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Chapter 16

Battle Casualties in Korea: Studies of the Surgical Research Team, Volume IV

A Survey of the Hemostatic Mechanisms in Acute Post-traumatic Renal Insufficiency

Private First Class George L. Deaver, USA

(This information has been abstracted from a longer report prepared by Pfc Deaver.)

Hemorrhagic disease often appears in patients with severe renal insufficiency of whatever etiology. In medical cases it may manifest itself only by the appearance of large bruises at points of venipuncture, but in the battle casualty the disease is more serious because of the presence of wounds.

In December 1952 Captain Paul Teschan made a survey of the patients at the Renal Insufficiency Center and reported the following manifestations of hemorrhagic disease:

Patient 1-Gingival bleeding on the fourth post-wound day.

Patient 2-Tarry stools on post-wound days 9 to 15.

Patient 3-Bloody diarrhea on post-wound days 14 to 24.

Patient 4-Profuse bleeding from cut-downs and from wounds when dressings were changed.

Patient 5-Bleeding from drains in the right upper quadrant on the thirteenth day. Laparotomy showed a generalized oozing from the bed of the right kidney.

Patient 6-Bloody vomitus, bloody diarrhea and bleeding through his incision. A laparotomy revealed generalized oozing from the traumatized areas.

Patient 7-Brisk bleeding from the wound on the eleventh day.

The tendency to bleed in these patients may sometimes threaten their lives. It was for this reason that a study was undertaken to learn if possible the reason for this bleeding disease in battle casualties with post-traumatic renal insufficiency.

Materials and Methods. The study was carried out in the first half of the year 1953 at the Renal Insufficiency Center, 11th Evacuation Hospital, operating in support of the U. S. Eighth Army at Wonju in Korea. The work was carried out under the supervision of Captain Paul E. Teschan and Major William A Meroney following a protocal that had been prepared by Lieutenant Russell Scott and Lieutenant Colonel William H. Crosby. The methods for tests of the hemostatic system have been described by Scott and Crosby.1 The


304

chemical procedures were performed in the laboratory of the Renal Insufficiency Center. The methods have been described elsewhere.2 A battery of tests was made serially in each case from the time the casualty was admitted to the Center until he died or was evacuated to Japan. Twenty-seven patients with severe renal insufficiency were included in the investigation.

Results. Table 1 shows the results of the battery of tests performed on several patients at times when marked abnormalities of one or more tests were evident. Table 2 shows the results of the serial testing done on a single patient during the first 2 weeks of his convalescence. This demonstrates the extent of the battery of tests and the interval at which the tests were performed in each of the subjects. An abstract of the results in all patients follows.

Coagulation time determined in 27 patients was usually prolonged in those with hemorrhagic disease and the prolongation seemed proportional to the severity of the disease. Patients with abdominal wounds seemed more severely affected than patients with wounds of the extremities but in general those with abdominal wounds were in a more critical condition than the others.

Clot retraction was often grossly abnormal and when it occurred in a patient it usually remained abnormal for several days. This was observed in two patients with thrombocytopenia, but it also occurred where the platelet count was adequate (Table 1, patient 102).

Platelet count (or an estimation of platelets made by examining a stained smear) demonstrated an adequate number in all patients excepting the two who had a temporary (5 or 6 days) but significant thrombocytopenia.

Tourniquet test for capillary fragility was abnormal in the two men with thrombocytopenia. The test was not performed consistently in all patients but it was usually negative when done. A few positive results were encountered in some patients during the time of hemorrhagic disease.

Fibrinogen levels were measured serially in 17 patients. Elevated levels were encountered almost invariably during the first 5 days after wounding and in some cases persisted for as long as 39 days. Fibrinogenopenia was not encountered.

Fibrinolytic activity was measured in 10 cases and the amount of lysis ranged from zero to 15 per cent, which values are not abnormal. In one patient only was there sufficient fibrinolytic activity to lyse completely the whole-blood clot in 24 hours.

Plasma prothrombin activity as determined by the one-stage method was usually moderately reduced. It was never so low that it alone would have caused abnormal bleeding.


305

Table 1. Hemostatic Tests in Acute Post-traumatic Renal Insufficiency

Patient

81

102

104

Site of Wound

Abdomen and Extremities

Extremities

Extremities

Day post-wound

6

11

12

23

26

17

23

27

Coagulation time (min.)

61

120s

120s

35

19

18

19

21

Clot retraction (1 hour)

    poor

poor

complete

poor

poor

poor

complete

complete

Plasma prothrombin (% of normal)

25

35

50

70

95

95

73

95

Prothrombin consumption (% of plasma prothrombin)

 

 

 

0

90

65

95

95

Fibrinogen (mg./100 ml.)

610

 

 

439

556

 

572

590

Fibrinolysis

 

complete

complete

 

 

 

 

12

Bleeding time (min.)

4.5

 

 

35

2.5

1.5

 

 

Platelets

low

 

adeq.

low

140,000

adeq.

adeq.

adeq.

