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Guilabert P, Abarca L, Usúa G, Martin N, Alonso M, Barret JP, Colomina MJ. Factor XIII in major burns coagulation. Burns 2024; 50:1769-1778. [PMID: 38902134 DOI: 10.1016/j.burns.2024.05.002] [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: 08/22/2023] [Revised: 04/25/2024] [Accepted: 05/02/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND In the days following a burn injury, major burn patients (MBP) present a multifactorial coagulation disorder known as acute burn-induced coagulopathy. Several studies have investigated coagulation in MBPs; however, Factor XIII (FXIII), which converts fibrin monomers into a stable clot and promotes wound healing, has not yet been studied. OBJECTIVE To determine the kinetics of FXIII and other coagulation factors and cofactors in MBPs in order to clarify coagulopathy in these patients and its potential relationship with surgical bleeding. METHODS Prospective observational pilot study of the kinetics of FXIII and other coagulation factors and cofactors in MBPs during the first 30 days of burn injury. RESULTS FXIII levels show a significant decline of 75.10% in the interval between the burn injury and surgery, and a decline of 87.70% in the 24 h following surgery. Patients undergo surgery with a median antigenic FXIII of 32%. Plasma levels of most factors decrease significantly 24 h after the burn injury. CONCLUSION MBPs experience a significant decrease in plasma levels of FXIII from the time of admission up to 24 h after surgery. Abnormally low levels were observed at the time of surgery that could not be detected by other coagulation tests. The decrease in most factors at 24 h seems to be associated with dilution due to intensive fluid resuscitation.
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Affiliation(s)
- Patricia Guilabert
- Anesthesia and Critical Care Department. University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Luis Abarca
- Anesthesia and Critical Care Department. University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Gemma Usúa
- Anesthesia and Critical Care Department. University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Nuria Martin
- Anesthesia and Critical Care Department. Hospital Clinic Barcelona, Spain.
| | - María Alonso
- Anesthesia and Critical Care Department. University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Joan P Barret
- Plastic Surgery Department and Burn Centre. University Hospital Vall d'Hebron. Autonomous University of Barcelona, Barcelona, Spain.
| | - Maria J Colomina
- Anesthesia and Critical Care Department, University Bellvitge Hospital, University of Barcelona, Barcelona, Spain.
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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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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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Pfister P, Garcia Wendel PD, Kim BS, Schuepbach RA, Steiger P, Camen G, Buehler PK. Coagulation side effects of enzymatic debridement in burned patients. Burns 2023; 49:1272-1281. [PMID: 36566096 DOI: 10.1016/j.burns.2022.11.008] [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: 06/06/2022] [Revised: 09/19/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Bromelain-based enzymatic debridement has emerged as a valuable option to the standard surgical intervention for debridement in burn injuries. Adverse effects on coagulation parameters after enzymatic debridement have been described. The purpose of this study was to compare the effect of enzymatic and surgical debridement on coagulation. METHODS Between 03/2017 and 02/2021 patients with burn injuries with a total body surface area (TBSA) ≥ 1% were included in the study. Patients were categorized into two groups: the surgically debrided group and the enzymatically debrided group. Coagulation parameters were assessed daily for the first seven days of hospitalization. RESULTS In total 132 patients with a mean TBSA of 17% were included in this study, of which 66 received enzymatic debridement and 66 received regular surgical-debridement. Patients receiving enzymatic debridement presented significantly higher factor-V concentration values over the first seven days after admission (p = <0.01). Regarding coagulation parameters, we found no difference in INR-, aPTT-, fibrinogen-, factor-XIII- and thrombocyte-concentrations over the first seven days (p = >0.05). CONCLUSION Enzymatic debridement in burned patients does not appear to increase the risk of coagulation abnormalities compared with the regular surgical approach.
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Affiliation(s)
- Pablo Pfister
- Institute of intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | | | - Bong Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital of Zurich, Zurich, Switzerland
| | | | - Peter Steiger
- Institute of intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Giovanni Camen
- Institute of intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Karl Buehler
- Institute of intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland; Center of Intensive Care Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland
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5
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Guilabert P, Martin N, Usúa G, Vendrell M, Colomina MJ, Barret JP. Coagulation Alterations in Major Burn Patients: A Narrative Review. J Burn Care Res 2023; 44:280-292. [PMID: 36444638 DOI: 10.1093/jbcr/irac177] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Indexed: 11/30/2022]
Abstract
Major burn patients (MBP) can present multifactorial coagulation alterations induced by trauma and endothelial damage, fluid replacement therapy, hypothermia, hypoperfusion, acidosis, and activation of the inflammatory cascade. However, the multiple coagulation alterations that occur are still poorly defined. The aim of this review is to combine the results of the different coagulation tests currently used to study coagulation changes in these patients. The PubMed database was searched for articles reporting factor levels or coagulation tests using the keywords "Burns" and "Blood Coagulation". Of the 720 articles retrieved from the search, 20 were finally included in the review. Coagulopathy in the MBP differs from that of the trauma patient, insofar as the former present with an increase in factors VIII, IX, and vW on admission accompanied by an increase in fibrin and thrombin production. This is followed by activation of fibrinolysis and prolonged prothrombin (PT) and thromboplastin (aPTT) times in the first 24 hours, increased fibrinogen after 48 hours, and thrombocytosis between the second and third week. Viscoelastic testing shows a pattern that shifts from normal coagulation to a hypercoagulable state with no evidence of hyperfibrinolysis. Alterations in PT and aPTT together with elevated Factor VIII have been associated with mortality, while normalization of antithrombin, and protein C and S levels are associated with a good prognosis. Although standard coagulation tests initially show alterations, the MBP does not appear to be hypocoagulable, and viscoelastic testing shows a trend toward hypercoagulability over time. Coagulation disorders affect prognosis in the MBP.
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Affiliation(s)
- Patricia Guilabert
- Anesthesia and Critical Care Department, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Nuria Martin
- Anesthesia and Critical Care Department, Hospital Clinic Barcelona, Barcelona, Spain
| | - Gemma Usúa
- Anesthesia and Critical Care Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Marina Vendrell
- Anesthesia and Critical Care Department, Hospital Clinic Barcelona, Barcelona, Spain
| | - Maria J Colomina
- Anesthesia and Critical Care Department, University Bellvitge Hospital, University of Barcelona, Barcelona, Spain
| | - Juan P Barret
- Plastic Surgery Department and Burn Centre, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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6
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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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7
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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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8
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Nikolaidou E, Kakagia D, Kaldoudi E, Stouras J, Sovatzidis A, Tsaroucha A. Coagulation Disorders And Mortality In Burn Injury: A Systematic Review. ANNALS OF BURNS AND FIRE DISASTERS 2022; 35:103-115. [PMID: 36381344 PMCID: PMC9416686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/16/2022] [Indexed: 06/16/2023]
Abstract
Even though coagulopathy is a familiar entity in trauma, its relationship to burn injury remains unclear. Literature appears inconsistent as to the conclusions of the use of coagulation assays, either routine methods or newer viscoelastic coagulation assays (VCAs), thromboelastography (TEG) and rotational thromboelastometry (ROTEM), for prediction of patients' coagulation status and mortality. The use of diagnostic assays as mortality markers will be of great importance, since they would recognize at early stages patients with great medical demands and objectify burn injury severity. The aim of this study was to review the literature and evaluate burn patients' characteristics and coagulation markers in the early post burn period. The secondary outcome was to investigate the role of different coagulation assays in mortality prognosis. Literature search was performed using PubMed, ScienceDirect, Wiley Online Library, Google Scholar, Proquest Dissertation and Theses Global, Scopus and Cochrane Library databases. All types of articles referring to adults with any type of burn injury admitted in the first 24h assessing coagulation and mortality were included. PRISMA guidelines ensured the evidence-based process. Eleven studies met the eligibility criteria. This review demonstrated the indubitable relationship of coagulopathy with burn injury and its significant impact on mortality. The rapid and dynamic process of coagulation makes standard coagulation assays unable to detect short-lived haemostatic changes. More susceptible markers such as VCAs need to be applied to the routine assessment of burn patients in order to obtain an overview on coagulopathy and standardize the gained knowledge.
