Mj Asensio

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort study

IntroductionThe use of urinary output and vital signs to guide initial burn resuscitation may lead to suboptimal resuscitation. Invasive hemodynamic monitoring may result in over-resuscitation. This study aimed to evaluate the results of a goal-directed burn resuscitation protocol that used standard measures of mean arterial pressure (MAP) and urine output, plus transpulmonary thermodilution (TPTD) and lactate levels to adjust fluid therapy to achieve a minimum level of preload to allow for sufficient vital organ perfusion.MethodsWe conducted a three-year prospective cohort study of 132 consecutive critically burned patients. These patients underwent resuscitation guided by MAP (>65 mmHg), urinary output (0.5 to 1 ml/kg), TPTD and lactate levels. Fluid therapy was adjusted to achieve a cardiac index (CI) >2.5 L/minute/m2 and an intrathoracic blood volume index (ITBVI) >600 ml/m2, and to optimize lactate levels. Statistical analysis was performed using mixed models. We also used Pearson or Spearman methods and the Mann-Whitney U-test.ResultsA total of 98 men and 34 women (mean age, 48 ± 18 years) was studied. The mean total body surface area (TBSA) burned was 35% ± 22%. During the early resuscitation phase, lactate levels were elevated (2.58 ± 2.05 mmol/L) and TPTD showed initial hypovolemia by the CI (2.68 ± 1.06 L/minute/m2) and the ITBVI (709 ± 254 mL/m2). At 24 to 32 hours, the CI and lactic levels were normalized, although the ITBVI remained below the normal range (744 ± 276 ml/m2). The mean fluid rate required to achieve protocol targets in the first 8 hours was 4.05 ml/kg/TBSA burned, which slightly increased in the next 16 hours. Patients with a urine output greater than or less than 0.5 ml/kg/hour did not show differences in heart rate, mean arterial pressure, CI, ITBVI or lactate levels.ConclusionsInitial hypovolemia may be detected by TPTD monitoring during the early resuscitation phase. This hypovolemia might not be reflected by blood pressure and hourly urine output. An adequate CI and tissue perfusion can be achieved with below-normal levels of preload. Early resuscitation guided by lactate levels and below-normal preload volume targets appears safe and avoids unnecessary fluid input.

Risk factors for outbreaks of multidrug-resistant Klebsiella pneumoniae in critical burn patients.

The objective of this study is to identify the risk factors related to colonization or infection in an outbreak of multidrug-resistant Klebsiella pneumoniae in a burn patient unit. The authors studied the risk factors associated with colonization or infection using a case-control study design involving patients with multidrug resistant K. pneumoniae (n = 26) and controls (n = 50). They describe the outbreak and provide a retrospective analysis that encompasses patient demographics, microbiological isolation, culture sites, burn features, inhalation injury, biomarkers (lactate and N-terminal probrain natriuretic peptide), general illness severity scores (Acute Physiology and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment), burn-specific severity scores such as the Abbreviated Burn Severity Index (ABSI), length of stay, and mortality. Patients colonized with multidrug-resistant K. pneumoniae were older (55 vs 42 years), presented with larger burns (32 vs 18% of BSA), and more frequently had full-thickness burns (53 vs 22%). They also had higher ABSI, Acute Physiology and Chronic Health Evaluation II, and Sepsis-related Organ Failure Assessment scores, and they required more days of mechanical ventilation and longer stays in the critical burn unit. Multivariate analysis showed that the factors most significantly related to the development of infection or colonization with K. pneumoniae were burns located on head and neck (odds ratio, 4.81) and the ABSI score (odds ratio, 1.66). Control of the outbreak was achieved by enforcing contact precautions and extensive cleaning. An elevated ABSI score and burns located on the head and neck were the risk factors most significantly related to colonization or infection in an outbreak of multidrug-resistant K. pneumoniae in a critical burn patient unit.

Prevalence of intra-abdominal hypertension (IAH) among patients with severe burns

o solve the problem of non-availability of conventional sites or electrocardiogram (ECG) electrode placement in patients ith burn, authors have described successful use of ‘staple Panel A) [5]. The ‘left leg’ electrode was placed over burn free superior aspect of the left iliac crest [5]. The ECG tracing obtained (Fig. 1, Panel B) without any adjustment factor and in the bandwidth of 0.05–150 Hz was satisfactory (Philips Intellivue 40 monitor, Philips Medizin Systeme, Boeblingen, Germany) [5]. On examination of the ST and QT snippet, satisfactory wave morphology was observed (Fig. 1, Panel B). We have been using this technique since then. If ECG lead configuration of more than 3 leads is desirable, the description by Farroha et al. provides advantage over the technique presented by us [2]. But as ECG tracing is influenced b u r n s 4 0 ( 2 0 1 4 ) 5 2 5 – 5 3 7 32

Clinical and economic benefits associated with the management of a nosocomial outbreak resulting from multidrug-resistant Klebsiella pneumoniae.

2007 Lapin (2) and our study (3). We reported a blood pressure–lowering effect of kynurenine in spontaneously hyperten sive rats (3). We used hypertensive rats because in our hands kynurenine had no measurable effect on blood pressure in normotensive (Wistar Kyoto) rats. Also, the minimal dose of kynurenine required to elicit a discernable decrease in blood pressure in spontaneously hypertensive rats was ~1400 μg (corresponding to ~0.4 mM blood concentration in 250 g rats with an assumed blood volume of 17 mL) (1). Furthermore, we observed a concen tration-dependent decrease in blood pres sure for kynurenine doses up to ~5000 μg (3), without indication of a biphasic response or a blood pressure increasing effect of kynurenine. We cannot explain the apparent differences between the results of Lapin (2) and our study (3), but point out that commercial kynurenine prepara tions are not 100% pure and effects of contaminants are difficult to exclude because kynurenine is not a stable com pound (4). In any case, our studies (3, 5) provide multiple lines of evidence for, and mechanistic information on, the role of indoleamine 2,3-dioxygenase-mediated metabolism of tryptophan to kynurenine in the regulation of vascular tone and blood pressure in inflamma tion, both in animals and in human subjects. As such, our studies go well beyond the early observational findings reported by Lapin (2). Dr. Stocker received funding from the National Health and Medical Research Council, Australia.

Treatment of Toxic Epidermal Necrolysis With Immunoglobulins in a Burn Center

Toxic epidermal necrolysis is a serious infrequent skin disease, usually secondary to drug. It is associated with high morbidity and mortality, hence the importance of early detection and appropriate treatment, although currently the most effective treatment remains controversial.