Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited.

BACKGROUND: Recalcitrant coagulopathy "the bloody vicious cycle," produces the majority of deaths after torso trauma. A model predicting this life-threatening complication may facilitate clinical decision-making. METHODS: We prospectively analyzed patients > 15 years old who received a massive transfusion (> 10 units of packed red blood cells (PRBC)/24 h) over a 2-year period. Excluding massive head injuries and pre-existing disease, the 58 study patients had a mean age = 35.4 years, Injury Severity Score (ISS) = 30.6, and PRBC = 24.2 units/24 h. RESULTS: Defined as prothrombin time of two times that of normal laboratory controls and partial thromboplastin time as two times that of normal laboratory controls, 27 patients (47%) developed life-threatening coagulopathy. Using a multiple logistic regression model, the four significant risk factors (with odds ratio) were (1) pH < 7.10 (12.3), (2) temperature < 34 degrees C (8.7), (3) ISS > 25 (7.7), and (4) systolic blood pressure < 70 mm Hg (5.8). The conditional probability of developing coagulopathy was ISS > 25 + systolic blood pressure < 70 mm Hg = 39%, ISS > 25 + temperature < 34 degrees C = 49%, ISS > 25 + pH < 7.10 = 49%; with all four risk factors the incidence was 98%. CONCLUSION: Postinjury life-threatening coagulopathy in the seriously injured requiring massive transfusion is predicted by persistent hypothermia and progressive metabolic acidosis.

Jack A. Barney Resident Research Award. Cardiopulmonary hazards of perihepatic packing for major liver injuries.

BACKGROUND: Perihepatic packing has been shown to result in pathologic intra-abdominal hypertension. Although now recognized as impairing abdominal organ perfusion, the extent to which perihepatic packing affects cardiopulmonary function has not been elucidated. METHODS: We analyzed a 3-year experience with 11 patients who sustained major hepatic injuries requiring perihepatic packing to control hemorrhage. Pertinent hemodynamic indices consisting of pulmonary capillary wedge pressure (PCWP), cardiac index (CI), oxygen delivery index (DO2), and systemic vascular resistance (SVR), and pulmonary indices consisting of peak airway pressure (PAP), mean airway pressure (MAP), static compliance (CST), and PaO2/FiO2 were measured in the surgical intensive care unit immediately before and after packs were removed. RESULTS: Unpacking resulted in a significant increase in CI (3.1 +/- 0.4 to 4.2 +/- 0.6 L/min/m2), DO2 (539 +/- 41 to 689 +/- 43 mL min/m2), CST (26 +/- 6 to 36 +/- 4 mL/cm H2O), and PaO2/FiO2 (162 +/- 44 to 237 +/- 53 cm H2O), as well as a significant decrease in PAP (47 +/- 9 to 29 +/- 6 cm H2O), MAP (34 +/- 4 to 27 +/- 3 cm H2O), PCWP (21 +/- 4 to 13 +/- 3 mm Hg), and SVR (1,239 +/- 162 to 887 +/- 130 dyne/cm5). CONCLUSIONS: Abdominal compartment syndrome following temporary perihepatic packing can result in significant cardiopulmonary compromise. While perihepatic packing can be an early life-saving procedure, timely alleviation of the secondary syndrome may be critical to the ultimate salvage of patients with marginal cardiopulmonary reserve.