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Kruse M, Liesenborghs KE, Josuttis D, Plettig P, Guembel D, Lenz IK, Guethoff C, Gebhardt V, Schmittner MD. Early Autocalibrated Arterial Waveform Analysis for the Management of Burn Shock-A Cohort Study. J Intensive Care Med 2024; 39:655-664. [PMID: 38173245 DOI: 10.1177/08850666231224388] [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] [Indexed: 01/05/2024]
Abstract
Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group (P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient's volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.
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Affiliation(s)
- Marianne Kruse
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Konrad Ernst Liesenborghs
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - David Josuttis
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Philip Plettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Denis Guembel
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, DE, Germany
| | - Ida Katinka Lenz
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Claas Guethoff
- Centre for Clinical Research, Biostatistics, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Volker Gebhardt
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Marc Dominik Schmittner
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
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Badoiu SC, Enescu DM, Tatar R, Stanescu-Spinu II, Miricescu D, Greabu M, Ionel IP, Jinga V. Serum Plasminogen Activator Inhibitor-1, α 1-Acid Glycoprotein, C-Reactive Protein, and Platelet Factor 4 Levels-Promising Molecules That Can Complete the "Puzzle" of the Biochemical Milieu in Severe Burns: Preliminary Results of a Cohort Prospective Study. J Clin Med 2024; 13:2794. [PMID: 38792336 PMCID: PMC11121965 DOI: 10.3390/jcm13102794] [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: 03/17/2024] [Revised: 04/23/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Burns represent a serious health problem, associated with multiple-organ failure, prolonged hospitalization, septic complications, and increased rate of mortality. The main aim of our study was to evaluate the levels of various circulating molecules in children with severe burns (more than 25% TBSA), in three different moments: 48 h, day 10, and day 21 post-burn. Materials and Methods: This study included 32 children with burns produced by flame, hot liquid, and electric arc and 21 controls. Serum plasminogen activator inhibitor-1 (PAI-1), α 1-acid glycoprotein (AGP), C-reactive protein (CRP), and platelet factor 4 (PF4) were detected using the Multiplex technique. Several parameters, such as fibrinogen, leucocyte count, thrombocyte count, triiodothyronine, thyroxine, and thyroid-stimulating hormone were also determined for each patient during hospitalization. Results: Significant statistical differences were obtained for CRP, AGP, and PF4 compared to the control group, in different moments of measurements. Negative correlations between CRP, AGP, and PF4 serum levels and burned body surface, and also the hospitalization period, were observed. Discussions: CRP levels increased in the first 10 days after burn trauma and then decreased after day 21. Serum PAI-1 levels were higher immediately after the burn and started decreasing only after day 10 post-burn. AGP had elevated levels 48 h after the burn, then decreased at 7-10 days afterwards, and once again increased levels after 21 days. PF4 serum levels increased after day 10 since the burning event. Conclusions: Serum CRP, AGP, PAI-1, and PF4 seem to be promising molecules in monitoring patients with a burn within the first 21 days.
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Affiliation(s)
- Silviu Constantin Badoiu
- Department of Anatomy and Embriology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania;
- Department of Plastic and Reconstructive Surgery, Life Memorial Hospital, 365 Grivitei Street, 010719 Bucharest, Romania
| | - Dan Mircea Enescu
- Department of Plastic Reconstructive Surgery and Burns, Grigore Alexandrescu Clinical Emergency Hospital for Children, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (D.M.E.); (R.T.)
| | - Raluca Tatar
- Department of Plastic Reconstructive Surgery and Burns, Grigore Alexandrescu Clinical Emergency Hospital for Children, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (D.M.E.); (R.T.)
| | - Iulia-Ioana Stanescu-Spinu
- Discipline of Physiology, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania
| | - Daniela Miricescu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania;
| | - Maria Greabu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania;
| | - Ileana Paula Ionel
- Discipline of General Nursing, Faculty of Midwifery and Nursing, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Viorel Jinga
- Department of Urology, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania;
- Academy of Romanian Scientists, 3 Ilfov, 050085 Bucharest, Romania
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Huang S, Ma Q, Liao X, Yin X, Shen T, Liu X, Tang W, Wang Y, Wang L, Xin H, Li X, Chang L, Chen Z, Liu R, Wu C, Wang D, Guo G, Zhu F. Identification of early coagulation changes associated with survival outcomes post severe burns from multiple perspectives. Sci Rep 2024; 14:10457. [PMID: 38714778 PMCID: PMC11076290 DOI: 10.1038/s41598-024-61194-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 05/02/2024] [Indexed: 05/10/2024] Open
Abstract
Coagulation alterations manifest early after severe burns and are closely linked to mortality outcomes. Nevertheless, the precise characterization of coagulation changes associated with early mortality remains elusive. We examined alterations in indicators linked to mortality outcomes at both the transcriptomic and clinical characteristic levels. At the transcriptomic level, we pinpointed 28 differentially expressed coagulation-related genes (DECRGs) following burn injuries and endeavored to validate their causal relationships through Mendelian randomization. DECRGs tied to survival exhibit a significant association with neutrophil function, wherein the expression of CYP4F2 and P2RX1 serves as robust predictors of fatal outcomes. In terms of clinical indicators, early levels of D-dimer and alterations in serum calcium show a strong correlation with mortality outcomes. Coagulation depletion and fibrinolytic activation, stemming from the hyperactivation of coagulation pathways post-severe burns, are strongly linked to patient mortality. Monitoring these early coagulation markers with predictive value can effectively identify individuals necessitating priority critical care.
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Affiliation(s)
- Shengyu Huang
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi Province, China
| | - Qimin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Xincheng Liao
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi Province, China
| | - Xi Yin
- Department of Burns and Plastic Surgery, Zhangjiagang First People's Hospital, Suzhou, 215600, China
| | - Tuo Shen
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Xiaobin Liu
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Wenbin Tang
- Department of Burns, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, 510220, China
| | - Yusong Wang
- ICU of Burn and Trauma, the First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China
| | - Lei Wang
- Department of Burns and Plastic Surgery, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Haiming Xin
- Department of Burns and Plastic Surgery, The 924th Hospital of the Chinese People's Liberation Army, Guilin, 541002, China
| | - Xiaoliang Li
- Department of Burns and Plastic Surgery, Zhengzhou First People's Hospital, Zhengzhou, 450004, China
| | - Liu Chang
- Department of Burns and Plastic Surgery, the Fourth People's Hospital of Dalian, Dalian, 116031, China
| | - Zhaohong Chen
- Department of Burns, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Rui Liu
- Department of Burn Surgery, Heilongjiang Provincial Hospital, Harbin, 150036, China
| | - Choulang Wu
- Department of Burns, Taizhou Hospital of Zhejiang Province, Linhai, 317000, China
| | - Deyun Wang
- Department of Burns, Wuhan Third Hospital, Wuhan, 430060, China
| | - Guanghua Guo
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi Province, China.
| | - Feng Zhu
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China.
- ICU of Burn and Trauma, the First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China.
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Al Sulaiman KA, Al-Ramahi G, Aljuhani O, Al-Joudi K, Alhujayri AK, Al-Shomer F, Silas J, Al Dabbagh T, Al Harbi S, AlDekhayel S, Eldali A, Alqahtani R, Vishwakarma R, Al-Dorzi HM. Comparison of the safety and efficacy for different regimens of pharmaco-prophylaxis among severely burned patients: a randomized controlled trial. Eur J Trauma Emerg Surg 2024; 50:567-579. [PMID: 38240791 DOI: 10.1007/s00068-024-02443-9] [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: 06/20/2023] [Accepted: 12/31/2023] [Indexed: 04/23/2024]
Abstract
PURPOSE Venous thromboembolism (VTE) is a common complication in critically ill patients, including severe burn cases. Burn patients respond differently to medications due to pharmacokinetic changes. This study aims to assess the feasibility and safety of different VTE pharmaco-prophylaxis in patients admitted to the ICU with severe burns. METHODS A pilot, open-label randomized controlled trial was conducted on ICU patients with severe burns (BSA ≥ 20%). By using block randomization, patients were allocated to receive high-dose enoxaparin 30 mg q12hours (E30q12), standard-dose enoxaparin 40 mg q24hours (E40q24), or unfractionated heparin (UFH) 5000 Units q8hours. In this study, the primary outcomes assessed were the recruitment and consent rates, as well as bleeding or hematoma at both the donor and graft site. Additionally, secondary measures were evaluated to provide further insights. RESULTS Twenty adult patients out of 114 screened were enrolled and received E30q12 (40%), E40q24 (30%), and UFH (30%). The recruitment rate was one patient per month with a 100% consent rate. Donor site bleeding occurred in one patient (16.7%) in the UFH group. On the other hand, graft site bleeding was only reported in one patient (12.5%) who received E30q12. Major bleeding happened in two patients, one in E30q12 and one in the UFH group. Five patients (25.0%) had minor bleeding; two patients (25.0%) received E30q12, two patients E40q24, and one patient UFH. RBC transfusion was needed in four patients, two on E30q12 and two on UFH. Only one patient had VTE, while four patients died in the hospital. CONCLUSION The study observed a low recruitment rate but a high consent rate. Furthermore, there were no major safety concerns identified with any of the three pharmacologic prophylaxis regimens that were evaluated. TRIAL REGISTRATION NUMBER NCT05237726.
