1
|
Țichil I, Rus IC, Cenariu D, Fodor L, Mitre I. Blood transfusions in non-major burns patients. Burns 2023; 49:1808-1815. [PMID: 37867053 DOI: 10.1016/j.burns.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/07/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Blood transfusions are essential to treating anaemia of burn injuries. It has recently been observed that patients with non-major burns < 20%TBSA may also develop anaemia requiring transfusion of blood products. Due to the morbidity and mortality rate associated with blood transfusions better understanding of risk factors may guide clinical practices to improve patient care. OBJECTIVE To determine risk factors for transfusion of blood products in patients with non-major burn injuries and assess transfusion practices to establish impact on patient outcome. METHOD Our study included 182 adult patients with non-major burn injuries, < 20%TBSA admitted over a 3-year period at the Department of Plastic Surgery and Burns Unit of the Emergency County Hospital Cluj-Napoca. We analysed patient and injury characteristics: age, gender, %TBSA burn, %FT burn, burn site, mechanism of injury, inhalation injury, Hb lab determinations throughout admission and surgical management. Charlson comorbidities index has been determined based on cardiovascular, neurological, gastrointestinal and renal comorbidities as well as diabetes mellitus. We selected blood transfusions, wound infections and length of hospital stay as outcome for our analysis. RESULTS 37.9% of patients included in our study developed anaemia throughout admission and 7.7% underwent blood transfusions. Mean Hb levels triggering blood transfusions have been recorded at 7.4 (IQR=8.8-9.9) g/dL. Patients who received transfusions were older, presented with higher %TBSA and associated a higher comorbidity index. They also tended to develop coagulopathy and underwent more surgical procedures to achieve wound closure. In transfused patients who associate comorbidities we observed a higher rate of wound infections and longer hospital stay. CONCLUSIONS Patient related comorbidities correlate with higher transfusion rates in non-major burn injuries. Due to the risk associated with the use of blood products decision to transfuse should adhere to current guideline practices and be tailored to specific patient requirements.
Collapse
Affiliation(s)
- Ioana Țichil
- University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj Napoca, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; Emergency County Hospital, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania; Department of Haematology "Ion Chiricuta" Institute of Oncology, 34-36 Republicii Street, Cluj-Napoca 400015, Romania.
| | - Ioana Codruta Rus
- Department of Haematology "Ion Chiricuta" Institute of Oncology, 34-36 Republicii Street, Cluj-Napoca 400015, Romania
| | - Diana Cenariu
- University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj Napoca, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; MEDFUTURE - Research Centre for Advanced Medicine, 8 Louis Pasteur Street, 400347 Cluj-Napoca, Romania
| | - Lucian Fodor
- Emergency County Hospital, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Ileana Mitre
- University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj Napoca, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; Emergency County Hospital, 3-5 Clinicilor Street, 400006 Cluj-Napoca, Romania
| |
Collapse
|
2
|
Souto J, Rodrigues AG. Reducing Blood Loss in a Burn Care Unit: A Review of Its Key Determinants. J Burn Care Res 2023; 44:459-466. [PMID: 36106386 DOI: 10.1093/jbcr/irac114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with a major burn injury differ considerably from the typical critical ill and trauma population. Very often, burn patients suffer from anemia throughout their hospital stay. This is caused both by combination of persistent blood loss with decreased erythropoiesis. Therefore, burn patients do have major transfusion requirements. However, transfusion is not devoid of risks or costs. We hereby review the best surgical techniques and medical approaches, aiming to reduce blood loss in a burn patient and optimize red cell production, so that we can reduce the need of RBC transfusion. The implementation of a combination of surgical techniques aiming to reduce blood loss and medical care approaches to prevent anemia, rather than single attitudes, should be adopted in burn care. There is an urgent need for clear guidelines that can easily be accepted, applied, and spread across different burn units to methodically implement measures to reduce blood loss and transfusion needs, and ultimately improve burn patients' outcome and the health care financial status.
Collapse
Affiliation(s)
- João Souto
- Faculty of Medicine, University of Porto, Portugal
| | - Acacio Goncalves Rodrigues
- Burn Unit and Department of Plastic and Reconstructive Surgery, Faculty of Medicine, S. João University Hospital Center, Porto, Portugal.,CINTESIS@RISE, Faculty of Medicine, University of Porto, Portugal
| |
Collapse
|
3
|
Peng C, Yang F, Yu J, Chen C, He J, Jin Z. Temporal trends, predictors of blood transfusion and in-hospital outcomes among patients with severe burn injury in the United States-A national database-based analysis. Transfusion 2022; 62:1537-1550. [PMID: 35789008 DOI: 10.1111/trf.16999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/13/2022] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Severe burn can be accompanied by life-threatening bleeding on some occasions, thus, blood transfusion is often required in these patients during their hospitalization. Therefore, we aimed to examine temporal trends, predictors, and in-hospital outcomes of blood transfusion in these patients in the United States. METHODS The National Inpatient Sample was used to identify severe burn patients between January 2010 and September 2017 in the United States. Trends in the utilization of blood transfusion were analyzed using the Cochran-Armitage trend test. Moreover, propensity score matching (PSM) was employed, and then in-hospital outcomes were compared between these two groups in the matched cohort. Multivariable logistic regressions were further used to validate the results of PSM. RESULTS Among 27,260 severe burn patients identified during the study period, 2120 patients (7.18%) received blood transfusion. Blood transfusion rates decreased significantly from 9.52% in 2010 to 5.02% in 2017 (p for trend <.001). In the propensity-matched cohort (2120 pairs with and without transfusion), patients transfused were at increased risk of in-hospital mortality (13.3% vs 8.77%, p < .001), overall postoperative complications (88.3% vs 72.59%, p < .001), longer hospital stays (defined as > median hospital stays = 5 d) (73.8% vs 50.6%, p < .001) and increased overall cost (defined as > median overall costs = 30,746) (81.6% vs 57.3%, p < .001). This was also the case for the multivariable analysis. CONCLUSIONS Blood transfusion following severe burn injury may be associated with worse clinical outcomes. The utility for blood transfusion in burn patients warrants further prospective exploration.
