Akinori Osuka

Gastrointestinal dysmotility is associated with altered gut flora and septic mortality in patients with severe systemic inflammatory response syndrome: a preliminary study

Background  The gut is an important target organ for injury after severe insult, and resolution of feeding intolerance is crucial for critically ill patients. We investigated gut flora and motility to evaluate the impact of gastrointestinal dysmotility on septic complications in patients with severe systemic inflammatory response syndrome (SIRS).

Prognostic impact of fecal pH in critically ill patients

IntroductionWe have reported that altered gut flora is associated with septic complications and eventual death in critically ill patients with systemic inflammatory response syndrome. It is unclear how fecal pH affects these patients. We sought to determine whether fecal pH can be used as an assessment tool for the clinical course of critically ill patients.MethodsFour hundred ninety-one fecal samples were collected from 138 patients who were admitted to the Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan. These patients were treated in the intensive care unit for more than 2 days. Fecal pH, fecal organic acids, and fecal bacteria counts were measured and compared by survived group and nonsurvived group, or nonbacteremia group and bacteremia group. Logistic regression was used to estimate relations between fecal pH, age, sex, or APACHE II score and mortality, and incidence of bacteremia. Differences in fecal organic acids or fecal bacteria counts among acidic, neutral, and alkaline feces were analyzed.ResultsThe increase of fecal pH 6.6 was significantly associated with the increased mortality (odds ratio, 2.46; 95% confidence interval, 1.25 to 4.82) or incidence of bacteremia (3.25; 1.67 to 6.30). Total organic acid was increased in acidic feces and decreased in alkaline feces. Lactic acid, succinic acid, and formic acid were the main contributors to acidity in acidic feces. In alkaline feces, acetic acid was significantly decreased. Propionic acid was markedly decreased in both acidic and alkaline feces compared with neutral feces. No differences were noted among the groups in bacterial counts.ConclusionsThe data presented here demonstrate that the fecal pH range that extended beyond the normal range was associated with the clinical course and prognosis of critically ill patients.

Glycocalyx Shedding is Enhanced by Age and Correlates with Increased Fluid Requirement in Patients with Major Burns

Background: Massive fluid shift after severe burn injury leads to edema and intravascular fluid loss that may result in burn-induced compartment syndrome (BICS) when corrected by aggressive fluid resuscitation. Factors causing this fluid shift remain unclear. Because glycocalyx regulates endothelial permeability, we hypothesized that glycocalyx shedding would increase fluid requirements in burn patients. This prospective cohort study aimed to identify relationships between shedding of the glycocalyx and fluid requirements after burn injury. Methods: Patients aged more than 18 years with burn injury over more than 20% total body surface area (TBSA) were enrolled. Patient background factors including age, sex, burn size, and inhalation injury were recorded at patient enrollment. Serum syndecan-1, known as a biomarker of glycocalyx shedding, was serially measured on admission, day 1, days 3 to 5, around 1 and 2 weeks, and 1 month after the injury to observe postburn injury kinetics of syndecan-1. As biomarkers of endothelial damage, soluble thrombomodulin, antithrombin III, and plasminogen activator inhibitor-1 were also measured. We determined the relationship between syndecan-1 and initial 24-h fluid requirements and between syndecan-1 and morbidity/mortality. Results: We enrolled 39 patients (median age, 55 years; median burn size, 35%TBSA): 16 developed BICS, and 10 patients died. Syndecan-1 level on admission was significantly higher than that in healthy volunteers and remained so. Syndecan-1 level on admission was associated with patient age (&rgr; = 0.50, P = 0.001) but not burn size (&rgr; = 0.08, P = 0.63), and antithrombin III level on admission was negatively associated with burn size (&rgr; = −0.48, P = 0.002). The syndecan-1 level on admission was significantly associated with fluid requirement (mL/kg) (&rgr; = 0.38, P = 0.017). After adjustment for age, sex, %TBSA, and inhalation injury, syndecan-1 was an independent parameter for the increase in fluid requirement (P = 0.04) and development of BICS (P = 0.03) by multivariable regression analysis. These findings suggested that glycocalyx shedding increased in an age-dependent manner, whereas antithrombin III decreased according to burn size. Conclusions: Glycocalyx shedding occurs soon after burn injury in an age-dependent manner. To reduce fluid-related complications such as BICS, new strategies to protect glycocalyx in burn patients are needed.