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Affiliation(s)
- E. Nikolaidou
- General Hospital of Thessaloniki “G. Papanikolaou”, Thessaloniki, Greece
| | - D. Kakagia
- Democritus University of Thrace, Dragana, Alexandroupolis, Greece
| | - E. Kaldoudi
- Democritus University of Thrace, Dragana, Alexandroupolis, Greece
| | - J. Stouras
- National and Kapodistrian University of Athens, Athens, Greece
| | | | - A. Tsaroucha
- Democritus University of Thrace, Dragana, Alexandroupolis, Greece
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9
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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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10
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McEwan S, Iles K, Chrisco L, Pak J, Agala CB, Williams FN, King B, Nizamani R. Impact of Chronic Alcohol Use on Fluid Resuscitation in Burn Patients. J Burn Care Res 2022; 43:997-1001. [PMID: 35647685 DOI: 10.1093/jbcr/irac065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Acute alcohol intoxication in burn patients has been associated with increased mortality, renal dysfunction, and difficulty with adequate fluid resuscitation. It is less clear how chronic alcohol use, regardless of intoxication status on admission, impacts patient outcomes. In this study, we examine varying levels of alcohol use in burn patients and its impact on both short- and long-term outcomes.
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Affiliation(s)
- Sasha McEwan
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kathleen Iles
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lori Chrisco
- North Carolina Jaycee Burn Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joyce Pak
- The University of North Carolina, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chris B Agala
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Felicia N Williams
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,North Carolina Jaycee Burn Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Booker King
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,North Carolina Jaycee Burn Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rabia Nizamani
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,North Carolina Jaycee Burn Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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11
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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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12
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Kozynets GP, Tsyhankov VP, Korolova DS, Gornytska OV, Savchuk OM, Chernyshenko VO, Chernyshenko TM, Platonova TM. The rise of factor X level in blood plasma of patients at severe burn injuries. J Burn Care Res 2021; 43:965-970. [PMID: 34875688 DOI: 10.1093/jbcr/irab235] [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: 11/12/2022]
Abstract
This work is dedicated to the detection of imbalance between the pro- and anti-coagulant branches of hemostasis at severe burn injuries by evaluating the content or activity of individual clotting factors. To select the targets for accurate diagnostics we measured the concentrations of soluble fibrin monomeric complexes and fibrinogen, levels of total prothrombin, factor X, protein C and antithrombin III, and recorded the time of clotting in activated partial thromboplastin time and prothrombin time tests. Factor X level was increased in 26 % of patients on the first day after the burn and it rose further in 62 % patients on the 14 th day of recovery. Increasing factor X level is assumed to be a risk factor of thrombotic complications. We propose to use it as a marker of predisposition to thrombosis at severe burn injury.
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Affiliation(s)
- George P Kozynets
- Shupyk National Medical Academy of Postgraduate Education of Ministry of Health of Ukraine, Kyiv
| | - Volodymyr P Tsyhankov
- Shupyk National Medical Academy of Postgraduate Education of Ministry of Health of Ukraine, Kyiv
| | | | | | | | | | - Tamara M Chernyshenko
- Shupyk National Medical Academy of Postgraduate Education of Ministry of Health of Ukraine, Kyiv
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13
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Neuenfeldt FS, Weigand MA, Fischer D. Coagulopathies in Intensive Care Medicine: Balancing Act between Thrombosis and Bleeding. J Clin Med 2021; 10:5369. [PMID: 34830667 PMCID: PMC8623639 DOI: 10.3390/jcm10225369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Patient Blood Management advocates an individualized treatment approach, tailored to each patient's needs, in order to reduce unnecessary exposure to allogeneic blood products. The optimization of hemostasis and minimization of blood loss is of high importance when it comes to critical care patients, as coagulopathies are a common phenomenon among them and may significantly impact morbidity and mortality. Treating coagulopathies is complex as thrombotic and hemorrhagic conditions may coexist and the medications at hand to modulate hemostasis can be powerful. The cornerstones of coagulation management are an appropriate patient evaluation, including the individual risk of bleeding weighed against the risk of thrombosis, a proper diagnostic work-up of the coagulopathy's etiology, treatment with targeted therapies, and transfusion of blood product components when clinically indicated in a goal-directed manner. In this article, we will outline various reasons for coagulopathy in critical care patients to highlight the aspects that need special consideration. The treatment options outlined in this article include anticoagulation, anticoagulant reversal, clotting factor concentrates, antifibrinolytic agents, desmopressin, fresh frozen plasma, and platelets. This article outlines concepts with the aim of the minimization of complications associated with coagulopathies in critically ill patients. Hereditary coagulopathies will be omitted in this review.
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Affiliation(s)
| | | | - Dania Fischer
- Department of Anaesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (F.S.N.); (M.A.W.)
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14
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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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15
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Abstract
Burn-induced coagulopathy is not well understood, and consensus on diagnosis, prevention, and treatments are lacking. In this review, literature on burn-induced (and associated) coagulopathy is presented along with the current understanding of the effects of burn injury on the interactions among coagulation, fibrinolysis, and inflammation in the acute resuscitative phase and reconstructive phase of care. The role of conventional tests of coagulopathy and functional assays like thromboelastography or thromboelastometry will also be discussed. Finally, reported methods for the prevention and treatment of complications related to burn-induced coagulopathy will be reviewed.