Collapse
Affiliation(s)
- Chi Peng
- Department of Health Statistics, The Second Military Medical University, Shanghai, China
| | - Fan Yang
- Department of Plastic Surgery and Burns, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China.,Institute of Pathology and Southwest Cancer Center, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Jian Yu
- Department of Health Statistics, The Second Military Medical University, Shanghai, China
| | - Chenxin Chen
- Department of Health Statistics, The Second Military Medical University, Shanghai, China
| | - Jia He
- Department of Health Statistics, The Second Military Medical University, Shanghai, China
| | - Zhichao Jin
- Department of Health Statistics, The Second Military Medical University, Shanghai, China
| |
Collapse
|
4
|
Akkoç MF, Bülbüloğlu S. Investigation of red cell distribution width as a prognostic criterion in severe burns. Int Wound J 2021; 19:1428-1437. [PMID: 34904354 PMCID: PMC9493245 DOI: 10.1111/iwj.13736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/16/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022] Open
Abstract
This study was conducted to examine red cell distribution width (RDW) as a prognostic criterion in severe burns. The study is a descriptive correlational study and was carried out retrospectively. Patients with high RDW and low albumin values among severe burn injuries in the burn unit of a university hospital constituted half of the sample. Severe burns with RDW within normal range and a prognostic criterion for which albumin level normal and closest to normal accounted for the other half. RDW and albumin values were compared with the clinical results of patients with severe burns. IBM SPSS (Statistical Package for the Social Sciences) Statistics 25 was used for data analysis. Of the burn patients, 38.33% were between the age of 65–80, 51.67% were men, and 92.5% had third‐degree burns. The mean albumin level of the patients was 2.39 ± 0.34 g/dL, and the mean RDW level was 18.47 ± 6.15%. The length of the stay in the intensive care unit was 13.45 ± 7.83 days, and the duration of central venous catheter use was 23.41 ± 8.25 days. High RDW and low albumin values were found to be associated with death, length of stay in the intensive care unit, and more blood transfusion. High RDW and hypoalbuminemia significantly affect the clinical results of severe burns. Both parameters are effective in determining the clinical course of burn patients, the length of hospital stay, presence of catheters and medication treatment protocol.
Collapse
Affiliation(s)
- Mehmet Fatih Akkoç
- Division of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
| | - Semra Bülbüloğlu
- Division of Surgical Nursing, Nursing Department, Faculty of Health Sciences, Istanbul Aydin University, Istanbul, Turkey
| |
Collapse
|
5
|
Experience of outreach in a resource-constrained environment: 10 years of outcomes in burn care. Burns 2021; 47:1656-1664. [PMID: 33642122 DOI: 10.1016/j.burns.2021.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/09/2020] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The objective of this work was to describe an efficient and sustainable outreach model in a resource-constrained environment, with a multifaceted approach focusing on national policy change, telemedicine, injury prevention, education and treatment of burns. SUMMARY BACKGROUND DATA Burn injury constitutes a significant portion of morbidity and mortality worldwide, particularly in children, and in low- and middle-income countries. METHODS We reviewed the impact of ten-years of a burn outreach program. Our focus was on clinical data on burn care within one region of Ukraine. We assessed knowledge of burn prevention/first aid utilizing a large survey, analyzed clinical data from our outreach clinic and telemedicine program, and analyzed data within a newly created burn repository within Ukraine. RESULTS A national burn prevention policy has been implemented through our efforts along with a burn prevention program. Educational efforts have led to improvements of major complication rates (wound infection [7% vs. 16%], pneumonia [2.4% vs. 0.3%], sepsis [1.6% vs. 0.6%], UTI [2% vs. 0.6%], and cellulitis [11% vs. 3.4%]), respiratory support of acutely ill patients [1.3% vs. 0.4%], and blood transfusion triggers. CONCLUSIONS Broadly, our model could be an example of building sustainable outreach programs in resource-constrained environments. Through collaboration with local healthcare providers, we have developed and implemented an outreach program in a resource-constrained environment.
Collapse
|
6
|
Treatment of Anaemia in Patients with Acute Burn Injury: A Study of Blood Transfusion Practices. J Clin Med 2021; 10:jcm10030476. [PMID: 33514060 PMCID: PMC7865424 DOI: 10.3390/jcm10030476] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/25/2021] [Accepted: 01/25/2021] [Indexed: 12/24/2022] Open
Abstract
Objective: To determine blood transfusion practices, risk factors, and outcomes associated with the use of blood products in the setting of the acute management of burn patients at the Victorian Adult Burn Service. Background: Patients with burn injuries have variable transfusion requirements, based on a multitude of factors. We reviewed all acute admissions to the Victorian Adult Burns Service (VABS) between 2011 and 2017: 1636 patients in total, of whom 948 had surgery and were the focus of our analysis. Method and results: Patient demographics, surgical management, transfusion details, and outcome parameters were collected and analyzed. A total of 175 patients out of the 948 who had surgery also had a blood transfusion, while 52% of transfusions occurred in the perioperative period. The median trigger haemoglobin in perioperative was 80mg/dL (IQR = 76–84.9 mg/dL), and in the non-perioperative setting was 77 mg/dL (IQR = 71.61–80.84 mg/dL). Age, gender, % total body surface area (TBSA) burn, number of surgeries, and intensive care unit and hospital length of stay were associated with transfusion. Conclusions: The use of blood transfusions is an essential component of the surgical management of major burns. As observed in our study, half of these transfusions are related to surgical procedures and may be influenced by the employment of blood conserving strategies. Furthermore, transfusion trigger levels in stable patients may be amenable to review and reduction. Risk adjusted analysis can support the implementation of blood transfusion as a useful quality indicator in burn care.
