Burn Shock Period Research Articles

Early Autocalibrated Arterial Waveform Analysis for the Management of Burn Shock-A Cohort Study.

Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group (P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient's volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.

800 Immediate/Ultra-Early v. Early Burn Excision: A Systematic Review of Surgical Outcomes

IntroductionThis is a systematic review which seeks to establish if immediate/ultra-early excision (immediate: < 24 hours, ultra-early: 24 - 72 hours) and grafting is better or equivalent to early excision and grafting (early: 72 hours - 6 days) in adults with major burns. The concept of early excision and grafting, as opposed to late excision (late: >7 days), was introduced by Cope et al. and later popularized by Janzekovic in the 1970s when she introduced the concept of tangential excision. Delaying excision 24 to 48 hours has previously been thought to allow resuscitation and correction of physiologic derangements to optimize outcomes. However, timing for excision and grafting is subject to debate. The outcomes of interest include mortality, length of stay, complication rates, wound healing time, infection rates, physiologic demand, blood loss, and resting energy expenditure.MethodsIn this systematic review, we searched PubMed, Embase, CINAHL, Cochrane, Web of Science, and Scopus for studies that compared outcomes and complications between burn patients with ultra-early and early excisions. From this search, we screened 4235 articles. Through our selection criteria, five articles focusing on timing of burn excision were selected for systematic review.ResultsFive studies observing a total of 382 burn patients, published between 1995 and 2016, were included. All five studies are cohort studies, three were prospective studies while two were retrospective chart reviews. Two studies showed decreased length of stay with immediate/ultra-early excision (Still, Keshavarzi) and decreased time to healing with immediate/ultra-early excision (Guo, Lu). One study demonstrated decreased infection and mortality in ultra-early excision (Keshavarzi). One study demonstrated decreased resting energy expenditure in the ultra-early excision group (Gao). One study showed a decrease in blood transfusion in the immediate/ultra-early excision group (Guo). Both the Guo and Gao studies suggest that concerns over excision during the burn shock period may be unfounded provided that the patient is adequately resuscitated.ConclusionsStudies investigating the immediate/ultra-early excision of burns tend to show improved outcomes for adults with major burns. It is difficult to attain conclusive data due to the lack in overlap of reported outcomes in modern studies. More studies are needed which compare outcomes in adults with major burns between immediate/ultra-early excision and early excision.

POSSIBILITIES OF IMMUNOLOGY STUDIES IN ESTIMATION OF VALIDITY OF BURN WOUNDS FOR SKIN PLASTICITY

Immunological features of burn disease largely reflect the state of general and local changes caused by the action of thermal factors. They are fundamental in formation of physiological repair of damaged tissue and disorders of the local immune system, lead to disruption of protective mechanisms with increased risk of occurrence and progression of local and systemic complications. It is the period of burn shock that is one of the main ones in the course and consequences of burn disease. In patients, the burn septicemia period even starting from the third day is characterized by severe immune changes, frequent generalization of inflammation and infection. Since one of the main tasks in treatment of patients with thermal trauma is the earliest possible recovery of lost skin, which consists in early surgical treatment (excision of necrotized tissues followed by simultaneous or delayed autodermoplasty), it is necessary to take into account metabolic disorders and changes in immune reactivity, affecting reparation of damaged tissues. To study the main immunological parameters in treatment of skin burn defects and their impact on the results of skin grafting, 17 patients with deep burns were examined. The main indices of metabolic status and immune reactivity in t surgical treatment of skin lesions, namely, innate immunity, humoral and cell components of immunity, metabolism (phagocytic activity of neutrophils, oxygen−dependent metabolism of neutrophils, concentration of peptides) differentiation clusters CD22 +, CD25 +, HLA−DR +) were examined. It is established that the corresponding changes in the indices can be the markers to predict the results of skin grafting. In this research it was found that with an unfavorable result of autodermoplasty in the patients with deep burns significant changes in immune reactivity and metabolic disorders were revealed. Altered immune reactivity due to increased circulating immune complexes and medium molecular weight peptides that provide opsonization and elimination of cytotoxic antigens in patients with deep burns may affect the results of skin grafting in surgical treatment of skin defects. Key words: burns, immune reactivity, dermatoplasty, metabolic state, autological skin transplantation.