Indications of early intubation for patients with inhalation injury

For patients with inhalation injury, the indications for early intubation are diverse. The purpose of this study was to identify the most reliable symptoms, physical findings, and medical examinations with which to determine the indications for early intubation in patients with inhalation injury.

Haemostatic technique using a novel silicone gel dressing for tangential excisions in burn surgery.

Scalds from hot liquids are a common modality of injury in children, potentially resulting in long term disfigurement, functional impairment and future psychological morbidity. In addition, management of even minor paediatric scalds inflicts considerable financial impact on healthcare economics [1]. Fortunately, a large proportion of paediatric scalds is preventable and most commonly occurs as the result of everyday activities such as food and beverage preparation. Great strides towards prevention have been made in increasing awareness of the dangers of household items such as kettles and boiling pans in the last few decades, however less emphasis has been put on the danger of scalds arising directly from a cup of prepared beverage such as tea or coffee. As the use of tea bags and instant coffee is now ubiquitous in the British household and elsewhere throughout the world, a cup of either beverage can be extremely hazardous. Both are prepared directly with boiling water and may be placed within the child’s environment during consumption, easily knocked over and potentially causing high total body surface area burns (TBSA). At our burns centre, we analysed all scald injuries presenting between May and October 2009 and compared these to a set of historical data published from the UK roughly 20 years prior in order to determine any overall change in scald aetiology [2]. We hoped to provide preliminary suggestions as to how preventative measures regarding childhood scald injury could develop to match current household trends. Within our study, 106 scald injuries (55.2% of all paediatric burns) presented across the time period. Of these 58 (54.7%) pertained to scalds arising directly from hot beverages in cups (tea = 40, coffee = 14, hot-chocolate = 4), compared to 30 (28.3%) scalds resulting from contact with unprepared hot water alone. This demonstrates a marked change compared to UK data from 1991 by Eadie et al., [2] in which 44.6% of scalds arose due to contact with hot water, and 42.5% due to cupped beverages. Although from a different area of the UK, but of a roughly similar magnitude of cohort size (106 vs. 146), we believe this suggests that hot water scalds are markedly declining, however scalds from cupped beverages are on the increase. Considering this data trend (matching the recent anecdotal experience at our centre), we suggest a two pronged approach to further developing preventative measures. First of all, as the commonest cause of childhood scalds, the danger of cupped beverages should be at the forefront of any publicity campaign. Secondly, we believe a good preventative device is common place in many homes or at least readily available in stores: the use of insulated travel mugs could be highly beneficial for parents with infants and toddlers. Typically incorporating a tight lid for travel purposes, these could be placed with little danger around the child’s play environment, the closed lid completely preventing spillage (or if open the small outlet at least preventing large TBSA scalds). The insulated outer-layer would also remain cool to prevent contact burns with the container. Inexpensive and still useful once the child is older, encouraging the use of such beverage containers could alleviate the apparently rising trend in scalds from cupped beverages.

A Case Report of Severe Potassium Hydroxide (Alkaline) Burn with Hyperkalemia

A 28-year-old man suffered intentional dermal exposure to potassium hydroxide inside a psychiatric hospital bathroom during inpatient treatment for schizophrenia. He received initial treatment at a local emergency department (ED) and was transferred to our burn unit. On arrival at 18 hours after the injury, he was diagnosed as having 60% total body surface area (TBSA) chemical burns; third-degree: 24%, second-degree: 36%. At the outside ED, his serum potassium level peaked at 8.2 mEq/L (normal range: 3.5 to 5.0 mEq/L) and decreased to 6.9 mEq/L after he received intravenous glucose and insulin therapy. At our facility his potassium had increased to 7.3 mEq/L. The patient’s urine output was maintained at >100 mL/h, but his serum potassium level rose to 8.1 mEq/L and continuous hemodiafiltration was initiated within 5 h of admission. Early debridement was performed due to extensive thirddegree burns, risk of deep-tissue alkali injury, and persistent (chemical-induced) hyperkalemia. At 40 h after the injury, fascial resection of the lower leg was performed, involving 20% TBSA third-degree burn, and his serum potassium normalized. After five operations he was able to ambulate with assistance, and on hospital day 72 he was transferred to a rehabilitation hospital without major complications.

1610: INITIAL DESCRIPTION AND CLINICAL SIGNIFICANCE OF C1 INHIBITOR ACTIVITY IN SEVERELY BURNED PATIENTS

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Clostridial Septicum myonecrosis has a welldescribed association with colon cancer. Small bowel adenocarcinoma is difficult to diagnose due to its lack of specific findings and its rarity making it low on many physician’s differential.We describe clostridum septicum myonecrosis in the thigh secondary to an occult small bowel adenocarcinoma. Methods: The patient is a 76 year-old Albanian female with a past medical history significant for stroke, type II diabetes mellitus, and a two-year history of intermittent bloody diarrhea. This bloody diarrhea had previously been evaluated with an esophagogastroduodenoscopy and colonoscopy, both of which were negative. She presented with complaints of severe left hip and leg pain. She was afebrile, tachycardic, and mildly hypotensive. Physical exam revealed erythema and crepitus on the medial aspect her left thigh and a focally tender abdomen. A CT scan revealed extensive air in the medial aspect of the left thigh and an inflammatory mass in the right lower quadrant of the abdomen. Initial labs were significant for a lactic acid level of 1.9 and WBC count of 12000. Blood cultures were positive for the presence of gram-positive rods. Antibiotics were initiated, and the patient was transported to a tertiary care hospital. On arrival, the patient had worsening hypotension and lactic acidosis (4.7), despite administration of 6 L of crystalloid. The patient was immediately taken to the operating room and underwent an excisional debridement (30 x 25cm) of the left medial thigh down to the muscular fascia. An exploratory laparotomy was also performed where an inflammatory mass in the ileum, 30cm proximal to the cecum, was resected. Given the patient’s tenuous hemodynamic status, she was left in discontinuity and taken to the surgical ICU where she required ongoing pressor and ventilator support. The following day, the patient returned to the operating room and debridement of the left thigh medial compartment was performed. The patient remained in critical condition. Her course was complicated by an acute left MCA stroke. Blood cultures ultimately revealed clostridium septicum. The small bowel pathology was consistent with adenocarcinoma. After extensive discussions with the family, the patient was transitioned to comfort care and passed. Results: This is the first reported case of clostridium septicum myonecrosis secondary to small bowel adenocarcinoma. It is imperative to search for occult malignancies in clostridium septicum infection. 1609

A haemostatic technique using silicone gel dressing for burn surgery.

Significant blood loss and high rates of transfusion remain ongoing concerns in burn surgery. We have reported a haemostatic technique using silicone gel dressing to minimise bleeding during tangential excision in burn surgery. The purpose of this study was to identify the efficacy of our novel haemostatic technique for burn surgery. This study was a retrospective observational study. From 1 April 2011 to 31 March 2015, we collated data including pre‐ and 24‐hour postoperative haemoglobin levels from patients over 15 years of age who underwent tangential excision for burn injuries. We also collected data on the amounts of measured blood loss, blood transfusions, excised areas, harvest areas and duration of surgeries. The collected data were divided into a conventional group and a silicone gel dressing group. Then, we analysed the differences between the two groups. During the study period, 357 patients were admitted to our burn centre, and 60 operations (44 patients) were performed by tangential excision. The conventional group comprised 28 operations (20 patients), and the silicone gel dressing group comprised 32 operations (26 patients). Excised areas and harvested areas were significantly larger in the silicone gel dressing group than in the conventional group. The amount of blood loss per percent excised and the number of units of blood transfused were significantly lower in the silicone gel dressing group. Duration of the surgeries was almost the same between the two groups. Application of our new technique during tangential excision for burn injuries resulted in a remarkable reduction in blood loss and transfusion requirements.

Acute pancreatitis and necrotizing colitis following extensive burn injury

We describe a patient with severe pancreatitis and ischemic colitis after extensive burn injury. An 81‐year‐old man presented with a 55% total body surface area burn with inhalation injury. A low‐density area was detected in the pancreas on the abdominal computed tomography scan on admission. The clinical course of the patient was good until 28 days after injury when he complained of abdominal pain and distension. Abdominal computed tomography revealed acute pancreatitis and ischemic colitis.