1; Y. Kaloudová
1; M. Matýšková
2; M. Penka
2; H. Řihová
1; P. Brychta
Department of Burns and Reconstructive Surgery, Medical Faculty, Masaryk University Brno, and
1; Department of Clinical Hematology, Medical Faculty, Masaryk University Brno, Czech Republic
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 50, 4, 2008, pp. 115-118
intravascular coagulation (DIC) is a syndrome accompanying
serious conditions and in 82.9% it is part of systemic inflammatory
response syndrome (SIRS). Changes in the system of blood coagulation
play an important role in the development of multi-organ dysfunction
syndrome – MODS (1). Disseminated intravascular coagulation can be
caused by various clinical conditions, for example sepsis, trauma,
organ dysfunction, malignant changes, pregnancy complications,
vascular abnormality, severe liver failure, severe poisoning, fat
embolism and many others.
2001 the Scientic and Standardisation Committee (SSC), International
Society on Thrombosis and Haemostasis (ISTH) divided its Disseminated
intravascular coagulation into: non-overt DIC (indolent, compensated,
“low grade” form), which is characterized by mild hemostatic
dysfunction with mainly hypocoagulation trend, and overt DIC (acute,
fulminant, decompensated, “high-grade”) with dominating
hypercoagulation status (2).
of the hemocoagulation system is during the burn trauma more or less
impaired practically always. Extensive burn trauma leads to
activation of coagulation, decrease of fibrinolytic activity and
decrease of natural anticoagulation activity (3).
such rapid development of more exact and specific laboratory methods,
evaluating separate factors of hemocoagulation, we can better explain
impending, incipient or already ongoing hemocoagulation disorders (in
means of increased bleeding or thrombosis). That allows a renaissance
of evaluation and foremost dynamics of growth or decrease of the
D-dimers (soluble fibrin monomers) values in circulation. Laboratory
evaluation at the Faculty Hospital in Brno uses the methods ELISA and
LIA. For our patients we have used the method LIA. D-dimers are not
specific enough for prediction of the TED, because values of D-dimers
can also be elevated during increased physical activity,
insignificant infections, viral infections, SIRS, sepsis or
physiologically with aging (4).
our pilot study we have included total of 36 patients with various
extent of burn injury. They were hospitalized at the Intensive Care
Unit (ICU) as well as at Standard Unit (Tab. 1). See the blood tests
we used in Tab. 2 (5). In these chosen patients we have established
decisive days: the day of injury, the 5th
day after the injury, the day after the autotransplantation, (or 8th
day of hospitalization if the autotransplantation was not indicated
in deep 2nd
degree burns – deep partial-thickness skin destruction)) and at the
day of discharge. In these days, series of hemocoagulation blood
tests were done which were eventually evaluated according to the
scheme recommended by ISTH for overt and non-overt DIC (Tab. 3, 4).
Value of the overt DIC score above 5 meant positivity i.e. the
patient would have acute form of DIC.
part of the study included 12 patients hospitalized at our ICU. The
average value of D-dimers on the day of admission was 2.06 μg/ml
(0.27–7.49), on the 5th
day of the hospitalization was the average value of D-dimers 2.32
(0.45–5.27), the day after the autotransplantation was the value of
D-dimers 4.18 μg/ml
(0.78–6.97) and at the day of discharge 0.64 μg/ml
(0.22–0.96) (Graph 1). Only one patient of 12 in this group died
following a septic shock. On the day of injury the value of
overt DIC score reached 1.25 (0–3). Fifth day after the injury the
average value of DIC score was 1.83 (0–3). Day after the
autotransplantation it was 2.08 (0–3) and on the day of discharge
it was 0 (Tab. 5). The DIC score reached 2 in the deceased patient.
