Effect of blood transfusion on outcome after major burn injury: a multicenter study

Impact of red blood cell transfusion in massive burn: a multicenter cohort study

Blood transfusions were frequently in massive burn patients, current studies focus on the trigger threshold of red blood cell transfusion, and few studies focus on the impact of red blood cell transfusion volume on patient outcomes. We initiated a multicenter cohort study to explore the impact of red blood cell transfusions volume on patient mortality. 379 patients in three centers were enrolled to the cohort. The extroperative and overall RBC transfusion in the death group were significantly higher than those in the survival group (p < 0.001), and this difference became insignificant within the operation (p = 0.312). RBC transfusion volume and mortality risk of patients was obviously not linear (p < 0.0001) and would be L-shaped, and the threshold would be 6U. 1:1propensity matching was used to adjust the burn area, full thickness burned area and inhalation injury. There was no significant difference in the outcome and bloodstream infection between the two groups, but the length of stay, length of stay in burn ICU and mechanical ventilation time of the low red blood cell group were significantly lower than those of the high red blood cell group. Our findings therefore support the approach of a restrictive transfusion strategy in severely burned patients. This also confirms the scientificity of restrictive transfusion strategy and suggests that unnecessary red blood cell transfusion should be avoided in clinic.

Immune cell kinetics after allogeneic red blood cell transfusion in patients undergoing cardiovascular surgery

BACKGROUND AND OBJECTIVES

Recent reports have highlighted that allogeneic blood transfusions decrease immune responses and affect patient outcomes. However, the effects of allogeneic red blood cell transfusions on the composition of immune cells are unclear. We aimed to clarify the alterations in host immune cells in patients who received allogeneic red blood cell transfusions during the perioperative period of cardiovascular surgery.

MATERIALS AND METHODS

Eight non-transfused, 22 intraoperative autotransfusions, and 36 allogeneic red blood cell-transfused patients undergoing surgery were grouped, and lymphocyte subsets were analyzed using flow cytometry. Blood samples collected before surgery, approximately 1-week, and 1-month after surgery were used for analysis. Surgical parameters, operation time, blood loss, and length of hospital stay were also assessed.

RESULTS

The group receiving transfusions showed statistical significance compared to non-transfused in the above-mentioned surgical parameters. When comparing the autologous and allogeneic transfusion groups, only the allogeneic red blood transfusion group had a longer hospital stay. In comparing preoperative and 1-week and 1-month postoperative samples, there were almost no differences in CD4, CD20, or NK counts between the autotransfusions and the allogenic red blood cell transfusion groups. In contrast, a significant decrease in lymphocyte count was observed in the allogenic red blood cell transfused group 1-week postoperatively compared to preoperatively. Moreover, the number of CD8 + cells was statistically lowest in the allogeneic transfusion group 1 week after the operation.

CONCLUSION

Our results suggest that allogeneic red blood cell transfusion could alter immune cell composition especially CD8 + cells, potentially impacting immune function.

Burns in South Asia: Outcomes from South Asian Burn Registry (SABR)

BACKGROUND

South Asian region contributes 59 % to the global mortality due to burns. However, we find a paucity of literature on the outcomes of burns from low- and middle-income countries (LMICs). South Asian Burn Registry (SABR) is a facility-based burns registry that collected data on in-patient burn care. This study assesses factors associated with mortality, length of hospital stay at the burns center, and functional status of burn patients.

METHODS

Prospective data was collected from two specialized public sector burn centers between September 2014 - January 2015 from Bangladesh and Pakistan. Multivariable logistic, linear, and ordinal logistic regression was conducted to assess factors associated with inpatient-mortality, length of hospital stay, and functional status at discharge, respectively.

RESULTS

Data on 883 patients was analyzed. Increased association with mortality was observed with administration of blood product (OR:3, 95 % CI:1.18-7.58) and nutritional support (OR:4.32, 95 % CI:1.55-12.02). Conversely, antibiotic regimens greater than 8 days was associated with decreased mortality (OR:0.1, 95 % CI:0.03-0.41). Associated increase in length of hospital stay was observed in patients with trauma associated with their burn injury, history of seizures (CE:47.93, 95 % CI 12.05-83.80), blood product (CE:22.09, 95 % CI:0.83-43.35) and oxygen administration (CE:23.7, 95 % CI:7.34-40.06). Patients who developed sepsis (OR:6.89, 95 % CI:1.92-24.73) and received blood products during hospitalization (OR:2.55, 95 % CI:1.38- 4.73) were more likely to have poor functional status at discharge.

CONCLUSION

This study identified multiple factors associated with worse clinical outcomes for burn patients in South Asia. Understanding these parameters can guide targeted efforts to improve the process and quality of burn care in LMICs.