Collapse
|
7
|
Faria JCP, Cansian B, Arruda ÉEC, Victorino CA, Szulman A. Prescription of red cell concentrates by emergency physicians. ACTA ACUST UNITED AC 2020; 66:466-471. [PMID: 32578780 DOI: 10.1590/1806-9282.66.4.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/24/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the adequacy of the prescription of red cell concentrates by emergency physicians. METHODS A cross-sectional study based on the survey of transfusion requests records completed by emergency physicians, from May/2018 to April/2019, in an emergency hospital. Adequacy in the indication, volume, and subtype (filtered, irradiated, and washed) of prescribed erythrocytes were evaluated. To compare the qualitative data, we used the χ2 test. The significance level adopted was 5%. RESULTS One thousand and twenty-two transfusions were evaluated. The indication, volume, and subtypes were correct in 72.7%, 45.9%, and 81.6% respectively. Transfusion in symptomatic patients presented superior adequacy when compared to asymptomatic individuals with significant statistical difference (indication: 79,6% vs 67.2%, p <0.001; Volume: 63.5% vs 31.7%, p <0.001; subtype: 85.3% vs 78.7%, p 0.006). Among clinical situations, there were more errors in sepsis (39.7%) and pneumonia (36.3%). More than half of the prescriptions presented excessive volume, raising the risk of circulatory overload, observing that the mean age was 60.6 years. The specific analysis of the prescribed subtypes showed adequacy of 17.9% in the filtered, 1.7% in the irradiated, and none in the washed. Thirty transfusions should have been filtered, but the prescriber did not request the subtype. CONCLUSION One hypothesis for the observed inaccuracies is inadequate medical training on the subject, both in undergraduate and medical residency, associated with a lack of continuing education on transfusion protocols. The transfusion Committee received the results of this study with a proposal for continuing education measures on transfusion hemotherapy.
Collapse
Affiliation(s)
- João Carlos Pina Faria
- . Mestre em Ciências da Saúde pela Faculdade de Medicina do ABC , Santo André , SP , Brasil.,. Médico preceptor do Centro Universitário Saúde ABC ( Faculdade de Medicina do ABC ), Santo André , SP , Brasil.,. Docente do curso de Medicina da Universidade Nove de Julho , São Paulo , SP , Brasil
| | - Bianca Cansian
- . Discente do curso de Medicina da Universidade Nove de Julho , São Paulo , SP , Brasil
| | - Éric Edmur Camargo Arruda
- . Docente do curso de Medicina da Universidade Nove de Julho , São Paulo , SP , Brasil.,. Mestre em Ciências da Reabilitação pela Universidade Nove de Julho , São Paulo , SP , Brasil
| | - Camila Augusta Victorino
- . Mestre em Ciências da Saúde pela Faculdade de Medicina do ABC , Santo André , SP , Brasil.,. Médica docente do curso de Medicina da Universidade Nove de Julho . São Paulo , SP , Brasil
| | - Alexandre Szulman
- . Médico hematologista da Colsan ( Associação Beneficente de Coleta de Sangue ), São Paulo , SP , Brasil.,. Responsável técnico da agência transfusional do Hospital e Pronto-Socorro Central de São Bernardo do Campo , São Bernardo do Campo , SP , Brasil
| |
Collapse
|
8
|
Abstract
Background: Blood product transfusion has historically been utilized after major burn injury in the resuscitative as well as the acute phase. Transfusion has been implicated in infection and immunosuppression in many disease states. Recommendations for blood product transfusion has varied, but several landmark studies have helped define optimal burn transfusion strategies with respect to infection. The purpose of this article is to review the evidence describing the relation between transfusion and infection in burn injury during different phases of burn treatment to identify optimal transfusion strategies and suggest future targets for transfusion research in burns. Methods: This article presents the history, current status, and future research directions related to blood and blood product transfusion in burn injury. Results: Patients with burns are subject to infectious complications resulting from the loss of skin and burn-related immunosuppression. The use of blood in burn treatment has varied during both the resuscitative phase and the acute treatment phase. Whole-blood use in resuscitation was replaced with crystalloid infusion. Future trials are examining the role of plasma and albumin in burn resuscitation. A randomized prospective multicenter transfusion trial was able to decrease transfusion by 50% with no change in infection. Further examination of the role of hemostatic resuscitation in burn excision may help to better define transfusion goals. Conclusions: Blood product transfusion in burn injury has varied throughout the last century. Although advances in the understanding of blood transfusion in burn injury have occurred, initiatives to define optimal care better are required.
Collapse
Affiliation(s)
- Tina L Palmieri
- Department of Surgery, University of California, Davis, Sacramento, California, USA
- Shriners Hospital for Children Northern California, Sacramento, California, USA
| |
Collapse
|
9
|
Blears E, Sommerhalder C, Toliver-Kinsky T, Finnerty CC, Herndon DN. Current problems in burn immunology. Curr Probl Surg 2020; 57:100779. [PMID: 32507131 DOI: 10.1016/j.cpsurg.2020.100779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/22/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Elizabeth Blears
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Tracy Toliver-Kinsky
- Department of Anesthesiology, Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX.
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children, Galveston, TX
| | | |
Collapse
|
10
|
Increased risk of blood transfusion in patients with diabetes mellitus sustaining non-major burn injury. Burns 2019; 46:888-896. [PMID: 31848083 DOI: 10.1016/j.burns.2019.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/01/2019] [Accepted: 10/20/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Due to the increased mortality and morbidity associated with blood transfusion, identifying modifiable predictors of transfusion are vital to prevent or minimise blood use. We hypothesised that burn patients with diabetes mellitus were more likely to be prescribed a transfusion. These patients tend to have increased age, number of comorbidities, infection risk and need for surgery which are all factors reported previously to be associated with blood use. OBJECTIVE To determine whether patients with diabetes mellitus who have sustained a burn ≤20% total body surface area (TBSA) are at higher risk of receiving red blood cell transfusion compared to those without diabetes mellitus. METHOD This was a retrospective cohort study including patients admitted to the major Burns Unit in Western Australia for management of a burn injury. Only the first hospital admission between May 2008 to February 2017 were included. RESULTS Among 2101 patients with burn injuries ≤20% TBSA, 48 (2.3%) received packed red blood cells and 169 (8.0%) had diabetes. There were 13 (7.7%) diabetic patients that were transfused versus 35 (1.8%) non-diabetic patients. Patients with diabetes were 5.2 (p = 0.034) times more likely to receive packed red blood cells after adjusting for percentage TBSA, haemoglobin at admission or prior to transfusion, number of surgeries, total comorbid burden and incidence of infection. As percentage TBSA increases, the probability of packed red blood cell transfusion increases at a higher rate in DM patients. CONCLUSIONS This study showed that diabetic patients with burn injuries ≤20% TBSA have a higher probability of receiving packed red blood cell transfusion compared to patients without diabetes. This effect was compounded in burns with higher percentage TBSA.