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16
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Kaita Y, Nishimura H, Tanaka Y, Suzuki J, Yoshikawa K, Yamaguchi Y. Effect of acute coagulopathy before fluid administration in mortality for burned patients. Burns 2020; 47:805-811. [PMID: 33168267 DOI: 10.1016/j.burns.2020.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/30/2020] [Accepted: 10/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The presence of acute coagulopathy and its effect on prognosis in burn patients are unclear. No studies are extant verifying early coagulopathy before fluid administration in burn patients. The current study focused on arrival coagulopathy before volume resuscitation was begun in earnest. METHODS Data from 137 burn patients transported directly to the hospital without fluid administration from January 2006 to December 2019 were analyzed retrospectively. RESULTS The non-survival group had significantly increased age, total burn surface area (TBSA) burned, various scoring systems, prothrombin time-international normalized ratio (PT-INR), activated partial thromboplastin time (APTT), the presence of coagulopathy, and lactate levels compared to the survival group. In the logistic regression analysis, the incidence of coagulopathy was independently associated with mortality. The coagulopathy group had significant increases in TBSA burned, various scoring systems, PT-INR, APTT, lactate levels, and the mortality than the noncoagulopathy group. The prognostic burn index (PBI) was significantly correlated with PT-INR and APTT. We also found a significant correlation between the serum lactate and the PT-INR, APTT, and PBI. CONCLUSIONS Acute coagulopathy of burn patients might be present on arrival to the hospital before fluid replacement which is an independent risk factor for in-hospital mortality.
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Affiliation(s)
- Yasuhiko Kaita
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan.
| | - Hirotaka Nishimura
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Yuya Tanaka
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Jun Suzuki
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Kei Yoshikawa
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Yoshihiro Yamaguchi
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
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17
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Geng K, Liu Y, Yang Y, Ding X, Tian X, Liu H, Yan H. Incidence and Prognostic Value of Acute Coagulopathy After Extensive Severe Burns. J Burn Care Res 2020; 41:544-549. [PMID: 32036383 DOI: 10.1093/jbcr/irz178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Acute burn-induced coagulopathy (ABIC) occurs after severe burns. However, the incidence, prognostic value, and clinical significance of ABIC after an extensive severe burn remain inconclusive due to wide variances in burn severity and coagulation profile evaluation timings in previous studies. This retrospective study explored the incidence and clinical and prognostic significance of early phase ABIC in 129 adult patients with extensive burns (>50% total body surface area [TBSA]) admitted to the burn centers of two hospitals within 10 hours postburn injury during 2009–2017. Demographics (age and sex) and clinical data (burn severity, vital signs, prehospital fluid replacement volume, hemodynamic parameters, coagulation profile, blood gas, and blood biochemical indicators) were collected upon admission. The incidence of ABIC in patients with severe burns and its relationship with their survival and clinical significance were analyzed. The average postburn interval was 5.7 ± 2.7 hours, and the incidence of ABIC was 31% (40/129). A logistic regression analysis identified ABIC as an independent predictor of 4-week severe mortality due to severe burn. The incidence of ABIC was significantly associated with the total burn area, lactic acid levels upon admission, and postburn admission interval, but not with the prehospital fluid replacement volume. In conclusion, approximately 30% of patients with severe burns developed ABIC within 10 hours postburn, and this condition strongly predicts 4-week mortality. Although burn severity and tissue ischemia/hypoxia are main risk factors for ABIC, the pathogenesis is not fully understood and should be explored in future studies.
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Affiliation(s)
- Kang Geng
- Department of Plastic and Burn Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Yonglin Liu
- Department of Burns, Sichuan Corps Hospital of the Chinese People’s Armed Police Forces Leshan, Sichuan, China
| | - Yuting Yang
- Department of Plastic and Burn Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xiaobin Ding
- Department of Plastic and Burn Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xinli Tian
- Department of Plastic and Burn Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Hongjun Liu
- Department of Plastic and Burn Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Hong Yan
- Department of Plastic and Burn Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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18
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Marsden NJ, Lawrence M, Davies N, Davies G, Morris K, Williams PR, Whitaker IS, Evans PA. The effect of the acute inflammatory response of burns and its treatment on clot characteristics and quality: A prospective case controlled study. Burns 2019; 46:1051-1059. [PMID: 31866177 DOI: 10.1016/j.burns.2019.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/07/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Burns are known to have an effect on coagulation in the early period after burn. Current coagulation tests have been criticised in acute burns due to their inherent limitations. This study aims to investigate the potential for a new quantitative functional biomarker of clot quality, fractal dimension, to identify changes in clot microstructure as a result of the burn inflammatory response and its treatment. METHODS A total of fifty-eight burn patients were included in this prospective case-controlled study. The control group (29 patients mean TBSA 1%), and case group (29 patients mean TBSA 30%) were compared at baseline and the case group investigated further over four time points (baseline, 12h, 24h and 5-7 days). Fractal analysis was performed, as well as current markers of coagulation, inflammatory markers and point-of-care tests, Thromboelastography and Multiplate analysis. RESULTS Fractal dimension did not differ between groups at admission (1.73±0.06 and 1.72±0.1), and fell within the healthy index normal range (1.74±0.7), suggesting a normal clot microstructure in the early period after burn. Fractal dimension significantly reduced from baseline over the first 24h following injury (1.59±0.03 p<0.005), indicating a significant reduction in mechanical clot strength and functionality consistent with a hypocoagulable state, not identified with other markers. CONCLUSIONS This is the first study to quantify the changes in clot microstructure following burn injury. This study confirms clot microstructure is significantly altered during the first 24h after burn, with the production of a weaker, more porous fibrin clot, consistent with a hypocoagulable state.
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Affiliation(s)
- N J Marsden
- Haemostasis Biomedical Research Unit, Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea, UK; Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK
| | - M Lawrence
- Haemostasis Biomedical Research Unit, Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea, UK; Swansea University Medical School, Swansea, UK
| | - N Davies
- Haemostasis Biomedical Research Unit, Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea, UK; Swansea University Medical School, Swansea, UK
| | - G Davies
- Haemostasis Biomedical Research Unit, Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea, UK
| | - K Morris
- Cardiff School of Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - P R Williams
- School of Engineering, Swansea University, Swansea, UK
| | - I S Whitaker
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK
| | - P A Evans
- Haemostasis Biomedical Research Unit, Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea, UK; Swansea University Medical School, Swansea, UK.
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Osuka A, Ishihara T, Shimizu K, Shintani A, Ogura H, Ueyama M. Natural kinetics of blood cells following major burn: Impact of early decreases in white blood cells and platelets as prognostic markers of mortality. Burns 2019; 45:1901-1907. [PMID: 31383608 DOI: 10.1016/j.burns.2019.07.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/31/2019] [Accepted: 07/10/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Severely burned patients often suffer white blood cell and platelet drop following the injury. Though coagulopathy after burn injury have been reported, the association between leukopenia or thrombopenia and mortality is still unrevealed. To determine whether early drastic drops in white blood cells (WBCs) and platelets following injury can be prognostic markers in patients with major burns. METHODS This is a retrospective cohort study setting in a single Burn Center in Japan. Data comprising patients' characteristics and blood cell counts (red blood cells [RBCs], WBCs including neutrophils, monocytes, and lymphocytes, and platelets) over the first 30 days after burn injury were serially collected from patients suffering major burn injury (≥20% TBSA) from January 1, 2006 to December 31, 2015. To determine blood cell counts affecting 60-day mortality, we used multivariable Cox proportional hazard analysis to assess associations between each blood cell count and mortality, adjusting for age and %TBSA as covariates, and evaluated predicted value of the hazard ratio (HR) of death. RESULTS We enrolled 280 patients. Following burn injury, all blood cell counts were high at admission, then decreased. RBCs diminished progressively and plateaued 2 weeks after injury. WBCs decreased suddenly 2 days after injury, then increased and stabilized. Platelets decreased more rapidly than WBCs to their nadir at 3 days, then continually increased. After covariate adjustment, low RBCs from day 1 (HR: 0.566, 95% C.I. 0.423, 0.759) to day 5 (HR: 0.524, 95% C.I. 0.175, 0.576) were predictors of mortality. Neutrophil count was not a risk factor, but day 3 lymphocyte count (HR: 0.131, 95% C.I. 0.026, 0.646) and day 10 monocyte count (HR: 0.044, 95% C.I. 0.005, 0.396) were risk factors. Low platelet counts from day 3 (HR: 0.545, 95% C.I. 0.300, 0.981) to day 30 following injury were always a predictor of mortality. CONCLUSIONS Early thrombopenia and lymphopenia were independent risk factors for 60-day mortality, and prolonged thrombopenia and monocytopenia were independent risk factors for mortality. These findings might shed light on mechanisms of immune response following severe burns.
