Measuring coagulation in burns: an evidence-based systematic review
Scars, Burns & Healing. 3:2059513117728201, 2017 Jan-Dec.. 2017;3:2059513117728201
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.
Perioperative treatment algorithm for bleeding burn patients reduces allogeneic blood product requirements
British Journal of Anaesthesia. 2012;109((3):):376-81.
BACKGROUND Surgical excision of burn wounds is often associated with severe bleeding. Timely and targeted correction of coagulopathy reduces transfusion requirements and improves survival in trauma victims. We hypothesized that rapid correction of coagulopathy after a treatment algorithm based on point-of-care viscoelastic coagulation testing would decrease allogeneic blood product transfusions during surgical excision of burn wounds. METHODS Thirty consecutive patients undergoing surgical excision of burn wounds were enrolled into this prospective, randomized, controlled, single-centre study. In the control group, coagulation management was performed according to the clinicians' discretion. For the algorithm group, we standardized treatment based on the Austrian recommendation for the management of trauma-induced coagulopathy using point-of-care rotational thromboelastometry (ROTEM). The main outcome parameter was the cumulative number of allogeneic blood units transfused on the day of surgery. RESULTS The difference between the groups regarding the cumulative use of allogeneic blood products was highly significant with 3.0 (1.3-5.5) blood products in the algorithm group compared with 9.0 (6.0-12.3) in the control group [median (inter-quartile range); P=0.002]. No plasma was administered in the algorithm group compared with 5.0 (1.5-7.5) units overall in the control group (P<0.001). Fibrinogen concentrate administration was not significantly different between the groups (P=0.89). Tranexamic acid was not administered. CONCLUSIONS The significant reduction in allogeneic blood product requirements during surgical burn wound excision is a prospective proof of concept that a bleeding management algorithm based on thromboelastometry is efficacious. Hypofibrinogenaemia and hyperfibrinolysis are not significant pathomechanisms of bleeding in this setting and ROTEM helps to avoid unnecessary interventions.
A double-blinded prospective evaluation of recombinant human erythropoietin in acutely burned patients
Journal of Trauma-Injury Infection & Critical Care. 1995;38((2):):233-6.
OBJECTIVE To evaluate the effects of recombinant human erythropoietin (r-HuEPO) in attempting to prevent anemia in acutely burned patients. DESIGN Prospective double-blind randomized study of 40 patients. METHODS Patients with burns from 25% to 65% total body surface were enrolled. r-HuEPO or a placebo was begun within 72 hours of admission. Cell blood count, reticulocyte counts, transfusion requirements, and blood loss were measured. Comparison was carried out by the unpaired t test. MAIN RESULTS There was no statistically significant difference in hemoglobin, hematocrit, reticulocyte count, ferritin, serum iron, total iron blinding capacity, or transfusion requirements. In patients with burns from 25% to 35%, the reticulocyte counts were statistically significantly higher. CONCLUSION In our work the administration of r-HuEPO in acutely burned patients did not prevent the development of postburn anemia or decrease transfusion requirements. Increased erythropoiesis in smaller burns (25% to 35%) was observed and may indicate a reason for further study.
A randomized trial of plasma exchange in the treatment of burn shock
Journal of Burn Care & Rehabilitation. 1989;10((1):):17-26.
Hypovolemia following major thermal injury results from increased capillary permeability with subsequent loss of fluid into the interstitium. Investigations of burn shock have demonstrated the release of circulating factors that effect these fluid shifts. Previous studies have suggested that this process can be altered by the performance of plasma exchange in patients who fail to respond to conventional resuscitation. This study evaluated the effect of plasma exchange during burn shock. Twenty-two adult subjects were randomly assigned to one of two groups. The control group received standard fluid resuscitation guided by the Parkland formula; the treatment group received the same resuscitation in addition to a course of plasma exchange. Seventeen subjects, eight from the control group and nine from the plasma exchange group, completed the study. Control subjects had a mean age of 37 years, a mean burn size of 52.3% total body surface area, and a mean full-thickness injury of 24.6% total body surface area. Plasma exchange patients had a mean age of 38 years, a mean burn size of 49.4% total body surface area, and a mean full-thickness injury of 37.3% total body surface area (p less than 0.01 compared to the control group). Completion of resuscitation was accomplished earlier in the plasma exchange group (20.2 hours versus 30.8 hours; p less than 0.05). There was no difference in the total amount of fluid required to achieve resuscitation. The mean urine output during resuscitation was greater for the plasma exchange group (p less than 0.01). Performance of plasma exchange during the second 8-hour period after the burn did not alter the course of burn shock in this study group.