Collapse
|
11
|
Palmieri TL, Holmes JH, Arnoldo B, Peck M, Cochran A, King BT, Dominic W, Cartotto R, Bhavsar D, Tredget E, Stapelberg F, Mozingo D, Friedman B, Sen S, Taylor SL, Pollock BH. Restrictive Transfusion Strategy Is More Effective in Massive Burns: Results of the TRIBE Multicenter Prospective Randomized Trial. Mil Med 2019; 184:11-15. [PMID: 30371811 DOI: 10.1093/milmed/usy279] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/24/2018] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Studies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20-59% TBSA) burn using a restrictive or a liberal blood transfusion strategy. METHODS Patients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin <7 g/dL) or liberal (transfuse hemoglobin <10 g/dL) strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. RESULTS Three hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 ± 47.63 vs. 77.16 ± 55.0, p < 0.03 massive; 11.0 ± 16.70 vs. 16.78 ± 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20-59%) group (p > 0.05). CONCLUSIONS A restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing.
Collapse
Affiliation(s)
- Tina L Palmieri
- University of California Davis and Shriners Hospital for Children Northern California, 2425 Stockton Boulevard, Suite 718, Sacramento, CA
| | - James H Holmes
- Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Medical Center Blvd Winston-Salem, NC
| | - Brett Arnoldo
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX
| | - Michael Peck
- The Arizona Burn Center, The Arizona Burn Center and University of Arizona College of Medicine, 2601 E Roosevelt St, Phoenix, AZ
| | - Amalia Cochran
- University of Utah Department of Surgery, 50N Medical Dr, Salt Lake City, UT
| | - Booker T King
- Institute of Surgical Research, 3851 Roger Brooke Dr, Dept 2 Bld, San Antonio, TX
| | - William Dominic
- Community Regional Medical Center, 2823 Fresno St, Fresno, CA
| | - Robert Cartotto
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue D Wing, Room 712, Toronto, ON
| | - Dhaval Bhavsar
- Kansas University Medical Center, 3901 Rainbow Blvd, Kansas City, KS
| | - Edward Tredget
- University of Alberta, 2D, Walter C Mackenzie Health Sciences Centre - 8440 - 112 Street University of Alberta, Edmonton, Alberta, Canada
| | - Francois Stapelberg
- New Zealand National Burn Centre, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland, New Zealand
| | - David Mozingo
- University of Florida Health Science Center, 1600 SW Archer Rd, Room 7209 Gainesville, FL
| | | | - Soman Sen
- University of California Davis and Shriners Hospital for Children Northern California, 2425 Stockton Boulevard, Suite 718, Sacramento, CA
| | - Sandra L Taylor
- Department of Public Health Sciences, University of California Davis, Medical Sciences 1C, Room 104 University of California, Davis One Shields Avenue, Davis, CA
| | - Brad H Pollock
- Department of Public Health Sciences, University of California Davis, Medical Sciences 1C, Room 104 University of California, Davis One Shields Avenue, Davis, CA
| |
Collapse
|
12
|
Sen S, Hsei L, Tran N, Romanowski K, Palmieri T, Greenhalgh D, Cho K. Early clinical complete blood count changes in severe burn injuries. Burns 2019; 45:97-102. [DOI: 10.1016/j.burns.2018.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/23/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
|
13
|
Ho CWG, Kok YO, Chong SJ. Photographic evaluation of different adrenaline-containing tumescent solutions on skin graft donor site bleeding: A prospective randomised trial. Burns 2018; 44:2018-2025. [DOI: 10.1016/j.burns.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/18/2018] [Accepted: 03/09/2018] [Indexed: 12/30/2022]
|
14
|
Farny B, Fontaine M, Latarjet J, Poupelin J, Voulliaume D, Ravat F. Estimation of blood loss during adult burn surgery. Burns 2018; 44:1496-1501. [DOI: 10.1016/j.burns.2018.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 03/31/2018] [Accepted: 04/27/2018] [Indexed: 12/17/2022]
|
15
|
Carneiro JMGVDM, Alves J, Conde P, Xambre F, Almeida E, Marques C, Luís M, Godinho AMMG, Fernandez-Llimos F. Factor XIII-guided treatment algorithm reduces blood transfusion in burn surgery. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29269148 PMCID: PMC9391805 DOI: 10.1016/j.bjane.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background and objectives Major burn surgery causes large hemorrhage and coagulation dysfunction. Treatment algorithms guided by ROTEM® and factor VIIa reduce the need for blood products, but there is no evidence regarding factor XIII. Factor XIII deficiency changes clot stability and decreases wound healing. This study evaluates the efficacy and safety of factor XIII correction and its repercussion on transfusion requirements in burn surgery. Methods Randomized retrospective study with 40 patients undergoing surgery at the Burn Unit, allocated into Group A those with factor XIII assessment (n = 20), and Group B, those without assessment (n = 20). Erythrocyte transfusion was guided by a hemoglobin trigger of 10 g.dL−1 and the other blood products by routine coagulation and ROTEM® tests. Analysis of blood product consumption included units of erythrocytes, fresh frozen plasma, platelets, and fibrinogen. The coagulation biomarker analysis compared the pre- and post-operative values. Results and conclusions Group A (with factor XIII study) and Group B had identical total body surface area burned. All patients in Group A had a preoperative factor XIII deficiency, whose correction significantly reduced units of erythrocyte concentrate transfusion (1.95 vs. 4.05, p = 0.001). Pre- and post-operative coagulation biomarkers were similar between groups, revealing that routine coagulation tests did not identify factor XIII deficiency. There were no recorded thromboembolic events. Correction of factor XIII deficiency in burn surgery proved to be safe and effective for reducing perioperative transfusion of erythrocyte units.
