Measuring coagulation in burns: an evidence-based systematic review

Measuring coagulation in burns: an evidence-based systematic reviewShow all authorsNicholas J. Marsden, Martin Van, Samera Dean, ...First Published September 5, 2017 Review Article Download PDFPDF download for Measuring coagulation in burns: an evidence-based systematic reviewArticle information Open Access Creative Commons Attribution, Non Commercial 4.0 LicenseAbstractIntroduction: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

Egalitarianism in surgical training: let equity prevail

This study aimed to quantify core surgical trainee (CST) differential attainment (DA) related to three cohorts; white UK graduate (White UKG) versus black and minority ethnic UKG (BME UKG) versus international medical graduates (IMGs). The primary outcome measures were annual review of competence progression (ARCP) outcome, intercollegiate Membership of the Royal College of Surgeons (iMRCS) examination pass and national training number (NTN) selection. Intercollegiate Surgical Curriculum Programme (ISCP) portfolios of 264 consecutive CSTs (2010–2017, 168 white UKG, 66 BME UKG, 30 IMG) from a single UK regional post graduate medical region (Wales) were examined. Data collected prospectively over an 8-year time period was analysed retrospectively. ARCP outcomes were similar irrespective of ethnicity or nationality (ARCP outcome 1, white UKG 60.7% vs BME UKG 62.1% vs IMG 53.3%, p=0.395). iMRCS pass rates for white UKG vs BME UKG vs IMG were 71.4% vs 71.2% vs 50.0% (p=0.042), respectively. NTN success rates for white UKG vs BME UKG vs IMG were 36.9% vs 36.4% vs 6.7% (p=0.023), respectively. On multivariable analysis, operative experience (OR 1.002, 95% CI 1.001 to 1.004, p=0.004), bootcamp attendance (OR 2.615, 95% CI 1.403 to 4.871, p=0.002), and UKG (OR 7.081, 95% CI 1.556 to 32.230, p=0.011), were associated with NTN appointment. Although outcomes related to BME DA were equitable, important DA variation was apparent among IMGs, with iMRCS pass 21.4% lower and NTN success sixfold less likely than UKG. Targeted counter measures are required to let equity prevail in UK CST programmes

Summative supervisor reporting: a quality performance perspective

Objective This study aimed to quality assure Assigned Educational Supervisor (AES) reports, using UK Joint Committee on Surgical Training objective criteria, to evaluate contribution to Annual Review of Competence Progression. Design Consecutive 145 AES reports from 75 trainers regarding 68 Core Surgical Trainees were assessed from 9 hospitals (2 Tertiary centers [77 reports], 7 District General Hospitals [68 reports]). Reports were assessed by independent assessors based on free text related to performance mapped to curricular objectives, operative logbooks, and Clinical Supervisor reports, and overall summary grades assigned ranging from development required, adequate, good to excellent. Setting A core surgical training program serving a single UK (Wales) deanery. Participants Sixty-eight consecutively appointed core surgical trainees and 75 consultant surgeon trainers. Results Summary grades of adequate or above were achieved in 101 of 145 (69.7%) reports. Trainees’ objective setting meetings were completed within 6 weeks of starting placements in 124 of 145 (85.5%). The proportions of AES reports containing free text commentary on curricular objectives, portfolio objectives, and operative logbook development were 128 of 145, 123 of 145, and 55 of 145, respectively. AES report quality was not associated with hospital status, subspecialty, or trainee grade. Female trainers were significantly more likely to provide reports graded as Good or Excellent compared with their male colleagues (7 of 12 vs. 27 of 133, χ2 (2) = 9.389, p = 0.009). AES reports for male trainees were significantly more likely to be rated as further development required (40 of 85, 47.1%) when compared with female trainees (4 of 32, 12.5%, p = 0.007). Conclusions Three in ten AES reports were insufficient to contribute to objective Annual Review of Competence Progression outcomes and a gender gap was apparent related to engagement. AES trainers should provide more focus if this summative tool is to be an effective career progression metric

Trainee perspective of the causes of stress and burnout in surgical training: a qualitative study from Wales

Objectives Stress and burn-out among surgical trainees has been reported most prevalent in core surgical trainees (CST) and female trainees in particular. This study aimed to identify factors perceived by CSTs to be associated with stress and burnout in those at risk. Design An open-ended questionnaire was distributed to 79 CSTs and two researchers categorised responses independently, according to Michie’s model of workplace stress. Setting A UK regional postgraduate medical region (Wales). Participants Sixty-three responses were received; 42 males, 21 females. The response rate was 79.7%. Results Inter-rater reliability was good (k=0.792 (79.2%), p<0.001). The most common theme of Michie’s model related to CST stress and burnout was career development, with most statements associated with curriculum, examination and academic demands required to attain a CST certificate of completion of training, and higher surgical national training number appointment. This was closely followed by those intrinsic to the job with recurrent discussion around the difficulties balancing work perceived to be service provision (ward work and on-calls), outpatient clinic and operative experience. Conversely, the most common themes relevant to stress and burnout among female trainees were associated with relationships at work (primarily the male-dominated nature of surgery), extraorganisational factors (family–work life balance) and individual characteristics (personality and physiological differences). Conclusion CSTs’ perceptions regarding the causes of National Health Service related stress and burnout are numerous, and these findings provide a basis for the development of targeted stressor counter-measures to improve training and well-being

Using ordinal logistic regression to evaluate the performance of laser-Doppler predictions of burn-healing time

Background Laser-Doppler imaging (LDI) of cutaneous blood flow is beginning to be used by burn surgeons to predict the healing time of burn wounds; predicted healing time is used to determine wound treatment as either dressings or surgery. In this paper, we do a statistical analysis of the performance of the technique. Methods We used data from a study carried out by five burn centers: LDI was done once between days 2 to 5 post burn, and healing was assessed at both 14 days and 21 days post burn. Random-effects ordinal logistic regression and other models such as the continuation ratio model were used to model healing-time as a function of the LDI data, and of demographic and wound history variables. Statistical methods were also used to study the false-color palette, which enables the laser-Doppler imager to be used by clinicians as a decision-support tool. Results Overall performance is that diagnoses are over 90% correct. Related questions addressed were what was the best blood flow summary statistic and whether, given the blood flow measurements, demographic and observational variables had any additional predictive power (age, sex, race, % total body surface area burned (%TBSA), site and cause of burn, day of LDI scan, burn center). It was found that mean laser-Doppler flux over a wound area was the best statistic, and that, given the same mean flux, women recover slightly more slowly than men. Further, the likely degradation in predictive performance on moving to a patient group with larger %TBSA than those in the data sample was studied, and shown to be small. Conclusion Modeling healing time is a complex statistical problem, with random effects due to multiple burn areas per individual, and censoring caused by patients missing hospital visits and undergoing surgery. This analysis applies state-of-the art statistical methods such as the bootstrap and permutation tests to a medical problem of topical interest. New medical findings are that age and %TBSA are not important predictors of healing time when the LDI results are known, whereas gender does influence recovery time, even when blood flow is controlled for. The conclusion regarding the palette is that an optimum three-color palette can be chosen 'automatically', but the optimum choice of a 5-color palette cannot be made solely by optimizing the percentage of correct diagnoses