Tourniquet test

pos.

pos.

pos.

pos.

neg.

 

pos.

sl. pos.

Nonprotein nitrogen (mg./100 ml.)

390

282

348

285

193

216

247

188

Plasma sodium (mEq./L.)

135

151

146

139

148

134

170

149

Plasma potassium

6.3

6.0

6.1

4.3

3.8

6.1

5.1

5.2

Carbon dioxide (vol. %)

 

12.7

 

20

27

25

22

23

Plasma calcium (mg./100 ml.)

 

 

 

8.2

9.4

6.2

 

12.3

Plasma bilirubin (mg./100 ml.)

11.3

5.0

5.4

1.25

0.66

 

1.1

0.66

Urine output (ml./day)

1400

 

 

4085

2870

295

1570

2695


306

Table 2. Hemostatic Tests in Acute Post-traumatic Renal Insufficiency

Patient 102-Wounds of the Extremities.

Dialyzed on the Artificial Kidney on Post-wound Days 5, 9 and 13.

Day post-wound

2

3

4

6

7

8

9

10

11

12

13

14

Coagulation time (min.)

23

29

15

40

22

18

19

15

16

16

16

16

Clot retraction (1 hour)

    poor

poor

poor

poor

poor

poor

poor

poor

good

good

good

good

Plasma prothrombin (% of normal)

95

90

 

74

100

95

85

85

90

80

 

80

Prothrombin consumption (% of plasma prothrombin)

90

95

95

80

85

95

 

80

40

75

60

50

Fibrinogen (mg./100 ml.)

775

 

 

 

 

 

 

 

 

 

 

 

Bleeding time (min.)

3.5

3

 

 

 

 

 

 

 

 

 

 

Platelets

adeq

adeq

adeq

adeq

adeq

adeq

adeq

adeq

adeq

adeq

adeq

adeq

Tourniquet test

neg.

neg.

 

 

 

 

 

 

 

 

 

 

Hematocrit

 

40

34

 

 

 

 37

 

 

 

28

27

Nonprotein nitrogen (mg./100 ml.)

64

121

189

114

132

182

265

153

200

212

292

116

Sodium (mEq./L.)

129

127

147

144

146

135

130

141

151

132

146

136

Potassium (mEq./L.)

6.7

7.4

6.7

5.5

7.1

7.0

7.5

5.9

6.1

6.4

7.8

3.6

Carbon dioxide (vol. %)

27

27

26

27.5

 

21.0

19

24

22.0

22

14

22.5

Calcium (mg./100 ml.)

7.7

8.4

8.7

7.0

 

8.0

7.2

6.7

 

6.3

6.0

11.0

Bilirubin (mg./100 ml.)

1.78

1.44

0.54

1.00

0.76

1.00

0.51

0.49

0.71

0.76

 

3.44

Urine output (ml./day)

385

135

50

85

150

105

135

85

140

195

240

100


307

Serum prothrombin activity (prothrombin consumption) was studied in 13 patients. It was not often abnormal even when the coagulation time was grossly prolonged. Prothrombin consumption was sometimes deficient, even in the presence of an adequate number of platelets (Table 1, patient 104). When this was found in a patient it occurred consistently day after day for several days.

Discussion. The battery of tests performed on patients with acute post-traumatic renal insufficiency revealed no consistent single defect that would account for their tendency to bleed. In some patients there was transient thrombocytopenia of a degree capable of causing thrombocytopenic purpura. In others faulty clot retraction in the presence of adequate numbers of platelets suggested a qualitative deficiency in platelets. However, prothrombin consumption was not consistently decreased, suggesting that the platelets were not deficient in their ability to form thromboplastin even though the effect of clot retraction was diminished. The prolongation of clotting time remains unexplained. This was the most consistent abnormality and it is one that deserves further study.

Notable in the over-all results in these many patients is the presence of multiple small defects in the coagulation mechanism, differing in kind and degree from one patient to another. It is possible that the tendency to bleed results from the summation of small defects none of which would by itself interfere with hemostasis.

Summary

1. Patients with severe renal insufficiency frequently develop an abnormal tendency to bleed. A battery of tests of the hemostatic system was performed serially on 27 battle casualties who had severe post-traumatic renal insufficiency.

2. There was no consistent fault found by these tests excepting prolongation of coagulation time and moderate deficiency of prothrombin activity. Most of the patients showed other abnormalities but the time and degree were not consistent.

3. The cause of the bleeding disease in severe renal insufficiency has not been identified.

References

1. Scott, R. Jr., and Crosby, W. H.: Changes In the Coagulation Mechanism Following Wounding and Resuscitation with Stored Blood. A Study of Battle Casualties in Korea. Blood 9: 609-621 (June), 1954. (Chapter 8 in Volume II of this series.)

2. Meroney, W. H., and Herndon, R. F.: The Management of Acute Renal Insufficiency. J. A. M. A. 155: 877-883 (July 3), 1954. (Chapter 5 of this volume.)