A Contemporary Review of Blood Transfusion in Critically Ill Patients

Blood transfusion is a common therapeutic intervention in hospitalized patients. There are numerous indications for transfusion, including anemia and coagulopathy with deficiency of single or multiple coagulation components such as platelets or coagulation factors. Nevertheless, the practice of transfusion in critically ill patients has been controversial mainly due to a lack of evidence and the need to consider the appropriate clinical context for transfusion. Further, transfusion carries many risk factors that must be balanced with benefits. Therefore, transfusion practice in ICU patients has constantly evolved, and we endeavor to present a contemporary review of transfusion practices in this population guided by clinical trials and expert guidelines.

Ultra-restrictive red blood cell transfusion strategies in extensively burned patients

In recent years, due to the shortage of blood products, some extensive burn patients were forced to adopt an "ultra-restrictive" transfusion strategy, in which the hemoglobin levels of RBC transfusion thresholds were < 7 g/dl or even < 6 g/dl. This study investigated the prognostic impacts of ultra-restrictive RBC transfusion in extensive burn patients. This retrospective multicenter cohort study recruited extensive burns (total body surface area ≥ 50%) from three hospitals in Eastern China between 1 January 2016 and 30 June 2022. Patients were divided into an ultra-restrictive transfusion group and a restrictive transfusion group depending on whether they received timely RBC transfusion at a hemoglobin level < 7 g/dl. 1:1 ratio propensity score matching (PSM) was performed to balance selection bias. Modified Poisson regression and linear regression were conducted for sensitive analysis. Subsequently, according to whether they received timely RBC transfusion at a hemoglobin level < 6 g/dl, patients in the ultra-restrictive transfusion group were divided into < 6 g/dl group and 6-7 g/dl group to further compare the prognostic outcomes. 271 eligible patients with extensive burns were included, of whom 107 patients were in the ultra-restrictive transfusion group and 164 patients were in the restrictive transfusion group. The ultra-restrictive transfusion group had a significantly lower RBC transfusion volume than the restrictive transfusion group (11.5 [5.5, 21.5] vs 17.3 [9.0, 32.5] units, p = 0.004). There were no significant differences between the two groups in terms of in-hospital mortality, risk of infection, hospital length of stay, and wound healing time after PSM or multivariate adjustment (p > 0.05). Among the ultra-restrictive transfusion group, patients with RBC transfusion threshold < 6 g/dl had a significantly higher hospital mortality than 6-7 g/dl (53.1% vs 21.3%, p = 0.001). For extensive burn patients, no significant adverse effects of ultra-restrictive RBC transfusion were found in this study. When the blood supply is tight, it is acceptable to adopt an RBC transfusion threshold of < 7 g/dL but not < 6 g/dL.

Blood transfusions in non-major burns patients

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.

Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

IL-1/MyD88-Dependent G-CSF and IL-6 Secretion Mediates Postburn Anemia

The anemia of critical illness (ACI) is a nearly universal pathophysiological consequence of burn injury and a primary reason burn patients require massive quantities of transfused blood. Inflammatory processes are expected to drive postburn ACI and prevent meaningful erythropoietic stimulation through iron or erythropoietin supplementation, but to this day no specific inflammatory pathways have been identified as a critical mechanism. In this study, we examined whether secretion of G-CSF and IL-6 mediates distinct features of postburn ACI and interrogated inflammatory mechanisms that could be responsible for their secretion. Our analysis of mouse and human skin samples identified the burn wound as a primary source of G-CSF and IL-6 secretion. We show that G-CSF and IL-6 are secreted independently through an IL-1/MyD88-dependent mechanism, and we ruled out TLR2 and TLR4 as critical receptors. Our results indicate that IL-1/MyD88-dependent G-CSF secretion plays a key role in impairing medullary erythropoiesis and IL-6 secretion plays a key role in limiting the access of erythroid cells to iron. Importantly, we found that IL-1α/β neutralizing Abs broadly attenuated features of postburn ACI that could be attributed to G-CSF or IL-6 secretion and rescued deficits of circulating RBC counts, hemoglobin, and hematocrit caused by burn injury. We conclude that wound-based IL-1/MyD88 signaling mediates postburn ACI through induction of G-CSF and IL-6 secretion.

Reducing Blood Loss in a Burn Care Unit: A Review of Its Key Determinants

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.

Correlation between Bacterial Wound Colonization and Skin-Graft Loss in Burn Patients

Loss of skin grafts can be a dangerous complication during the early postoperative course of patients with extensive burns. A major risk factor for impaired healing of grafts is local wound infection due to bacterial colonization. Burn wounds are particularly prone to bacterial colonization. In this retrospective cohort study, we analyzed correlations between bacteria isolates from burn wounds and loss of skin grafts after surgical treatment. A cohort of patients with burn wounds who received split-skin grafts for wound coverage was divided into groups with and without loss of skin grafts. Demographics, comorbidities, trauma characteristics and bacterial isolates from wound cultures were reviewed and compared. Bacterial colonization isolated from burn wounds upon hospital admission was found to be a significant predictor of skin-graft loss. Additionally, an Abbreviated Burn Severity Index greater 6 predicted graft loss. When comparing bacterial swab results from admission with isolates from revision surgery after graft loss, causative pathogens were found to have changed.

