Prothrombin Fragment 1.2 and Modified Antithrombin as Predictors of Disseminated Intravascular Coagulation and Thrombotic Risk in Thermal Injury:

Thromboelastometric Analysis of the Correlation Between Burn-Induced Coagulopathy and Severity of Burn Injury

Background In this study, we aimed to analyze the association between the burn index (BI) and burn-induced coagulopathy. Methods Adult burn patients transported to our emergency department who underwent rotational thromboelastometry (ROTEM) between April 1, 2013, and December 31, 2021, were enrolled in this study. The patients were categorized into two groups based on burn severity. Severe burns were defined as BI scores of > 15. Patient demographics, clinical variables of burns, standard laboratory test data, ROTEM data, and clinical outcomes of both groups were evaluated. In addition, the correlation between severe burns and significant variables was evaluated using a univariate analysis. Results Seven patients were enrolled and categorized into the severe (n = 2) and control (n = 5) groups. The severe group had a significantly worse consciousness level and higher mortality rate and showed higher tendencies of burn severity and clinical severity scores. Disseminated intravascular coagulation was confirmed in one patient. All ROTEM variables in the severe group regarding clot firmness in the extrinsic coagulation cascade (EXTEM) and fibrinogen-specific coagulation cascade (FIBTEM) showed a decreasing tendency as compared to those in the control group. Moreover, correlation analyses revealed strong correlations between the BI and clot firmness (rho = -0.946 to -0.721). Conclusions Severe BI was strongly associated with decreased blood clot firmness in EXTEM, FIBTEM, and ROTEM. Future research using viscoelastic devices may provide new possibilities for the treatment of severe burns.

The rise of factor X level in blood plasma of patients at severe burn injuries

This work is dedicated to the detection of imbalance between the pro- and anti-coagulant branches of hemostasis at severe burn injuries by evaluating the content or activity of individual clotting factors. To select the targets for accurate diagnostics we measured the concentrations of soluble fibrin monomeric complexes and fibrinogen, levels of total prothrombin, factor X, protein C and antithrombin III, and recorded the time of clotting in activated partial thromboplastin time and prothrombin time tests. Factor X level was increased in 26 % of patients on the first day after the burn and it rose further in 62 % patients on the 14 th day of recovery. Increasing factor X level is assumed to be a risk factor of thrombotic complications. We propose to use it as a marker of predisposition to thrombosis at severe burn injury.

Burn-Induced Coagulopathies: a Comprehensive Review

Burn-induced coagulopathy is not well understood, and consensus on diagnosis, prevention, and treatments are lacking. In this review, literature on burn-induced (and associated) coagulopathy is presented along with the current understanding of the effects of burn injury on the interactions among coagulation, fibrinolysis, and inflammation in the acute resuscitative phase and reconstructive phase of care. The role of conventional tests of coagulopathy and functional assays like thromboelastography or thromboelastometry will also be discussed. Finally, reported methods for the prevention and treatment of complications related to burn-induced coagulopathy will be reviewed.

Early abnormal fibrinolysis and mortality in patients with thermal injury: a prospective cohort study

INTRODUCTION

Abnormal fibrinolysis early after injury has been associated with increased mortality in trauma patients, but no studies have addressed patients with burn injury. This prospective cohort study aimed to characterize fibrinolytic phenotypes in burn patients and to see if they were associated with mortality.

METHODS

Patients presenting to a regional burn centre within 4 h of thermal injury were included. Blood was collected for sequential viscoelastic measurements using thromboelastography (RapidTEG™) over 12 h. The percentage decrease in clot strength 30 min after the time of maximal clot strength (LY30) was used to categorize patients into hypofibrinolytic/fibrinolytic shutdown (SD), physiological (PHYS) and hyperfibrinolytic (HF) phenotypes. Injury characteristics, demographics and outcomes were compared.

RESULTS

Of 115 included patients, just over two thirds were male. Overall median age was 40 (i.q.r. 28-57) years and median total body surface area (TBSA) burn was 13 (i.q.r. 6-30) per cent. Some 42 (36.5 per cent) patients had severe burns affecting over 20 per cent TBSA. Overall mortality was 18.3 per cent. At admission 60.0 per cent were PHYS, 30.4 per cent were SD and 9.6 per cent HF. HF was associated with increased risk of mortality on admission (odds ratio 12.61 (95 per cent c.i. 1.12 to 142.57); P = 0.041) but not later during the admission when its incidence also decreased. Admission SD was not associated with mortality, but incidence increased and by 4 h and beyond, SD was associated with increased mortality, compared with PHYS (odds ratio 8.27 (95 per cent c.i. 1.16 to 58.95); P = 0.034).

DISCUSSION

Early abnormal fibrinolytic function is associated with mortality in burn patients.

Endogenous pro-thrombotic biomarkers from the arm and leg may not have the same value

Objective

Assessments of endogenous pro-thrombotic biomarkers are performed invariably on arm blood. However, the commonest site for thrombosis is in the leg. A leg blood sample may reflect local pro-thrombotic processes more accurately than systemic arm blood. The aim was to determine whether pro-thrombotic biomarkers from standard venous arm samples differed significantly from leg samples.

Method

Concurrent blood samples were taken from an ankle/lower calf varicose vein and an ante-cubital vein in 24 patients awaiting laser treatment as well as age approximated and sex matched healthy controls without venous disease. The following assays were performed: thrombin–antithrombin (ng/ml), antithrombin (%) activity, microparticles (nM), fibrinogen (mg/dl), prothrombin fragment 1.2 (F1.2) (pM) and P-selectin (ng/ml).

Results

Expressed as median (inter-quartile range). Significant arm/leg differences were observed in thrombin–antithrombin, antithrombin, prothrombin fragment 1.2 and P-selectin. The legs of patients had significantly reduced antithrombin activity and P-selectin concentrations compared to their arms (leg: 101 (90–108) versus arm: 112 (99–126), P = 0.001 and leg: 42 (26–52) versus 45 (27–52), P = 0.044, respectively). Control leg samples had significantly increased thrombin–antithrombin and P-selectin compared to control arm samples (leg: 2.1 (0.9–3.2) versus arm: 0.8 (0.5–1.7), P = 0.015 and leg: 36 (24–50) versus arm: 30 (23–41), P = 0.007, respectively). However, the control legs had significantly reduced F1.2 (leg: 265 (230–333) versus arm: 299 (236–361), P = 0.028). No significant arm/leg differences were detected in the microparticle or fibrinogen levels.

Conclusions

These findings indicate that venous arm blood is significantly different from venous leg blood in four out of six biomarkers studied. Recognition of local venous leg sampling as a site for investigation may unravel why the leg has a greater predisposition to thrombosis and lead the way towards an arm/leg differential test.