Audrey Cirodde

Cultured epithelial autografts in massive burns: A single-center retrospective study with 63 patients

UNLABELLED Cultured epithelial autografts (CEAs) have long been used to tackle limited donor site availability and difficulty of permanent skin coverage in massive burns, but this approach still has limited documentation. METHODS In this retrospective, single-center study, medical records of patients treated with CEAs in our burn center from 1991 until 2008 were analyzed in search of factors associated with outcome. RESULTS Out of 68 patients, 63 records were analyzable. Patients were aged 29 [17-41.5] years (seven children). Total body surface area (TBSA) burned was 81±10%, of which 69±14% TBSA full thickness. CEAs were first applied after 45±34 days, on a surface of 32±14% TBSA. Success rate at take down was 65±19%, correlating only with young age (r(2)=0.18; p=0.0006). At discharge, CEAs covered 26±15% TBSA. Infections (4.3±2 per patient), most frequently of skin, often complicated the clinical course. Mortality was 16% (10 patients). In multivariate analysis, the number of infections was the only factor associated with mortality (OR=2.05 per single infection, 95%CI 1.03-4.07, p=0.04). CONCLUSION Although complex and costly, CEAs can be used with reasonable success and satisfying survival results for the treatment of massive burns. In this study, favorable outcome was principally associated with young age and low number of infectious complications.

Acute Respiratory Distress Syndrome: Performance of Ventilator at Simulated Altitude

BACKGROUND Ventilation of Acute Respiratory Distress Syndrome (ARDS) is a challenge, and there is definitely a need for lack of variations between delivered and set tidal volume (Vt). We have assessed the ability of the ventilator T-birdVS02 and LTV-1000 to deliver to a lung model with ARDS a set Vt at different simulated altitudes. METHODS We used a decompression chamber to mimic the hypobaric environment at a range of simulated cabin altitudes of 1,500, 2,500, and 3,000 m (4,000, 6,670, and 8,000 feet, respectively). Ventilators were tested with realistic parameters. Vt was set at 400 mL and 250 mL in an ARDS lung model. Comparisons of preset to actual measured values were accomplished using a t test for each altitude. RESULTS The T-birdVS02 showed a decrease in the volume delivered. Comparisons of actual delivered Vt and set Vt demonstrated a significant difference starting at 1,500 m for a Vt set of 400 mL and at 2,500 m for Vt set of 250 mL. At these altitudes, the variations between Vt set and delivered were more than 10%. With decreasing barometric pressure, the LTV-1000 showed mostly an increase in volume delivered. Comparisons of actual delivered Vt and set Vt demonstrated a significant difference at 2,500 m for a Vt set of 400 mL and at 3,000 m for Vt set of 250 mL. The delivered Vt remained within 10% of the set Vt. CONCLUSION Clinicians involved in aerial evacuations must keep in mind the performance and limitations of their ventilator system.

Il y a-t-il une place pour le sérum salé hypertonique dans les états septiques graves ?

Fluid loading is the first step, necessary to care for severe sepsis. Two main classes of solutions are currently available: crystalloids and colloids. The concept of small volume resuscitation with hypertonic saline has emerged these last years in the care of traumatic haemorrhagic shock. The main benefits are the restoration of intravascular volume, improvement of cardiac output and improvement of regional circulations. Many experiments highlight modulation of immune and inflammatory cascades. We report the mechanisms of action of hypertonic saline based on experimental human and animal studies, which advocate its use in septic shock.

Hydroxy-ethyl-starches: are the conclusions always evidence-based?

Sir: Study design has considerably improved, especially statistical analysis. However, conclusions should focus on results only, not on one’s own beliefs, a recurrent problem with fluid resuscitation. Important papers have recently been published in this field, especially the VISEP study [1] and the paper from Schortgen et al. [2]. An accompanying editorial, and recent correspondence [3] point towards potential bias, but we wish to formulate supplementary observations. (1) Despite a prospective cohort of 822 patients, Schortgen’s study solely proves a link between hyperoncotic albumin use and probability of renal replacement therapy. Confidence intervals overlap (Fig. 2) shows that there are no differences among the other groups. So is Schortgen’s conclusion not evidence-based when she states that the ‘‘study shows a strong association between hyperoncotic colloı̈ds and kidney dysfunction’’. (2) The main design problem is that rather planning a randomisation, the authors based their analysis among an arbitrary pooling of fluids. In their discussion, Schortgen et al. mentioned their precedent study and the VISEP study which authors pretended they used a ‘‘modern hydroxyethyl-starch (HES), designed to have fewer side effects’’. In fact they used a hyperoncotic 10% HES (200/0.5), which in no way can be considered a modern HES. Similarly, Schortgen’s study pooled dextrans, HES (130/0.4) and older HES solutions in a so-called ‘‘artificial hyperoncotic colloids’’ group. This may be misleading. Because criticisms towards a first study where they wrote that even modern HES persist in tissues for months, which is not factual [4], Schortgen et al. build a new hypothesis about HES toxicity: the putative role of oncotic pressure. The problem is that discussing of HES, mix-up seems more common than clinical ‘‘misuse’’ is. Although macromolecule accumulation may induce osmotic-nephrosis-like lesions, HES widely differ in their physicochemical characteristics: mean molecular weight (Mw), substitution and concentration. The 6% (130/0.4) solution has a measured oncotic pressure of 36 mmHg: it cannot be assimilated with 10% solutions and considered hyperoncotic, but isoncotic. (3) The statistical analysis is modern and sophisticated. But the consequence of analysing a priori defined groups was the necessity of ‘‘several statistical methods’’, that carry the risk of majoring the first type error. Last, but not least, although a computed v comparing (130/0.4) and older HES gave a P value of 0.51, the study was not fitted to distinguish between incidences of renal adverse events in these groups of 119 and 270 patients (risk of type 2 error). As a matter of fact, the influence of HES on renal function remains controversial. Apart from being an efficient plasma-volume expander, HES has been associated with a reduction of endothelial damage during inflammation and sepsis. Gelatins are less efficacious and carry a fourfold greater risk of allergic reactions. So, there is for the present no evidence-based demonstration that we must banish a careful use of HES of low Mw from our medical armamentarium. The further step in improving our scientific knowledge [5] would perhaps be focusing our discussions on facts, not on our own convictions.

Successful management of a severe combat penetrating brain injury

We report the case of successful management of a transcranial penetrating high-energy transfer injury in a 20-year-old soldier. The bullet traversed both cerebral hemispheres and lacerated the superior sagittal sinus rendering him unconscious. We detail the care received at all stages following injury from ‘Buddy Aid’ on the battlefield, resuscitation by a forward medical team through to prompt neurosurgery within 2 h of injury. Subsequent aeromedical evacuation and continuing aggressive critical care has allowed the patient to survive with acceptable neurological impairment after what is generally considered an unsurvivable injury.

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.