Fibrinogen function after severe burn injury
Introduction
Burns larger than 30% of the total body surface area (TBSA) result in a systemic inflammatory response syndrome with simultaneous activation of the clotting cascade [1]. About 30% of patients with severe burns develop disseminated intravascular coagulation (DIC) [2]. Major blood loss during burn wound excision is a well known phenomenon [3], [4]. But there is also growing evidence regarding hypercoagulability in the first week after burn trauma [5], [6], [7]. Park and colleagues showed that thrombelastography is clearly superior to plasma-based clotting assays regarding detection of hypercoagulability in non-burned and burned trauma victims. They hypothesized that this hypercoagulable state may partly be caused by increased fibrinogen levels, [7] but a functional fibrinogen assay has not been employed in this study.
Rotational thrombelastometry (ROTEM®, Pentapharm, Munich, Germany) is a technological advance of thrombelastography also capable of visualizing hypercoagulability [8], [9]. Besides the conventional contact-activated assay (INTEM®), ROTEM® offers a tissue factor-activated test (EXTEM®) and a test which measures functional fibrinogen (FIBTEM®) [10]. ROTEM® and thrombelastography have gained acceptance in the management of bleeding disorders in trauma and elective surgery [11], [12]. Fibrinogen correlated highly with the clinical outcome of bleeding in patients after coronary bypass surgery [13], [14], a statistically significant correlation between fibrinogen level and FIBTEM® has already been shown in pregnant women and trauma patients [11], [15]. To test the hypothesis that in patients with severe burns fibrinogen function changes over time, we simultaneously measured FIBTEM® and fibrinogen concentration early after burn trauma.
Section snippets
Materials and methods
This study was approved by the Ethics Committee of the Medical University of Vienna. Consecutive patients with severe burn trauma with burn-size greater than 15% TBSA and burn-depth IIb-III admitted to the burn intensive care unit of the General Hospital of Vienna within 12 h after trauma were included in the study. Exclusion criteria were age under 18 years, current intake of oral anticoagulants or platelet aggregation inhibitors or abnormal bleeding history [16].
On admission, demographic data
Results
20 consecutive patients were included in the study. Patient's characteristics are shown in Table 1. Five patients (mean ABSI 12.6) died of various reasons during the course of ICU stay. There were no clinical thrombosis and bleeding events during the observation period of 48 h after admission.
Mean FIBTEM® MCF was within the reference range until 24 h after trauma but increased significantly 48 h after trauma (p = 0.002). At this time point 65% of the patients showed FIBTEM® MCF values above the
Discussion
The results of this prospective observational study show that fibrinogen function visualized by ROTEM® changes early after burn trauma. In our study we confirmed the results of Park et al., showing increased fibrinogen concentration after burn trauma which is suggested to be a result of increased fibrinogen synthesis [7].
The increase of fibrinogen measured with the Clauss method correlated with the increase in FIBTEM® MCF which implies that FIBTEM® can be used as a point-of care assay sensitive
Disclosure
S.K.L. received honoraria for lecturing and an unrestricted grant for an e-learning project among others from Pentapharm, Munich, Germany.
The other authors state that there is no conflict of interest.
Acknowledgements
The study was funded by the Oesterreichische Nationalbank.
The study sponsor had no involvement in the study design, in the collection, analysis and interpretation of data; in writing of the manuscript; and in the decision to submit the manuscript for publication.
We thank the intensive care personnel and especially P. Metnitz, director of the burn intensive care unit, for their professional cooperation.
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