P.C. Fuchs

Cortisol in severely burned patients: investigations on disturbance of the hypothalamic-pituitary-adrenal axis.

Thermal injuries of more than 20% of body surface area lead to conditions resembling a severe systemic inflammatory response syndrome, such as in septic shock. It has been shown that septic shock may lead to disturbances in cortisol metabolism and balance of the hypothalamic-pituitary-adrenal axis. To investigate whether such a disturbance also occurs in the very early stages of systemic inflammatory response syndrome in burned patients, we performed 20 corticotropin-releasing hormone tests on day 1 after admission to our unit. In 7 of 20 patients, a disturbance of cortisol secretion could be demonstrated. Four patients developed adrenal insufficiency. The correlation between the abbreviated burn severity index and the risk of developing adrenal insufficiency was significant (P = 0.008). We observed a higher mortality rate in adrenally insufficient patients; however, because of the small patient number, we were not able to prove this observation with a statistical significant correlation (P = 0.11). Our findings indicate that temporary adrenal insufficiency occurs in the early stages of severe injury. Further investigations will have to be performed to clarify whether such patients benefit from cortisol replacement.

MRSA—retrospective analysis of an outbreak in the burn centre Aachen

The growing interest in methicillin-resistant Staphylococcus aureus (MRSA) has been caused by its increased appearance in hospital and community populations. In our burn centre, an outbreak of MRSA was noticed during an 8-month period. We were able to isolate MRSA in eight patients. DNA analysis by pulsed-field gel electrophoresis (PFGE) demonstrated the development of five different strains during this period. Only two patients developed an infection caused by MRSA colonisation. The infections were proven by positive blood culture or catheter colonisation. One patient developed a clinical vancomycin-resistant sepsis which was treated successfully with the additional application of Quinupristin/Dalfopristin. THIS ANALYSIS SHOWS THAT: (1) the development of MRSA in a burn unit is often created in a single patient by long-term antibiotic therapy and not a result of cross-infection, (2) manifest MRSA infection seldom occurs even in colonised burn patients, and (3) a clinically vancomycin-resistant MRSA infection in burn patients can be treated sufficiently with Quinupristin/Dalfopristin.

The mobilisation of mononuclear cells and endothelial progenitor cells after burn injury in a porcine model.

BACKGROUNDnMononuclear blood cells (MNCs) consist of heterogeneous cell populations, for example, CD34+ cells and endothelial progenitor cells (EPCs). EPCs are involved in vasculogenesis, but little is known about their role during burn trauma.nnnAIMnThis study investigates the role of MNCs and their subpopulations during and after burn injury in an experimental porcine setting.nnnMETHODSnEighteen 8-week-old German land pigs were scalded by immersion in 70 degrees C hot water for 3 min, resulting in a 30% total body surface area (TBSA) full-thickness burn. Vascular endothelial growth factor (VEGF) serum concentrations and MNC, EPC and CD34+ cell counts were measured at eight different time points up to 48 h following trauma.nnnRESULTSnThe experimental porcine setting made it possible to determine the cell counts of MNCs, EPCs and CD34+ cells directly during burn trauma, which has not been described before. The data revealed a fulminant drop in MNC and EPC during burn trauma, whereas the CD34+ cell fraction rose. Besides significant changes in the VEGF serum concentration, a correlation between VEGF and EPC was also observed.nnnCONCLUSIONnThe results show that MNCs and their subpopulations are significantly affected by burn trauma and underpin their potential diagnostic and therapeutic importance during and after burn injury.

Intra-alveolar IL-6 levels following burn and inhalation injury

Burn combined with inhalation injury is a major challenge and requires further study. Using a small-animal model, excretion of IL-6 was investigated during the first 6h after exposure of rats to wood/polyvinyl chloride smoke, with and without concomitant skin burn. In controls, respirator therapy alone was found to release IL-6 into the serum and the alveolar space. These levels of IL-6 were reduced when associated with either inhalation injury or burn, but were increased when the traumas were combined. Thus, during the first 6h of mechanical respiration the presence of burn or of inhalation injury seems to decrease IL-6 excretion, but a combination of these traumas reverses this effect.

[Heated car seats--a potential burn risk for paraplegics].