Determining transfusion use in major burn patients: A retrospective review and analysis from 2009 to 2019

Blood transfusion is an important treatment for patients with major burns. Understanding the predictive factors of blood product usage in major burns can improve effective transfusion therapy. We retrospectively reviewed the medical records of the Burn Center, First Affiliated Hospital of the Chinese Naval Military Medical University, from August 2009 to July 2019 and enrolled all patients with major burns treated in that decade. Basic information, condition, and blood-transfusion details of the patients were analyzed to identify predictive factors for blood use and prognosis. Despite a yearly decreasing trend, the frequency of use of blood-product usage in major burns was high at 57.72%, with 5.39 times and 28.76 units of blood usage per person. Burn area was the most important predictive factor for blood transfusion at different stages. Burn depth, combined with injury, age, and other factors, affected blood use. Blood use or volume correlated with prognosis; especially, platelet and cryoprecipitate use was significantly associated with increased mortality. Blood product usage in major burns patients is related not only to the clinical condition, but also to doctors' experience, which can predict prognosis. Blood use is associated with increased mortality, although we found no evidence of a causal association.

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

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.

Management strategies for perioperative anaemia in the severely burn-injured Jehovah’s Witness patients who decline a blood transfusion: A systematic review with illustrative case reports

BACKGROUND

The management of severe burn-injured Jehovah's Witness patients who decline a blood transfusion poses unique challenges. The literature is scant for guiding perioperative anaemia management in these patients. We present a systematic review of this patient group, along with illustrative, consecutive case reports of our experience.

METHODS

A systematic review was performed on Embase, MEDLINE and PubMed databases on articles discussing the treatment of burn-injured Jehovah's Witness patients. Articles were excluded if discussing isolated inhalation injury, or if blood transfusions were permitted.

RESULTS

Nine articles including a total of 11 patients revealed consistent themes. A multimodal medical and surgical approach is suggested. Medical strategies are directed at reducing blood loss and optimising haematopoiesis and include rationalising blood collection, reversing coagulopathy, administering tranexamic acid and regular erythropoietin. Surgical strategies include staged aggressive debridement, tumescent adrenaline infiltration and limb tourniquets. We found that the argon beam coagulator was an effective haemostatic adjunct not previously described in literature.

DISCUSSION

Management of anaemia in severely burn-injured Jehovah's Witness patients is challenging. This systematic review presents a summary of strategies directed at minimising blood loss, and optimising haematopoiesis. Careful preoperative planning, meticulous surgical technique, and postoperative physiological support are caveats to success.

Enzymatic debridement in critically injured burn patients - Our experience in the intensive care setting and during burn resuscitation

BACKGROUND

Much of the recent literature on bromelain based enzymatic debridement of burn injury has focused on its use in smaller burn injury and specialist areas such as the hands or genitals (Krieger et al., 2012; Schulz et al., 2017a,b,c,d). This is despite the original papers describing its use in larger burn injury (Rosenberg et al., 2004, 2014). The current EMA license for Nexobrid™ advises that it should not be used for burn injuries of more than 15% TBSA and should be used with caution in patients with pulmonary burn trauma and suspected pulmonary burn trauma. The original safety and efficacy trial of NexoBrid™ limited its use to 15% TBSA aliquots with concern regarding the effect of bromelain on coagulation. In a European consensus paper of experienced burns clinicians, now on its second iteration, 100% of respondents agreed that "up to 30% BSA can be treated by enzymatic debridement based on individual decision" (Hirche et al., 2017). Hofmaenner et al.'s recent study on the safety of enzymatic debridement in extensive burns larger than 15% provides some further evidence that "bromelain based enzymatic debridement can be carried out safely in large-area burns" (Hofmaenner et al., 2020) but the literature is scant in these larger debridement areas. In our centre we have been using enzymatic debridement for resuscitation level burn injury since 2016. We have gained significant learning in this time; this article aims to describe our current protocol for enzymatic debridement in this patient population and highlight specific learning points that might aid other centres in using enzymatic debridement for larger burn injury.

METHOD

We performed a search of the IBID database to identify all adult patients who satisfied the inclusion criteria of resuscitation level burn injury (defined as total burn surface area (TBSA) ≥15% in patients aged >16 years), or level 3 admission following burn injury and who underwent Enzymatic Debridement. A case note review was completed, and details comprising patient demographics, TBSA, mechanism of burn, presence of inhalation injury, sequencing of debridement, length of ICU and hospital stay, blood product utilisation and the need for autografting were recorded. No ethical approval has been sought for this retrospective review.

