| BackgroundTrauma-induced coagulopathy after severe trauma has been intensively studied and reported,and its early warning value and prevention strategies have significantly improved the prognosis of such patients.As a special form of trauma,severe stress state,endothelial injury,hypothermia,acidosis and massive fluid resuscitation in the early stage of severe burn patients cause extensive activation,interaction and cascade amplification effect of platelets,endothelial system,coagulation system and the complement system,which are highly likely to lead to the development of coagulation disorders.In recent years,there have been sporadic studies and reports on burn-related coagulation dysfunction at home and abroad,and it was found that there is a certain association with post-burn wound repair and infection,and it cannot be fully explained by the mechanism and theory of traumatic coagulopathy.However,most of these studies have problems such as small data sample sizes,poor study stratification,and partially contradictory findings.The coagulation characteristics,mechanisms,definitions,optimal diagnostic methods and management strategies for severe burns and the impact on prognosis have not been elucidated.ObjectiveTaking critically burned patients as the research object,we combined multicenter large sample data to explore the early coagulation characteristics and early warning value of adult severe burn patients,establish a model with a coagulation holistic picture,seek the objective indexes that are most guiding for condition judgment and treatment,explore the correlations between coagulation and inflammation,nutrition and other indexes,and lay the theoretical foundation for future research.MethodsThis study: 1.To collect medical records and relevant clinical data of severe adult burn patients(TBSA≧30%)admitted to 12 collaborating units from January 2015 to December2020 according to the nadir criteria to explore the early(within 48 h post-injury)coagulation characteristics of adult critically ill burn patients.2.Patients were grouped by 28-day outcome(death or survival),clinical data and basic information were collected for comparison between groups,forest plots were drawn for univariate analysis of variables,and multiple Logistic regression analysis was used to establish a model to analyze the prognostic impact of each coagulation index and those with significant differences between groups(P<0.05).3.ROC curve analysis was used to predict the effect of the outcome,the H-L test was used to measure the degree of model fit,and the best threshold was selected according to the maximum of the Jorden index.All patients were then divided into high and low-scoring groups according to the optimal threshold,the Kaplan-Meier method was used to calculate survival rates,and the Log-rank test was used to compare survival curves between groups.4.Burn patients were stratified by TBSA and age,respectively,and the effect of these factors on prognosis was analyzed using CMH test.5.A preliminary exploration of coagulation function was analyzed in correlation with inflammatory and nutritional indicators.6.To investigate the safety and efficacy of clinical disposition against coagulation function/indicators based on thrombosis/bleeding.Results1.In this study,a total of 683 patients fulfilling the inclusion criteria were collected as study subjects.The overall coagulation characteristics of the study population showed mild hypocoagulation and mild hyperfibrinolysis based on the routine coagulation indexes and relevant blood test results at 48 h post-injury.2.111 cases in the death group and 572 cases in the survival group were grouped according to the patients’ 28-day outcomes.There were significant differences in patient age,TBSA,and degree of inhalation injury(P<0.05).PT,APTT,TT was significantly prolonged,D-D and FDP were significantly higher in the death group compared with the surviving group,which showed a hypocoagulated and hyperfibrinolytic state,and the comparison between groups was statistically significant(P<0.05).3.3.There were statistically significant differences between groups in albumin,glucose,pH,lactate,WBC,NLR,total bilirubin,blood creatinine,SOFA score,modified BAUX score,ABSI score,clinical interventions(ventilatory support,early anticoagulation,use of vasoactive drugs,and CRRT treatment)(P<0.05).4.Six models were obtained by multivariate Logistic regression: model score 2 =-9.665+ 0.038 × age + 0.038 × TBSA + 0.028 × APTT + 0.092 × FDP + 0.689 × creatinine + 0.049× blood glucose maximum area under the curve,Cut-off value of-1.7035,the sensitivity of87.4% and a specificity of 85.8%.The Kaplan-Meier method was used to calculate the survival rate,and the Log-rank test was used to compare the survival curves between groups.The difference in survival time between the low-scoring and high-scoring groups was statistically significant(P<0.05),and the prognosis of the low-scoring group was better than that of the high-scoring group.5.APTT and FDP were correlated with PLT,albumin and TBSA.WBC was positively correlated with PT,TT and INR,and negatively correlated with FIB.6.Controlling for the effects of age and burn area stratification factors,APTT and FDP have a good early warning value for prognosis.7.55 patients were treated with early(48h after injury)anticoagulation.4 patients died of definite gastrointestinal bleeding and no thrombotic events were observed.ConclusionsA multicenter retrospective analysis proved that the early coagulation characteristics of severe burn patients showed mild procoagulant impairment with mild hyperfibrinolysis,and early coagulation function was associated with prognosis.Through stratified analysis,covariate screening,disease modeling,and treatment guidance,a theoretical basis for further basic research and clinical trials related to coagulation in severe burns was established. |
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