Progressive postinjury thrombocytosis is associated with thromboembolic complications

doi:10.1016/j.surg.2010.07.013

Surgery

Volume 148, Issue 4, October 2010, Pages 667-675

Presented at the 45th annual meeting of the Central Surgical Association, March 11, 2010, Chicago, Illinois.

https://doi.org/10.1016/j.surg.2010.07.013 Get rights and content

Background

Our previous investigation demonstrated that despite routine chemoprophylaxis, thrombelastography, which is a comprehensive test measuring the viscoelastic properties of blood, identified a hypercoagulable state in a cohort of critically ill surgical patients that was associated with thromboemobolic events. Furthermore, because thrombelastography allows for the comprehensive assessment of coagulation status, this work suggested that platelet hyperactivity is a component of the hypercoagulable state. We hypothesized that progressive postinjury thrombocytosis contributes to a hypercoagulable state that is associated with thrombelastography.

Methods

One thousand four hundred and forty severely injured patients surviving >48 h were entered into a database prospectively over 12 years. The variables that were evaluated in associated with thrombocytosis (platelet count >450,000) included age, Injury Severity Score, packed red blood cell transfusions in 12 h, and thromboemobolic complications (TE) (deep venous thrombosis, pulmonary embolus, mesenteric thrombosis, stroke, and arterial thrombosis). The time frame for the development of thrombocytosis was assessed at greater or less than 7 days postinjury. Logistic regression was used to identify the independent variables predictive of thrombocytosis and to adjust the association of thrombocytosis with TE for other risk factors. C-statistic was used to assess the discriminative power of thrombocytosis for prediction of TE.

Results

The mean age was 37.4 ± 0.4 years. The Injury Severity Score was 29.3 ± 0.3, and mean red blood cell transfusions in 12 h was 4.4 ± 0.2 units. Injury via blunt force occurred in 76% of patients, and 72% of patients were male. Thrombocytosis was identified in 447 (31%) patients and was noted almost exclusively >7 days postinjury (98%). TE developed in 35 (8%) of the 447 patients with thrombocytosis, compared with 45 (4.5%) of the remaining 993 patients who did not develop thrombocytosis. Persistent thrombocytosis >7 days was associated with TE (P > .0001). Logistic regression analysis indicated that when adjusted for intensive care unit duration of stay, transfusions, age, and Injury Severity Score, patients with sustained thrombocytosis more than 3 days were noted to have a 1.4 × increased risk of TE (odds ratio, 1.12; 95% confidence interval, 1.04–1.2; P = .002; C-statistic = 0.82).

Conclusion

Persistent thrombocytosis in critically injured patients receiving routine chemoprophylaxis is associated with thrombotic complications. Subsequent investigation is warranted to differentiate enzymatic from platelet hypercoagulability to ascertain the role of antiplatelet therapy for prevention of TE.

Section snippets

Materials and methods

This study was conducted via a compilation of data from the Denver multiple organ failure (MOF) database, which has been a repository of prospectively collected data on critically injured patients admitted to the surgical intensive care unit (SICU) of the Rocky Mountain Regional Trauma Center at Denver Health Medical Center since 1992, a state-designated level 1 trauma center verified by the American College of Surgeons Committee on Trauma. From 1992 to 2004, we collected data on more than

General demographics

General demographic data were collected on 1,440 severely injured patients over a 12-year period (Table I). The average age was 37.4 ± 16.6 years, and 72% were male patients. Blunt force occurred in 76% of injuries, and the overall ISS was 29.3 ± 11.3, which reflected the severe injuries noted in this cohort. MOF developed in 346 (24.5%) patients, and 118 (8.2%) patients died. Infectious as well as noninfectious complications developed in 692 (48.1%) patients and 685 (47.6%) patients,

Discussion

Despite widespread acceptance of the importance of chemoprophylaxis for the prevention of thromboembolic complications in high-risk, critically ill patients,12, 13, 14 continuing evidence suggests that DVT, PE, mesenteric thrombosis, and other thrombotic conditions contribute significantly to a disease process that has stimulated a national call for action by the center for Medicare and Medicaid Services, who have labeled these processes “never events” if they occur after certain operative