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Affiliation(s)
- Khalid A Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia.
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia.
| | - Ghassan Al-Ramahi
- Plastic Surgery Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khuloud Al-Joudi
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz K Alhujayri
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Feras Al-Shomer
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Johanna Silas
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Nursing Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Tarek Al Dabbagh
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Shmeylan Al Harbi
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Salah AlDekhayel
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Eldali
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Rahaf Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | | | - Hasan M Al-Dorzi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Wermine K, Song J, Gotewal S, Huang L, Corona K, Bagby S, Villarreal E, Chokshi S, Efejuku T, Chaij J, Joglar A, Iglesias NJ, Keys P, De La Tejera G, Golovko G, El Ayadi A, Wolf SE. The Utilisation of INR to identify coagulopathy in burn patients. PLoS One 2024; 19:e0278658. [PMID: 38394094 PMCID: PMC10889632 DOI: 10.1371/journal.pone.0278658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/21/2022] [Indexed: 02/25/2024] Open
Abstract
Studies conflict on the significance of burn-induced coagulopathy. We posit that burn-induced coagulopathy is associated with injury severity in burns. Our purpose was to characterize coagulopathy profiles in burns and determine relationships between % total burn surface area (TBSA) burned and coagulopathy using the International Normalized Ratio (INR). Burned patients with INR values were identified in the TriNetX database and analyzed by %TBSA burned. Patients with history of transfusions, chronic hepatic failure, and those on anticoagulant medications were excluded. Interquartile ranges for INR in the burned study population were 1.2 (1.0-1.4). An INR of ≥ 1.5 was used to represent those with burn-induced coagulopathy as it fell outside the 3rd quartile. The population was stratified into subgroups using INR levels <1.5 or ≥1.5 on the day of injury. Data are average ± SD analyzed using chi-square; p < .05 was considered significant. There were 7,364 burned patients identified with INR <1.5, and 635 had INR ≥1.5. Comparing TBSA burned groups, burn-induced coagulopathy significantly increased in those with ≥20% TBSA; p = .048 at 20-29% TBSA, p = .0005 at 30-39% TBSA, and p < .0001 for 40% TBSA and above. Age played a significant factor with average age for those with burn-induced coagulopathy 59 ± 21.5 years and 46 ± 21.8 for those without (p < .0001). After matching for age, TBSA, and demographics, the risk of 28 day-mortality was higher in those with burn-induced coagulopathy compared to those without (risk difference 20.9%, p < .0001) and the odd ratio with 95% CI is 4.45 (3.399-5.825). Investigation of conditions associated with burn-induced coagulopathy showed the effect of heart diseases to be significant; 53% of patients with burn-induced coagulopathy had hypertension (p < .0001). Burn-induced coagulopathy increases with %TBSA burned. The information gained firmly reflects a link between %TBSA and burn-induced coagulopathy, which could be useful in prognosis and treatment decisions.
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Affiliation(s)
- Kendall Wermine
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Juquan Song
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Sunny Gotewal
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Lyndon Huang
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Kassandra Corona
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Shelby Bagby
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Elvia Villarreal
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Shivan Chokshi
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Tsola Efejuku
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Jasmine Chaij
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Alejandro Joglar
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Nicholas J. Iglesias
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Phillip Keys
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Giovanna De La Tejera
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Georgiy Golovko
- Department of Pharmacology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Amina El Ayadi
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Steven E. Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
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Bordeanu-Diaconescu EM, Grosu-Bularda A, Frunza A, Grama S, Andrei MC, Neagu TP, Hariga CS, Lascar I. Venous Thromboembolism in Burn Patients: A 5-Year Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:258. [PMID: 38399545 PMCID: PMC10889946 DOI: 10.3390/medicina60020258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Burn patients manifest all components of Virchow's triad, amplifying the concern for venous thromboembolism (VTE). Routine prophylaxis for VTE remains a subject of debate, with the central concern being the occurrence of associated adverse events. Materials and Methods: We conducted a five-year retrospective study on burn patients admitted to our burn center. Demographic data, comorbidities, burn lesions characteristics, surgical interventions, anticoagulant medication, the need for transfusions, the presence of a central venous catheter, length of stay, complications, and mortality were recorded. Results: Of the overall number of patients (494), 2.63% (13 patients) developed venous thromboembolic complications documented through paraclinical investigations. In 70% of cases, thrombosis occurred in a limb with central venous catether (CVC). Every patient with VTE had a Caprini score above 8, with a mean score of 12 points in our study group. Conclusions: Considering each patient's particularities and burn injury characteristics, individualized approaches may be necessary to optimize thromboprophylaxis effectiveness. We suggest routinely using the Caprini Risk Assessment Model in burn patients. We recommend the administration of pharmacologic thromboprophylaxis in all patients and careful monitoring of patients with Caprini scores above 8, due to the increased risk of VTE. Additionally, ongoing research in this field may provide insights into new strategies for managing thrombotic risk in burn patients.
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Affiliation(s)
- Eliza-Maria Bordeanu-Diaconescu
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Andreea Grosu-Bularda
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Adrian Frunza
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Sabina Grama
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
| | - Mihaela-Cristina Andrei
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Tiberiu Paul Neagu
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Cristian-Sorin Hariga
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Ioan Lascar
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
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Capitelli-McMahon H, McCrossan S, Kershaw J, Muthayya P, Anwar MU, Carter A, Sloan B. The use of NexoBrid™ enzymatic debridement and coagulation abnormalities. Burns 2024; 50:123-131. [PMID: 37827936 DOI: 10.1016/j.burns.2023.06.012] [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: 01/02/2023] [Revised: 06/02/2023] [Accepted: 06/20/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES Current evidence on how the use of bromelain-based enzymatic debridement techniques (NexoBrid™) affect patient coagulation is limited. A single patient case report [1] suggests that a patient with 15% total body surface area (TBSA) burn developed decreased coagulation activity following debridement with NexoBrid™ enzymatic debridement (ED). Regional Burns Centres in the United Kingdom may be reluctant to use ED, particularly in larger burns, citing concerns regarding coagulation. At our centre we have routinely used ED on deep partial thickness burns since 2017 including on patients with burns over 15% TBSA. This study aims to investigate whether there is a significant disruption in coagulation in patients undergoing ED with burns > 15% TBSA or admitted to intensive care compared to the standard of care (SOC) which is surgical debridement in theatre. METHODS This single-centre retrospective study includes all patients with a burn treated with ED at Pinderfields General Hospital Regional Burns Centre intensive care unit (ITU) from 2017 to 2020. Patients were matched to those treated with SOC at the same centre by age, % TBSA burn and presence of inhalational injury. These parameters correlate with the Baux score [9]. Percentage of burn debrided was matched as closely as possible, with coagulation profiles and platelet count taken the day before, the day of and three days following surgery. RESULTS Thirty-one patients were treated with ED in the intensive care unit between 2017 and 2020. Four patients were excluded due to insufficient records and one patient was anti-coagulated. Twenty-six patients were included and matched as described above. Average age of patients receiving ED was 44 years, the same in the matched group. Average TBSA burn is 35.5% (35.8% in matched group). No statistically significant difference in coagulation was seen between patients undergoing ED compared to SOC when considering prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelet count. Both groups slightly breached the upper limit of normal on day 2 post ED and SOC. There was a slight breach of the lower limit of the average platelet count on day 2 post-ED which was neither statistically nor clinically significant. CONCLUSIONS Large burns are associated with coagulation abnormalities, therefore isolating a single variable in this cohort is challenging. However, this study found no significant change following ED use when compared to SOC and therefore no convincing evidence that ED is associated with coagulation abnormalities. This study represents one of the largest focusing on coagulation abnormalities following the use of ED, as the current literature is limited. Our study suggests that concerns regarding coagulation abnormalities should not prevent patients with large, deep partial thickness burns or full thickness burns being treated with ED.
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Affiliation(s)
| | - Susan McCrossan
- Pinderfields General Hospital, Mid-Yorkshire Trust, Wakefield, UK
| | - Jonathan Kershaw
- Pinderfields General Hospital, Mid-Yorkshire Trust, Wakefield, UK
| | - Preetha Muthayya
- Pinderfields General Hospital, Mid-Yorkshire Trust, Wakefield, UK
| | | | - Andrew Carter
- Pinderfields General Hospital, Mid-Yorkshire Trust, Wakefield, UK
| | - Brendan Sloan
- Pinderfields General Hospital, Mid-Yorkshire Trust, Wakefield, UK
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8
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Koami H, Sakamoto Y, Matsuoka A, Shinada K. Thromboelastometric Analysis of the Correlation Between Burn-Induced Coagulopathy and Severity of Burn Injury. Cureus 2024; 16:e54489. [PMID: 38516476 PMCID: PMC10955108 DOI: 10.7759/cureus.54489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 03/23/2024] Open
Abstract
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.
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Affiliation(s)
- Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
| | - Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Saga University Hospital, Saga, JPN
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
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9
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Jian F, Lu C, Jia H, Na L, Peng Y, Maohong B, Xulin C. Characteristics of blood clotting on thromboelastography in patients with early burns. Transfus Apher Sci 2023; 62:103824. [PMID: 37813753 DOI: 10.1016/j.transci.2023.103824] [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: 02/11/2023] [Revised: 09/12/2023] [Accepted: 09/22/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Thromboelastography (TEG) is a viscoelastic test that may be used to evaluate the hemostatic function of whole blood, and it may be useful for burn patients with multiple hemostatic defects. METHODS We retrospectively recruited patients with burns between January 2019 and July 2021. Blood samples were drawn on admission and subjected to coagulation parameter assessment, including conventional coagulation tests and TEG assessment. Receiver operating characteristic (ROC) analysis was performed to predict the occurrence of complications in patients with early burns. RESULTS Ninety-three patients with early burns met the inclusion criteria. Patients with minor, moderate, severe, and extremely severe burns accounted for 19.4 %, 36.6 %, 16.1 %, and 27.9 % of all patients, respectively. Compared with the healthy controls, patients with early burns showed significant reductions in the R and K values, and significant elevation in the maximum amplitude (MA), coagulation index (CI), and alpha angle. Compared with minor and moderate burn patients, patients with severe and extremely severe burns had lower K values and thrombin time and higher alpha angle, CI, prothrombin time, international normalized ratio, D-dimer, and fibrin degradation products. Patients with hypercoagulation had lower R and K values, longer MA, longer CI, and greater alpha angle. After ROC analysis, the areas under the ROC curve for acute lung injury, acute kidney injury, and bleeding were 0.789, 0.802, and 0.900, respectively. CONCLUSION TEG provides insight into the hemostatic state of patients with early burns, and can predict complications in early burn patients when combined with conventional coagulation tests.
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Affiliation(s)
- Fang Jian
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230001, China
| | - Chen Lu
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230001, China
| | - He Jia
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230001, China
| | - Li Na
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230001, China
| | - Yang Peng
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230001, China
| | - Bian Maohong
- Department of Blood Transfusion, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230001, China.
| | - Chen Xulin
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230001, China.
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10
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Roggan CLM, Akbas S, Arvanitakis M, Mannil L, Spahn DR, Plock JA, Kaserer A. Changes in coagulation and temperature management in burn patients - A survey of burn centers in Switzerland, Austria and Germany. Burns 2023; 49:1566-1573. [PMID: 36914441 DOI: 10.1016/j.burns.2023.02.010] [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: 09/06/2022] [Revised: 01/13/2023] [Accepted: 02/19/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Severely burned patients suffer from both coagulopathy and hypothermia, with a lack of international consensus and appropriate treatment guidelines. This study examines recent developments and trends in coagulation and temperature management in European burn centers. METHODS A survey was sent to burn centers in Switzerland, Austria and Germany in 2016 and again in 2021. The analysis was performed using descriptive statistics, with categorical data reported in absolute numbers (n) and percentages (%) and numerical data reported as mean and standard deviation. RESULTS The rate of completed questionnaires was 84 % (16 of 19 questionnaires) in 2016 and 91 % (21 of 22 questionnaires) in 2021. The number of global coagulation tests performed has decreased over the observation period in favor of single factor determination and bed-side point-of-care coagulation tests. This has also led to increased administration of single factor concentrates in therapy. Although many centers had a defined treatment protocol for hypothermia in 2016, coverage increased such that in 2021 all centers surveyed had such a protocol. The body temperature was measured more consistently in 2021; thus, hypothermia was more actively sought, detected and treated. CONCLUSION A point-of-care guided, factor-based coagulation management and the maintenance of normothermia have gained importance in the care of burn patients in recent years.
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Affiliation(s)
- Celine L M Roggan
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Samira Akbas
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Michael Arvanitakis
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland
| | - Lijo Mannil
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Jan A Plock
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery; Cantonal Hospital Aarau; Aarau, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
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11
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Fijany AJ, Givechian KB, Zago I, Olsson SE, Boctor MJ, Gandhi RR, Pekarev M. Tranexamic acid in burn surgery: A systematic review and meta-analysis. Burns 2023; 49:1249-1259. [PMID: 37268542 DOI: 10.1016/j.burns.2023.05.009] [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: 12/31/2022] [Revised: 04/11/2023] [Accepted: 05/06/2023] [Indexed: 06/04/2023]
Abstract
Burn injury causes a coagulopathy that is poorly understood. After severe burns, significant fluid losses are managed by aggressive resuscitation that can lead to hemodilution. These injuries are managed by early excision and grafting, which can cause significant bleeding and further decrease blood cell concentration. Tranexamic acid (TXA) is an anti-fibrinolytic that has been shown to reduce surgical blood losses; however, its use in burn surgery is not well established. We performed a systematic review and meta-analysis to investigate the influence TXA may have on burn surgery outcomes. Eight papers were included, with outcomes considered in a random-effects model meta-analysis. Overall, when compared to the control group, TXA significantly reduced total volume blood loss (mean difference (MD) = -192.44; 95% confidence interval (CI) = -297.73 to - 87.14; P = 0.0003), the ratio of blood loss to burn injury total body surface area (TBSA) (MD = -7.31; 95% CI = -10.77 to -3.84; P 0.0001), blood loss per unit area treated (MD = -0.59; 95% CI = -0.97 to -0.20; P = 0.003), and the number of patients receiving a transfusion intraoperatively (risk difference (RD) = -0.16; 95% CI = -0.32 to - 0.01; P = 0.04). Additionally, there were no noticeable differences in venous thromboembolism (VTE) events (RD = 0.00; 95% CI = -0.03 to 0.03; P = 0.98) and mortality (RD = 0.00; 95% CI = -0.03 to 0.04; P = 0.86). In conclusion, TXA can potentially be a pharmacologic intervention that reduces blood losses and transfusions in burn surgery without increasing the risk of VTE events or mortality.
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Affiliation(s)
- Arman J Fijany
- Anne Burnett Marion School of Medicine, Texas Christian University, 1604 W. Rosedale St., Suite 104, Fort Worth, TX 76104, USA.
| | | | - Ilana Zago
- Anne Burnett Marion School of Medicine, Texas Christian University, 1604 W. Rosedale St., Suite 104, Fort Worth, TX 76104, USA
| | - Sofia E Olsson
- Anne Burnett Marion School of Medicine, Texas Christian University, 1604 W. Rosedale St., Suite 104, Fort Worth, TX 76104, USA
| | - Michael J Boctor
- Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL, 60611
| | - Rajesh R Gandhi
- Anne Burnett Marion School of Medicine, Texas Christian University, 1604 W. Rosedale St., Suite 104, Fort Worth, TX 76104, USA
| | - Maxim Pekarev
- Anne Burnett Marion School of Medicine, Texas Christian University, 1604 W. Rosedale St., Suite 104, Fort Worth, TX 76104, USA
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12
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Britton GW, Wiggins AR, Halgas BJ, Cancio LC, Chung KK. Critical Care of the Burn Patient. Surg Clin North Am 2023; 103:415-426. [PMID: 37149378 DOI: 10.1016/j.suc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Care of the critically ill burned patient must integrate a multidisciplinary care team composed of burn care specialists. As resuscitative mortality decreases more patients are surviving to experience multisystem organ failure relating to complications of their injuries. Clinicians must be aware of physiologic changes following burn injury and the implicated impacts on management strategy. Promoting wound closure and rehabilitation should be the backdrop for which management decisions are made.
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Affiliation(s)
- Garrett W Britton
- US Army Institute of Surgical Research, 3698 Chambers Pass Road, San Antonio, TX 78234, USA; Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA.
| | - Amanda R Wiggins
- US Army Institute of Surgical Research, 3698 Chambers Pass Road, San Antonio, TX 78234, USA
| | - Barret J Halgas
- US Army Institute of Surgical Research, 3698 Chambers Pass Road, San Antonio, TX 78234, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, 3698 Chambers Pass Road, San Antonio, TX 78234, USA; Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
| | - Kevin K Chung
- Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
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13
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Hasham S, Riyat H, Fletcher A, O’Boyle CP, Alexander S. To bleed or not to bleed? Case series and discussion of haemorrhage risk with enzymatic debridement in burn injuries. Scars Burn Heal 2023; 9:20595131231168333. [PMID: 37124159 PMCID: PMC10134154 DOI: 10.1177/20595131231168333] [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] [Indexed: 05/02/2023] Open
Abstract
Introduction Surgical burn excision (along with skin grafting) carries the risk of blood loss. The use of enzymatic debridement agents such as Nexobrid® has gained increased popularity as an alternative to surgical debridement in the management of burns with its reported benefits of selective burn debridement, minimising blood loss and potentially reducing the need for skin grafting. However, there is limited evidence regarding its effects on bleeding. Currently, the manufacturer declares there is no evidence for increased risk of localised bleeding and its systemic effects upon coagulation are less clear. Methods We present two clinical cases demonstrating the possible effects of Nexobrid® on coagulation and bleeding at the debridement site. Comparisons are drawn with the manufacturers' guidance as well as evaluating the current recommendations of its use. Discussion Nexobrid® is a novel therapy and there are few adverse effects reported in the literature. The basis of its appeal is the reduced blood loss at the debridement site and the selectivity it possesses in preserving healthy dermis. However, our cases have demonstrated that haemorrhage can occur and that those using Nexobrid® should be mindful of the potential bleeding risk from varicosities within the burn wound. We have also illustrated that Nexobrid® can be used in patients with pre-existing clotting disorders without requiring the use of blood products. However, we emphasise the importance of haematological support for its safe administration. Lay Summary Nexobrid®, a debriding agent that contains enzymes, has been developed as an alternative to surgery which for most surgeons is the traditional method of removing dead tissue following a burn injury. The active agent is bromelain and this is derived from the stems of pineapples. This novel treatment is increasingly being used in the management of middle to deep skin thickness burns and it seems to have a number of benefits such as reducing blood loss, reducing the need for skin grafting as well as being able to treat burns in certain areas of the body that would be technically challenging to remove in the standard fashion. It simply targets the dead tissue leaving viable remnants of the skin that would hopefully allow healing to occur without the need for surgical intervention. Being a relatively new concept, current evidence regarding the safety and value of Nexobrid® continues to develop. In 2020, an agreement guideline outlining best practice with the use of Nexobrid® was published. In this statement, it was advised that caution should be taken when using Nexobrid® in patients who have blood clotting disturbances as this could increase the likelihood of bleeding. However, they did not mention that excessive bleeding can potentially occur with this treatment.We present two clinical cases demonstrating the possible effects of Nexobrid® on the clotting system and bleeding at the application site. Comparisons are drawn with the manufacturers' guidance as well as assessing the current recommendations of its use. We illustrate that Nexobrid® can be safely used in patients with pre-existing clotting disturbances if the correct procedures are performed. We also highlight the potential complication of excessive bleeding if Nexobrid® is used in patients who have co-existing enlarged surface veins along with their burn injury. We feel the guidance should be updated to reflect these findings.
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Affiliation(s)
- Saiidy Hasham
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Saiidy Hasham, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB, UK.
| | - Harjoat Riyat
- St Helens and Knowsley Teaching Hospitals NHS Trust, Liverpool, UK
| | | | - Ciaran P O’Boyle
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham Medical School, Nottingham, UK
| | - Skaria Alexander
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham Medical School, Nottingham, UK
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14
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Bunch CM, Chang E, Moore EE, Moore HB, Kwaan HC, Miller JB, Al-Fadhl MD, Thomas AV, Zackariya N, Patel SS, Zackariya S, Haidar S, Patel B, McCurdy MT, Thomas SG, Zimmer D, Fulkerson D, Kim PY, Walsh MR, Hake D, Kedar A, Aboukhaled M, Walsh MM. SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock. Front Physiol 2023; 14:1094845. [PMID: 36923287 PMCID: PMC10009294 DOI: 10.3389/fphys.2023.1094845] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/07/2023] [Indexed: 03/03/2023] Open
Abstract
Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Eric Chang
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States
| | - Hunter B Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States.,Department of Transplant Surgery, Denver Health and University of Colorado Health Sciences Center, Denver, CO, United States
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Mahmoud D Al-Fadhl
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Anthony V Thomas
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Nuha Zackariya
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Shivani S Patel
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Sufyan Zackariya
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Saadeddine Haidar
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Bhavesh Patel
- Division of Critical Care, Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Scott G Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Donald Zimmer
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Daniel Fulkerson
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Daniel Hake
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Archana Kedar
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Michael Aboukhaled
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Mark M Walsh
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States.,Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
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15
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Li Q, Zhang T, Wang L, Li F, Chen Q, Cao S, Ba T. Clinical significance of R-TEG in severe burn patients with coagulation dysfunction. Injury 2022; 53:3993-3999. [PMID: 36210205 DOI: 10.1016/j.injury.2022.09.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/27/2022] [Accepted: 09/29/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study was to retrospectively analyze Thrombelastography (TEG) data of severe burn patients to provide a clinical basis for timely diagnosis and treatment of coagulation dysfunction. METHODS The present study comprised burn patients with full thickness TBSA ≥ 60%. The patients included in the study were admitted to the Third Affiliated Hospital of Inner Mongolia Medical University between March 2019 and March 2022 and died within 10 days. Patient demographic and clinical data, including abbreviated burn severity index (ABSI) score, full thickness and overall total surface burn area (TBSA), injury cause, International Society on Thrombosis and Hemostasis (ISTH) score, were retrieved from the electronic medical record system. TEG data (including ACT, K, α, MA and LY30), platelet count (PLT), mean platelet volume (MPV) and platelet distribution width (PDW) data were obtained from the records of included patients for analysis. RESULTS A total of 9 patients were enrolled. The average burn area was 90.0% TBSA and the full-thickness TBSA was 72.0%. The results showed that α, MA and PLT count values were significantly lower relative to those at obtained throughout admission period (all p < 0.05). PDW and MPV were significantly higher compared with the values at admission (all p < 0.05). ACT time was significantly longer from day 2 after severe burn compared with the ACT time at admission (all p < 0.05). LY30 value from day 3 after severe burn was significantly higher compared with the value at admission (p < 0.05). One patient was diagnosed with diffuse intravascular coagulation (DIC) on admission, whereas eight patients were diagnosed with DIC on the day of death. CONCLUSION Coagulation dysfunction after severe burn is mainly characterized by procoagulant disorders and hyperfibrinolysis, which can be timely detected by TEG. Coagulation after severe burn exhibits a gradual aggravation, and can lead to death of patients.
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Affiliation(s)
- Quan Li
- Department of Burn Surgery, Institute of Burn Research of Inner Mongolia, The Third Affiliated Hospital of Inner Mongolia Medical University, Baogang Hospital, No. 20 Shaoxian Road, Kundulun District, Baotou 014010, China
| | - Tiening Zhang
- Department of Burn Surgery, Institute of Burn Research of Inner Mongolia, The Third Affiliated Hospital of Inner Mongolia Medical University, Baogang Hospital, No. 20 Shaoxian Road, Kundulun District, Baotou 014010, China
| | - Lingfeng Wang
- Department of Burn Surgery, Institute of Burn Research of Inner Mongolia, The Third Affiliated Hospital of Inner Mongolia Medical University, Baogang Hospital, No. 20 Shaoxian Road, Kundulun District, Baotou 014010, China
| | - Fang Li
- Department of Burn Surgery, Institute of Burn Research of Inner Mongolia, The Third Affiliated Hospital of Inner Mongolia Medical University, Baogang Hospital, No. 20 Shaoxian Road, Kundulun District, Baotou 014010, China
| | - Qiang Chen
- Department of Burn Surgery, Institute of Burn Research of Inner Mongolia, The Third Affiliated Hospital of Inner Mongolia Medical University, Baogang Hospital, No. 20 Shaoxian Road, Kundulun District, Baotou 014010, China
| | - Shengjun Cao
- Department of Burn Surgery, Institute of Burn Research of Inner Mongolia, The Third Affiliated Hospital of Inner Mongolia Medical University, Baogang Hospital, No. 20 Shaoxian Road, Kundulun District, Baotou 014010, China.
| | - Te Ba
- Department of Burn Surgery, Institute of Burn Research of Inner Mongolia, The Third Affiliated Hospital of Inner Mongolia Medical University, Baogang Hospital, No. 20 Shaoxian Road, Kundulun District, Baotou 014010, China.
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Ebrahimi Z, Mahdi Z, Khairi AA, Behrangi E, Zare AG, Dehghani A, Goodarzi A. Oral propranolol and topical timolol in the treatment of post‐burn pyogenic granuloma: Two cases and a review of the literature. Clin Case Rep 2022; 10:e6538. [DOI: 10.1002/ccr3.6538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/14/2022] [Accepted: 10/15/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Zahra Ebrahimi
- Department of General Medicine, School of Medicine Iran University of Medical Sciences Tehran Iran
| | - Zeinab Mahdi
- Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine Iran University of Medical Science Tehran Iran
| | - Ali Asghar Khairi
- Department of Plastic Surgery, Sina Hospital, School of Medicine Tabriz University of Medical Sciences Tabriz Iran
| | - Elham Behrangi
- Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine Iran University of Medical Science Tehran Iran
- Stem Cell Research Center Tehran University of Medical Sciences Tehran Iran
| | - Armaghan Gharehaghaji Zare
- Department of Dermatology, Sina Hospital, School of Medicine Tabriz University of Medical Sciences Tabriz Iran
| | - Abbas Dehghani
- Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine Iran University of Medical Science Tehran Iran
| | - Azadeh Goodarzi
- Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine Iran University of Medical Science Tehran Iran
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McDonough MM, Keyloun J, Orfeo T, Brummel-Zeidins K, Bynum JA, Wu X, Darlington DN, Shupp JW, Burmeister DM. A Natural History Study of Coagulopathy in a Porcine 40% Total Body Surface Area Burn Model Reveals the Time-Dependent Significance of Functional Assays. Burns 2022; 48:1805-1815. [DOI: 10.1016/j.burns.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/29/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022]
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18
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Tan AWK, Li RHL, Ueda Y, Stern JA, Hussain M, Haginoya S, Sharpe AN, Gunther-Harrington CT, Epstein SE, Nguyen N. Platelet Priming and Activation in Naturally Occurring Thermal Burn Injuries and Wildfire Smoke Exposure Is Associated With Intracardiac Thrombosis and Spontaneous Echocardiographic Contrast in Feline Survivors. Front Vet Sci 2022; 9:892377. [PMID: 35909698 PMCID: PMC9329816 DOI: 10.3389/fvets.2022.892377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Wildfires pose a major health risk for humans, wildlife, and domestic animals. We previously discovered pathophysiologic parallels between domestic cats with naturally occurring smoke inhalation and thermal burn injuries and human beings with similar injuries; these were characterized by transient myocardial thickening, cardiac troponin I elevation and formation of intracardiac thrombosis. While the underlying mechanisms remain unclear, results from murine models suggest that platelet priming and activation may contribute to a global hypercoagulable state and thrombosis. Herein, we evaluated and compared the degree of platelet activation, platelet response to physiologic agonists and levels of platelet-derived microvesicles (PDMV) in 29 cats with naturally occurring wildfire thermal injuries (WF), 21 clinically healthy cats with subclinical hypertrophic cardiomyopathy (HCM) and 11 healthy cats without HCM (CC). We also quantified and compared circulating PDMVs in WF cats to CC cats. In addition, we examined the association between thrombotic events, severity of burn injuries, myocardial changes, and the degree of platelet activation in cats exposed to wildfires. Flow cytometric detection of platelet surface P-selectin expression showed that WF cats had increased platelet response to adenosine diphosphate (ADP) and thrombin compared to the two control groups indicating the presence of primed platelets in circulation. In addition, cats in the WF group had increased circulating levels of PDMV, characterized by increased phosphatidylserine on the external leaflet. Cats in the WF group with documented intracardiac thrombosis had elevated platelet activation and platelet priming in the presence of ADP. While high dose arachidonic acid (AA) mostly resulted in platelet inhibition, persistent response to AA was noted among cats in the WF group with intracardiac thrombosis. Univariate and multiple logistic regression analyses demonstrated that increased platelet response to AA was independently associated with thrombotic events. This is the first study reporting the significant association between platelet priming and intracardiac thrombosis in domestic cats with naturally occurring wildfire-related injuries and smoke inhalation. Further studies are required to delineate additional mechanisms between inflammation and thrombosis, especially regarding platelet primers and the cyclooxygenase pathway.
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Affiliation(s)
- Avalene W. K. Tan
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Ronald H. L. Li
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
- *Correspondence: Ronald H. L. Li
| | - Yu Ueda
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Joshua A. Stern
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Mehrab Hussain
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Satoshi Haginoya
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Ashely N. Sharpe
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Catherine T. Gunther-Harrington
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Steven E. Epstein
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Nghi Nguyen
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
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Kuznetsova TA, Andryukov BG, Besednova NN. Modern Aspects of Burn Injury Immunopathogenesis and Prognostic Immunobiochemical Markers (Mini-Review). BIOTECH 2022; 11:biotech11020018. [PMID: 35822791 PMCID: PMC9264396 DOI: 10.3390/biotech11020018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 11/18/2022] Open
Abstract
Burn injuries are among the most common peacetime injuries, with mortality ranging from 2.3% to 3.6%. At the same time, 85–90% of patients with burns are people of working age and children. Burn injury leads to metabolic disorders and systemic inflammatory response, inefficient energy consumption, and other physiological changes that can lead to dysfunction of organs and systems. The most formidable complication of burn injuries is sepsis mediated by multiple organ failure, the most common cause of poor prognosis in patients and has specific differences in these injuries. The purpose of this article was to dwell in detail on the most promising immunobiochemical markers of sepsis in the format of a mini-review, based on the main aspects of the immunopathogenesis of this complication. The pathogenesis of a burn injury and any general pathological process is based on an inflammatory reaction and large-scale changes in the skin and mucous membranes. This review is devoted to the progress in understanding the main aspects of the immunopathogenesis of burn lesions and the features of post-burn immune dysfunction, manifested by disorders in the innate and adaptive immunity systems. Attention is focused on the role in the immunopathogenesis of the development of systemic and local disorders in burn injury. Characterization of primary immunobiochemical markers of burn injury (cytokines, growth factors, C-reactive protein, procalcitonin, presepsin, matrix metalloproteinases, reactive oxygen species, nitric oxide, hemostasis parameters) is presented. The problem of treating burn lesions is associated with constant monitoring of the condition of patients and regular monitoring of specific immunobiochemical markers predicting sepsis for the timely initiation of a specific therapy.
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Affiliation(s)
- Tatyana A. Kuznetsova
- Somov Institute of Epidemiology and Microbiology, Russian Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, 690087 Vladivostok, Russia; (B.G.A.); (N.N.B.)
- Correspondence: ; Tel.: +7-(423)-244-2446
| | - Boris G. Andryukov
- Somov Institute of Epidemiology and Microbiology, Russian Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, 690087 Vladivostok, Russia; (B.G.A.); (N.N.B.)
- School of Medicine, Far Eastern Federal University (FEFU), 690091 Vladivostok, Russia
| | - Natalia N. Besednova
- Somov Institute of Epidemiology and Microbiology, Russian Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing, 690087 Vladivostok, Russia; (B.G.A.); (N.N.B.)
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20
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Zhang TN, Ba T, Li F, Chen Q, Chen ZP, Zhou B, Yan ZQ, Li Q, Cao SJ, Wang LF. Coagulation dysfunction of severe burn patients: A potential cause of death. Burns 2022; 49:678-687. [PMID: 35623933 DOI: 10.1016/j.burns.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/18/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Research on coagulation dysfunction following burns is controversial. This study aimed to describe the coagulation changes in severe burn patients by examining coagulation parameters. METHODS Patients with third-degree total body surface area (TBSA) burns of ≥30% were enrolled between 2017 and 2020. Platelet (PLT) count and coagulation indexes (including APTT, INR, FIB, DD, and AT Ⅲ) were measured at admission and once weekly for 8 weeks, and statistical analysis was performed. The patient medical profiles were reviewed to extract demographic and clinical data, including TBSA, third-degree TBSA, and inhalation injury. The total intravenous fluids and transfusions of crystalloids, fresh frozen plasma (FFP), and red blood cells (RBC) were calculated during the forty-eight-hour period. The number of sepsis cases was recorded. RESULTS We enrolled 104 patients , and while the overall coagulation trend fluctuated, inflection points appeared around one week and demonstrated hypercoagulability. INR was significantly higher in the non-survival group than in the survivors' group from admission to three weeks after burn (all p<0.01). From post-injury week 1 to post-injury week 3, the APTT in the non-survival group was greater than in the survival group, but the non-survival group's PLT count was lower than that in the survival group (all p<0.05). At two and three weeks after burns, the FIB levels in the non-survival group were significantly lower than those of the survival group (both p<0.01). The prevalence of inhalation injury and the proportion of sepsis cases were significantly higher in the non-survival group than in the survival group ( p < 0.05, p < 0.001, respectively). At the time of death, APTT, INR, and FDP levels were significantly higher in the non-survival group in the survivor group, and FIB, ATIII, and PLT were significantly lower than in the survivor group (all p<0.01). On the day of death, nine of the 12 dead patients had disseminated intravascular coagulation (DIC). CONCLUSIONS Coagulation dysfunction was most prominent in severe burn patients 1 week after injury and presented as hypercoagulability. Large-area burn injury, large amounts of fluid resuscitation, inhalation injury, and sepsis may all contribute to coagulation dysfunction, which can further develop into DIC and even death in severe burns patients.
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Affiliation(s)
- Tie-Ning Zhang
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China
| | - Te Ba
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China
| | - Fang Li
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China
| | - Qiang Chen
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China
| | - Zhi-Peng Chen
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China
| | - Biao Zhou
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China
| | - Zeng-Qiang Yan
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China
| | - Quan Li
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China.
| | - Sheng-Jun Cao
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China.
| | - Ling-Feng Wang
- Department of Burn Surgery, The Third Affiliated Hospital of Inner Mongolia Medical University, Institute of Burn Research of Inner Mongolia, Baotou, China.