The Fenix II study: A longitudinal study of psychopathology among burn patients

Psychological symptoms are common among burn survivors. However, knowledge about epidemiology and predictors of psychopathology has shown great heterogeneity in this population. The Fenix-II Project was the first epidemiological study on the psychopathological consequences of burns developed in Spain, providing a detailed analysis of the progression of psychological symptoms during the first six months after injury. Three hundred and thirty-three patients were screened and 183 were included in this study. Posttraumatic, depression and anxiety symptoms showed a general decreasing tendency across time. At 6 months, 34 patients showed clinically significant Posttraumatic Stress Disorder (PTSD) symptoms (20.5% of 166 patients reached at 6 months) as assessed with the MINI Neuropsychiatric Interview. Within this group of patients, anxiety, depression and hyperarousal increased at 30 days, and avoidance 90 days after injury. The most accurate predictors of PTSD were found to be being burned in a Motor Vehicle Crash, risk of social exclusion, low body-image adjustment, anterior trunk location of the burn and life threat perception during the burn-shock period. Considering these factors, clinicians may identify patients at risk of PTSD development, allowing an adequate follow up and preventive interventions which may minimize the psychological consequences of burns.

The Combination of Parkland Formula, Using Normal Saline, with Muir &amp;amp; Barclay Formula for Fluid Resuscitation in the Initial Burn Shock Period

Objectives: Evaluation of the effects of withholding plasma during the initial part of the burn shock period (the shock period in the study is estimated as the first 36 hours following the burns) when it will be lost into the interstitial tissues through the permeable capillaries. During that time crystalloids are administered. Another objective is to evaluate the effect of administering normal saline as the crystalloid resuscitation fluid during the initial part of the shock period. Design: A Retrospective 4 years study compares the use of normal saline as the resuscitative intravenous fluid during the first 12 hours post burns followed by intravenous 5% Purified Plasma Protein Fraction (PPPF) during the rest of the shock period i.e. the remaining 24 hours, with the use of the PPPF throughout the burns shock period according to Muir and Barclay formula. Setting: The Plastic Surgery Department and the Department of Laboratory, Directorate General of Khoula Tertiary Hospital, Muscat, Sultanate of Oman. Patients and Methods: The study included 2 groups of patients; Group A: Patients who received 5% Plasma (Human PPPF) throughout the shock period and Group B: Patients who received crystalloids in the form of normal saline during the first 12 hours post burn followed by plasma for the next 24 hours. Monitoring of the patients in both groups was done by using clinical signs of pulse, blood pressure, temperature and urine output and by using laboratory investigations in the form of the haematocrit value, sodium, potassium, chloride, total proteins and albumin levels in the blood at the time of admission and at the end of the shock period. Results: 140 patients were included in the study; 64 in Group A and 76 in Group B. There was no mortality and the vital signs were maintained during the shock period in both groups. The mean values of urine output were nearer to the normal level in Group B compared to Group A. The same was observed regarding the Haematocrit value. In both groups the mean values showed no hypoproteinaemia or hypoalbuminaemia at the end of the shock period. There was no hypernatraemia in spite of giving 150 mmol/L of Na during the initial 12 hours post burns in Group B. The mean values of potassium and chloride levels were normal in both groups at the end of the shock period. Conclusion: Giving plasma during the first 12 hours of the burn shock period when the capillary leakage is maximum has no significant benefit. The plasma usage can be reduced by 50% compared to the use of the Muir and Barclay Formula from the beginning of the shock period with reduction of the costs and the possibility of transmission of undetected pathogens by nearly the same value if crystalloids are given during the first 12 hours of burns shock period. The use of isotonic normal saline during the first 12 hours appears more appropriate as it maintains adequate sodium balance to correct the hyponatraemia and at the same time prevents elevation of the serum potassium during the period when potassium is released from the cells. In addition, it does not have a significant reduction on the level of the serum proteins.