RESULTS

We identified 29 patients satisfying the inclusion criteria (Table 1). Between June 2016 and June 2020 the average total burn size of patients who had at least some of their burn treated by enzymatic debridement increased from 21.4% in 2016/17 to 34.7% in 2019/20. In these patients the actual area treated by enzymatic debridement also increased from 11.9% TBSA to 20.3% TBSA. 19 patients (66%) had enzymatic debridement performed within 24 h of injury, a further 2 patients (7%) within 48 h after injury. Patients were more likely to have enzymatic debridement commenced in the first 24 h after injury if they had circumferential limb injury (39% vs 9%) or were planned for enzyme only debridement (78% vs 28%). Those who were planned for combination enzyme and surgical debridement were more likely to have enzymatic debridement commenced after the first 48 h (75%). We have performed enzymatic debridement overnight on one occasion, for a patient who presented with circumferential limb injury and was determined to undergo urgent debridement.

CONCLUSION

Much of the literature has described the use of enzymatic debridement in smaller burns, and specialist areas. However, it is our opinion that the advantages of enzymatic debridement appear to be greater in larger burns with a facility for whole burn excision on the day of admission in the ICU cubicle. We have demonstrated significantly reduced blood loss, improved dermal preservation, reduced need for autografting, and a reduction in the number of trips to theatre. We would advocate that both the team and the patient need to be as prepared as they would be for a traditional surgical excision. The early part of our learning curve for enzymatic debridement in resuscitation level injuries was steep, and we were able to build on experience from managing smaller injuries. We recommend any team wishing to using enzymatic debridement gain experience in the same way and develop robust local pathways prior to attempting use in larger burn injuries.

Enzymatic debridement: past, present, and future

INTRODUCTION

Early surgical debridement of the deep second and third-degree burns is still the standard of care (SOC) to prepare the wound bed for skin grafting. However, this technique has some drawbacks that explain the growing interest in enzymatic debridement as an alternative. In this article, we provide a historic overview as well as the current state-of-the-art and future prospective of this type of non-surgical debridement.

MATERIALS AND METHODS

A narrative review of the available literature was conducted using a systematic search.

RESULTS

A total of 32 articles were included. The only enzyme mixture still used nowadays for burn eschar removal is bromelain-based. There is increasing evidence that this type of enzymatic debridement is a powerful tool to selectively remove the eschar in deep burns, thereby reducing the need for autologous skin grafting compared to surgical SOC. Moreover, off-label use of enzymatic debridement with NexoBrid^® (facial, pediatric, and >15%TBSA burns) has proven to be effective and safe.

CONCLUSION

There is increasing evidence that bedside administered NexoBrid^®, preferably under regional anesthesia, is a powerful tool for selective burn eschar removal. However, the clinical wound bed evaluation post-NexoBrid^® procedure in relation to the optimal treatment decision-conservative treatment vs. surgery-is not yet completely elucidated. More high-quality prospective clinical trials are necessary to compare enzymatic debridement of objectively confirmed deep burns with the current standard treatment and assess the effectiveness of the eschar removal, the need for surgery, the healing time of such wounds, and the long-term scar quality.

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial

OBJECTIVE

Early excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery.

METHODS

Patients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA.

RESULTS

Twenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542).

DISCUSSION

This study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.

Novel Application of a Surgeon-Operated Clysis Delivery System in Burn Surgery

Insufflation of epinephrine-containing solutions (clysis) has shown to decrease blood loss in burn surgery. Current delivery methods are associated with significant cost and may predispose burn patients to hypothermia. This was a proof-of-concept study to evaluate a novel surgeon-operated clysis delivery system. Our initial experience with a novel fluid management system is presented. Temperature, pressure, and volume of clysis was recorded. Patient and burn factors were evaluated and complications collected. Finally, a cost-effectiveness analysis was conducted. Thirty-seven consecutive cases comprising 22 adult patients (15/22, 68% male), with a mean age of 49 years (+/-19) were reviewed. The mean % total body surface area of all patients was 39 (+/-21.7). The mean temperature, pressure, and volume of administered clysis was 32.2 degrees Celsius (+/-4.4), 265.04 mmHg (+/-56.17), and 5805.8 mL (+/-4844.4), respectively. The mean dose of epinephrine administered was 14.5 mg (+/-12.1). The mean temperature variability was 1.1 °C (+/-1.2). The total mean of packed red blood cells (PRBC) transfused was 507.6 mL (+/-624.4). There were no recorded complications. We identified a cost savings of CAD 20,766 over the cases examined, compared to our conventional clysis delivery technique. This novel technique provides rapid and safe infiltration of warmed clysis in burn surgery. We were able to maintain intra-operative euthermia. In addition, this technique may be transfusion-sparing. The introduction of this method of clysis administration was associated with significant cost-savings. Future randomized study is necessary.

Red cell distribution width/albumin ratio and 90-day mortality after burn surgery

Background

Red cell distribution width (RDW) and serum albumin concentration are associated with postoperative outcomes. However, the usefulness of the RDW/albumin ratio in burn surgery remains unclear. Therefore, we evaluated the association between RDW/albumin ratio and 90-day mortality after burn surgery.

