Prophylactic anti-coagulation after severe burn injury in critical care settings

Blake, Megan; Roadley-Battin, Ruth; Torliński, Tomasz

doi:10.6001/actamedica.v26i1.3954

Cited by 5 publications

(9 citation statements)

References 17 publications

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“…They play an important role in increasing comorbidity and mortality (responsible for more than 3% of all deaths after burn injuries). [ 3 17 ] The accurate pathophysiology is still unclear, but at least, in part, the activation of the coagulopathy may be a consequence of a mixture or one of the following mechanisms: tissue hypo-perfusion and the resultant acidemia, burn wound excision, SIRS, the endothelial damage following the burn, sepsis, hemodilution, and hypothermia. [ 17 ] Unfortunately, we still lack well-defined recommendations for management of coagulopathy in severe burn patients.…”

Section: Discussionmentioning

confidence: 99%

“…[ 18 ] Moreover, Blake et al . [ 3 ] have reported the need for increased dosage of LWMH in severe burn patients.…”

Section: Discussionmentioning

confidence: 99%

“…-Not recommending any changes in opioid management strategies. Cross-clinical aspects II : Coagulopathy Blake et al [3] The UK A retrospective study -Thromboembolic complications are commonly seen in severe cases. -Thromboembolic complications play an important role in increasing comorbidity and mortality.…”

Section: Rehabilitation Treatment and Dischargementioning

confidence: 99%

“…However, ACCP Guidelines (2008) recommends routine chemical venous thromboembolism (VTE) prophylaxis for burn patients with particular risk factors such as old age, lower limb burns, drawn-out immobilization, associated trauma, femoral central venous catheterization and unhealthy obesity. [18] Moreover, Blake et al [3] have reported the need for increased dosage of LWMH in severe burn patients.…”

Section: Coagulopathymentioning

confidence: 99%

“…[ 2 ] Therefore, multiple burn centers and health facilities have suggested management strategies for burn treatment during this pandemic. A burn is considered an acute condition associated with many systemic disorders, most notably coagulopathy,[ 3 ] which is also a major complication in COVID-19 patients. [ 4 ] Moreover, pain experienced by burn patients can be unbearable and requires serious attention and efficient management.…”

Section: Introductionmentioning

confidence: 99%

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Burn management during the COVID-19 pandemic: Recommendations and considerations

2020

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Coronavirus disease-2019 (COVID-19) is a respiratory disease, caused by a novel coronavirus (SARS-COV-2). This disease has been raising international public health concerns since its recent outbreak in December 2019. As the virus is easily transmitted by respiratory droplets, all hospital departments needed to change their practices in an attempt to control the spread of this virus. Burn units and clinics are particularly affected by this pandemic because of the larger risk of contamination for both patients and caregivers. Furthermore, cross-clinical aspects especially pain management and complications such as coagulopathy might be caused by both extensive burns and COVID-19 infections, which makes the management of these patients particularly challenging. That’s why we covered both main aspects in this review. In addition, we present briefly a synthesis of guidelines from several entities to help manage the health crisis and provide optimal care for all burn patients during this pandemic. Highlights: • All new burn patients, including pediatric burn patients, should undergo solitary isolation for 3–5 days, 14 days is recommended if possible, for medical observation. • Preliminary screening, which includes blood routine and chest CT examinations, is performed routinely on all newly admitted patients. • Severe burn patients should be admitted to burn intensive care unit (BICU) and should be treated as suspects of COVID-19. • Sputum absorption, airway lavage, and other invasive operations should be minimized as much as possible. • For urgent surgeries, lung CT and routine blood tests must be performed right before any surgical procedure, and the COVID-19 PCR test should be performed based on clinical symptoms and epidemiology. • Surgery is the highest risk point of COVID-19 infection exposure especially in the early treatment of burn patients. • For patients with negative COVID-19 testing, urgent procedures have to be administrated in negative-pressure operating rooms, and healthcare staff must take proper protective precautions. • Patients are advised to do an online check-in and share their status and improvement of rehabilitation. • It is recommended to suspend the rehabilitation treatment with close contact. • The therapeutic strategy for underlying pain management in COVID-19 burn patients remains similar to the regular burn patients; however, more attention for the opioid administration should be paid. • Burn patients associated with COVID-19 require strict monitoring and follow-up. Routine chemical venous thromboembolism (VTE) prophylaxis should be also applied. An escalated dose VTE prophylaxis should be seriously considered as the risk of coagulopathy notably increases in such cases.

