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Acute blood loss during burn and soft tissue excisions: An observational study of blood product resuscitation practices and focused review

Pidcoke, Heather F. MD, PhD; Isbell, Claire L. MD; Herzig, Maryanne C. PhD; Fedyk, Chriselda G. MS; Schaffer, Beverly S. PhD; Chung, Kevin K. MD; White, Christopher E. MD, MSc; Wolf, Steven E. MD; Wade, Charles E. PhD; Cap, Andrew P. MD, PhD

Journal of Trauma and Acute Care Surgery: June 2015 - Volume 78 - Issue 6 - p S39–S47
doi: 10.1097/TA.0000000000000627
Original Articles

BACKGROUND Many military and civilian centers have shifted to a damage-control resuscitation approach, focused on providing oxygen-carrying capacity while simultaneously mitigating coagulopathy with a balanced ratio of platelets and plasma to red blood cells. It is unclear to what degree this strategy is used during burn or soft tissue excision. Here, we characterized blood product transfusion during burn and soft tissue surgery and reviewed the published literature regarding intraoperative coagulation changes. We hypothesized that blood product resuscitation during burn and soft tissue excision is not hemostatic and would be insufficient to address hemorrhage-induced coagulopathy.

METHODS Consented adult patients were enrolled into an institutional review board–approved prospective observational study. Number, component type, volume, and age of the blood products transfused were recorded during burn excision/grafting or soft tissue debridement. Component bags (packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate) were collected, and the remaining sample was harvested from the bag and tubing. Aliquots of 1/1,000th the original volume of each blood product were obtained and combined, producing an amalgam sample containing the same ratio of product transfused. Platelet count, rotational thromboelastometry, and impedance aggregometry were measured. Significance was set at p < 0.05.

RESULTS Amalgamated transfusate samples produced abnormally weak clots (p ≤ 0.001) particularly if they did not contain platelets. Clot strength (48.8 [2.6] mm; reference range, 49–71 mm) for platelet-containing amalgams was below the lower limit of the reference range despite platelet–red blood cell ratios greater than 1:1. Platelet aggregation was abnormally low; transfused platelets were functionally inferior to native platelets.

CONCLUSION Our study and focused review demonstrate that further work is needed to fully understand the needs of patients undergoing tissue excision. The three studies reviewed and the results of our observational work suggest that coagulopathy and thrombocytopenia may contribute to intraoperative hemorrhage. Blood product resuscitation during burn and soft tissue excision is not hemostatic.

LEVEL OF EVIDENCE Epidemiologic study, level V.

From the US Army Institute of Surgical Research (H.F.P., M.C.H., C.G.F., B.S.S., K.K.C., C.E.Wh., A.P.C.), San Antonio; Department of Surgery (C.L.I, S.E.W.), University of Texas Southwestern Medical Center, Dallas; and Department of Surgery and the Center for Translational Injury Research (C.E.Wa.), University of Texas Health Sciences Center, Houston, Texas; and Uniformed Services University of the Health Sciences (K.K.C., A.P.C.), Bethesda, Maryland.

Submitted: December 17, 2014, Accepted: February 2, 2015.

Presented at the 4th Annual Remote Damage Control Resuscitation Symposium of the Trauma Hemostasis and Oxygenation Research Network, June 9–11, 2014, in Bergen, Norway.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

This study was conducted under a protocol reviewed and approved by the US Army Medical Research and Materiel Command Institutional Review Board and in accordance with the approved protocol.

Address for reprints: Heather F. Pidcoke, MD, PhD, Coagulation and Blood Research Program, US Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX 78234–4504; email: heather.f.pidcoke2.civ@mail.mil.

© 2015 Lippincott Williams & Wilkins, Inc.