Methods

Between 2013 and 2020, a retrospective review of patients in a burn intensive care unit (ICU) was performed. Receiver operating characteristic curve, multivariate Cox logistic regression, multivariate logistic regression and Kaplan–Meier analyses were conducted to evaluate the association between RDW/albumin ratio and 90-day mortality after burn surgery. Additionally, prolonged ICU stay rate (>60 days) and ICU stay were assessed.

Results

Ninety-day mortality was 22.5% (210/934) in burn patients. Risk factors for 90-day mortality were RDW/albumin ratio at postoperative day 1, age, American Society of Anesthesiologists physical status, diabetes mellitus, inhalation injury, total body surface area burned, hypotensive event and red blood cell transfusion volume. The area under the curve of the RDW/albumin ratio at postoperative day 1 to predict 90-day mortality, after adjusting for age and total body surface area burned, was 0.875 (cut-off value, 6.8). The 90-day mortality was significantly higher in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (49.2% vs 12.3%, p < 0.001). Prolonged ICU stay rate and ICU stay were significantly higher and longer in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (34.5% vs 26.5%; 21 [11–38] vs 18 [7–32] days).

Conclusion

RDW/albumin ratio >6.8 on postoperative day 1 was associated with higher 90-day mortality, higher prolonged ICU stay rate and longer ICU stay after burn surgery.

Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds - A double blind randomised controlled trial

INTRODUCTION

This study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns.

METHODS

This was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15-55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH).

RESULTS

Thirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm²; p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups.

CONCLUSION

TXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.

Intraoperative blood transfusions in burn patients

BACKGROUND

Donated blood is a valuable and limited resource. Excision of burn wounds often leads to significant blood loss requiring transfusion. Accurately estimating blood loss is difficult, so examining the amount of blood products given intraoperatively is a clinically relevant way to measure utilization of this valuable resource. In this study, we examined the factors that influenced the amount of blood given intraoperatively during burn wound excisions.

STUDY DESIGN AND METHODS

A retrospective analysis of patients admitted to a single burn center over 5 years who underwent excision of their burn wounds and received intraoperative blood products was performed. Patient and burn characteristics as well as pertinent surgical data and laboratory values on the day of surgery and postoperatively were gathered. A linear regression analysis examined factors influencing the number of units of products given and a predictive model was generated.

RESULTS

A total of 563 operations performed on 166 patients were included. The amount of burn excised was the most influential variable on the amount of blood products given. Hemoglobin level, international normalized ratio, and platelet count on the day of surgery were associated with transfusion of different blood products. A predictive model was generated to aid in preoperative ordering of blood products.

CONCLUSION

The amount of burn excised and common hematology and coagulation lab values were associated with the amount of different blood products administered during burn surgery. The predictive model generated needs to be validated prospectively to aid in preoperative planning for burn excisions.

Intraoperative transfusion practice in burned children in a university hospital over four years: a retrospective analysis

BACKGROUND

Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline.

METHODS

We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression.

RESULTS

During the four-year period, 138 children (median age 21 months, minimum-maximum 9-101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3-11.3 g/dL) and 10.7 (7-13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p <  0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines.

CONCLUSIONS

Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines.

Treatment of Anaemia in Patients with Acute Burn Injury: A Study of Blood Transfusion Practices

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.

Inhalation Injury Does Not Influence the Amount of Blood Transfused to Major Burn Patients: A Secondary Analysis from the Transfusion Requirement in Burn Care Evaluation Study

Patients with major burn injuries typically require numerous blood transfusions. It is not known if an inhalation injury (INHI) directly influences the need for blood transfusion. The purpose of this study was to determine whether INHI increases the amount of blood transfused to major burn patients. A secondary analysis from the Transfusion Requirement in Burn Care Evaluation (TRIBE) study was conducted. Patients with INHI were compared with patients without INHI. The number of red blood cell (RBC) transfusions per day (RBC per day) between INHI and No INHI was analyzed with a multivariable regression. Patients with INHI (n = 78) had significantly larger burns (P = .0004), larger full-thickness burns (P = .0007), greater admission APACHE score (P < .0001), higher admission multiple organ dysfunction scores (P < .0001), and were transfused more RBC per day (P = .009) than No INHI patients (n = 267). In the multivariable regression analysis, RBC per day was significantly associated with the %TBSA burn (P < .0001), age of the patient (P = .004), the need for more than 1 day of mechanical ventilation (P < .0001), the occurrence of at least one blood stream infection (BSI; P = .044), and being assigned to the liberal transfusion arm of TRIBE (P < .001) but not the presence of INHI (P = .056). The null hypothesis that INHI exerts no influence on the amount of blood transfused could not be rejected. Larger burn size, advanced patient age, mechanical ventilation, and BSIs are important determinants of the blood transfusion rate in major burn patients.