Collapse
|
16
|
Algoritmo de tratamento guiado pelo fator XIII reduz a transfusão sanguínea na cirurgia de queimados. Braz J Anesthesiol 2018; 68:238-243. [DOI: 10.1016/j.bjan.2017.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/30/2017] [Accepted: 11/20/2017] [Indexed: 11/19/2022] Open
|
17
|
A Severely Burned Hemophiliac. J Burn Care Res 2018; 38:e456-e459. [PMID: 27058584 DOI: 10.1097/bcr.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients suffering from moderate or severe hemophilia A are particularly vulnerable to trauma injury, being on high risk of immediate exsanguination. Due to a rareness of this disease, there are very few reports about the management of severe injuries of the affected patients. No guidelines for the management of burn trauma of hemophiliac patients have been yet established. Since, to our knowledge, this is the first case report about a successful treatment of a severely burned hemophiliac, requiring intensive care, long-time intubation, and multiple epifascial necrosectomies of third grade wounds, the authors are proposing the approach to this condition. The factor VIII has been substituted, enhancing its activity to over 70% during the planned interventions and keeping it above 30% in the intervals between the operations. To minimize the risk of surgical bleeding, our therapeutic strategy consisted of multiple short radical operations. The patient was healed and was dismissed after 68 days. The surgical blood loss was comparable with noncoagulopathic patients with similar burn extension. In case of a vast burn injury of the moderate or severe hemophiliacs, where the trauma-related consumption coagulopathy is expected and deep necrosectomies are required, the authors suggest starting a substitution of the factor VIII immediately after the admission, followed by a structured operative planning.
Collapse
|
18
|
Blood transfusion in burn patients: Triggers of transfusion in a referral burn center in Iran. Transfus Clin Biol 2018; 25:58-62. [DOI: 10.1016/j.tracli.2017.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/07/2017] [Indexed: 11/19/2022]
|
19
|
Palmieri TL, Holmes JH, Arnoldo B, Peck M, Potenza B, Cochran A, King BT, Dominic W, Cartotto R, Bhavsar D, Kemalyan N, Tredget E, Stapelberg F, Mozingo D, Friedman B, Greenhalgh DG, Taylor SL, Pollock BH. Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury. Ann Surg 2017; 266:595-602. [PMID: 28697050 PMCID: PMC5848498 DOI: 10.1097/sla.0000000000002408] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality. BACKGROUND Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown. METHODS This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7-8 g/dL) or liberal (hemoglobin 10-11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. RESULTS Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 ± 32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 ± 44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, χ test). CONCLUSIONS A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).
Collapse
Affiliation(s)
- Tina L Palmieri
- *Department of Surgery, University of California Davis and Shriners Hospital for Children Northern California, Sacramento, CA †Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC ‡Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX §Department of Surgery, The Arizona Burn Center, The Arizona Burn Center and University of Arizona College of Medicine, Phoenix, AZ ¶Department of Surgery, University of California San Diego, San Diego, CA ||Department of Surgery, University of Utah, Salt Lake City, UT **Department of Surgery, Institute of Surgical Research, San Antonio, TX ††Department of Surgery, Community Regional Medical Center, Fresno, CA ‡‡Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada §§Department of Surgery, Kansas University Medical Center, Kansas City, KS ¶¶Department of Surgery, Oregon Burn Center, Portland, OR ||||Department of Surgery, University of Alberta, Edmonton, AB, Canada ***Department of Anesthesia, New Zealand National Burn Centre, Middlemore Hospital, Middlemore, New Zealand †††Department of Surgery, University of Florida Health Science Center, Gainesville, FL ‡‡‡Department of Surgery, JM Still Burn Center, Augusta, GA §§§Department of Public Health Sciences, University of California Davis, Sacramento, CA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Hasan S, Johnson NB, Mosier MJ, Shankar R, Conrad P, Szilagyi A, Gamelli RL, Muthumalaiappan K. Myelo-erythroid commitment after burn injury is under β-adrenergic control via MafB regulation. Am J Physiol Cell Physiol 2016; 312:C286-C301. [PMID: 28031160 PMCID: PMC5401945 DOI: 10.1152/ajpcell.00139.2016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 12/22/2016] [Accepted: 12/22/2016] [Indexed: 12/12/2022]
Abstract
Severely injured burn patients receive multiple blood transfusions for anemia of critical illness despite the adverse consequences. One limiting factor to consider alternate treatment strategies is the lack of a reliable test platform to study molecular mechanisms of impaired erythropoiesis. This study illustrates how conditions resulting in a high catecholamine microenvironment such as burns can instigate myelo-erythroid reprioritization influenced by β-adrenergic stimulation leading to anemia. In a mouse model of scald burn injury, we observed, along with a threefold increase in bone marrow LSK cells (linneg Sca1+cKit+), that the myeloid shift is accompanied with a significant reduction in megakaryocyte erythrocyte progenitors (MEPs). β-Blocker administration (propranolol) for 6 days after burn, not only reduced the number of LSKs and MafB+ cells in multipotent progenitors, but also influenced myelo-erythroid bifurcation by increasing the MEPs and reducing the granulocyte monocyte progenitors in the bone marrow of burn mice. Furthermore, similar results were observed in burn patients' peripheral blood mononuclear cell-derived ex vivo culture system, demonstrating that commitment stage of erythropoiesis is impaired in burn patients and intervention with propranolol (nonselective β1,2-adrenergic blocker) increases MEPs. Also, MafB+ cells that were significantly increased following standard burn care could be mitigated when propranolol was administered to burn patients, establishing the mechanistic regulation of erythroid commitment by myeloid regulatory transcription factor MafB. Overall, results demonstrate that β-adrenergic blockers following burn injury can redirect the hematopoietic commitment toward erythroid lineage by lowering MafB expression in multipotent progenitors and be of potential therapeutic value to increase erythropoietin responsiveness in burn patients.
