Haemostatic activation markers in brain injury for mortality prediction: comparison of blood samples from the jugular bulb and central venous line

Objective

Our aim was the identification of coagulopathy disorders and their relation to outcome in severely head-injured patients.

Patients and methods

A prospective study was performed June 2003–March 2004. Included were critically ill patients with isolated closed severe head trauma. Collected data were demographics, management prior to and during ICU hospitalization (sedation, catecolamin drug use, blood product transfusion, intracranial pressure monitoring, neurosurgical emergency surgery, etc.), CT-scan results, daily worst Glasgow Coma Scale score, and admission Simplified Acute Physiology Score II. We inserted an arterial catheter for invasive pressure monitoring, a central venous catheter and a unilateral jugular bulb in front of the most damaged brain hemisphere (cf. CT scan). Jugular bulb thrombosis was prevented by continuous infusion of 2 ml/hour isotonic serum without heparin. Blood samples were obtained simultaneously from the central venous line (K) and jugular bulb (B) at admission, 6 hours, 12 hours, and then in case of neurological aggravation or daily until 5 days. We measured the platelet count, prothrombin time (PT), activated partial thromboplastin time (ACT), fibrinogen concentration (Fib), prothrombin fraction 1+2 (F) and thrombin–antithrombin complex (TAT). During the study only central venous blood samples (PT, ACT, Fib and platelet count) could be available if necessary. Otherwise blood samples were centrifuged and preserved refrigerated for post-hoc analysis. Statistical analysis was by Student's t test, paired t test for paired results and analysis of variance. Significance was set as P < 0.05.

Results

The total n = 19; nine survivors (S) and 10 deaths (NS). No differences between S and NS in demographics, management modalities, admission GCS score (7 ± 3), CT scan, and SAPS II (27 ± 10 vs 30 ± 17, P = 0.69). The B vs simultaneous K platelet count was significantly lower in all drawn blood samples, with a trend to decrease over time. S vs NS at day 2 and day 3: 191 ± 60 vs 125 ± 35 (P = 0.017). The admission B thrombin fraction was higher in NS (1,000 ± 209 vs 460 ± 294, P = 0.014). The B day 1 TAT was higher in NS: 45 ± 20 vs 9.6 ± 12 (P = 0.02). No difference was observed for other tests between B vs K and S vs NS for different paired tests.

Conclusion

Procoagulant factors (F and TAT) are valuable prognostic factors at day 1 in closed isolated severe head trauma.