Relationship Between Admission Coagulopathy And Prognosis In Children With Traumatic Brain Injury: A Retrospective Study

Background: Coagulopathy in adult patients with traumatic brain injury(TBI)is strongly associated with unfavorable outcomes.However,few reports focus on pediatric TBI-associated coagulopathy.Methods: We retrospectively identified children with Glasgow Coma Scale ≤ 13 in a tertiary pediatric hospital from April 2012 to December 2019 to evaluate the impact of admission coagulopathy on their prognosis.The children were divided into survivors and non-survivors according to the outcome at the time of discharge.The two groups were compared in age,sex,weight,severity of injury,type of head injury,vital signs in admission including blood pressure and pupillary reaction,and various laboratory investigations in admission,including lactate level,hemoglobin,white blood cell,and most importantly,the coagulation parameters such as International normalized ratio,activated partial thromboplastin time(APTT),fibrinogen,Thrombin time,D-dimer and platelet.The receiver operator curve analysis of coagulation parameters was carried out to investigate the predictive value of in-hospital mortality.A classification and regression tree(CART)analysis using coagulation parameters was performed to analyze which coagulation parameter best predict in-hospital mortality and the best cut-off values.Then we investigate whether there was significant difference in the prognostic indicators in patients with coagulopathy including in-hospital mortality,length-of-stay in hospital and the intensive care unit,the duration of intubation time.Finally,based on the cut-off values of CART analysis,multivariate logistic regression analysis was performed to assess whether coagulopathy in admission was an independent risk factor for in-hospital mortality in children with moderate to severe TBI.Results: A total of 281 children with moderate to severe TBI were enrolled.A receiver operating characteristic curve showed that activated partial thromboplastin time(APTT)and fibrinogen were effective predictors of in-hospital mortality.According to the CART analysis,APTT of 39.2s was identified as the best discriminator,while 120 mg/d L fibrinogen was the second split in the subgroup of APTT≤39.2s.Patients were stratified into three groups,in which mortality was as follows: 4.5%(APTT≤39.2s,fibrinogen>120 mg/d L),20.5%(APTT≤39.2s and fibrinogen ≤120 mg/d L)and 60.8%(APTT>39.2s).Furthermore,length-of-stay in the ICU and duration of mechanical ventilation were significantly prolonged in patients with deteriorated APTT or fibrinogen values.Multiple logistic regression analysis showed that APTT>39.2s and fibrinogen ≤120 mg/d L was independently associated with mortality in children with moderate to severe TBI.Conclusions: We concluded that admission APTT>39.2s and fibrinogen ≤120 mg/d L was independently associated with mortality in children with moderate to severe TBI.Early identification and intervention of abnormal APTT and fibrinogen in pediatric TBI patients may be beneficial to their prognosis.