Lethal triad in severe burns

Sherren, Peter B.; Hussey, Joseph; Martin, R Shayn; Kundishora, T.; Parker, Michael; Emerson, Beth

doi:10.1016/j.burns.2014.04.011

Cited by 48 publications

(26 citation statements)

References 20 publications

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“…Indeed, severe burn patients are commonly subjected to an aggressive fluid treatment in an effort to mitigate burn shock . Whether coagulopathy is induced or exacerbated by fluid therapy is currently debated in the literature . Furthermore, hypothermia induced by either massive fluid therapy or loss of heat through evaporation from non‐epithelialized areas may also induce or worsen coagulopathy .…”

Section: Pathophysiology and Time Course Of Coagulopathy In Patients mentioning

confidence: 99%

“…Coagulopathy in combination with hypothermia and acidemia, a feared triad in trauma patients, has also been found to be associated with increased mortality of patients with severe burns . Indeed, patients who present with coagulopathy, hypothermia and acidemia at hospital admission have a five‐fold higher mortality rate than patients who do not develop this triad . Two recent prospective studies identified coagulopathy as an independent predictor of 28‐day mortality in patients with severe burns .…”

Section: Outcome Of Patients With Severe Burns With Coagulopathymentioning

confidence: 99%

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Coagulopathy and its management in patients with severe burns

Glas

Levi

Schultz

2016

Journal of Thrombosis and Haemostasis

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To cite this article: Glas GJ, Levi M, Schultz MJ. Coagulopathy and its management in patients with severe burns. J Thromb Haemost 2016; 14: 865-74.Summary. 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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Section: Pathophysiology and Time Course Of Coagulopathy In Patients mentioning

confidence: 99%

Section: Outcome Of Patients With Severe Burns With Coagulopathymentioning

confidence: 99%

Coagulopathy and its management in patients with severe burns

Glas

Levi

Schultz

2016

Journal of Thrombosis and Haemostasis

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“…A clear association of coagulopathy with increased morbidity and mortality was described in the general trauma population (11, 26–28), but studies in burn patients have not been consistent. One study, in which the criteria used for defining coagulopathy were fairly strict (INR ≥ 1.3, aPTT ≥ 1.5 times mean normal, and PLT = 150–440 × 10 9 /L), reported no cases of burn patients with acute coagulopathy of trauma at admission (33), whereas another found that early coagulopathy (INR > 1.2) was present in 39% of burned subjects and that it was an independent predictor of mortality by logistic regression analysis (34, 35), a finding in line with other studies (36, 37). …”

Section: Focused Reviewmentioning

confidence: 99%

Acute blood loss during burn and soft tissue excisions

Pidcoke

Isbell

Herzig

et al. 2015

Journal of Trauma and Acute Care Surgery

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Background Many military and civilian centers have shifted to a Damage Control Resuscitation (DCR) 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 IRB-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 (pRBCs, FFP, PLTs, and cryoprecipitate) were collected and the remaining sample harvested from the bag and tubing. Aliquots of 1/1000th 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: 49–71mm) for platelet-containing amalgams was below the lower limit of the reference range despite PLT:RBC 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 in order 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.

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“…Patients with burn injuries present a unique blood management challenge [16]. Multiple excision and grafting procedures are common and may lead to several extensive blood loss events during a single hospitalization.…”

Section: Introductionmentioning

confidence: 99%

Accurate Measurement of Intraoperative Blood Loss during Wound Excision Leads to More Appropriate Transfusion and Reduced Blood Utilization

Bernal¹,

Castro²,

Burton³

et al. 2017

J Anesth Clin Res

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Objective: To determine if accurate measurement of surgical blood loss using a novel device that photographs surgical sponges and calculates their hemoglobin content affects transfusion practice. Methods:We retrospectively compared transfusion events for patients having wound excisions using visual estimation of blood loss (traditional group; n=178) to similar events following device implementation (study group; n=221). Results:The study group (age 43 ± 22 years, body surface area burn 11.2 ± 18.0%, excision area 624, IQR 757 cm 2 , preoperative hemoglobin 10.7 ± 2.4 g/dl) did not differ significantly from the traditional group (age 42 ± 23 years (p=0.527), body surface area burn 12.2 ± 22.6% (p=0.661), excision area 753, IQR 505 cm 2 (p=0.485), and preoperative hemoglobin 10.7 ± 2.2 g/dl (p=0.833).Postoperative transfusion rates were significantly lower in the study group (6.3% vs. 12.9%; p=0.024), as was the proportion of transfused patients undergoing multiple transfusion events (13.0% vs. 34.9%; p=0.01). Red cell dose (units/transfused patient) was less in the study group compared to the traditional group (1.83 ± 1.09 vs. 2.51 ± 1.61 units; p=0.021).In a subgroup of patients requiring excision of burned areas ≥ 1,000 cm 2 (traditional group n=36, study group n=43), these differences were more significant. The postoperative transfusion rate fell from 44.4% to 14.0% (p=0.003), as did the percent of transfused patients experiencing multiple transfusion events (50.0% vs. 14.3%; p=0.004).Conclusions: Accurate measurement of surgical blood loss was associated with a decrease in transfusions suggesting more timely decision making. Informed transfusion decisions may result in fewer transfusions by avoiding over-transfusion related to both excessive hemodilution and inaccurate visual estimates.

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Lethal triad in severe burns

Cited by 48 publications

References 20 publications

Coagulopathy and its management in patients with severe burns

Coagulopathy and its management in patients with severe burns

Acute blood loss during burn and soft tissue excisions

Accurate Measurement of Intraoperative Blood Loss during Wound Excision Leads to More Appropriate Transfusion and Reduced Blood Utilization

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