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Thrombocytosis is an uncommon yet important laboratory abnormality with significant considerations for patients undergoing cardiac surgery. The etiology of thrombocytosis can be categorized by those related to reactive processes; acquired platelet disorders (ie, myeloproliferative neoplasms, hematologic malignancies); or inherited platelet disorders (ie, hereditary thrombocythemia). A foundational understanding of the normal physiologic function of platelets and the abnormalities associated with each of these disorders is critical when considering implications and optimization to prevent perioperative complications. This review systematically outlines the platelet disorders that cause thrombocytosis with an emphasis on how the disorder affects normal physiologic processes, summarizes the literature related to the disorder, and the describes the implications and recommendations for patients undergoing cardiac surgery.
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Because these clinical and laboratory results are consistent with the definition of reactive thrombocytosis, these patients were diagnosed as PE associated with reactive thrombocytosis [25]. Recent observational studies have reported that reactive thrombocytosis is associated with an increased risk of venous thromboembolism (VTE) in patients after major trauma [26,27]. Although we did not demonstrate significant increase of platelet count in patients with preoperative VTE, reactive thrombocytosis after major trauma may be associated with high incidence of preoperative VTE in the high energy injury group.
The purpose of this study was to identify the incidence of preoperative venous thromboembolism (VTE), and determine if high energy hip fracture affects preoperative VTE occurrence.
Three-hundred nine patients (244 low and 61 high energy injuries) treated between March 2015 and March 2017 were included in this study. Indirect multidetector computed tomographic venography for the detection of preoperative VTE was performed at admission. The incidence of preoperative VTE was compared between high and low energy injury hip fractures. Logistic regression analysis was used to identify independent risk factors for preoperative VTE.
The overall incidence of preoperative VTE was 18.4% (56 of 305 patients). Preoperative VTE was identified in 17 (27.9%) and 39 (16.0%) patients in the high and low energy injury groups, respectively (p = 0.034). Multivariate logistic regression analysis showed that high energy injury, history of VTE, and myeloproliferative disease were significant predictive factors of preoperative VTE (OR = 2.451; 95% CI = 1.227–4.896, OR = 11.174; 95% CI = 3.500–35.673, OR = 6.936; 95% CI = 1.641–29.321, respectively)
Because high energy hip fracture is significantly associated with preoperative VTE occurrence, preoperative evaluation and proper thromboprophylaxis should be performed for patients with a high-energy hip fracture.
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Perioperative and short-term postoperative parameters are similar comparing spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). But there are no sound data evaluating the long term risk of postoperative thromboses and infectious complications after splenectomy. The present study evaluated whether the coagulation status differs in patients after SPDP and DPS, and whether that matters clinically.
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Coagulation tests revealed a significant enhanced tendency for blood-platelet aggregation and coagulation activation in patients after DPS compared to patients after SPDP. No septic or thromboembolic events were observed in any patient.
Hypercoagulability in splenectomized patients persists over years. Thus, a correlation of this finding with thromboembolic events and mortality years after splenectomy should to be performed in a large cohort.
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Thrombocytosis is common following elective splenectomy and major trauma. However, little is known about the in-hospital course of platelet count (PC) and incidence of thrombocytosis after splenic trauma. Extreme thrombocytosis (PC > 1000 × 10⁹) is associated with increased risk of venous thromboembolism (VTE) in primary thrombocytosis leading to the use of acetylsalicylic acid (ASA) for risk reduction, but the need for this agent in splenic trauma is undefined.
Retrospective cohort study of all patients with splenic trauma between April 1, 2010 and March 31, 2014. The in-hospital course of PC was assessed based on splenic injury management type. The association of management type with thrombocytosis was evaluated using a multivariable logistic regression model adjusting for potential confounders. The association of thrombocytosis, extreme thrombocytosis, and ASA use for the outcome of VTE was explored.
156 patients were eligible, PC initially increased in all patients with the highest peak after total splenectomy. The incidence of thrombocytosis was 41.0% (64/156). Thrombocytosis was more likely following splenectomy compared with spleen preserving strategies independent of length of stay, injury grade, ISS, age and transfusion (OR 7.58, 95% CI: 2.26–25.45). Splenectomy was associated with extreme thrombocytosis (OR 10.39, 95% CI: 3.59–30.07).
Thrombocytosis in splenic trauma is more likely after splenectomy than with spleen preserving strategies. Splenectomy is associated with extreme thrombocytosis. There was insufficient data in our study to determine the use of ASA as primary prevention of VTE after splenic trauma.
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Clear cell carcinoma is known to have an even higher level of IL-6 than serous histology that could result in accelerated thrombocytosis by a similar mechanism [14]. Thromboembolic events, then, occur as a consequence of thrombocytosis [15–17]. Therefore, it is suggested that VTE in cancer patients represents a “clinical manifestation” of tumor progression via the IL-6 cascade.
To profile characteristics and survival of endometrial cancer patients who develop venous thromboembolism (VTE) and to establish a predictive model of VTE in endometrial cancer.
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: Supported by grants P50GM049222 and T32GM08315 from the National Institute of General Medical Sciences.

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Central Surgical AssociationProgressive postinjury thrombocytosis is associated with thromboembolic complications

Background

Methods

Results

Conclusion

Section snippets

Materials and methods

General demographics

Discussion

Hematol Oncol Clin North Am

Chest

J Am Coll Surg

Br J Anaesth

Blood