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Section: Discussionmentioning

confidence: 99%

“…[ 18 ] Moreover, Blake et al . [ 3 ] have reported the need for increased dosage of LWMH in severe burn patients.…”

Section: Discussionmentioning

confidence: 99%

Section: Rehabilitation Treatment and Dischargementioning

confidence: 99%

Section: Coagulopathymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Burn management during the COVID-19 pandemic: Recommendations and considerations

2020

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Heparin resistance in severe thermal injury: a prospective cohort study

et al. 2021

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Background Low molecular-weight heparin (LMWH) is routinely administered to burn patients for thromboprophylaxis. Some studies have reported heparin resistance, yet the mechanism(s) and prevalence have not been systematically studied. We hypothesized that nucleosomes, composed of histone structures with associated DNA released from injured tissue and activated immune cells in the form of neutrophil extracellular traps (NETs or NETosis), neutralize LMWH resulting in suboptimal anticoagulation, assessed by reduction in anti-factor Xa activity. Methods Blood was sampled from >15% total body surface area (TBSA) burn patients receiving LMWH on days 5, 10 and 14. Peak anti-factor Xa (AFXa) activity, anti-thrombin (ATIII) activity, cell-free DNA (cfDNA) levels and nucleosome levels were measured. Mixed effects regression was adjusted for multiple confounders, including injury severity and ATIII activity, and was used to test the association between nucleosomes and AFXa. Results A total of 30 patients with severe burns were included. Mean TBSA 43% (SD 17). Twenty-three (77%) patients were affected by heparin resistance (defined by AFXa activity <0.2 IU/mL). Mean peak AFXa activity across samples was 0.18 IU/mL (SD 0.11). Mean ATIII was 81.9% activity (SD 20.4). Samples taken at higher LWMH doses were found to have significantly increased AFXa activity, though the effect was not observed at all doses, at 8000 IU no samples were heparin resistant. Nucleosome levels were negatively correlated with AFXa (r = −0.29, p = 0.050) consistent with the hypothesis. The final model, with peak AFXa as the response variable, was adjusted for nucleosome levels (p = 0.0453), ATIII activity (p = 0.0053), LMWH dose pre-sample (p = 0.0049), drug given (enoxaparin or tinzaparin) (p = 0.03), and other confounders including severity of injury, age, gender, time point of sample. Conclusions Heparin resistance is a prevalent issue in severe burns. Nucleosome levels were increased post-burn, and showed an inverse association with AFXa consistent with the hypothesis that they may interfere with the anticoagulant effect of heparin in vivo and contribute to heparin resistance. Accurate monitoring of AFXa activity with appropriate therapy escalation plans are recommended with dose adjustment following severe burn injury.

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Fluid resuscitation based on pulse contour cardiac output monitoring is associated with improved prognosis in adult severe burn patients: a retrospective cohort study

Zhu¹,

Yang²,

Ding³

et al. 2021

Ann Palliat Med

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Background: A monitoring method is needed to further guide fluid resuscitation in severe burn injury. This study was performed to investigate the effects of pulse contour cardiac output (PCCO) monitoring on the prognosis of adult severe burns patients. Methods:We conducted a retrospective study enrolling patients from January 2015 to December 2020, who were divided into a control group receiving conventional monitoring and a study group receiving PCCO monitoring. The primary outcomes were 28-day mortality and total mortality, and the secondary outcomes included burn-related complications and the length of hospital stay and ICU stay. Multivariable logistic regression analysis and linear regression analysis were performed to determine the risk factors of burnsrelated complications and length of hospital stay in enrolled patients.Results: A total of 109 patients in the control group and 82 patients in the study group were enrolled. While the area of full thickness burn was much higher in the control group than in the study group (P=0.021), no significant difference was found in other characteristics between the two groups. During fluid resuscitation, the fluid volume ratio of the study group was significantly different from that of the control group, and both in the first 24 hours and the second 24 hours, the resuscitation fluid volume ratio and colloid volume ratio was significantly higher in the control group than in the study group (all P<0.001). Eight patients died during treatment, and there were more patients experiencing AKI and ARDS in the control group than in the study group (P=0.029 and 0.016). The lengths of hospital stay and ICU stay in the study group was much shorter than in the control group (P<0.001 and 0.005). In addition, TBSA was an important risk factor for both AKI and ARDS, and the existence of inhalation injury and older age increased the incidence of ARDS. Higher TBSA, inhalation injury, and burn-related complications were related to longer hospital stay in enrolled patients.Conclusions: Fluid resuscitation according to PCCO monitoring can effectively reduce the volume of colloid and overall fluid volume and reduce the incidence of burns-related complications and shorten the length of hospital stay.

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Prophylactic anti-coagulation after severe burn injury in critical care settings

Cited by 5 publications

References 17 publications

Burn management during the COVID-19 pandemic: Recommendations and considerations

Burn management during the COVID-19 pandemic: Recommendations and considerations

Heparin resistance in severe thermal injury: a prospective cohort study

Fluid resuscitation based on pulse contour cardiac output monitoring is associated with improved prognosis in adult severe burn patients: a retrospective cohort study

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