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Affiliation(s)
- Akinori Osuka
- Department of Trauma, Critical Care Medicine and Burn Center, Japan Community Healthcare Organization Chukyo Hospital, 1-1-10 Sanjo, Minami-ku, Nagoya, Aichi 457-8510, Japan; Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, 065-0871 Osaka, Japan.
| | - Takuma Ishihara
- Department of Clinical Statistics, Osaka City University Graduate School of Medicine, 1-5-7, Asahimachi, Abeno-ku, Osaka 545-8586, Japan; Gifu University Hospital Innovative and Clinical Research Promotion Center, 1-1, Yanagido, 501-1194 Gifu, Japan.
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, 065-0871 Osaka, Japan.
| | - Ayumi Shintani
- Department of Clinical Statistics, Osaka City University Graduate School of Medicine, 1-5-7, Asahimachi, Abeno-ku, Osaka 545-8586, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, 065-0871 Osaka, Japan.
| | - Masahi Ueyama
- Department of Trauma, Critical Care Medicine and Burn Center, Japan Community Healthcare Organization Chukyo Hospital, 1-1-10 Sanjo, Minami-ku, Nagoya, Aichi 457-8510, Japan.
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20
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Bravo MC, Tejiram S, McLawhorn MM, Moffatt LT, Orfeo T, Jett-Tilton M, Pusateri AE, Shupp JW, Brummel-Ziedins KE. Utilizing Plasma Composition Data to Help Determine Procoagulant Dynamics in Patients with Thermal Injury: A Computational Assessment. Mil Med 2019; 184:392-399. [PMID: 30901410 DOI: 10.1093/milmed/usy397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/19/2018] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The development of methods that generate individualized assessments of the procoagulant potential of burn patients could improve their treatment. Beyond its role as an essential intermediate in the formation of thrombin, factor (F)Xa has systemic effects as an agonist to inflammatory processes. In this study, we use a computational model to study the FXa dynamics underlying tissue factor-initiated thrombin generation in a small cohort of burn patients. MATERIALS AND METHODS Plasma samples were collected upon admission (Hour 0) from nine subjects (five non-survivors) with major burn injuries and then at 48 hours. Coagulation factor concentrations (II, V, VII, VIII, IX, X, TFPI, antithrombin (AT), protein C (PC)) were measured and used in a computational model to generate time course profiles for thrombin (IIa), FXa, extrinsic tenase, intrinsic tenase and prothrombinase complexes upon a 5 pM tissue factor stimulus in the presence of 1 nM thrombomodulin. Parameters were extracted from the thrombin and FXa profiles (including max rate (MaxRIIa and MaxRFXa) and peak level (MaxLIIa and MaxLFXa)). Procoagulant potential was also evaluated by determining the concentration of the complexes at select times. Parameter values were compared between survivors and non-survivors in the burn cohort and between the burn cohort and a simulation based on the mean physiological (100%) concentration for all factor levels. RESULTS Burn patients differed at Hour 0 (p < 0.05) from 100% mean physiological levels for all coagulation factor levels except FV and FVII. The concentration of FX, FII, TFPI, AT and PC was lower; FIX and FVIII were increased. The composition differences resulted in all nine burn patients at Hour 0 displaying a procoagulant phenotype relative to 100% mean physiological simulation (MaxLIIa (306 ± 90 nM vs. 52 nM), MaxRIIa (2.9 ± 1.1 nM/s vs. 0.3 nM/s), respectively p < 0.001); MaxRFXa and MaxLFXa were also an order of magnitude greater than 100% mean physiological simulation (p < 0.001). When grouped by survival status and compared at the time of admission, non-survivors had lower PC levels (56 ± 18% vs. 82 ± 9%, p < 0.05), and faster MaxRFXa (29 ± 6 pM/s vs. 18 ± 6 pM/s, p < 0.05) than those that survived; similar trends were observed for all other procoagulant parameters. At 48 hours when comparing non-survivors to survivors, TFPI levels were higher (108 ± 18% vs. 59 ± 18%, p < 0.05), and MaxRIIa (1.5 ± 1.4 nM/s vs. 3.6 ± 0.7 nM/s, p < 0.05) and MaxRFXa (13 ± 12 pM/s vs. 35 ± 4 pM/s, p < 0.05) were lower; similar trends were observed with all other procoagulant parameters. Overall, between admission and 48 hours, procoagulant potential, as represented by MaxR and MaxL parameters for thrombin and FXa, in non-survivors decreased while in survivors they increased (p < 0.05). In patients that survived, there was a positive correlation between FX levels and MaxLFXa (r = 0.96) and reversed in mortality (r= -0.91). CONCLUSIONS Thrombin and FXa generation are increased in burn patients at admission compared to mean physiological simulations. Over the first 48 hours, burn survivors became more procoagulant while non-survivors became less procoagulant. Differences between survivors and non-survivors appear to be present in the underlying dynamics that contribute to FXa dynamics. Understanding how the individual specific balance of procoagulant and anticoagulant proteins contributes to thrombin and FXa generation could ultimately guide therapy and potentially reduce burn injury-related morbidity and mortality.
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Affiliation(s)
- Maria Cristina Bravo
- The Department of Biochemistry, College of Medicine, University of Vermont, 360 South Park Drive, Colchester, VT
| | - Shawn Tejiram
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, 110 Irving Street, NW; Suite 3B-55, Washington, DC
| | - Melissa M McLawhorn
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, 110 Irving Street, NW; Suite 3B-55, Washington, DC
| | - Lauren T Moffatt
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, 110 Irving Street, NW; Suite 3B-55, Washington, DC
| | - Thomas Orfeo
- The Department of Biochemistry, College of Medicine, University of Vermont, 360 South Park Drive, Colchester, VT
| | - Marti Jett-Tilton
- United States Army Center for Environmental Health Research, US Army Medical Command, 568 Doughten Drive, Fort Detrick, MD
| | - Anthony E Pusateri
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA - Fort Sam Houston, TX
| | - Jeffrey W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, 110 Irving Street, NW; Suite 3B-55, Washington, DC
| | - Kathleen E Brummel-Ziedins
- The Department of Biochemistry, College of Medicine, University of Vermont, 360 South Park Drive, Colchester, VT
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Sen S, Hsei L, Tran N, Romanowski K, Palmieri T, Greenhalgh D, Cho K. Early clinical complete blood count changes in severe burn injuries. Burns 2019; 45:97-102. [DOI: 10.1016/j.burns.2018.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/23/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
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Welling H, Ostrowski SR, Stensballe J, Vestergaard MR, Partoft S, White J, Johansson PI. Management of bleeding in major burn surgery. Burns 2018; 45:755-762. [PMID: 30292526 DOI: 10.1016/j.burns.2018.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/25/2018] [Accepted: 08/17/2018] [Indexed: 12/22/2022]
Abstract
Major burn surgery is often associated with excessive bleeding and massive transfusion, and the development of a coagulopathy during major burn surgery is associated with increased morbidity and mortality. The aim of this study was to review the literature on intraoperative haemostatic resuscitation of burn patients during necrectomy to reveal strategies applied for haemostatic monitoring and resuscitation. We searched PubMed, EMBASE, and CENTRAL for studies published in the period 2006-2017 concerning bleeding issues related to burn surgery i.e. coagulopathy, transfusion requirements and clinical outcomes. In a broad search, a total of 1375 papers were identified. 124 of these fulfilled the inclusion criteria, and six of these were included for review. The literature confirmed that transfusion requirements increases with burn injury severity and that haemostatic monitoring by TEG® (thrombelastography) or ROTEM® (rotational thromboelastometry) significantly decreased intraoperative transfusions and was useful in predicting and goal-directing haemostatic therapy during excision surgery. Resuscitation of bleeding during major burn surgery in many instances was neither standardized nor haemostatic. We suggest that resuscitation should aim for normal haemostasis during the bleeding phase through close haemostatic monitoring and resuscitation. Randomised controlled trials are highly warranted to confirm the benefit of this concept.
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Affiliation(s)
- Harald Welling
- Section for Transfusion Medicine, Rigshospitalet, Capital Region Blood Bank, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Sisse Rye Ostrowski
- Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Jakob Stensballe
- Section for Transfusion Medicine, Rigshospitalet, Capital Region Blood Bank, Copenhagen University Hospital, Copenhagen, Denmark; Department of Anaesthesiology, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Martin Risom Vestergaard
- Department of Anaesthesiology, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Søren Partoft
- Department of Burn Surgery, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Jonathan White
- Department of Intensive Care, Abdominal Centre, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | - Pär Ingemar Johansson
- Section for Transfusion Medicine, Rigshospitalet, Capital Region Blood Bank, Copenhagen University Hospital, Copenhagen, Denmark; Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research (CeTIR), University of Texas Medical School at Houston, TX, USA; Centre for Systems Biology, The School of Engineering and Natural Sciences, University of Iceland, Iceland.
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23
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Marck RE, van der Bijl I, Korsten H, Lorinser J, de Korte D, Middelkoop E. Activation, function and content of platelets in burn patients. Platelets 2018; 30:396-402. [DOI: 10.1080/09537104.2018.1448379] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Roos E. Marck
- Department of Plastic, Reconstructive & Hand Surgery, Academical Medical Center, Amsterdam, the Netherlands
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands
- Research Institute MOVE, VU University Medical Center, Amsterdam, the Netherlands
| | - Ivo van der Bijl
- Sanquin Research, Department of Blood Cell Research Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Herbert Korsten
- Department Product and Process Development, Sanquin Blood Bank, Amsterdam, the Netherlands
| | - Jos Lorinser
- Department Product and Process Development, Sanquin Blood Bank, Amsterdam, the Netherlands
| | - Dirk de Korte
- Sanquin Research, Department of Blood Cell Research Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department Product and Process Development, Sanquin Blood Bank, Amsterdam, the Netherlands
| | - Esther Middelkoop
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands
- Research Institute MOVE, VU University Medical Center, Amsterdam, the Netherlands
- Association of Dutch Burn Centers, Beverwijk, The Netherlands
- Department of Plastic, Reconstructive & Hand Surgery, VU University Medical, Amsterdam, the Netherlands
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Marsden NJ, Van M, Dean S, Azzopardi EA, Hemington-Gorse S, Evans PA, Whitaker IS. Measuring coagulation in burns: an evidence-based systematic review. Scars Burn Heal 2017; 3:2059513117728201. [PMID: 29799542 PMCID: PMC5965330 DOI: 10.1177/2059513117728201] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction Dynamic monitoring of coagulation is important to predict both haemorrhagic and thrombotic complications and to guide blood product administration. Reducing blood loss and tailoring blood product administration may improve patient outcome and reduce mortality associated with transfusion. The current literature lacks a systematic, critical appraisal of current best evidence on which clinical decisions may be based. Objectives Establishing the role of different coagulation markers in burn patients, diagnosing coagulopathy, tailoring blood product administration and indicating prognosis. Methods Literature during 2004-2017 from the Cochrane Library, PubMed, Scopus, Medline and Embase was reviewed. Eligibility criteria included randomised controlled trials, systematic reviews, multi-/single-centre study and meta-analyses. Keywords searched were 'burns', 'blood coagulation disorders', 'rotem', 'blood coagulation' and 'thromboelastography'. The PRISMA flow system was used for stratification and the CASP framework for appraisal of the studies retrieved. Results In total, 13 articles were included after inclusion/exclusion criteria had been applied to the initial 79 studies retrieved. Hypercoagulation increases in proportion to the severity of thermal injury. Whole blood testing, using thrombelastography (TEG) and rotation thromboelastometry (ROTEM), was superior to standard plasma based tests, including prothrombin time (PT) and activated partial thromboplastin time (APTT) at detecting burn-related coagulopathies. Conclusions Routine laboratory markers such as PT/APTT are poor indicators of coagulation status in burns patients. Viscoelastic tests, such as TEG and ROTEM, are efficient, fast and have a potential use in the management of burn patients; however, strong evidence is lacking. This review highlights the need for more randomised controlled trials, to guide future practice.
