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The Effect of Anticoagulation on Outcomes After Liver and Spleen Injuries: A Research Consortium of New England Centers for Trauma (ReCONECT) Study
Bishwajit Bhattacharya1, *Reza Askari2, Kimberly A Davis1, *Jon Dorfman3, *Ahmed I Eid4, *Ahmed E Elsharkawy4, *George Kasotakis5, *Sandra Mackey6, *Stephen Odom7, *Barbara U. Okafur2, *Michael Rosenblatt6, George Velmahos4, Adrian A Maung1
1Yale School of Medicine, New Haven, CT;2Brigham and Women's Hospital, Boston, MA;3UMass Medical School, Worcester, MA;4Massachusetts General Hospital, Boston, MA;5Boston University, Boston, MA;6Lahey Clinic, Burlington, MA;7Beth Israel Deaconess Medical Center, Boston, MA

Objective: Study the effect of anticoagulation (AC) in patients with liver and or spleen injuries. Design: Multicenter retrospective study. Setting: Adult trauma centers. Patients: Adult trauma patients with liver or spleen injury. Main Outcomes: Transfusion requirements, success on non-operative management, LOS, mortality. Results: 1254 patients (64 on AC) were analysed. AC patients were older (60.9 vs. 38.6 years, p < 0.001). 57.5% of patients had a splenic injury, 52.8% a liver injury and 10.5% both. The most common AC agent was warfarin (70.3%), the most common indication was atrial fibrillation (46.9%). There was no significant difference in injury grade between AC and non-AC patients. AC patients required a blood products more often (57.8 vs 40.1%, p=0.005) especially FFP (42.1 vs 18.9%, p< 0.01). Among those transfused, non-AC patients required more PRBC's (5.7 vs 3.8 units, p=0.018), similar amounts of FFP (3.2 vs 3.1 units, p=0.92). The two groups had no significant difference in the rates of initial non-operative management (50% (AC) vs 55.7% (non-AC), p=0.3)) or failure of non-operative management (7.1 vs 3.5%, p=0.16). Patients on AC were more likely to be managed initially with angiography (37.5 vs 20.3%, p=0.001) while non-AC patients with surgery (23.9% vs 12.5%, p=0.03). There was no significant difference in LOS and mortality. Conclusions: The use of anticoagulation agents did not result in a difference in outcomes.
Table 1.


Demographics

All

AC

Non-AC

Comparison (AC vs Not)
Age39.71 19.0160.88 19.5538.56 18.30p < 0.001
Gender (% Male)6870.3 (45)67.9 (808)Chi Square 0.163 p=0.687
ISS (Mean +/- SD)22.37 13.521.42 13.622.42 13.52p=0.566
Spleen % (n)57.5 (721)76.6 (49)56.5 (672)Chi Square 10.032 p=0.002
Mean Spleen Grade2.511.2562.35 1.322.52 (1.25)
Median Spleen Grade222p = 0.346
Spleen IQR (25-75)2 (1-3)2 (1-3)2 (1-3)
Liver % (n)52.8 (662)35.9 (23)53.7 (639)Chi Square 7.726 p=0.005
Mean Liver Grade2.311.2392 1.132.32 1.24p = 0.218
Median Liver Grade222
Liver IQR (25-75)2 (1-3)2 (1-3)2 (1-3)
% Both10.512.5 (8)10.4 (124)Chi Square 0.2798 p=0.597

Table 2.

Outcomes

All

AC

Non-AC
Chi SquareP Value
Required Transfusion % (N)40.9 (512)57.8 (37)40.1 (475)7.9220.005
Mean # PRBC (Limited to those transfused)5.6 8.43.8 4.25.7 8.70.018
Mean # FFP (Limited to those transfused)3.2 7.53.1 4.03.2 7.70.92
Mean # Plts ((Limited to those transfused)1.76.81.64.41.87.00.87
Initial Operative Management % (N)23.4 (293)12.5 (8)23.9 (285)4.450.035
Initial IR Management % (N)21.2 (266)37.5 (24)20.3 (242)10.710.001
Initial Non-OP Management % (N)55.4 (695)50 (32)55.7 (663)0.8030.370
Failure of Non-Op Management (All)3.7 (36)7.1 (4)3.5 (32)1.90.168
Failure of Initial IR Management8.3 (22)16.7 (4)7.4 (18)2.50.117
Failure of Non-Op Management (No IR)2.0 (14)0 (0)2.1 (14)0.6900.406
Subsequent IR Management (All)3.4(33)0 (0)3.6 (33)2.1150.146
ICU Admission70.6 (886)78.1 (50)70.2 (836)1.8160.178
LOS Days Mean SD9.610.912.0 11.69.411.00.069
Mortality8.0 (100)4.7 (3)8.2 (97)0.9930.319


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