Department of Anaesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Austria.
Br J Anaesth. 2012 Sep;109(3):376-81. doi: 10.1093/bja/aes186. Epub 2012 Jun 19.
Surgical excision of burn wounds is often associated with severe bleeding. Timely and targeted correction of coagulopathy reduces transfusion requirements and improves survival in trauma victims. We hypothesized that rapid correction of coagulopathy after a treatment algorithm based on point-of-care viscoelastic coagulation testing would decrease allogeneic blood product transfusions during surgical excision of burn wounds.
Thirty consecutive patients undergoing surgical excision of burn wounds were enrolled into this prospective, randomized, controlled, single-centre study. In the control group, coagulation management was performed according to the clinicians' discretion. For the algorithm group, we standardized treatment based on the Austrian recommendation for the management of trauma-induced coagulopathy using point-of-care rotational thromboelastometry (ROTEM(®)). The main outcome parameter was the cumulative number of allogeneic blood units transfused on the day of surgery.
The difference between the groups regarding the cumulative use of allogeneic blood products was highly significant with 3.0 (1.3-5.5) blood products in the algorithm group compared with 9.0 (6.0-12.3) in the control group [median (inter-quartile range); P=0.002]. No plasma was administered in the algorithm group compared with 5.0 (1.5-7.5) units overall in the control group (P<0.001). Fibrinogen concentrate administration was not significantly different between the groups (P=0.89). Tranexamic acid was not administered.
The significant reduction in allogeneic blood product requirements during surgical burn wound excision is a prospective proof of concept that a bleeding management algorithm based on thromboelastometry is efficacious. Hypofibrinogenaemia and hyperfibrinolysis are not significant pathomechanisms of bleeding in this setting and ROTEM(®) helps to avoid unnecessary interventions.
外科切除烧伤创面常伴有严重出血。及时和有针对性地纠正凝血障碍可减少创伤患者的输血需求并提高生存率。我们假设，基于即时检测的粘弹性凝血检测的治疗算法可快速纠正凝血障碍，从而减少外科切除烧伤创面时异体血液制品的输注。
本前瞻性、随机、对照、单中心研究纳入了 30 例连续接受外科切除烧伤创面的患者。在对照组中，凝血管理根据临床医生的判断进行。对于算法组，我们根据使用即时检测旋转血栓弹性仪（ROTEM(®)）的奥地利创伤诱导性凝血障碍管理建议，对治疗进行标准化。主要结局参数是手术当天输注的异体血液单位总数。
两组之间异体血液制品的累积使用差异具有高度显著性，算法组为 3.0（1.3-5.5）个单位，对照组为 9.0（6.0-12.3）个单位[中位数（四分位数间距）；P=0.002]。与对照组中总体输注 5.0（1.5-7.5）个单位的血浆相比，算法组未输注血浆[P<0.001]。纤维蛋白原浓缩物的给药在两组之间无显著差异（P=0.89）。未给予氨甲环酸。
外科切除烧伤创面时异体血液制品需求的显著减少是一个前瞻性概念验证，表明基于血栓弹性图的出血管理算法是有效的。在这种情况下，低纤维蛋白原血症和纤维蛋白溶解亢进并不是出血的重要发病机制，ROTEM(®)有助于避免不必要的干预。