Collapse
Affiliation(s)
- Shirin Hasan
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, Illinois; and.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, Illinois
| | - Nicholas B Johnson
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, Illinois; and.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, Illinois
| | - Michael J Mosier
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, Illinois; and.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, Illinois
| | - Ravi Shankar
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, Illinois; and.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, Illinois
| | - Peggie Conrad
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, Illinois; and.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, Illinois
| | - Andrea Szilagyi
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, Illinois
| | - Richard L Gamelli
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, Illinois; and.,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, Illinois
| | - Kuzhali Muthumalaiappan
- Department of Surgery, Loyola University Chicago, Health Sciences Division, Maywood, Illinois; and .,Burn and Shock Trauma Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, Illinois
| |
Collapse
|
21
|
Wu G, Zhuang M, Fan X, Hong X, Wang K, Wang H, Chen Z, Sun Y, Xia Z. Blood transfusions in severe burn patients: Epidemiology and predictive factors. Burns 2016; 42:1721-1727. [PMID: 27576934 DOI: 10.1016/j.burns.2016.06.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/20/2016] [Accepted: 06/02/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Blood is a vital resource commonly used in burn patients; however, description of blood transfusions in severe burns is limited. The purpose of this study was to describe the epidemiology of blood transfusions and determine factors associated with increased transfusion quantity. METHODS This is a retrospective study of total 133 patients with >40% total body surface area (TBSA) burns admitted to the burn center of Changhai hospital from January 2008 to December 2013. The study characterized blood transfusions in severe burn patients. Univariate and Multivariate regression analyses were used to evaluate the association of clinical variables with blood transfusions. RESULTS The overall transfusion rate was 97.7% (130 of 133). The median amount of total blood (RBC and plasma), RBC and plasma transfusions was 54 units (Interquartile range (IQR), 20-84), 19 units (IQR, 4-37.8) and 28.5 units (IQR, 14.8-51.8), respectively. The number of RBC transfusion in and outside operation room was 7 (0, 14) and 11 (2, 20) units, and the number of plasma was 6 (0.5, 12) and 21 (11.5, 39.3) units. A median of one unit of blood was transfused per TBSA and an average of 4 units per operation was given in the series. The consumption of plasma is higher than that of RBC. On multivariate regression analysis, age, full-thickness TBSA and number of operations were significant independent predictors associated with the number of RBC transfusion, and coagulopathy and ICU length showed a trend toward RBC consumption. Predictors for increased plasma transfusion were female, high full-thickness TBSA burn and more operations. CONCLUSIONS Severe burn patients received an ample volume of blood transfusions. Fully understanding of predictors of blood transfusions will allow physicians to better optimize burn patients during hospitalization in an effort to use blood appropriately.
Collapse
Affiliation(s)
- Guosheng Wu
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Mingzhu Zhuang
- Department of Blood Transfusion, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Xiaoming Fan
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Xudong Hong
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Kangan Wang
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - He Wang
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Zhengli Chen
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Yu Sun
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Zhaofan Xia
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| |
Collapse
|
22
|
Koljonen V, Tuimala J, Haglund C, Tukiainen E, Vuola J, Juvonen E, Lauronen J, Krusius T. The Use of Blood Products in Adult Patients with Burns. Scand J Surg 2016; 105:178-85. [DOI: 10.1177/1457496915622127] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/11/2015] [Indexed: 11/15/2022]
Abstract
Introduction: Burn anemia represents a common complication following a burn injury. Burn anemia etiology carries distinct features occurring at each stage of the post-injury and treatment periods resulting from different causes. We aimed to analyze the use of blood components in Finnish burn victims and to identify patient- and injury-related factors influencing their use. Methods: To study the use of blood products in burn patients, we used data collected from the Optimal Use of Blood registry, developed through co-operation between 10 major hospital districts and the Finnish Red Cross Blood Service. Burn patients ⩾18 years treated at the Helsinki University Hospital between 2005 and 2011 with an in-hospital stay ⩾1 day who received at least one transfusion during their hospital stay were included in this study. Results: Among all 558 burn patients, 192 (34%) received blood products during their hospital stay. The transfused cohort comprised 192 burn patients. The study cohort received a total of 6087 units of blood components, 2422 units of leukoreduced red blood cells, 1728 units of leukoreduced platelets, and 420 units of single-donor fresh frozen plasma or, after 2007, 1517 units of Octaplas® frozen plasma. All three types of blood components were administered to 29% of patients, whereas 45% received only red blood cells and 6% received only Octaplas. Transfused patients were significantly older (p < 0.001), experienced fire-/flame-related accidents and burns to multiple locations (p < 0.001), and their in-hospital mortality exceeded that for non-transfused burn patients fivefold (p < 0.05). Discussion: We show that Finnish adult burn patients received ample transfusions. The number of blood components transfused varied according to the anatomical location of the injury and patient survival. Whether the additional mortality is related directly to transfusions or is merely a manifestation of the more severe burn injury remains unknown.
Collapse
Affiliation(s)
- V. Koljonen
- Department of Plastic Surgery, University of Helsinki and Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | | | - C. Haglund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Programs Unit, Translational Cancer Biology, University of Helsinki, Helsinki, Finland
| | - E. Tukiainen
- Department of Plastic Surgery, University of Helsinki and Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - J. Vuola
- Department of Plastic Surgery, University of Helsinki and Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - E. Juvonen
- Finnish Red Cross Blood Service, Helsinki, Finland
| | - J. Lauronen
- Clinical Consultations Unit, Finnish Red Cross Blood Service, Helsinki, Finland
| | - T. Krusius
- Finnish Red Cross Blood Service, Helsinki, Finland
| |
Collapse
|
23
|
Impact of Anemia in Critically Ill Burned Casualties Evacuated From Combat Theater via US Military Critical Care Air Transport Teams. Shock 2016; 44 Suppl 1:50-4. [PMID: 25643014 DOI: 10.1097/shk.0000000000000336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND US military Critical Care Air Transport Teams (CCATT) transport critically ill burn patients out of theater. Blood transfusion may incur adverse effects, and studies report lower hemoglobin (Hgb) value may be safe for critically ill patients. There are no studies evaluating the optimal Hgb value for critically ill burn patients prior to CCATT evacuation. OBJECTIVE The aim of the study was to determine if critically ill burn casualties with an Hgb of 10 g/dL or less, transported via CCATT, have similar clinical outcomes at 30 days as compared with patients with an Hgb of greater than 10 g/dL. METHODS We conducted an institutional review board-approved retrospective cohort study involving patients transported via CCATT. We separated our study population into two cohorts based on Hgb levels at the time of theater evacuation: Hgb ≤10 g/dL or Hgb ≥10 g/dL. We compared demographics, injury description, physiologic parameters, and clinical outcomes. RESULTS Of the 140 subjects enrolled, 29 were Hgb ≤10, and 111 were Hgb ≥10. Both groups were similar in age and percent total body surface area burned. Those Hgb ≤10 had a higher injury severity score (34 ± 19.8 vs. 25 ± 16.9, P = 0.02) and were more likely to have additional trauma (50% vs. 25%, P = 0.04). Modeling revealed no persistent differences in mortality, and other clinical outcomes measured. CONCLUSIONS Critical Care Air Transport Teams transport of critically ill burn patients with an Hgb of 10 g/dL or less had no significant differences in complications or mortality as compared with patients with an Hgb of greater than 10 g/dL. In this study, lower hemoglobin levels did not confer greater risk for worse outcomes.