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Affiliation(s)
- Nicholas J Marsden
- NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea, UK.,Welsh Centre for Burns and Plastic Surgery, Swansea, UK
| | - Martin Van
- Welsh Centre for Burns and Plastic Surgery, Swansea, UK
| | - Samera Dean
- Welsh Centre for Burns and Plastic Surgery, Swansea, UK
| | - Ernest A Azzopardi
- Welsh Centre for Burns and Plastic Surgery, Swansea, UK.,Reconstructive Surgery and Regenerative Medicine Group, Institute of Life Science, College of Medicine, Swansea University, Wales, UK
| | | | - Phillip A Evans
- NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea, UK.,Reconstructive Surgery and Regenerative Medicine Group, Institute of Life Science, College of Medicine, Swansea University, Wales, UK
| | - Iain S Whitaker
- Welsh Centre for Burns and Plastic Surgery, Swansea, UK.,Reconstructive Surgery and Regenerative Medicine Group, Institute of Life Science, College of Medicine, Swansea University, Wales, UK
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25
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Platelet and coagulation function before and after burn and smoke inhalation injury in sheep. J Trauma Acute Care Surg 2017; 83:S59-S65. [PMID: 28452873 DOI: 10.1097/ta.0000000000001472] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Smoke inhalation and burn injury remain a major source of morbidity and mortality. There is known dysregulation of hemostasis in burn patients, but either hypercoagulation or hypocoagulation states are reported. Sheep are an established animal model for studying burn pathology and provide robust data on hemostatic function at baseline and after injury. METHODS After an IACUC-approved protocol, 15 sheep were anesthetized and subjected to a 40% full thickness burn with smoke inhalation. Blood was sampled at baseline, 1 day postinjury (early effects) and days 2, 3, and 4 (late effects) after injury. Assays at each timepoint assessed: hemostatic function by thromboelastography (TEG), platelet counts and function by flow cytometry and aggregometry, coagulation protein levels, and free hemoglobin. Data were analyzed by the Wilcoxon paired test (nonparametric) with significance set at less than 0.05. RESULTS By 24 hours postinjury, platelet counts had dropped, whereas the percent activated platelets increased. Absolute platelet functional response to the agonist adenosine diphosphate (ADP) decreased, whereas response to collagen showed no significant difference. On a per platelet basis, ADP response was unchanged, whereas the collagen response was elevated. Prothrombin time and activated partial thromboplastin time were prolonged. TEG parameters decreased significantly from baseline. Fibrinogen and factor V were trending up; coagulation proteins ATIII, factors IX and X were decreased.Late effects were followed in six animals. At day 4, platelet counts remained depressed compared with baseline with a nadir at day 2; responses to agonist on a per platelet basis remained the same for ADP and stayed elevated for collagen. Platelets continued to have elevated activation levels. Fibrinogen and factor V remained significantly elevated, whereas TEG parameters and prothrombin time, factors IX and X returned to near baseline levels. CONCLUSION Coagulation parameters and hemostasis are dysregulated in sheep after smoke inhalation and burn. By 24 hours, sheep were hypocoagulable and subsequently became hypercoagulable by day 4. These results suggest a three-stage coagulopathy in burn injuries with a known early consumptive hypercoagulable state which is followed by a relatively hypocoagulable state with increased bleeding risk and then a return to a relatively unknown hypercoagulability with increased susceptibility to thrombotic disorders.
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Abstract
BACKGROUND Acute traumatic coagulopathy affects 20% to 30% of trauma patients, but the extensive collinearity of the coagulation cascade complicates attempts to clarify global clotting factor dysfunction. This study aimed to characterize phenotypes of clotting factor dysfunction and their contributions to mortality after major trauma. METHODS This prospective cohort study examines all adult trauma patients of the highest activation level presenting to San Francisco General Hospital between February 2005 and February 2015. Factors II, V, VII, VIII, IX, and X and protein C activity on admission and mortality status at 28 days were assessed. Predictors of 28-day mortality in univariate analysis were included in multiple logistic regression controlling for traumatic brain injury (TBI), acidosis, age, and mechanism of injury. Principal component analysis was utilized to identify phenotypic coagulation. RESULTS Complete coagulation factor data were available for 876 (61%) of 1,429 patients. In multiple logistic regression, factors V (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.76-0.97), VIII (OR, 0.97; 95% CI, 0.95-0.99), and X (OR, 0.79; 95% CI, 0.68-0.92) and protein C (OR, 1.17; 95% CI, 1.05-1.30) significantly predicted 28-day mortality after controlling for age, base deficit, mechanism of injury, and TBI. Principal component analysis identified two significant principal components (Phenotypes 1 and 2) that accounted for 66.3% of the total variance. Phenotype 1 (factors II, VII, IX, and X and protein C abnormalities) explained 49.3% and was associated with increased injury, coagulopathy, TBI, and mortality. Phenotype 2 (factors V and VIII abnormalities) explained 17.0% and was associated with increased coagulopathy, blunt injury, and mortality. Only Phenotype 2 remained significantly associated with 28-day mortality in multiple logistic regression. CONCLUSIONS Principal component analysis identified two distinct phenotypes within the entirety of global clotting factor abnormalities, and these findings substantiate the crucial association of factors V and VIII on mortality following trauma. This may be the first step toward identifying unique phenotypes after injury and personalizing hemostatic resuscitation. LEVEL OF EVIDENCE Prognostic study, level III.
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O’Dea KP, Porter JR, Tirlapur N, Katbeh U, Singh S, Handy JM, Takata M. Circulating Microvesicles Are Elevated Acutely following Major Burns Injury and Associated with Clinical Severity. PLoS One 2016; 11:e0167801. [PMID: 27936199 PMCID: PMC5148002 DOI: 10.1371/journal.pone.0167801] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/21/2016] [Indexed: 01/26/2023] Open
Abstract
Microvesicles are cell-derived signaling particles emerging as important mediators and biomarkers of systemic inflammation, but their production in severe burn injury patients has not been described. In this pilot investigation, we measured circulating microvesicle levels following severe burns, with severe sepsis patients as a comparator group. We hypothesized that levels of circulating vascular cell-derived microvesicles are elevated acutely following burns injury, mirroring clinical severity due to the early onset and prevalence of systemic inflammatory response syndrome (SIRS) in these patients. Blood samples were obtained from patients with moderate to severe thermal injury burns, with severe sepsis, and from healthy volunteers. Circulating microvesicles derived from total leukocytes, granulocytes, monocytes, and endothelial cells were quantified in plasma by flow cytometry. All circulating microvesicle subpopulations were elevated in burns patients on day of admission (day 0) compared to healthy volunteers (leukocyte-microvesicles: 3.5-fold, p = 0.005; granulocyte-microvesicles: 12.8-fold, p<0.0001; monocyte-microvesicles: 20.4-fold, p<0.0001; endothelial- microvesicles: 9.6-fold, p = 0.01), but decreased significantly by day 2. Microvesicle levels were increased with severe sepsis, but less consistently between patients. Leukocyte- and granulocyte-derived microvesicles on day 0 correlated with clinical assessment scores and were higher in burns ICU non-survivors compared to survivors (leukocyte MVs 4.6 fold, p = 0.002; granulocyte MVs 4.8 fold, p = 0.003). Mortality prediction analysis of area under receiver operating characteristic curve was 0.92 (p = 0.01) for total leukocyte microvesicles and 0.85 (p = 0.04) for granulocyte microvesicles. These findings demonstrate, for the first time, acute increases in circulating microvesicles following burns injury in patients and point to their potential role in propagation of sterile SIRS-related pathophysiology.