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21
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Cartotto R, Burmeister DM, Kubasiak JC. Burn Shock and Resuscitation: Review and State of the Science. J Burn Care Res 2022; 43:irac025. [PMID: 35218662 DOI: 10.1093/jbcr/irac025] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Indexed: 12/31/2022]
Abstract
Burn shock and acute fluid resuscitation continue to spark intense interest and debate among burn clinicians. Following a major burn injury, fluid resuscitation of burn shock is life-saving, but paradoxically can also be a source of increased morbidity and mortality because of the unintended consequence of systemic edema formation. Considerable research over the past two decades has been devoted to understanding the mechanisms of edema formation, and to develop strategies to curb resuscitation fluids and limit edema development. Recognition of burn endotheliopathy - injury to the endothelium's glycocalyx layer- is one of the most important recent developments in our understanding of burn shock pathophysiology. Newer monitoring approaches and resuscitation endpoints, along with alternative resuscitation strategies to crystalloids alone, such as administration of albumin, or plasma, or high dose ascorbic acid, have had mixed results in limiting fluid creep. Clear demonstration of improvements in outcomes with all of these approaches remains elusive. This comprehensive review article on burn shock and acute resuscitation accompanies the American Burn Association's State of the Science meeting held in New Orleans, LA on November 2-3, 2021 and the Proceedings of that conference published in this journal.
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Affiliation(s)
- Robert Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and University of Toronto, Canada
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland and United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas USA
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22
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Assessing Factor V Antigen and Degradation Products in Burn and Trauma Patients. J Surg Res 2022; 274:169-177. [PMID: 35180493 DOI: 10.1016/j.jss.2021.12.049] [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: 05/04/2021] [Revised: 11/19/2021] [Accepted: 12/27/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Proposed mechanisms of acute traumatic coagulopathy (ATC) include decreased clotting potential due to factor consumption and proteolytic inactivation of factor V (FV) and activated factor V (FVa) by activated protein C (aPC). The role of FV/FVa depletion or inactivation in burn-induced coagulopathy is not well characterized. This study evaluates FV dynamics following burn and nonburn trauma. METHODS Burn and trauma patients were prospectively enrolled. Western blotting was performed on admission plasma to quantitate levels of FV antigen and to assess for aPC or other proteolytically derived FV/FVa degradation products. Statistical analysis was performed with Spearman's, Chi-square, Mann-Whitney U test, and logistic regression. RESULTS Burn (n = 60) and trauma (n = 136) cohorts showed similar degrees of FV consumption with median FV levels of 76% versus 73% (P = 0.65) of normal, respectively. Percent total body surface area (TBSA) was not correlated with FV, nor were significant differences in median FV levels observed between low and high TBSA groups. The injury severity score (ISS) in trauma patients was inversely correlated with FV (ρ = -0.26; P = 0.01) and ISS ≥ 25 was associated with a lower FV antigen level (64% versus. 93%; P = 0.009). The proportion of samples showing proteolysis-derived FV was greater in trauma than burn patients (42% versus. 16%; P = 0.0006). CONCLUSIONS Increasing traumatic injury severity is associated with decreased FV antigen levels, and a greater proportion of trauma patient samples exhibit proteolytically degraded FV fragments. These associations are not present in burns, suggesting that mechanisms underlying FV depletion in burn and nonburn trauma are not identical.
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23
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Lin JC, Chen XD, Xu ZR, Zheng LW, Chen ZH. Association of the Circulating Supar Levels with Inflammation, Fibrinolysis, and Outcome in Severe Burn Patients. Shock 2021; 56:948-955. [PMID: 34779798 PMCID: PMC8579993 DOI: 10.1097/shk.0000000000001806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/19/2021] [Accepted: 04/28/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hyperfibrinolysis and pro/anti-inflammatory imbalance usually occur in the early stage of severe burns. Soluble urokinase-type plasminogen activator receptor (suPAR) is involved in fibrinolysis and inflammation. To date, the levels of circulating suPAR in non-survivors with severe burns remain unknown. This study aimed to investigate the early association between circulating suPAR levels and biomarkers of fibrinolysis, pro/anti-inflammatory, and prognosis. METHODS Sixty-four consecutive Chinese patients with severe burns and 26 healthy volunteers were enrolled in a prospective observational cohort. Clinical characteristics and laboratory data were collected prospectively. Blood samples were collected at 48 h post-burn, and suPAR and biomarkers of pro/anti-inflammatory and fibrinolysis were detected by enzyme-linked immunosorbent assays. Important indicators between non-survivors and survivors were compared. Linear regression analysis was performed to screen variables associated with suPAR. Logistic regression analysis and receiver operating characteristic curve (ROC) analysis were performed to evaluate the prognostic value of suPAR. RESULT Compared with the control group, the circulating suPAR levels in the survivors (P < 0.001) and non-survivors (P = 0.017) were higher. Compared with survivors, non-survivors had lower circulating suPAR levels at 48 h post-burn, and they showed a higher degree of fibrinolysis (higher D-dimer) and a lower TNF-α/IL-10 ratio. According to linear regression analysis, the variables independently associated with a lower suPAR level were lower platelet factor 4 (PF-4), urokinase-type plasminogen activator (uPA), and TNF-α/IL-10 levels and a higher D-dimer level. Logistic regression and ROC analyses indicated that a suPAR level ≤ 4.70 μg/L was independently associated with 30-day mortality. CONCLUSION Low circulating suPAR levels at 48 h post-burn in severe burn patients may reflect decreased TNF-α/IL-10 ratio and increased hyperfibrinolysis. suPAR can predict 30-day mortality in patients with severe burn.
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Affiliation(s)
- Jian-Chang Lin
- Fujian Provincial Key Laboratory of Burn and Trauma, Fujian Burn Institute, Fujian Burn Medical Center, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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24
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Fu S, Yu S, Zhao Y, Ma X, Li X. Unfractionated Heparin Attenuated Histone-Induced Pulmonary Syndecan-1 Degradation in Mice: a Preliminary Study on the Roles of Heparinase Pathway. Inflammation 2021; 45:712-724. [PMID: 34657233 DOI: 10.1007/s10753-021-01578-w] [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: 07/08/2021] [Revised: 09/07/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
Endothelial glycocalyx degradation is thought to facilitate the development of sepsis. Histone is a significant mediator in sepsis. Unfractionated heparin (UFH) possessed beneficial effects on sepsis. Thereby, this study aims to figure out whether histone can disrupt glycocalyx and to investigate the protective effect and mechanism of UFH. Male mice (C57BL/6, 8-10 weeks old, weighing 20-25 g) were randomly divided into five groups including control group, histone group, histone + UFH group, histone + heparinase (HPA) inhibitor group, and histone + UFH + HPA inhibitor group. The mice were treated with histone (50 mg/kg) via tail vein immediately after HPA (20 mg/kg) injection. UFH (400 U/kg) was injected 1h after histone administration. The other groups were injected with equal volume of sterile saline accordingly. UFH alleviated histone-induced lung injury and pulmonary edema. UFH inhibited histone-induced lung coagulation activation and inflammatory response. UFH treatment markedly inhibited pulmonary glycocalyx degradation by reducing the histone-induced decrease in the levels of lung syndecan-1 mRNA and protein. UFH downregulated histone-induced expression of HPA mRNA and protein, and thus alleviated glycocalyx degradation. UFH protects against histone-induced pulmonary glycocalyx injury partly by heparinase pathway.
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Affiliation(s)
- Sifeng Fu
- Department of Critical Care Medicine, the First Affiliated Hospital, China Medical University, North Nanjing Street 155, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Sihan Yu
- Department of Critical Care Medicine, the First Affiliated Hospital, China Medical University, North Nanjing Street 155, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Yilin Zhao
- Department of Critical Care Medicine, the First Affiliated Hospital, China Medical University, North Nanjing Street 155, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Xiaochun Ma
- Department of Critical Care Medicine, the First Affiliated Hospital, China Medical University, North Nanjing Street 155, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Xu Li
- Department of Critical Care Medicine, the First Affiliated Hospital, China Medical University, North Nanjing Street 155, Shenyang, 110001, Liaoning Province, People's Republic of China.
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25
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Valente TM, Tiraboschi¹ FA, Santos ÍSO, de Brito MEM, Valente TM, da Silva GPF. Burns and patients infected with COVID-19 at a burn treatment centre in Brazil: a series of case-reports. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2021; 11:412-417. [PMID: 34858722 PMCID: PMC8610816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND In December 2019, in Wuhan, China, several cases of viral pneumonia, caused by a new type of coronavirus (SARS-CoV-2, a disease that became known as COVID-19) emerged. Being an alarming situation, many resources were directed to fight this pandemic. However, other diseases and conditions, such as burn injuries, continued to occur in this period, thus creating multiple challenges. METHOD Four patients with COVID-19 treated in a reference burn treatment centre from the Northeast region of Brazil, in the city of Fortaleza were analysed between April to June 2020. RESULTS All patients were admitted in the service without signs of COVID-19 infection; however the symptoms appeared a few days after hospitalisation. The most common symptom was fever, especially when it occurred in only one spike. Patients who evolved to an unfavourable outcome had comorbidities prior to the infection and burn injury. In addition to this, these two patients had a worsening of their renal function, in contrast to the other two patients that received hospital discharge. CONCLUSION The burned patient is a complex one that requires the health professional's attention and special care. This became even more evident during the period of the COVID-19 pandemic. Thus, the patients' changes and symptoms must be cautiously analysed, their diagnosis should not be delayed and it must be made under standardised protocols accordingly with the socio-economic and cultural realities of each service.