part of the study included 24 patients hospitalized at the Standard
Unit of our Department. The average extent of burn injury in these
patients was 5.9% TBSA (0.5–12%) and the average age was 49.13
years (17–94 years). At the day of admission the average value of
D-dimers was 0.51 μg/ml
(0.07–1.93). On the 5th
day of hospitalization the average value of the D-dimers was 1.37
(0.88–1.77), on the day of autotransplantation or the 8th
day of hospitalization was the value of D-dimers 1.72 μg/ml
(0.35–4.31) and at the day of discharge it was 0.92 μg/ml
(0.65–1.08) (Graph 2). On the day of the injury the value of overt
DIC score reached 0.25 (0–2), the day after the autotransplantation
it was 1.83 (0–3) and on the day of discharge 0.02 (0–2) (see
the scoring of DIC it is important to establish values of D-dimers in
which would be considered as mid or high growth of the D-dimers
level. For these purposes, Dempfle et al. defined stratification,
which we also used for our scoring. Values of D-dimers 0–1 μg/ml
are evaluated by 0 points, values 1–3 μg/ml
are evaluated by 2 points and growth above 3 μg/ml
then by 3 points (7). In 2001 the ISTH issued a recommendation
for the frequency of blood taking and also evaluation of the DIC
score, which in patients with high risk should be completed daily.
Therefore the basic principle of DIC scoring is the evaluation of
dynamics of growth or decrease of the obtained values.
ISTH overt DIC score system can assist in more accurate diagnostics
in patient with severe sepsis and multi-organ failure. According to
the literature results of the scoring clearly correlate with
mortality, particularly in septic patients. Growth of the overt DIC
score during sepsis means high probability of other organ involvement
within the multi-organ failure and decreases the probability of
survival. We have not found any elevated overt DIC score (over 5) in
any of our patients, which means that we did not confirm ongoing
acute DIC. DIC score can be an interesting promise for
objectification of impending and ongoing disorders of
hemocoagulation; can lead to a purposeful prevention and faster
therapeutic intervention, which can reverse the unfavorable prognosis
of the patient. Of course, it does not mean that burned patients are
out of the life-threatening situation due to DIC, but more likely, it
can assist in the therapy management of burn trauma patient by the
adequate administration of antithrombotic doses of heparin and, in
the indicated cases, substitution of hemocoagulation factors;
non-specifically (by administration of fresh frozen plasma) or
specifically (for example substitution of Antithrombin). The care of
these patients must always be a result of multidiscipline
cooperation of a specialist in burns, hematologist,
microbiologist and anesthesiologist.
of Burns and Reconstructive Surgery,
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3. Lavrentieva A., Kontakiotis T., Bitzani M., Parlapani A., Thomareis O., Scourtis H., Tsotsolis N., Lazaridis L., Giala M-A. The efficacy of antithrombin administration in the acute phase of burn injury. Tromb. Haemost., 100, 2008, p. 286–290.
4. Herndon DN. Total Burn Care.: Saunders ELSEVIER, 2007, p. 325–342.
5. Lehman CM., Wilson LW., Rodgers GM. Analytic validation and clinical evaluation of the STA LIA TEST Immunoturbidimetric D-dimer assay for the diagnosis of disseminated intravascular coagulation. Am. J. Clin. Pathol., 122(2), 2004, p. 217–221.
6. Toh CH., Hoots WK., on behalf of the SSC on Disseminated Intravascular Coagulation of the ISTH. The scoring system of the Scientific and Standardisation Committee on Disseminated Intravascular Coagulation of the International Society on Thrombosis and Haemostasis: a 5-year overview. J. Thromb. Haemost., 5, 2007, p. 604–606.
7. Dempfle CE., Wurst M., Smolinski M., Lorenz S., Osika A., Olenik D., Fiedler F., Borggrefe M. Use of soluble fibrin antigen instead of D-dimer as fibrin-related marker may enhance the prognostic power of the ISTH overt DIC score. Thromb. Haemost., 91, 2004, p. 812–818.
8. Königová R. et al. Komplexní léčba popálenin. Praha: Grada, 1999, p. 153–200, 205–215, 240–245.