Plasma TNFα and Unknown Factor/s Potentially Impede Erythroblast Enucleation Obstructing Terminal Maturation of Red Blood Cells in Burn Patients

INTRODUCTION

In this study, using burn patient's peripheral blood mononuclear cells (PBMCs), we have shown that the Epo independent stage of terminal enucleation to reticulocyte formation is impeded in the presence of autologous plasma (BP). Furthermore, substitution with allogeneic control plasma (CP) from the healthy individual in place of BP rectified this enucleation defect. The exclusive role of burn microenvironment in late-stage erythropoiesis defect was further demarcated through control healthy human bone marrow cells cultured in the presence of CP, BP, and cytokines.

METHODS

PBMCs and human bone marrow (huBM) were differentiated ex vivo to enucleated reticulocytes in the presence of required growth factors and 5% CP or BP. Effect of systemic mediators in burn microenvironment like IL-6, IL-15, and TNFα was also explored. Neutralization experiments were carried out by adding varying concentrations (25 ng-400 ng/mL) of Anti-TNFα Ab to either CP+TNFα or BP.

RESULTS

Reticulocyte proportion and maturation index were significantly improved upon substituting BP with CP during differentiation of burn PBMCs. In the huBM ex vivo culture, addition of IL-6 and IL-15 to CP inhibited the proliferation stages of erythropoiesis, whereas TNFα supplementation caused maximum diminution at erythroblast enucleation stage. Supplementation with anti-TNFα in the BP showed significant but partial restoration in the enucleation process, revealing the possibility of other crucial microenvironmental factors that could impact RBC production in burn patients.

CONCLUSION

Exogenous TNFα impairs late-stage erythropoiesis by blocking enucleation, but neutralization of TNFα in BP only partially restored terminal enucleation indicating additional plasma factor(s) impair(s) late-stage RBC maturation in burn patients.

The best strategy for red blood cell transfusion in severe burn patients, restrictive or liberal: A randomized controlled trial

INTRODUCTION

Although blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold.

MATERIAL AND METHODS

Eighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications.

RESULT

The mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups.

CONCLUSION

Applying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications.

CLINICAL TRIAL REGISTRATION REFERENCE

IRCT20190209042660N1.

Transfusion and Infections in the Burn Patient

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.

Increased risk of blood transfusion in patients with diabetes mellitus sustaining non-major burn injury

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.

Burn injury and blood transfusion

PURPOSE OF REVIEW

Blood transfusion is ubiquitous in major burn injury. The present article describes recent research findings directly impacting blood transfusion strategies in major burn injury both in the operating room and the ICU.

RECENT FINDINGS

Transfusion strategies have been the focus of recent burn investigations. First, a randomized prospective trial encompassing both the ICU and operating room reported that a restrictive red blood cell transfusion threshold (7 g/dl) had equivalent outcomes to a traditional threshold (10 g/dl) for burns more than 20% in terms of mortality, infection, length of stay, duration of mechanical ventilation, and wound healing despite receiving significantly fewer transfusions. The second burn transfusion advance addresses coagulation. Although burn patients initially have elevated fibrinogen, thrombocytopenia and other coagulation disorders develop during excision. Blood product repletion should be based on measurements such as thromboelastography in addition to traditional tests. Finally, a recent randomized trial suggests that fresh-frozen plasma and platelets during burn excision more than 20% may decrease transfusion requirements.

SUMMARY

A restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. Repletion of coagulation products should focus on measured deficits of platelets, fibrinogen, and factors.

Effects of a restrictive blood transfusion protocol on acute pediatric burn care: Transfusion threshold in pediatric burns

BACKGROUND

Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients.

METHODS

We implemented a change in hemoglobin threshold from 10 g/dL to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p less than 0.05.

RESULTS

Patient characteristics and baseline hemoglobin concentrations (pre, 13.5 g/dL; post, 13.3 g/dL; p > 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre, 1012 mL; post, 824 mL; p < 0.001) and on days without surgical procedures (pre, 602 mL; post, 353 mL; p < 0.001), and had a lower mortality (pre, 8.0%; post, 3.9%; mortality hazard decline, 0.55 [45%]; p < 0.05). Both groups had a comparable incidence of physiological sepsis, though the more restrictive threshold group had a lower number of sepsis days per patient.

CONCLUSION

More restrictive transfusion protocols are safe and efficacious in pediatric burn patients. The associated reduction of transfused blood may lessen medical risks of blood transfusion and lower economic burden.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Bipolar Sealer Devices Used in Posterior Spinal Fusion for Neuromuscular Scoliosis Reduce Blood Loss and Transfusion Requirements

BACKGROUND

Reducing perioperative blood loss and the need for transfusions in patients undergoing spinal surgery is especially important for those with neuromuscular disorders. These patients require extensive spino-pelvic exposure and are often medically fragile. We have used Amicar to decrease blood loss since 2001. As an effort to further reduce blood loss and transfusions, we use a bipolar sealer device (Aquamantys) as an adjunct to electrocautery. We present the results of our first 64 neuromuscular patients to show the efficacy of the device.

