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Pulmonary Activation of Coagulation and Inhibition of Fibrinolysis After Burn Injuries and Inhalation Trauma

Hofstra, Jorrit J. MD; Vlaar, Alexander P. MD, PhD; Knape, Paul MD; Mackie, Dave P. MD; Determann, Rogier M. MD, PhD; Choi, Goda MD, PhD; van der Poll, Tom MD, PhD; Levi, Marcel MD, PhD; Schultz, Marcus J. MD, PhD, FCCP

Journal of Trauma-Injury Infection & Critical Care: June 2011 - Volume 70 - Issue 6 - pp 1389-1397
doi: 10.1097/TA.0b013e31820f85a7
Original Article

Background: Pulmonary coagulopathy is intrinsic to pneumonia and other forms of acute lung injury. We hypothesized patients with burn injuries and inhalation trauma to have similar alterations in pulmonary coagulation and fibrinolysis.

Methods: We performed a prospective study on changes in pulmonary and systemic thrombin generation and fibrinolytic activity in patients with burn injuries and inhalation trauma requiring mechanical ventilation. Nondirected bronchial lavage was performed on alternate days. Patients requiring mechanical ventilation for nonpulmonary reasons who did not meet the North American European Consensus Conference criteria for acute lung injury functioned as control patients.

Results: We studied 13 patients with burn injuries and inhalation trauma and 15 control patients. On admission, patients with burn injuries and inhalation trauma showed a significant increase in thrombin generation in the airways compared with control patients, as reflected by increased lavage fluid levels of thrombin-antithrombin complexes and fibrin degradation products, and decreased lavage fluid levels of activated protein C and antithrombin. Simultaneously, burn patients showed a significant decrease in fibrinolytic activity, as reflected by decreased lavage fluid levels of plasminogen activator activity. Pulmonary coagulopathy persisted throughout the period of mechanical ventilation and was accompanied by similar changes in systemic coagulation and fibrinolysis. There was no significant correlation between changes in coagulation and fibrinolysis and the extent of burn injury.

Conclusions: Patients with burn injuries and inhalation trauma requiring mechanical ventilation show a distinct and sustained procoagulant and antifibrinolytic shift in the pulmonary compartment. Pulmonary coagulopathy could be an important therapeutic target in these patients.

From the Departments of Intensive Care Medicine (J.J.H., A.P.V., M.J.S.), Anesthesiology (J.J.H.), and Internal Medicine (R.M.D., G.C., T.v.d.P., M.L.) and Center for Experimental and Molecular Medicine (T.v.d.P.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and Department of Anesthesiology (P.K., D.P.M.), Rode Kruis Ziekenhuis, Brandwonden Centrum Beverwijk, Beverwijk, The Netherlands.

Submitted for publication December 24, 2009.

Accepted for publication January 10, 2011.

The first two authors contributed equally to this work.

Address for reprints: Alexander P.J. Vlaar, MD, Department of Intensive Care Medicine, C3-329, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; email: a.p.vlaar@amc.uva.nl.

© 2011 Lippincott Williams & Wilkins, Inc.