Collapse
|
24
|
Johnson NB, Posluszny JA, He LK, Szilagyi A, Gamelli RL, Shankar R, Muthumalaiappan K. Perturbed MafB/GATA1 axis after burn trauma bares the potential mechanism for immune suppression and anemia of critical illness. J Leukoc Biol 2016; 100:725-736. [PMID: 26992433 DOI: 10.1189/jlb.1a0815-377r] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 03/01/2016] [Indexed: 12/18/2022] Open
Abstract
Patients who survive initial burn injury are susceptible to nosocomial infections. Anemia of critical illness is a compounding factor in burn patients that necessitates repeated transfusions, which further increase their susceptibility to infections and sepsis. Robust host response is dependent on an adequate number and function of monocytes/macrophages and dendritic cells. In addition to impaired RBC production, burn patients are prone to depletion of dendritic cells and an increase in deactivated monocytes. In steady-state hematopoiesis, RBCs, macrophages, and dendritic cells are all generated from a common myeloid progenitor within the bone marrow. We hypothesized in a mouse model of burn injury that an increase in myeloid-specific transcription factor V-maf musculoaponeurotic fibrosarcoma oncogene homolog B at the common myeloid progenitor stage steers their lineage potential away from the megakaryocyte erythrocyte progenitor production and drives the terminal fate of common myeloid progenitors to form macrophages vs. dendritic cells, with the consequences being anemia, monocytosis, and dendritic cell deficits. Results indicate that, even though burn injury stimulated bone marrow hematopoiesis by increasing multipotential stem cell production (LinnegSca1poscKitpos), the bone marrow commitment is shifted away from the megakaryocyte erythrocyte progenitor and toward granulocyte monocyte progenitors with corresponding alterations in peripheral blood components, such as hemoglobin, hematocrit, RBCs, monocytes, and granulocytes. Furthermore, burn-induced V-maf musculoaponeurotic fibrosarcoma oncogene homolog B in common myeloid progenitors acts as a transcriptional activator of M-CSFR and a repressor of transferrin receptors, promoting macrophages and inhibiting erythroid differentiations while dictating a plasmacytoid dendritic cell phenotype. Results from small interfering RNA and gain-of-function (gfp-globin transcription factor 1 retrovirus) studies indicate that targeted interventions to restore V-maf musculoaponeurotic fibrosarcoma oncogene homolog B/globin transcription factor 1 balance can mitigate both immune imbalance and anemia of critical illness.
Collapse
Affiliation(s)
| | - Joseph A Posluszny
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Burn and Shock Trauma Research Institute, Loyola University Chicago, Chicago, Illinois, USA; and
| | - Li K He
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Burn and Shock Trauma Research Institute, Loyola University Chicago, Chicago, Illinois, USA; and
| | - Andrea Szilagyi
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Chicago, Illinois, USA; and
| | - Richard L Gamelli
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Burn and Shock Trauma Research Institute, Loyola University Chicago, Chicago, Illinois, USA; and
| | - Ravi Shankar
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Burn and Shock Trauma Research Institute, Loyola University Chicago, Chicago, Illinois, USA; and
| | - Kuzhali Muthumalaiappan
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Burn and Shock Trauma Research Institute, Loyola University Chicago, Chicago, Illinois, USA; and
| |
Collapse
|
25
|
Walsh K, Nikkhah D, Dheansa B. What is the evidence for tranexamic acid in burns? Burns 2014; 40:1055-7. [PMID: 24836822 DOI: 10.1016/j.burns.2014.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 04/19/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Karl Walsh
- The Royal Albert and Edward Infirmary, Wigan Lane, Wigan, Lancashire WN1 2NN, UK.
| | - Dariush Nikkhah
- Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead RH19 3DZ, UK.
| | - Baljit Dheansa
- Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead RH19 3DZ, UK.
| |
Collapse
|
26
|
Musiychuk K, Sivalenka R, Jaje J, Bi H, Flores R, Shaw B, Jones RM, Golovina T, Schnipper J, Khandker L, Sun R, Li C, Kang L, Voskinarian-Berse V, Zhang X, Streatfield S, Hambor J, Abbot S, Yusibov V. Plant-produced human recombinant erythropoietic growth factors support erythroid differentiation in vitro. Stem Cells Dev 2013; 22:2326-40. [PMID: 23517237 PMCID: PMC3730378 DOI: 10.1089/scd.2012.0489] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 03/21/2013] [Indexed: 01/11/2023] Open
Abstract
Clinically available red blood cells (RBCs) for transfusions are at high demand, but in vitro generation of RBCs from hematopoietic stem cells requires significant quantities of growth factors. Here, we describe the production of four human growth factors: erythropoietin (EPO), stem cell factor (SCF), interleukin 3 (IL-3), and insulin-like growth factor-1 (IGF-1), either as non-fused proteins or as fusions with a carrier molecule (lichenase), in plants, using a Tobacco mosaic virus vector-based transient expression system. All growth factors were purified and their identity was confirmed by western blotting and peptide mapping. The potency of these plant-produced cytokines was assessed using TF1 cell (responsive to EPO, IL-3 and SCF) or MCF-7 cell (responsive to IGF-1) proliferation assays. The biological activity estimated here for the cytokines produced in plants was slightly lower or within the range cited in commercial sources and published literature. By comparing EC50 values of plant-produced cytokines with standards, we have demonstrated that all four plant-produced growth factors stimulated the expansion of umbilical cord blood-derived CD34+ cells and their differentiation toward erythropoietic precursors with the same potency as commercially available growth factors. To the best of our knowledge, this is the first report on the generation of all key bioactive cytokines required for the erythroid development in a cost-effective manner using a plant-based expression system.
