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Trending Fibrinolytic Dysregulation: Changes in Fibrinolysis Over Hospitalization Predict Poor Outcome in Severely-injured Children
Christine Leeper, Matthew D. Neal, Christine McKenna, Barbara Gaines
Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA

OBJECTIVE(S): Fibrinolytic derangement at the time of admission after trauma is common in severely-injured children; no studies examine fibrinolysis status days after injury. Objectives were to trend fibrinolysis and determine the influence of traumatic brain injury(TBI) and massive transfusion on fibrinolysis status.
METHODS: Prospective study of severely-injured children at our academic level 1 pediatric trauma center. Rapid thromboelastography(TEG) was obtained on admission and daily for 1 week. Standard TEG definitions of hyperfibrinolysis (HF; LY30≥3), fibrinolysis shutdown (SD; LY30≤0.8), and normal (LY30=0.9-2.9) were applied. Tranexamic acid(TXA) use was documented. Outcomes were death, disability, and venous thromboembolism. Exploratory subgroups included massively-transfused and severe TBI patients.
RESULTS: 67 patients were analyzed with median(IQR) age=9(4.5-12.5) and ISS=22(13-34), 75% blunt mechanism, 40% severe TBI, 24% massively transfused. Outcomes were 15% mortality, 40% disability and 14% DVT. Remaining in or trending to SD was associated with death(p=0.033), disability(p=0.042) and DVT(p=0.011). Hyperfibrinolysis without associated shutdown was not related to poor outcome. The majority(56%) of massively-transfused patients in hemorrhagic shock were in SD on admission. All with HF(25%) corrected after hemostatic resuscitation without TXA. Severe TBI was associated with SD at all time points beyond admission (all p<0.05).
CONCLUSIONS: Fibrinolysis shutdown is common post-injury and predicts poor outcomes. Severe TBI is associated with sustained shutdown. Empiric antifibrinolytics for children should be questioned; TEG-directed selective use should be considered for patients with ongoing hyperfibrinolysis.

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