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.

References1. Brohi K, Singh J, Heron M, Coats T. Acute Traumatic coagulopathy. J Trauma. 2003;54:1127-1130.2. Davenport R, Manson J, De’Arth H, Platton S, Coates A, Allard S, Hart D, Pearse RM, Pasi J, MacCullum P, Stanworth S, Brohi

K. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med. 2011;39(12):2652-2658.3. Maegele M, Lefering R, Yucei N, Tjardes T, Rixen D,Paffrath T, Simanski C, Neugebauer E, Bouillon B; AG Polytrauma of

the German Trauma Society (DGU). Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007 Mar;38(3):298-304.

4. Firth D, Davenport R, Brohi K. Acute traumatic coagulopathy. Curr Opin Anaesthesiol. 2012 Apr;25(2):229-34.5. Schlag G, Redl H. Mediators in Trauma. Act Anesthesiol Belg. 1987;31:281-291.6. Vindenes HA, Ulvestad E, Bjerknes R. Concentrations of cytokines in plasma of patients with large burns: their relation

to time after injury, burn size, inflammatory variables, infection, and outcome. Eur J Surg. 1988 Sep;164(9):647-56.7. Latenser BA. Critical care of the burn patient: the first 48 hours. Crit Care Med. 2009 Oct;37(10):2819-26.8. Lavrentieva A, Kontakiotis T, Bitzani M, Papaioannou-Gaki G, Parlapani A, Thomareis O, Tsotsolis N, Giala MA. Early

coagulation disorders after severe burn injury: impact on mortality. Intensive Care Medicine. 2008 Apr;34(4):700-6.9. King DR, Namias N, Andrews DM. Coagulation abnormalities following thermal injury. Blood Coagul Fibrinolysis. 2010

Oct;21(7):666-9.10. Kowal-Vern A, Gamelli RL, Walenga JM, Hoppensteadt D, Sharp-Pucci M, Schumacher HR. The effect of burn wound size

on hemostasis: a correlation of the hemostatic changes to the clinical state. J Trauma. 1992 Jul;33(1):50-56; discussion 56-57.

11. Garcia-Avello A, Lorente JA, Cesar-Perez J, Garcia-Frade LJ, Alvardo R, Arevalo JM, Navarro JL, Esteban A. Degree of hypercoagulability and hyperfibrinolysis is related to organ failure and prognosis after burn trauma. Thromb Res. 1998 Jan;89(2):59-64.

12. Hendon DN. Total Burn Care. Vol 3. Saunders; 2003.13. Roberts G, Lloyd M, Parker M, Martin R, Philip B,Shelley O, Dziewulski P. The Baux score is dead. Long live the Baux

score: 27 year retrospective cohort study of mortality at a regional burns service. J Trauma. 2012;72(1):251-256.14. Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn severity index. Ann Emerg Med. 1982 May;11(5):260-2.15. Barret JP, Gomez PA. Disseminated intravascular coagulation: a rare entity in burn injury. Burns. 2005 May;31(3):354-7.16. Kowal-Vern A, Sharp-Pucci MM< Walenga JM, Dries GJ, Gamelli RL. Trauma and thermal injury: Comparison of

hemostatic and cytokine changes in the acute phase of injury. J Trauma. 1998 Feb;44(2):325-9.