Measuring coagulation in burns: an evidence-based systematic review

• Published in: Scars, Burns & Healing Vol. 3; p. 2059513117728201
• Main Authors: Marsden, Nicholas J., Van, Martin, Dean, Samera, Azzopardi, Ernest A., Hemington-Gorse, Sarah, Evans, Phillip A., Whitaker, Iain S.
• Format: Book Review Journal Article
• Language: English
• Published: London, England SAGE Publications 01.01.2017; Sage Publications Ltd; SAGE Publishing
• Subjects: Blood products; Burns; Review; viscoelastic test; clotting; thrombelastography; Burns; rotation thromboelastometry; coagulation tests; point-of-care
• ISSN: 2059-5131; 2059-5131
• DOI: 10.1177/2059513117728201

Introduction: Dynamic monitoring of coagulation is important to predict both haemorrhagic and thrombotic complications and to guide blood product administration. Reducing blood loss and tailoring blood product administration may improve patient outcome and reduce mortality associated with transfusion. The current literature lacks a systematic, critical appraisal of current best evidence on which clinical decisions may be based. Objectives: Establishing the role of different coagulation markers in burn patients, diagnosing coagulopathy, tailoring blood product administration and indicating prognosis. Methods: Literature during 2004–2017 from the Cochrane Library, PubMed, Scopus, Medline and Embase was reviewed. Eligibility criteria included randomised controlled trials, systematic reviews, multi-/single-centre study and meta-analyses. Keywords searched were ‘burns’, ‘blood coagulation disorders’, ‘rotem’, ‘blood coagulation’ and ‘thromboelastography’. The PRISMA flow system was used for stratification and the CASP framework for appraisal of the studies retrieved. Results: In total, 13 articles were included after inclusion/exclusion criteria had been applied to the initial 79 studies retrieved. Hypercoagulation increases in proportion to the severity of thermal injury. Whole blood testing, using thrombelastography (TEG) and rotation thromboelastometry (ROTEM), was superior to standard plasma based tests, including prothrombin time (PT) and activated partial thromboplastin time (APTT) at detecting burn-related coagulopathies. Conclusions: Routine laboratory markers such as PT/APTT are poor indicators of coagulation status in burns patients. Viscoelastic tests, such as TEG and ROTEM, are efficient, fast and have a potential use in the management of burn patients; however, strong evidence is lacking. This review highlights the need for more randomised controlled trials, to guide future practice. Lay Summary Introduction: It is important to measure how easily or how difficult it is for blood to clot in patients who have sustained severe burn injuries. By doing this, we can predict bleeding and blood-clotting risks and it can help us determine when blood transfusions are needed. The medical literature does not currently have any articles which systematically summarise the best evidence regarding this topic. Methods: Databases containing medical research articles were searched in a systematic way and each article was scrutinised for its quality and how reliable the conclusions are based on how the study was performed. Results: Seventy-nine scientific articles were identified and narrowed down to 13 relevant ones. Patients with larger burn injuries are more likely to suffer abnormalities in their blood which leads to blood clotting more easily than normal. Blood tests called thrombelastography (TEG) and rotation thromboelastometry (ROTEM) seemed to be better than standard blood tests called prothrombin time (PT) and activated partial thromboplastin time (APTT) at detecting clotting disorders in burn patients. Conclusions: Standard blood clotting tests such as PT and APTT are not good at detecting blood-clotting abnormalities in burns patients. Other tests, TEG and ROTEM, are an efficient and fast way of monitoring blood clotting in burns patients. These tests have a potential use in the treatment of burns patients, but strong evidence to support this statement is lacking. This study highlights the need for more evidence, especially bigger and better research studies to guide future recommendations.