Post on 12-Nov-2014
description
Acute Burn Induced Coagulopathy
BLSA Trainee Prize Day07 Aug 2012
Tapiwa Kundishora §, Peter Sherren§Joseph Hussey*, Rabecca Martin*, Bruce Emerson*
Mike Parker~§ST6/7 Anaesthesia
*Consultant Anaesthetist ~Statistician- Anglia Ruskin University
IntroductionCoagulopathy in trauma is multifactorial;
Hypothermia, acidosis, dilutional coagulopathy, pre-existing bleeding diathesis, Disseminated Intravascular Coagulation
Acute Traumatic Coagulopathy (ATC) demonstrated by Brohi et al in 25 % of injured patients.
ATC is associated with a higher mortality.Coagulopathy in burns patients also exists
but is less well understoodThe presence of coagulopathy impacts in
early burn excision and grafting.
DiscussionMechanisms of Coagulopathy in Trauma
AimTo determine the incidence of acute burn
induced coagulopathy (ABIC) in burns patients
To determine whether ABIC has any significance in terms of patient outcomes
To determine if ABIC is an independent predictor of mortality in burns patients
MethodsRetrospective review medical records -St
Andrews Burns and Plastics Centre Intensive Care Unit.
Inclusion CriteriaAll patients admitted Jan 2006 to Dec 2011Burns > 30 % Total Body Surface Area
(TBSA)
MethodsExclusion Criteriaadmission ≥ 12 hours after the burn,suspected cyanide poisoningpre-existing bleeding diathesis or receipt of
anticoagulantsblood product administrationmajor non-thermal injuriesmedical skin lossMissing records
DefinitionsAcute Burn Induced Coagulopathy (ABIC):
PT ≥14.6 s and/or APTT ≥ 45 s (local lab. reference & Davenport et al) < 12 hours after thermal injury in patients included in our study.
Abbreviated Burn Severity Index( ABSI)age, sex, Total Burnt Surface Area (TBSA), full thickness Burn, inhalational injury
ABSIAge Sex Inhalation
al InjuryFull Thickness
TBSA
0-20 121-40 241-60 361-80 481-100 5
Female 1Male 0
Yes 1No 0
Yes 1No 2
1-10 111-20 221-30 331-40 441-50 551-60 661-70 771-80 881-90 991-100 10
MethodsAnalysed for association between coagulopathy with
demographics, Abbreviated Burn Severity Index ( ABSI) and fluid administration.
Non parametric data- median (IQR). Mann Whitney U and Fisher’s exact tests
Logistic regression modelling to assess prognostic value of a coagulopathy on the 28 day mortality rate.
Analysis of data was performed using Microsoft Excel 2010 (Microsoft, USA) and program R (R Foundation for Statistical Computing, Austria) by a statistician.
A p value < 0.05 was considered statistically significant.
Results
total cases reviewed(n=205)
Normal Clotting(n=71)
Acute Coagulopathy(n=46)
excluded(n=60)
missing data (n=28)
Results
Results
Results Incidence of coagulopathy with varying Abbreviated Injury Severity score (ABSI).
Results28 day mortality in analysed patients
Results Mortality rates in patients with normal coagulation and a
coagulopathy according to Abbreviated Burn Severity Index (ABSI).
Results
Scatter plot of Prothrombin time versus Abbreviated Burn Severity Index (ABSI). Pearson product moment correlation coefficient r - 0.292 and p - 0.0013.
ResultsScatterplot of Prothrombin time versus serum lactate
Pearson product moment correlation coefficient r - 0.292 and p - 0.0013
ResultsPredictive value of ABIC Possible predictors of mortality assessed
included coagulopathy and all the components of the ABSI(Age, sex, inhalational injury, full thickness burn and TBSA).
The addition of an early coagulopathy to ABSI improved the goodness of fit for the 28 day mortality model from a R2 37.9% to 43.0% and a Scaled Brier score 26.6% to 29.5% (p – 0.027).
As an independent predictor of 28 day mortality, ABIC has an odds ratio (OR) of 3.42 (1.11-10.56).
DiscussionVarious derangements of coagulation in
major burns patients has been describedMost of the published work focuses on DIC
and a delayed hypercoagulable stateThe incidence of DIC is variable.
Barret et al 0.09 % incidence in 3331 patientsLavrentieva et al 41/45 patients
Small number of patients overall in most( 5-60)
DiscussionABIC was present in 39.3% of our patients.
Brohi et al showed an incidence of ATC of 25 %
ABIC was associated with severity and thickness of burn (ABSI) & inhalational injury.
Acute Traumatic Coagulopathy is caused by endothelial damage & hypoperfusion leading to increased thrombomodulin expression
Similar mechanisms are likely to be involved in burns patients
ConclusionIn patients with major thermal injuries, ABIC
exists.This coagulopathy correlates to serum lactate
and ABSI but is unrelated to fluid administration. Mortality is higher in patients with ABICABIC may be an independent predictor of
mortality, however a more robust study would be required to prove this.
More research is required to evaluate clotting in burns patients using methods other than PT/APTT like thromboelastometry.
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