A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation

Background: Ever since Charles Baxter's recommendations the standard regime for burn shock resuscitation remains crystalloid infusion at a rate of 4 ml/kg/% burn in the first 24 h following the thermal injury. A growing number of studies on invasive monitoring in burn shock, however, have raised a debate regarding the adequacy of this regime. The purpose of this prospective, randomised study was to compare goal-directed therapy guided by invasive monitoring with standard care (Baxter formula) in patients with burn shock. Patients and methods: Fifty consecutive patients with burns involving more than 20% body surface area were randomly assigned to one of two treatment groups. The control group was resuscitated according to the Baxter formula (4 ml/kg BW/% BSA burn), the thermodilution (TDD) group was treated according to a volumetric preload endpoint (intrathoracic blood volume) obtained by invasive haemodynamic monitoring. Results: The baseline characteristics of the two treatment groups were similar. Fluid administration in the initial 24 h after burn was significantly higher in the TDD treatment group than in the control group ( P = 0.0001). The results of haemodynamic monitoring showed no significant difference in preload or cardiac output parameters. Signs of significant intravasal hypovolemia as indicated by subnormal values of intrathoracic and total blood volumes were present in both treatment groups. Mortality and morbidity were independent on randomisation. Conclusion: Burn shock resuscitation due to the Baxter formula leads to significant hypovolemia during the first 48 h following burn. Haemodynamic monitoring results in more aggressive therapeutic strategies and is associated with a significant increase in fluid administration. Increased crystalloid infusion does not improve preload or cardiac output parameters. This may be due to the fact that a pure crystalloid resuscitation is incapable of restoring cardiac preload during the period of burn shock.

Reduced gastric acid production in burn shock period and its significance in the prevention and treatment of acute gastric mucosal lesions.

AIM:To investigate the changes of gastric acid production and its mechanism in shock period of severe burn in rats.METHODS:A rat model with 30% TBSA full thickness burn injury was employed and the gastric acid production,together with gastric mucosal blood flow (GMBF) and energy charge (EC) were measured serially within 48h postburn.RESULTS:The gastric acid production in the acute shock period was markedly inhibited after severe burn injury.At the 3rd h postburn,the gastric juice volume, total acidity and acid output were already significantly decreased (P < 0.01 =, and reached the lowest point, 0.63mL/L ± 0.20mL/L, 10.81mmol/L ± 2.58mmol/L and 2.23mmol/h ± 0.73mmol/h respectively, at the 12th h postburn. Although restored to some degree 24h after thermal injury, the variables above were still statistically lower, compared with those of control animals at the 48th h postburn. The GMBF and EC were also significantly reduced after severe burns, consistent with the trend of gastric acid production changes.CONCLUSION:Gastric acid production, as well as GMBF and EC was predominantly decreased in the early postburn stage, suggesting that gastric mucosal ischemia and hypoxia with resultant disturbance in energy metabolism, but not gastric acid proper, might be the decisive factor in the pathogenesis of AGML after thermal injury, and that the preventive use of anti-acid drugs during burn shock period was unreasonable in some respects. Therefore, taking effective measures to improve gastric mucosal blood perfusion as early as possible postburn might be more preferable for the AGML prevention and treatment.

Burn injury results in decreased gastric acid production in the acute shock period.

Gastrointestinal complications including acute stress ulcerations occur after burn injury. The causes of acute gastric derangements are multiple, and tissue ischemia in the acute period of burn shock may promote breakdown of the gastric mucosal protective barrier. We compared gastric pH in mice after 25% total body surface area, full-thickness murine burn injury with that in unburned control animals. Animals were anesthetized with methoxyflurane and were resuscitated with 1 ml normal saline solution immediately after burn. Animals were killed at intervals up to 24 hours after burn injury, stomachs were removed and opened, and gastric mucosal pH was measured by use of a surface pH probe. In other animals mixed venous blood was obtained via direct inferior vena cava puncture, and blood gas analysis was performed at intervals up to 24 hours after burn injury. Unexpectedly, gastric mucosal pH increased in burned mice compared with that in controls. The peak difference, greater than one log pH unit, occurred at 3 hours after burn injury (pH 4.45 burn vs pH 3.34 control, p < 0.00001), and this difference was maintained through 12 hours (pH 4.88 burn vs pH 3.20 control, p < 0.005). In this model, shock was observed to begin as early as 1 hour after burn injury and reached its maximal period (base deficit, -27.8 mEq/L) at 12 hours after burn injury. In view of the higher gastric pH in burned mice with concomitant profound shock, gastric acid production appears to be impaired during this time, which suggests acute postburn gastrointestinal ulcerations may be primarily due to ischemia. Prevention of organ ischemia may play a key role in the prevention of acute gastric ulcerations after burn injury.