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Sahli SD, Pedrazzi N, Braun J, Spahn DR, Kaserer A, Plock JA. Effect of a factor-based coagulation management on blood product use after major burn injury: A retrospective cohort study. Burns 2021; 47:1486-1494. [PMID: 34465509 DOI: 10.1016/j.burns.2021.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Transfusion of allogenic blood products was shown to be associated with more adverse events and a higher mortality in severely burned patients. This study investigated the impact of a goal-directed and factor-based coagulation algorithm on blood product use and clinical outcomes in severely burned patients. METHODS This retrospective cohort study included adult patients admitted to the burn center of the University Hospital Zurich with major burn injuries compromising 20-80% of total body surface area. We compared two 3-year periods, one before the introduction of a goal-directed coagulation and transfusion algorithm (period 1: 2009-2011) and one after (period 2: 2016-2018). We applied linear and logistic regression models adjusted for confounders. RESULTS We analyzed 36 patients (27.8% female) versus 42 patients (14.3% female) in period 1 and 2, respectively. Comorbidities and burn types were comparable between both collectives. Treatment according to the coagulation algorithm resulted in an overall reduction of 33 units of red blood cells (95% CI -52.8 to -12.9, p = 0.002), 9 units fresh frozen plasma (95% CI -14.7 to -2.6, p = 0.006) and 1.4g fibrinogen (95% CI -2.2 to -0.5, p = 0.001) per patient. We observed less infections (61.8% vs. 41.5%, p = 0.11) and a reduced mortality (38.9% vs. 26.8%, p = 0.33) during the algorithm treated period, although not significant. CONCLUSION Treatment of severely burned patients with a goal-directed coagulation algorithm reduced blood product use and resulted in target-oriented administration of coagulation factors to improve outcomes.
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Affiliation(s)
- Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
| | - Nadine Pedrazzi
- Department of Plastic and Hand Surgery, Lausanne University Hospital, Lausanne, Switzerland.
| | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
| | - Jan A Plock
- Department of Plastic Surgery and Hand Surgery, Burn Center, University and University Hospital Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Cantonal Hospital Aarau, Aarau, Switzerland.
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27
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Keyloun JW, Le TD, Pusateri AE, Ball RL, Carney BC, Orfeo T, Brummel-Ziedins KE, Bravo MC, McLawhorn MM, Moffatt LT, Shupp JW. Circulating Syndecan-1 and Tissue Factor Pathway Inhibitor, Biomarkers of Endothelial Dysfunction, Predict Mortality in Burn Patients. Shock 2021; 56:237-244. [PMID: 33394974 PMCID: PMC8284378 DOI: 10.1097/shk.0000000000001709] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/27/2020] [Accepted: 12/08/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the association between burn injury and admission plasma levels of Syndecan-1 (SDC-1) and Tissue Factor Pathway Inhibitor (TFPI), and their ability to predict 30-day mortality. BACKGROUND SDC-1 and TFPI are expressed by vascular endothelium and shed into the plasma as biomarkers of endothelial damage. Admission plasma biomarker levels have been associated with morbidity and mortality in trauma patients, but this has not been well characterized in burn patients.Methods: This cohort study enrolled burn patients admitted to a regional burn center between 2013 and 2017. Blood samples were collected within 4 h of admission and plasma SDC-1 and TFPI were quantified by ELISA. Demographics and injury characteristics were collected prospectively. The primary outcome was 30-day in-hospital mortality. RESULTS Of 158 patients, 74 met inclusion criteria. Most patients were male with median age of 41.5 years and burn TBSA of 20.5%. The overall mortality rate was 20.3%. Admission SDC-1 and TFPI were significantly higher among deceased patients. Plasma SDC-1 >34 ng/mL was associated with a 32-times higher likelihood of mortality [OR: 32.65 (95% CI, 2.67-399.78); P = 0.006] and a strong predictor of mortality (area under the ROC [AUROC] 0.92). TFPI was associated with a nine-times higher likelihood of mortality [OR: 9.59 (95% CI, 1.02-89.75); P = 0.002] and a fair predictor of mortality (AUROC 0.68). CONCLUSIONS SDC-1 and TFPI are associated with a higher risk of 30-day mortality. We propose the measurement of SDC-1 on admission to identify burn patients at high risk of mortality. However, further investigation with a larger sample size is warranted.
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Affiliation(s)
- John W. Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Tuan D. Le
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, University of Texas Health Science Center, Tyler, Texas
| | | | - Robert L. Ball
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Bonnie C. Carney
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
- Department of Biochemistry, Georgetown University, Washington, DC
| | - Thomas Orfeo
- Department of Surgery, Georgetown University, Washington, DC
| | | | - Maria C. Bravo
- Department of Surgery, Georgetown University, Washington, DC
| | - Melissa M. McLawhorn
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Lauren T. Moffatt
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
- Department of Biochemistry, Georgetown University, Washington, DC
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Jeffrey W. Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
- Department of Biochemistry, Georgetown University, Washington, DC
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Burlington, Vermont
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28
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What'S New in Shock, August 2020? Shock 2021; 54:141-143. [PMID: 32665535 DOI: 10.1097/shk.0000000000001614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Keyloun JW, Le TD, Brummel-Ziedins KE, Mclawhorn MM, Bravo MC, Orfeo T, Johnson LS, Moffatt LT, Pusateri AE, Shupp JW. Inhalation Injury is Associated with Endotheliopathy and Abnormal Fibrinolytic Phenotypes in Burn Patients: A Cohort Study. J Burn Care Res 2021; 43:432-439. [PMID: 34089618 PMCID: PMC8946676 DOI: 10.1093/jbcr/irab102] [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] [Indexed: 11/12/2022]
Abstract
Burn injury is associated with endothelial dysfunction and coagulopathy and concomitant inhalation injury increases morbidity and mortality. The aim of this work is to identify associations between inhalation injury (IHI), coagulation homeostasis, vascular endothelium, and clinical outcomes in burn patients. One-hundred and twelve patients presenting to a regional burn center were included in this retrospective cohort study. Whole blood was collected at set intervals from admission through 24 hours and underwent viscoelastic assay with rapid TEG (rTEG). Syndecan-1 (SDC-1) on admission was quantified by ELISA. Patients were grouped by the presence (n=28) or absence (n=84) of concomitant IHI and rTEG parameters, fibrinolytic phenotypes, SDC-1, and clinical outcomes were compared. Of the 112 thermally injured patients, 28 (25%) had IHI. Most patients were male (68.8%) with a median age of 40 (IQR, 29-57) years. Patients with IHI had higher overall mortality (42.68% vs. 8.3%; p<0.0001). rTEG LY30 was lower in patients with IHI at hours 4 and 12 (p<0.05). There was a pattern of increased abnormal fibrinolytic phenotypes among IHI patients. There was a greater proportion of IHI patients with endotheliopathy (SDC-1 > 34 ng/mL) (64.7% vs. 26.4%; p=0.008). There was a pattern of increased mortality among patients with inhalation injury and endotheliopathy (0% vs. 72.7%; p=0.004). Significant differences between patients with and without IHI were found in measures assessing fibrinolytic potential and endotheliopathy. Mortality was associated with abnormal fibrinolysis, endotheliopathy, and inhalation injury. However, the extent to which IHI associated dysfunction is independent of TBSA burn size remains to be elucidated.
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Affiliation(s)
- John W Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Tuan D Le
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX.,Department of Epidemiology and Biostatistics, University of Texas Health Science Center, Tyler, TX
| | | | - Melissa M Mclawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Maria C Bravo
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT
| | - Thomas Orfeo
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT
| | - Laura S Johnson
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC.,Department of Biochemistry Georgetown University, Washington, DC
| | | | - Jeffrey W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC.,Department of Biochemistry Georgetown University, Washington, DC
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30
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Heard TC, Gómez BI, Saathoff ME, Duarte J, Dubick MA, Bynum JA, Christy RJ, Burmeister DM. Minimal Effects of Intravenous Administration of Xenogeneic Adipose Derived Stem Cells on Organ Function in a Porcine 40%TBSA Burn Model. J Burn Care Res 2021; 42:870-879. [PMID: 34057993 DOI: 10.1093/jbcr/irab094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Adipose stem cells (ASCs) have shown therapeutic promise for various conditions, including burn injury. While ASCs have immunomodulatory properties, concerns exist over pro-coagulant activity after intravenous (IV) administration. In the present study, we examined IV human ASC delivery in terms of coagulation, organ function, and inflammation in a 40% total body surface area (TBSA) swine burn model. Anesthetized female Yorkshire swine were burned and randomized to receive 15ml/kg Lactated Ringer's containing: no ASCs; a low dose (5x10 5 ASCs/kg), or a high dose (5x10 6 ASCs/kg). For biochemical analysis, blood was collected at baseline (BL), 3, 6, 12, and 24 hours post-burn, while kidney and liver tissue was collected post-euthanasia. A significant, but transient, effect of ASCs was seen on prothrombin times and INR, wherein low doses revealed slight hypercoagulation. Burns increased partial thromboplastin time, fibrinogen, and d-dimer levels, which was unchanged with ASC administration. ASCs tended to exacerbate increases in bilirubin at 3 hours, but this didn't reach statistical significance. A significant effect of ASCs on creatinine and BUN was seen, wherein low doses elevated levels at 24 hours (creatinine, p=0.0012; BUN, p=0.0195). Hepatic and renal TUNEL staining were similar for all groups. A dose-dependent decrease in IL-8 was observed, while low doses significantly increased IL-1RA at 3 (p=0.050), IL-12 at 12 (p=0.021) and IL-6 at 24 hours post-burn (p=0.035). IV administration of xenogeneic ASCs slightly increased coagulation, but effects on burn-induced renal and hepatic dysfunction effects were minimal. Despite some significant immunomodulation, organ dysfunction effects were modest. Collectively, this study provides evidence to be skeptical about xenogeneic ASC administration in regards to burn.