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Affiliation(s)
- Kieran P. O’Dea
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - John R. Porter
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Intensive Care Unit, Chelsea and Westminster Hospital, London, United Kingdom
| | - Nikhil Tirlapur
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Umar Katbeh
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Suveer Singh
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Intensive Care Unit, Chelsea and Westminster Hospital, London, United Kingdom
| | - Jonathan M. Handy
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Intensive Care Unit, Chelsea and Westminster Hospital, London, United Kingdom
| | - Masao Takata
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
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28
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Lavrentieva A, Depetris N, Kaimakamis E, Berardino M, Stella M. Monitoring and treatment of coagulation abnormalities in burn patients. an international survey on current practices. ANNALS OF BURNS AND FIRE DISASTERS 2016; 29:172-177. [PMID: 28149244 PMCID: PMC5266232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 05/04/2016] [Indexed: 06/06/2023]
Abstract
The magnitude of coagulation abnormalities, and the definition and treatment of coagulopathy in burn patients are inadequately understood and continue to be discussed in the literature. We aimed to analyse physicians' views on monitoring and treating coagulation abnormalities in burn patients. A total of 350 questionnaires were distributed electronically to burn ICU physicians. Participation was voluntary and anonymous. Responses were analysed electronically and comparisons were made according to the region of the ICU or the specialty of the physician. Of the 350 questionnaires distributed, 55 (15.7%) were returned. The majority of burn specialists consider sepsis-induced coagulopathy to be the most frequent coagulopathy in burn patients, and 74.5% declare that they do not use any specific definition/scoring system in their department to detect coagulopathy. The majority of specialists (70.8%) use standard coagulation tests. The most frequent indications for plasma transfusion are massive bleeding (32.8%) and Disseminated Intravascular Coagulation syndrome treatment (20%). The main specific factors reported in our study are cryoprecipitate (23.2%) and fibrinogen concentrate (18.9%). 21.1% of respondents state that they do not use any specific coagulation factor substitution in burn patients. Specific coagulation factor substitution is not a routine practice. The low response rate precludes the generalization of our results.
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Affiliation(s)
| | - N. Depetris
- Anaesthesia and ICU - Orthopaedic and Trauma Centre A.O., Città della Salute e della Scienza, Turin, Italy
| | - E. Kaimakamis
- Burn ICU, Papanikolaou Hospital, Thessaloniki, Greece
| | - M. Berardino
- Anaesthesia and ICU - Orthopaedic and Trauma Centre A.O., Città della Salute e della Scienza, Turin, Italy
| | - M. Stella
- Burn Centre - Orthopaedic and Trauma Centre A.O., Città della Salute e della Scienza, Turin, Italy
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29
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Wade CE, Baer LA, Cardenas JC, Folkerson LE, Nutall-Aurora K, Cotton BA, Matijevic N, Holcomb JB, Cross JM, Huzar T. Upon admission coagulation and platelet function in patients with thermal and electrical injuries. Burns 2016; 42:1704-1711. [PMID: 27692780 DOI: 10.1016/j.burns.2016.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/14/2016] [Accepted: 05/02/2016] [Indexed: 11/19/2022]
Abstract
RATIONAL There has been increased focus on hemostatic potential and function in the initial assessment of the patient with traumatic injuries, that not been extensively studied in patients with burns. We proposed to determine the hemostatic potential of patients with burns upon admission to the emergency department and contrasted their condition with that of healthy controls and patients with other traumatic injuries. In addition we assessed differences due to thermal versus electrical injury and evaluated the effect of burn size. METHODS This is a patient based prospective observational study conducted with delayed consented. Subjects at the highest level of trauma activation upon admission to the ED had a blood sample collected for research purposes and were subsequently consented. Hemostatic potential was measured by rapid thromelastography (r-TEG®), thrombin generation by calibrated automated thrombogram (CAT) and platelet function by Multiplate® using five activators. Burn subjects were compared to subjects with other traumatic injuries and controls. Within the burn subjects additional analysis compared mechanism (thermal vs. electrical) and burn size. Values are medians (IQR). RESULTS Two hundred and eighty two trauma patients (with burns n=40, 14%) and 27 controls were enrolled. Upon admission, compared to controls, subjects with burns or trauma were hyper-coagulable based on r-TEG and CAT, with increased rates of clot formation and thrombin generation. There were no differences in burns compared to other traumatic injuries. The presence of hyper-coagulation did not appear to be related to the type of burn or the percentage of total body surface area involved. Employing previous defined cut points for R-TEG driven therapeutic interventions burn patients had similar rates of hyper- and hypo-coagulation noted in patients with traumatic injuries. CONCLUSION Upon admission patients with burns are in a hyper-coagulable state similar to that of other trauma patients. Employing demonstrated cut points of hemostatic potential in trauma patients associated with increased risk of poor outcomes demonstrated the incidence in burn patients to be similar, suggesting that these values could be used in the early assessment of the patient with burns to guide treatment interventions.
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Affiliation(s)
- Charles E Wade
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States.
| | - Lisa A Baer
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
| | - Jessica C Cardenas
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
| | - Lindley E Folkerson
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
| | - Kisha Nutall-Aurora
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
| | - Bryan A Cotton
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
| | - Nena Matijevic
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
| | - John B Holcomb
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
| | - James M Cross
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
| | - Todd Huzar
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, United States
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30
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Koljonen V, Tuimala J, Haglund C, Tukiainen E, Vuola J, Juvonen E, Lauronen J, Krusius T. The Use of Blood Products in Adult Patients with Burns. Scand J Surg 2016; 105:178-85. [DOI: 10.1177/1457496915622127] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/11/2015] [Indexed: 11/15/2022]
Abstract
Introduction: Burn anemia represents a common complication following a burn injury. Burn anemia etiology carries distinct features occurring at each stage of the post-injury and treatment periods resulting from different causes. We aimed to analyze the use of blood components in Finnish burn victims and to identify patient- and injury-related factors influencing their use. Methods: To study the use of blood products in burn patients, we used data collected from the Optimal Use of Blood registry, developed through co-operation between 10 major hospital districts and the Finnish Red Cross Blood Service. Burn patients ⩾18 years treated at the Helsinki University Hospital between 2005 and 2011 with an in-hospital stay ⩾1 day who received at least one transfusion during their hospital stay were included in this study. Results: Among all 558 burn patients, 192 (34%) received blood products during their hospital stay. The transfused cohort comprised 192 burn patients. The study cohort received a total of 6087 units of blood components, 2422 units of leukoreduced red blood cells, 1728 units of leukoreduced platelets, and 420 units of single-donor fresh frozen plasma or, after 2007, 1517 units of Octaplas® frozen plasma. All three types of blood components were administered to 29% of patients, whereas 45% received only red blood cells and 6% received only Octaplas. Transfused patients were significantly older (p < 0.001), experienced fire-/flame-related accidents and burns to multiple locations (p < 0.001), and their in-hospital mortality exceeded that for non-transfused burn patients fivefold (p < 0.05). Discussion: We show that Finnish adult burn patients received ample transfusions. The number of blood components transfused varied according to the anatomical location of the injury and patient survival. Whether the additional mortality is related directly to transfusions or is merely a manifestation of the more severe burn injury remains unknown.