Plasma tumour necrosis factor-α (TNF-α) levels in patients with burns

Levels of plasma tumour necrosis factor-α (TNF-α) were determined consecutively in 42 patients with burns > 20 per cent of the total body surface area using an enzyme-linked immunosorbent assay. In the early period after injury (including the period of burn shock), 24 patients had detectable TNF-α levels in their plasma. However, the plasma TNF-α levels at the time of admission were very low and did not correlate with the extent of the burn or the prognosis. In contrast, the maximum plasma TNF-α level over the whole clinical course was significantly correlated with the area of the burn and the prognosis. No correlation was found between the plasma TNF-α and plasma endotoxin levels. TNF-α may be produced locally in infected burns and monitoring of plasma TNF-α levels may be a useful prognostic indicator for burns patients.

Pulmonary complications in burn patients resuscitated with a low-volume colloid solution

The occurrence of the adult respiratory distress syndrome (ARDS) and pneumonia was assessed in 482 patients with severe burns, but without evidence of inhalation injury. The patients were resuscitated during the burn shock period with a low-volume formula consisting mainly of plasma. The incidence of ARDS was 2.5 per cent for the entire burn population, and 9.4 per cent for 65 patients with burns covering more than 50 per cent of the body surface area. The general incidence of pneumonia was 4.4 per cent but was 12.5 per cent for the 65 patients with the extensive burns. These incidences were compared with other studies, and a pathophysiological explanation has been offered to explain differences in the frequency of pulmonary complications. The present review indicates that resuscitation with a low-volume formula consisting mainly of colloids can act as prophylaxis for reducing the incidence of ARDS and pneumonia

Ultrastructural changes in the erythrocytes and platelets of patients with severe thermal burns during the burn shock period

Ultrastructural changes in the erythrocytes and platelets of patients with severe thermal burns during the burn shock period

A controlled trial comparing human plasma protein fraction with freeze-dried plasma for resuscitation during the burn shock period

A controlled trial was conducted comparing the use of freeze-dried plasma (FDP) with human protein fraction (HPPF) in the resuscitation of patients during the burn shock period. Twenty-four children and 13 adults were studied during the first week post burn. It was found that those who received HPPF tended to have depressed globulin levels: the immunoglobulin levels were depressed, the prothrombin time was prolonged and the fibrinogen level was also transiently decreased. In contrast those who received FDP had raised immunoglobulin levels and the prothrombin time was shortened. The incidence of septicaemia was markedly greater during the first week if HPPF was used. The differences between the two solutions were most marked in the more extensive burns. Although the physical properties of HPPF enable it to suffice as a plasma expander, it lacks certain physiological properties of FDP. The superiority of FDP over HPPF in the resuscitation of major burns is emphasized.

Radioimmunoassay of ADH in the burn shock period: A preliminary report

A severely burned patient was admitted and resuscitated. She maintained normal blood and urine volumes, normal osmolality and renal functions. During the burn shock period, blood and urine samples were collected for measurement of ADH by means of radioimmunoassay. Marked oversecretion of ADH and cortisol was noted, independent of changes in plasma osmolality and volume, which remained stable. It was concluded that under such circumstances, stress and severe pain in burn shock may be the chief factors in producing the very high levels of ADH and cortisol in blood and urine.

Electron-histochemical investigation of capillary permeability of the central nervous system in burn shock

The permeability of capillary walls in the CNS in burn shock was studied in experiments on animals. During the period of burn shock, a marker (peroxidase) was introduced into the blood stream of the animals. Electron-microscopic investigation showed that the capillary wall in the CNS is permeable to substances with a molecular weight of 40,000, such as peroxidase, in an animal in the stage of burn shock.