Collapse
Affiliation(s)
| | | | - Jennifer Jaje
- Fraunhofer USA Center for Molecular Biotechnology, Newark, Delaware
| | - Hong Bi
- Fraunhofer USA Center for Molecular Biotechnology, Newark, Delaware
| | - Rosemary Flores
- Fraunhofer USA Center for Molecular Biotechnology, Newark, Delaware
| | - Brenden Shaw
- Fraunhofer USA Center for Molecular Biotechnology, Newark, Delaware
| | - R. Mark Jones
- Fraunhofer USA Center for Molecular Biotechnology, Newark, Delaware
| | - Tatiana Golovina
- Fraunhofer USA Center for Molecular Biotechnology, Newark, Delaware
| | | | | | - Ruiqiang Sun
- Celgene Cellular Therapeutics, Warren, New Jersey
| | - Chang Li
- Celgene Cellular Therapeutics, Warren, New Jersey
| | - Lin Kang
- Celgene Cellular Therapeutics, Warren, New Jersey
| | | | | | | | - John Hambor
- Celgene Cellular Therapeutics, Warren, New Jersey
| | | | - Vidadi Yusibov
- Fraunhofer USA Center for Molecular Biotechnology, Newark, Delaware
| |
Collapse
|
27
|
Lu RP, Ni A, Lin FC, Ortiz-Pujols SM, Adams SD, Monroe DM, Whinna HC, Cairns BA, Key NS. Major burn injury is not associated with acute traumatic coagulopathy. J Trauma Acute Care Surg 2013; 74:1474-9. [PMID: 23694874 DOI: 10.1097/ta.0b013e3182923193] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The pathophysiology and time course of coagulopathy after major burns are inadequately understood. Our study objectives were to determine whether acute traumatic coagulopathy (ATC) is seen in burn patients at admission and to determine the changes in international normalized ratio (INR), activated partial thromboplastin time (aPTT), platelet count (PLT), and hemoglobin (Hgb) in the first 7 days after injury. METHODS We conducted a retrospective study of patients with burn injury of at least 15% total body surface area who presented to the University of North Carolina. Data on patient demographics, injury characteristics, and laboratory data (INR, aPTT, PLT, and Hgb) at admission and within the first 7 days after injury were recorded. We defined ATC as INR of 1.3 or greater, aPTT of 1.5 or greater times the mean normal limit, and normal PLT at admission. RESULTS We studied the hematologic profile of 102 patients with burn injury of 15% to 100% total body surface area but did not identify a single patient with ATC at admission. The screening hematologic profile at admission was not influenced by burn severity. In the first 7 days after injury, the INR and aPTT were relatively preserved, while the PLT quickly recovered to baseline after an early decline and the Hgb remained stable at around 10 g/dL; all these changes occurred during the time when the burn patients had received large amounts of fluid resuscitation. CONCLUSION The screening hematologic profile of burn patients at admission is normal, and the standard screening assays do not suggest the existence of ATC at admission. While this is a relatively small study, it provides evidence to suggest that ATC is unique to trauma patients. LEVEL OF EVIDENCE Prognostic study, level III.
Collapse
Affiliation(s)
- Rommel P Lu
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Peripheral blood mononuclear cell-derived erythroid progenitors and erythroblasts are decreased in burn patients. J Burn Care Res 2013; 34:133-41. [PMID: 23292581 DOI: 10.1097/bcr.0b013e3182642ccd] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Patients with large burns suffer from anemia of critical illness. Administration of exogenous erythropoietin is ineffective, and transfusion remains the only effective treatment. We have previously shown that erythroid precursors are decreased 1 week after burn in an animal model. Therefore, we have used a two-phase liquid culture system to quantify peripheral blood mononuclear cell (PBMC) compartment-derived erythroid progenitors (EPs) in burn patients. Institutional review board approval and informed consent were obtained. Blood samples were collected at 1 to 30 days after burn, with a mean TBSA of 37.7 ± 15.8% (n = 10; 90% men; age, 46.0 ± 18 years). Four healthy volunteers served as controls. PBMCs were isolated by Ficoll-Hypaque density-gradient centrifugation and were placed in serum-free expansion medium containing cyclosporine A (1 ng/ml), granulocyte macrophage colony-stimulating factor (20 ng/ml), stem cell factor (30 ng/ml), and interleukin-3 (5 ng/ml; phase I). On day 7, cells were reseeded in serum-free expansion medium containing erythropoietin (1 U/ml), holotransferrin (0.3 mg/ml), and stem cell factor (10 ng/ml; phase II). Aliquots from the phase II culture system on day 6 were incubated with anti-CD71, CD235a, and CD36. EPs (CD71 CD36) and erythroblast subpopulations (colony-forming unit erythroids, Proerythroblasts, and intermediate erythroblasts) were identified based on the expressions of CD71 and CD235a by flow cytometry, calculated per million expanded cells, and expressed as a percentage of controls. Total EPs were significantly decreased by days 28 to 31 after the burn (19%; P < .05). Among the erythroblast subpopulations, colony-forming unit erythroids (11%; P < .004) and proerythroblasts (24%; P < .05), were decreased significantly by days 28 to 31 after the burn. PBMCs of burn patients can be used to study impaired erythropoiesis and anemia of critical illness.
Collapse
|
29
|
Lu RP, Lin FC, Ortiz-Pujols SM, Adams SD, Whinna HC, Cairns BA, Key NS. Blood utilization in patients with burn injury and association with clinical outcomes (CME). Transfusion 2012; 53:2212-21; quiz 2211. [PMID: 23278449 DOI: 10.1111/trf.12057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Uncontrolled bleeding is an important cause of increased transfusion in burn victims; however, description of blood utilization patterns in the burn population is lacking. STUDY DESIGN AND METHODS We conducted a single-institution, retrospective cohort study to measure blood utilization in 89 consecutive burn patients with 15% to 65% total body surface area (TBSA) burn within 60 days of injury. We also evaluated the relationship of blood product utilization with clinical variables including anticoagulant usage and mortality. RESULTS We determined that: 1) the predictors for increased red blood cells (RBCs) and plasma transfusions were high TBSA burn and the use of argatroban anticoagulation (for suspected heparin-induced thrombocytopenia [HIT]); 2) TBSA burn and patient age were independent predictors of mortality, but not RBC or plasma transfusion; and 3) the incidence of symptomatic venous thromboembolic events is not uncommon (11.2%), although HIT is rare (1.1%). CONCLUSION Despite concerns about adverse correlation between increased number of transfusions and mortality in other clinical settings, we did not find this association in our study. However, we demonstrated that the type and intensity of anticoagulation carries substantial risk for increased RBC as well as plasma usage.
Collapse
Affiliation(s)
- Rommel P Lu
- Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Biostatistics and North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Surgery, Division of Trauma and Critical Care Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | | | | |
Collapse
|