion