Acute blood loss during burn and soft tissue excisions

An observational study of blood product resuscitation practices and focused review

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

Research output: Contribution to journalArticle

12 Citations (Scopus)

Abstract

BACKGROUND: Many military and civilian centers have shifted to a damage-control resuscitation approach, focused on providing oxygencarrying 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.

Original languageEnglish (US)
Pages (from-to)S39-S47
JournalJournal of Trauma and Acute Care Surgery
Volume78
Issue number6
DOIs
StatePublished - Jun 1 2015
Externally publishedYes

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Resuscitation
Observational Studies
Blood Platelets
Erythrocytes
Hemostatics
Blood Volume
Reference Values
Hemorrhage
Thrombelastography
Research Ethics Committees
Debridement
Electric Impedance
Platelet Count
Platelet Aggregation
Blood Transfusion
Thrombocytopenia
Prospective Studies

Keywords

  • Acute traumatic coagulopathy
  • Burn excision
  • Damage control resuscitation
  • Severe hemorrhage
  • Soft tissue excision

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Acute blood loss during burn and soft tissue excisions : An observational study of blood product resuscitation practices and focused review. / Pidcoke, Heather F.; Isbell, Claire L.; Herzig, Maryanne C.; Fedyk, Chriselda G.; Schaffer, Beverly S.; Chung, Kevin K.; White, Christopher E.; Wolf, Steven; Wade, Charles E.; Cap, Andrew P.

In: Journal of Trauma and Acute Care Surgery, Vol. 78, No. 6, 01.06.2015, p. S39-S47.

Research output: Contribution to journalArticle

Pidcoke, Heather F. ; Isbell, Claire L. ; Herzig, Maryanne C. ; Fedyk, Chriselda G. ; Schaffer, Beverly S. ; Chung, Kevin K. ; White, Christopher E. ; Wolf, Steven ; Wade, Charles E. ; Cap, Andrew P. / Acute blood loss during burn and soft tissue excisions : An observational study of blood product resuscitation practices and focused review. In: Journal of Trauma and Acute Care Surgery. 2015 ; Vol. 78, No. 6. pp. S39-S47.
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abstract = "BACKGROUND: Many military and civilian centers have shifted to a damage-control resuscitation approach, focused on providing oxygencarrying 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.",
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AU - Fedyk, Chriselda G.

AU - Schaffer, Beverly S.

AU - Chung, Kevin K.

AU - White, Christopher E.

AU - Wolf, Steven

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