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Affiliation(s)
- Tiffany C Heard
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States of America
| | - Belinda I Gómez
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States of America
| | - Micaela E Saathoff
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States of America
| | - Jamila Duarte
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States of America
| | - Michael A Dubick
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States of America
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States of America
| | - Robert J Christy
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States of America
| | - David M Burmeister
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
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31
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Pusateri AE, Le TD, Keyloun JW, Moffatt LT, Orfeo T, Brummel-Ziedins KE, McLawhorn MM, Callcut RA, Shupp JW. Early abnormal fibrinolysis and mortality in patients with thermal injury: a prospective cohort study. BJS Open 2021; 5:6248890. [PMID: 33893737 DOI: 10.1093/bjsopen/zrab017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/03/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- A E Pusateri
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - T D Le
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA.,Department of Epidemiology and Biostatistics, University of Texas Health Science Center, Tyler, Texas, USA
| | - J W Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - L T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,Department of Biochemistry, Georgetown University, Washington, DC, USA
| | - T Orfeo
- Department of Biochemistry, College of Medicine, University of Vermont, Colchester, Vermont, USA
| | - K E Brummel-Ziedins
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - M M McLawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - R A Callcut
- Department of Surgery, University of California Davis School of Medicine, Sacramento, California, USA
| | - J W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,Department of Surgery, Georgetown University, Washington, DC, USA
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32
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Zhao R, Lang TC, Kim A, Wijewardena A, Vandervord J, McGrath R, Fulcher G, Xue M, Jackson C. Early protein C activation is reflective of burn injury severity and plays a critical role in inflammatory burden and patient outcomes. Burns 2021; 48:91-103. [PMID: 34175158 DOI: 10.1016/j.burns.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/17/2021] [Accepted: 03/09/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Navigating the complexities of a severe burn injury is a challenging endeavour where the natural course of some patients can be difficult to predict. Straddling both the coagulation and inflammatory cascades that feature strongly in the burns systemic pathophysiology, we propose the pleiotropic protein C (PC) system may produce a viable biomarker to assist traditional evaluation methods for diagnostic and prognostic purposes. METHODS We enrolled 86 patients in a prospective observational cohort study. Over three weeks, serial blood samples were taken and measured for PC, activated (A)PC, their receptor endothelial protein C receptor (EPCR), and a panel of inflammatory cytokines including C-reactive protein (CRP), tumour necrosis factor-α, interleukin (IL)-1β, IL-6, IL-8, and IL-17. Their temporal trends were analysed alongside clinical factors including burn size, burn depth, presence of inhalational injury, and a composite outcome of requiring increased support. RESULTS (i) APC increased from a nadir on Day 3 (2.3±2.1ng/mL vs 4.1±2.5ng/mL by Day 18, p<0.0005), only becoming appropriately correlated to PC from Day 6 onwards (r=0.412-0.721, p<0.05 for all Days 6-21). (ii) This early disturbance in the PC system was amplified in the more severe burns (≥30% total body surface area, predominantly full thickness, or with inhalational injury), which were characterised by a marked fall in PC activation (approximated by APC/PC ratio) and APC levels during Days 0-3 with low unchanged PC levels. Critically low levels of this cytoprotective agent was associated with greater inflammatory burden, as reflected by significantly elevated CRP, IL-6, and IL-8 levels in the more severe compared to less severe burns, and by negative correlations between both PC and APC with most inflammatory cytokines. (iii) Alongside clinical markers of severity at admission (burn size, burn depth, and presence of inhalational injury), only Day 0 APC/PC ratio (OR 1.048 (1.014-1.083), p=0.006), APC (OR 1.364 (1.032-1.803), p=0.029), PC (OR 0.899 (0.849-0.953), p<0.0005), and not any inflammatory cytokines were predictive markers of requiring increased support. Uniquely, decreased Day 0 PC was further individually associated with each increased total length of stay, ICU length of stay, intravenous fluid resuscitation, and total surgeries, as well as possibly mortality. CONCLUSION An early functional depletion of the cytoprotective PC system provides a physiological link between severe burns and the cytokine storm, likely contributing to worse outcomes. Our findings on the changes in APC, PC and PC activation during this pathological state support APC and PC as early diagnostic and prognostic biomarkers, and provides a basis for their therapeutic potential in severe burn injuries.
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Affiliation(s)
- Ruilong Zhao
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
| | - Thomas Charles Lang
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Albert Kim
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | | | - John Vandervord
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Rachel McGrath
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Gregory Fulcher
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Meilang Xue
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Christopher Jackson
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia
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Moore-Lotridge SN, Ihejirika R, Gibson BHY, Posey SL, Mignemi NA, Cole HA, Hawley GD, Uppuganti S, Nyman JS, Schoenecker JG. Severe injury-induced osteoporosis and skeletal muscle mineralization: Are these related complications? Bone Rep 2020; 14:100743. [PMID: 33490313 PMCID: PMC7804603 DOI: 10.1016/j.bonr.2020.100743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 12/10/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022] Open
Abstract
Severely injured patients are beleaguered by complications during convalescence, such as dysregulated biomineralization. Paradoxically, severely injured patients experience the loss of bone (osteoporosis), resulting in diminished skeletal integrity and increased risk of fragility fractures; yet they also accrue mineralization in soft tissues, resulting in complications such as heterotopic ossification (HO). The pathophysiology leading to dysregulated biomineralization in severely injured patients is not well defined. It has been postulated that these pathologies are linked, such that mineralization is "transferred" from the bone to soft tissue compartments. The goal of this study was to determine if severe injury-induced osteoporosis and soft tissue calcification are temporally coincident following injury. Using a murine model of combined burn and skeletal muscle injury to model severe injury, it was determined that mice developed significant progressive bone loss, detectable as early as 3 days post injury, and marked soft tissue mineralization by 7 days after injury. The observed temporal concordance between the development of severe injury-induced osteoporosis and soft tissue mineralization indicates the plausibility that these complications share a common pathophysiology, though further experiments are required.
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Key Words
- BMD, bone mineral density
- BV/TV, bone volume/tissue volume
- Biomineralization
- Burn
- CTX, cardiotoxin
- DC, dystrophic calcification
- DPI, days post injury
- DXA, dual energy X-ray absorptiometry
- Dystrophic calcification
- H&E, hematoxylin and eosin
- HO, heterotopic ossification
- Heterotopic ossificaiton
- Osteoporosis
- STiCSS, soft tissue calcification scoring system
- Severe injury
- Severe injury-induced osteoporosis
- Soft tissue mineralization
- Trauma
- μCT, microcomputed tomography
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Affiliation(s)
- Stephanie N Moore-Lotridge
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Center of Bone Biology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rivka Ihejirika
- Vanderbilt University Medical School, Vanderbilt University, Nashville, TN 37232, USA
| | - Breanne H Y Gibson
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
| | - Samuel L Posey
- Vanderbilt University Medical School, Vanderbilt University, Nashville, TN 37232, USA
| | - Nicholas A Mignemi
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Heather A Cole
- Department of Nuclear Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Gregory D Hawley
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Sasidhar Uppuganti
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Center of Bone Biology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Tennessee Valley Healthcare System, Vanderbilt University, Nashville, TN 37232, USA
| | - Jeffry S Nyman
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Center of Bone Biology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Tennessee Valley Healthcare System, Vanderbilt University, Nashville, TN 37232, USA
| | - Jonathan G Schoenecker
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Center of Bone Biology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
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34
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Burmeister DM, Smith SL, Muthumalaiappan K, Hill DM, Moffatt LT, Carlson DL, Kubasiak JC, Chung KK, Wade CE, Cancio LC, Shupp JW. An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation. J Burn Care Res 2020; 42:113-125. [PMID: 33306095 DOI: 10.1093/jbcr/iraa214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.
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Affiliation(s)
- David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Susan L Smith
- The Warden Burn Center, Orlando Regional Medical Center, Orlando, Florida
| | | | - David M Hill
- Firefighters' Burn Center, Regional One Health, Memphis, Tennessee
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Deborah L Carlson
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C Kubasiak
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Charles E Wade
- Center for Translational Injury Research, and Department of Surgery, McGovern School of Medicine and The John S. Dunn Burn Center, Memorial Herman Hospital, Houston, Texas
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
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