The comfort of heated car seats has gained popularity worldwide. We present a rare case of severe second- and third-degree burn in the lower back and sacral region of a 42-year-old post-traumatic paraplegic patient while using a heated car seat. The patient was admitted to our burn unit and required several reconstructive surgery procedures. Inadvertent thermal injury is a constant potential hazard for individuals with impaired sensibility such as paraplegics and other neurologically impaired patients. Early education of patients, manufacturers, and health care personnel is of eminent importance to prevent severe burn injuries in this risk population.ZusammenfassungBeheizte Autositze werden mit steigender Popularität in Anspruch genommen. Wir stellen den klinischen Fall einer schweren zweit- und drittgradigen Verbrennung der Sakroglutealregion eines 42-jährigen posttraumatisch Querschnittsgelähmten vor. Der Patient wurde in unserer Verbrennungsklinik aufgenommen und zahlreiche Operationen wurden notwendig. Querschnittsgelähmte Patienten sind durch ihre Sensibilitäts- und Schmerzempfindungsstörung einem erhöhten Verbrennungsrisiko durch Autositzheizungen ausgesetzt. Wir empfehlen eine frühzeitige adäquate Aufklärung der Patienten, Hersteller und aller Bezugspersonen zur Vermeidung derartig schwerwiegender Verbrennungsereignisse.SummaryThe comfort of heated car seats has gained popularity worldwide. We present a rare case of severe second- and third-degree burn in the lower back and sacral region of a 42-year-old post-traumatic paraplegic patient while using a heated car seat. The patient was admitted to our burn unit and required several reconstructive surgery procedures. Inadvertent thermal injury is a constant potential hazard for individuals with impaired sensibility such as paraplegics and other neurologically impaired patients. Early education of patients, manufacturers, and health care personnel is of eminent importance to prevent severe burn injuries in this risk population.

The ALT chimera flap: expanding the indications

The anterolateral thigh (ALT) perforator flap has become one of the major workhorses in reconstructive surgery because of its reliability and low donor site morbidity. However, the indications for this flap are limited when underlying cavities need to be filled or a separate bulk of muscular tissue is needed. To overcome these setbacks, an adipocutaneous-muscle ALT chimera flap with a muscular appendage supplied by a separate branchlet of the perforator pedicle is a useful tool. This work describes the surgical procedure and shows the results of 15 patients with a chimera ALT flap in a series of 88 patients with ALT flaps. Patients with defects after trauma (nu2009=u20098), cavities after tumour resection (nu2009=u20095) or patients with fasciitis (nu2009=u20092) were considered for an ALT chimera flap. A separate vessel for the muscular appendage was found in all 15 cases and the chimera flap could be raised successfully. Filling the underlying cavities and smooth cutaneous defect coverage was possible in all cases. No flap failure was seen (failure rate 5.6% in the whole series), but two patients required microsurgical revisions. Other complications were similar to regular ALT flap procedures. Only one patient developed a complication possibly related to including the muscular component (donor site haematoma). A separate muscular appendage added to the classical ALT flap allows an expansion of the indications of a flap well known for its low complication rate and versatility in reconstructive surgery.

Die Autositzheizung — eine potenzielle Verbrennungsgefahr für den Querschnittsgelähmten@@@Heated car seats — a potential burn risk for paraplegics

The comfort of heated car seats has gained popularity worldwide. We present a rare case of severe second- and third-degree burn in the lower back and sacral region of a 42-year-old post-traumatic paraplegic patient while using a heated car seat. The patient was admitted to our burn unit and required several reconstructive surgery procedures. Inadvertent thermal injury is a constant potential hazard for individuals with impaired sensibility such as paraplegics and other neurologically impaired patients. Early education of patients, manufacturers, and health care personnel is of eminent importance to prevent severe burn injuries in this risk population.ZusammenfassungBeheizte Autositze werden mit steigender Popularität in Anspruch genommen. Wir stellen den klinischen Fall einer schweren zweit- und drittgradigen Verbrennung der Sakroglutealregion eines 42-jährigen posttraumatisch Querschnittsgelähmten vor. Der Patient wurde in unserer Verbrennungsklinik aufgenommen und zahlreiche Operationen wurden notwendig. Querschnittsgelähmte Patienten sind durch ihre Sensibilitäts- und Schmerzempfindungsstörung einem erhöhten Verbrennungsrisiko durch Autositzheizungen ausgesetzt. Wir empfehlen eine frühzeitige adäquate Aufklärung der Patienten, Hersteller und aller Bezugspersonen zur Vermeidung derartig schwerwiegender Verbrennungsereignisse.SummaryThe comfort of heated car seats has gained popularity worldwide. We present a rare case of severe second- and third-degree burn in the lower back and sacral region of a 42-year-old post-traumatic paraplegic patient while using a heated car seat. The patient was admitted to our burn unit and required several reconstructive surgery procedures. Inadvertent thermal injury is a constant potential hazard for individuals with impaired sensibility such as paraplegics and other neurologically impaired patients. Early education of patients, manufacturers, and health care personnel is of eminent importance to prevent severe burn injuries in this risk population.

MRSA—Analyse des Ausbruchs auf einer Verbrennungsintensivstation

Methicillinresistente Staphylokokkus aureus (MRSA)-Stamme sind heutzutage eine haufige Ursache fur schwere nosokomiale Infekte. Ist die alleinige Kolonisation der Patienten noch nicht mit einer erhohten Mortalitat verbunden, stellt eine manifeste Infektion eine lebensbedrohliche Komplikation dar. Schwerbrandverletzte Patienten haben aufgrund des Verlustes der Schutzfunktion der Haut ein erhohtes Risiko, dass die Kolonisation in eine Infektion ubergeht.