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Affiliation(s)
- V. Koljonen
- Department of Plastic Surgery, University of Helsinki and Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | | | - C. Haglund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Programs Unit, Translational Cancer Biology, University of Helsinki, Helsinki, Finland
| | - E. Tukiainen
- Department of Plastic Surgery, University of Helsinki and Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - J. Vuola
- Department of Plastic Surgery, University of Helsinki and Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - E. Juvonen
- Finnish Red Cross Blood Service, Helsinki, Finland
| | - J. Lauronen
- Clinical Consultations Unit, Finnish Red Cross Blood Service, Helsinki, Finland
| | - T. Krusius
- Finnish Red Cross Blood Service, Helsinki, Finland
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31
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Glas GJ, Levi M, Schultz MJ. Coagulopathy and its management in patients with severe burns. J Thromb Haemost 2016; 14:865-74. [PMID: 26854881 DOI: 10.1111/jth.13283] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 01/26/2016] [Indexed: 11/30/2022]
Abstract
Severe burn injury is associated with systemic coagulopathy. The changes in coagulation described in patients with severe burns resemble those found patients with sepsis or major trauma. Coagulopathy in patients with severe burns is characterized by procoagulant changes, and impaired fibrinolytic and natural anticoagulation systems. Both the timing of onset and the severity of hemostatic derangements are related to the severity of the burn. The exact pathophysiology and time course of coagulopathy are uncertain, but, at least in part, result from hemodilution and hypothermia. As the occurrence of coagulopathy in patients with severe burns is associated with increased comorbidity and mortality, coagulopathy could be seen as a potential therapeutic target. Clear guidelines for the treatment of coagulopathy in patients with severe burns are lacking, but supportive measures and targeted treatments have been proposed. Supportive measures are aimed at avoiding preventable triggers such as tissue hypoperfusion caused by shock, or hemodilution and hypothermia following the usually aggressive fluid resuscitation in these patients. Suggested targeted treatments that could benefit patients with severe burns include systemic treatment with anticoagulants, but sufficient randomized controlled trial evidence is lacking.
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Affiliation(s)
- G J Glas
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Center, Amsterdam, the Netherlands
| | - M Levi
- Department of Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - M J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Center, Amsterdam, the Netherlands
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
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32
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In-depth analysis of clotting dynamics in burn patients. J Surg Res 2016; 202:341-51. [PMID: 27229109 DOI: 10.1016/j.jss.2016.01.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/28/2015] [Accepted: 01/05/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Studies associating coagulopathic changes with burn injury have relied on limited tests such as partial thromboplastin time (PTT) and international normalized ratio (INR). Understanding the clotting dynamics and associated risk factors after burn injury could influence management. This work aimed to identify real-time changes in coagulation after burn injury not indicated by PTT or INR alone. MATERIALS AND METHODS Nine burn-injured patients at a regional burn center were enrolled for blood collection at admission and set intervals over 96 h. Patient demographics, management, and laboratory data (PTT and INR) were collected. Plasma assays determined factors II, V, VII, VIII, IX, X, XI, antithrombin, and protein C functional activity as well as PAP, D-Dimer, fibrin monomer, TFPI, IL-1b, IL-6, IL-10, IL-12p.70, and TNF-α concentrations. RESULTS Overall, five patients died. These patients had higher mortality scores and were more acidotic. All patients had normal coagulation studies (INR < 1.5, PTT < 45 s) within 24 h of admission, and only two were abnormal after. Increased factor VIII and IX activity were identified in seven patients at admission. Decreased antithrombin and protein C activity were seen in all patients. Patients had increased PAP, D-Dimer, and fibrin monomer concentrations throughout their hospital course. At admission, increased fold changes were seen in IL-6 (2.5-117) and IL-10 (2.4-32), whereas IL-1b and TNF-α levels were depressed in all patients. CONCLUSIONS Extensive changes not identified by PTT or INR were seen after burn injury that may explain perturbed coagulation in these patients. This approach further characterizes the impact thermal injury has on coagulation.
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Acute blood loss during burn and soft tissue excisions: An observational study of blood product resuscitation practices and focused review. J Trauma Acute Care Surg 2015; 78:S39-47. [PMID: 26002262 DOI: 10.1097/ta.0000000000000627] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many military and civilian centers have shifted to a damage-control resuscitation approach, focused on providing oxygen-carrying capacity while simultaneously mitigating coagulopathy with a balanced ratio of platelets and plasma to red blood cells. It is unclear to what degree this strategy is used during burn or soft tissue excision. Here, we characterized blood product transfusion during burn and soft tissue surgery and reviewed the published literature regarding intraoperative coagulation changes. We hypothesized that blood product resuscitation during burn and soft tissue excision is not hemostatic and would be insufficient to address hemorrhage-induced coagulopathy. METHODS Consented adult patients were enrolled into an institutional review board-approved prospective observational study. Number, component type, volume, and age of the blood products transfused were recorded during burn excision/grafting or soft tissue debridement. Component bags (packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate) were collected, and the remaining sample was harvested from the bag and tubing. Aliquots of 1/1,000th the original volume of each blood product were obtained and combined, producing an amalgam sample containing the same ratio of product transfused. Platelet count, rotational thromboelastometry, and impedance aggregometry were measured. Significance was set at p < 0.05. RESULTS Amalgamated transfusate samples produced abnormally weak clots (p ≤ 0.001) particularly if they did not contain platelets. Clot strength (48.8 [2.6] mm; reference range, 49-71 mm) for platelet-containing amalgams was below the lower limit of the reference range despite platelet-red blood cell ratios greater than 1:1. Platelet aggregation was abnormally low; transfused platelets were functionally inferior to native platelets. CONCLUSION Our study and focused review demonstrate that further work is needed to fully understand the needs of patients undergoing tissue excision. The three studies reviewed and the results of our observational work suggest that coagulopathy and thrombocytopenia may contribute to intraoperative hemorrhage. Blood product resuscitation during burn and soft tissue excision is not hemostatic. LEVEL OF EVIDENCE Epidemiologic study, level V.
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Coagulopathy in burn patients: one part of a deadly trio. Burns 2015; 41:419-20. [PMID: 25681959 DOI: 10.1016/j.burns.2014.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 11/20/2022]
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Wolf SE, Phelan HA, Arnoldo BD. The year in burns 2013. Burns 2014; 40:1421-32. [PMID: 25454722 DOI: 10.1016/j.burns.2014.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 10/31/2014] [Indexed: 12/22/2022]
Abstract
Approximately 3415 research articles were published with burns in the title, abstract, and/or keyword in 2013. We have continued to see an increase in this number; the following reviews articles selected from these by the Editor of one of the major journals (Burns) and colleagues that in their opinion are most likely to have effects on burn care treatment and understanding. As we have done before, articles were found and divided into the following topic areas: epidemiology of injury and burn prevention, wound and scar characterization, acute care and critical care, inhalation injury, infection, psychological considerations, pain and itching management, rehabilitation and long-term outcomes, and burn reconstruction. The articles are mentioned briefly with notes from the authors; readers are referred to the full papers for details.
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Affiliation(s)
- Steven E Wolf
- Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas - Southwestern Medical Center, United States.
| | - Herbert A Phelan
- Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas - Southwestern Medical Center, United States
| | - Brett D Arnoldo
- Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas - Southwestern Medical Center, United States
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