METHODS

Using a prospectively maintained database we reviewed the operative time, estimated perioperative blood loss, cell saver use, and intraoperative and postoperative transfusion rate in patients who underwent posterior spinal fusion for neuromuscular scoliosis. Sixty-four patients were identified who fit these criteria since the use of the bipolar sealer device was instituted.We compared these patients with a control group of the preceding 65 patients in whom this device was not used for hemostasis. All patients, including those in the study group, received Amicar (infusion of 100 mg/kg over 15 to 20 min, then 10 mg/kg/h throughout the remainder of the procedure). The surgical technique did not differ between the 2 groups.

RESULTS

Baseline characteristics between the 2 groups were similar except for the number of patients having an all-screw construct which was larger in the investigational group (25% vs. 8%, P=0.03). There were no significant differences in operative time or duration of hospital stay. Intraoperative blood loss was lower in the study group (741 mL) as compared with the control group (1052 mL, P=0.003). Total perioperative blood loss, however, showed no significant difference. Thirty-five (55%) patients in the study group and 50 (77%) patients in the control group required additional intraoperative or postoperative transfusions (P=0.01). The number of packed red cell units transfused per patient was 0.81 in the study group and 1.57 in the control group (P=0.001). Although the intraoperative cell saver transfusion was same, the total blood volume transfused, which includes cell saver and any other transfusions, was significantly lower in the study group, 425 mL versus 671 mL (P=0.002).

CONCLUSIONS

Use of a bipolar sealer device in posterior spinal fusion for neuromuscular scoliosis significantly reduced intraoperative blood loss and transfusion rate when compared with a control group in this retrospective review.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

The Effects of Red Blood Cell Transfusion on Functional Outcome after Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects.

OBJECTIVE

To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH.

METHODS

A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection.

RESULTS

Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65).

CONCLUSIONS

Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.

Anemia and Red Blood Cell Transfusion: Advances in Critical Care

Anemia is common in the intensive care unit (ICU), resulting in frequent administration of red blood cell (RBC) transfusions. Significant advances have been made in understanding the pathophysiology of anemia in the ICU, which is anemia of inflammation. This anemia is related to high hepcidin concentrations resulting in iron-restricted erythropoiesis, and decreased erythropoietin concentrations. A new hormone (erythroferrone) has been identified, which mediates hepcidin suppression to allow increased iron absorption and mobilization from iron stores. RBC transfusions are most commonly administered to ICU patients for treatment of anemia. All strategies to reduce anemia in the ICU should be implemented.

Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury

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).

Discrete β-adrenergic mechanisms regulate early and late erythropoiesis in erythropoietin-resistant anemia

BACKGROUND

Anemia of critical illness is resistant to exogenous erythropoietin. Packed red blood cells transfusions is the only treatment option, and despite related cost and morbidity, there is a need for alternate strategies. Erythrocyte development can be divided into erythropoietin-dependent and erythropoietin-independent stages. We have shown previously that erythropoietin-dependent development is intact in burn patients and the erythropoietin-independent early commitment stage, which is regulated by β1/β2-adrenergic mechanisms, is compromised. Utilizing the scald burn injury model, we studied erythropoietin-independent late maturation stages and the effect of β1/β2, β-2, or β-3 blockade in burn mediated erythropoietin-resistant anemia.

METHODS

Burn mice were randomized to receive daily injections of propranolol (nonselective β1/β2 antagonist), nadolol (long-acting β1/β2 antagonist), butoxamine (selective β2 antagonist), or SR59230A (selective β3 antagonist) for 6 days after burn. Total bone marrow cells were characterized as nonerythroid cells, early and late erythroblasts, nucleated orthochromatic erythroblasts and enucleated reticulocyte subsets using CD71, Ter119, and Syto-16 by flow cytometry. Multipotential progenitors were probed for MafB expressing cells.

RESULTS

Although propranolol improved early and late erythroblasts, only butoxamine and selective β3-antagonist administrations were positively reflected in the peripheral blood hemoglobin and red blood cells count. While burn impeded early commitment and late maturation stages, β1/β2 antagonism increased the early erythroblasts through commitment stages via β2 specific MafB regulation. β3 antagonism was more effective in improving overall red blood cells through late maturation stages.

CONCLUSION

The study unfolds novel β2 and β3 adrenergic mechanisms orchestrating erythropoietin resistant anemia after burn, which impedes both the early commitment stage and the late maturation stages, respectively.

Thermal injury of the skin induces G-CSF-dependent attenuation of EPO-mediated STAT signaling and erythroid differentiation arrest in mice

Inflammation-mediated impairment of erythropoiesis plays a central role in the development of the anemia of critical illness (ACI). ACI develops despite elevation of endogenous erythropoietin (EPO), does not respond to exogenous erythropoietin (EPO) supplementation, and contributes significantly to transfusion requirements in burned patients. We have reported previously that the reduction of red blood cell mass in the bone marrow of a burn-injured ACI mouse model is granulocyte colony-stimulating factor (G-CSF) dependent. Given that elevated G-CSF levels also have been associated with lower hemoglobin levels and increased transfusion requirements in trauma victims, we postulated that G-CSF mediates postburn EPO resistance. In ACI mice, we found that bone marrow erythroid differentiation, viability, and proliferation are impaired after thermal injury of the skin. These changes in the marrow were associated with attenuated phosphorylation of known EPO-responsive signaling nodes, signal transducer and activator of transcription 5 (STAT5) Y694 and STAT3 S727, in bone marrow erythroid cells and developed despite highly elevated levels of endogenous EPO. Severely blunted STAT5 Y694 phosphorylation in bone marrow erythroid cells after exogenous EPO supplementation confirmed that EPO signaling was impaired in ACI mice. Importantly, parenteral administration of anti-G-CSF largely rescued postburn bone marrow erythroid differentiation arrest and EPO signaling in erythroid cells. Together, these data provide strong evidence for a role for G-CSF in the development of ACI after burn injury through suppression of EPO signaling in bone marrow erythroid cells.

Determinants and time to blood transfusion among thermal burn patients admitted to Mulago Hospital

Background

Blood transfusion, a practice under re-evaluation in general, remains common among thermal burn patients due to the hematological alterations associated with burns that manifest as anemia. Today advocacy is for restrictive blood transfusion taking into account individual patient characteristics. We went out to identify the parameters that may determine transfusion requirement and the time to blood transfusion for thermal burn patients in Mulago Hospital in order to build statistics and a basis to standardize future practice and Hospital protocol.

Methods

112 patients with thermal burns were enrolled into a prospective cohort study conducted in the Surgical Unit of the Accidents and Emergency Department and Burns Unit of Mulago Hospital. Relevant data on pre-injury, injury and post-injury factors was collected including relevant laboratory investigations and treatment modalities like surgical intervention. Patients were clinically followed up for a maximum period of 28 days and we identified those that were transfused.

Results

22.3% of patients were transfused. The median time to transfusion was 17 days from time of injury and varied with different patient characteristics. The median pre-transfusion hemoglobin (Hb) level was 8.2 g/dL. Transfusion was significantly related to; admission to the intensive care unit (p = 0.001), a body mass index (BMI) <2 kg/m² (p = 0.021), % total burn surface area (TBSA) >20 (p = 0.049), pre-existing illness (p = 0.046), and white blood cell (WBC) count <4000 or >12,000/μL (p = 0.05).

Conclusion

Pre-existing illnesses, a low BMI, TBSA of >20%, admission to the intensive care unit and abnormalities in the WBC count are useful predictors of blood transfusion among thermal burns patients admitted to Mulago Hospital. The precise time to transfusion from time of burns injury cannot be generalized. With close monitoring of each individual patient lies the appropriateness and timeliness of their management.

Important Developments in Burn Care

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the epidemiology of severe burn injury in the context of socioeconomic status, gender, age, and burn cause. 2. Describe challenges with burn depth evaluation and novel methods of adjunctive assessment. 3. Summarize the survival and functional outcomes of severe burn injury. 4. State strategies of fluid resuscitation, endpoints to guide fluid titration, and sequelae of overresuscitation. 5. Recognize preventative measures of sepsis. 6. Explain intraoperative strategies to improve patient outcomes, including hemostasis, restrictive transfusion, temperature regulation, skin substitutes, and Meek skin grafting. 7. Translate updates in the pathophysiology of hypertrophic scarring into novel methods of clinical management. 8. Discuss the potential role of free tissue transfer in primary and secondary burn reconstruction.

SUMMARY

Management of burn-injured patients is a challenging and unique field for plastic surgeons. Significant advances over the past decade have occurred in resuscitation, burn wound management, sepsis, and reconstruction that have improved outcomes and quality of life after thermal injury. However, as patients with larger burns are resuscitated, an increased risk of nosocomial infections, sepsis, compartment syndromes, and venous thromboembolic phenomena have required adjustments in care to maintain quality of life after injury. This article outlines a number of recent developments in burn care that illustrate the evolution of the field to assist plastic surgeons involved in burn care.

Patient Safety in Burn Care: Application of Evidence-based Medicine to Improve Outcomes

This article reviews 5 areas in burn care that increasingly use evidence-based medicine to optimize quality and safety: resuscitation protocols, transfusion practices, vascular access, venous thromboembolic prophylaxis, and rational use of antibiotics.

Myelo-erythroid commitment after burn injury is under β-adrenergic control via MafB regulation

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 (lin^neg 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.