Stroke Volume and Stroke Volume Variation, but not Cardiac Index Is Associated With Survival of Majorly Burned Patients in Early Burn Shock.

Adequate fluid therapy is crucial to maintain organ function after burn trauma. Major burns lead to a systemic response with fluid loss and cardiac dysfunction. To guide fluid therapy, measurement of cardiac pre- and afterload is helpful. Whereas cardiac function is usually measured after admission to intensive care unit (ICU), in this study, hemodynamic monitoring was performed directly after arrival at hospital. We conducted a prospective cohort study with inclusion of 19 patients (male/female 13/6, 55 ± 18 years, mean total body surface area 36 ± 19%). Arterial waveform analysis (PulsioFlexProAqt®, Getinge) was implemented immediately after admission to hospital to measure cardiac pre- and afterload and to guide resuscitation therapy. Cardiac parameters 3.75 (2.67-6.0) h after trauma were normal regarding cardiac index (3.45 ± 0.82) L/min/m², systemic vascular resistance index (1749 ± 533) dyn sec/cm5 m2, and stroke volume (SV; 80 ± 20) mL. Stroke volume variation (SVV) was increased (21 ± 7) % and associated with mortality (mean SVV survivors vs nonsurvivors 18.92 (±6.37) % vs 27.6 (±5.68) %, P = .017). Stroke volume was associated with mortality at the time of ICU-admission (mean SV survivors vs nonsurvivors 90 (±20) mL vs 50 (±0) mL, P = .004). Changes after volume challenge were significant for SVV (24 ± 9 vs19 ± 8%, P = .01) and SV (68 ± 24 vs 76 ± 26 mL, P = .03). We described association of SVV and SV with survival of severely burned patients in an observational study. This indicates high valence of those parameters in the early postburn period. The use of an autocalibrated device enables a very early monitoring of parameters relevant to burn shock survival.

From Esthetic Medicine to Optimizing Reconstructive Outcome: A Feasibility Trial on Secondary Refinement of Fasciocutaneous Anterolateral Thigh Flaps with Cryolipolysis.

BACKGROUND: Free adipocutaneous anterolateral thigh (ALT) flaps have evolved as workhorse flaps to reconstruct complex, multicompound defects. While coverage is safely achieved, flaps may remain bulky. As a standard of care, flaps are refined with liposuction, partial excision, or combination of both. Cryolipolysis is widely used for fat reduction in esthetic medicine. This pilot comparative study analyses whether cryolipolysis may serve as a safe alternative method to effectively reduce volume in fasciocutaneous flaps. Moreover, patients' satisfaction with the procedure is evaluated. METHODS: In this single-center, retrospective, interventional comparative cohort study, 10 patients with free subfascial ALT flaps for distal extremity reconstruction underwent cryolipolysis (60 minutes, -9°C). Circumference of the extremities and subcutaneous fat thickness were determined before (T1) and 12 weeks (T2) after cryolipolysis. Patient satisfaction was evaluated with a questionnaire of Likert's scale questions. Duration of hospital stay, intervention time, costs, and possible complications were analyzed and compared with surgical flap contouring (n = 12). RESULTS: All patients undergoing cryolipolysis were male, with a median age of 52 years without arterial disease-like state or deep vein thrombosis (DVT). At T2, a significant reduction of circumference of 1.8 ± 0.9 cm (p < 0.001) and subcutaneous fat layer of 7.7 ± 3.0 mm (p < 0.0001) was recorded. Overall, 90% of the patients were satisfied with the result. Cryolipolysis was well tolerated. One patient developed a second-degree frostbite which healed without further intervention. Cryolipolysis proofed to be as safe as surgical flap contouring. Hospital stay was significantly shorter (p < 0.01) and personal resources were spared when flap contouring was performed with cryolipolysis. CONCLUSION: This is a novel application of evolving body-contouring cryolipolysis from esthetic medicine into optimizing outcomes in reconstructive surgery. Cryolipolysis has been shown to be relatively safe and effective to reduce ALT's volume with high patients' satisfaction. This successful pilot study encourages further investigation with a prospective randomized control trial.

Prehospital treatment of severely burned patients: a retrospective analysis of patients admitted to the Berlin burn centre.

BACKGROUND: Prehospital management of severely burned patients is extremely challenging. It should include adequate analgesia, decision-making on the necessity of prehospital endotracheal intubation and the administration of crystalloid fluids. Guidelines recommend immediate transport to specialised burn centres when certain criteria are met. To date, there is still insufficient knowledge on the characteristics of prehospital emergency treatment. We sought to investigate the current practice and its potential effects on patient outcome. METHODS: We conducted a single centre, retrospective cohort analysis of severely burned patients (total burned surface area > 20%), admitted to the Berlin burn centre between 2014 and 2019. The relevant data was extracted from Emergency Medical Service reports and digital patient charts for exploratory data analysis. Primary outcome was 28-day-mortality. RESULTS: Ninety patients (male/female 60/30, with a median age of 52 years [interquartile range, IQR 37-63], median total burned surface area 36% [IQR 25-51] and median body mass index 26.56 kg/m2 [IQR 22.86-30.86] were included. The median time from trauma to ED arrival was 1 h 45 min; within this time, on average 1961 ml of crystalloid fluid (0.48 ml/kg/%TBSA, IQR 0.32-0.86) was administered. Most patients received opioid-based analgesia. Times from trauma to ED arrival were longer for patients who were intubated. Neither excessive fluid treatment (> 1000 ml/h) nor transport times > 2 h was associated with higher mortality. A total of 31 patients (34,4%) died within the hospital stay. Multivariate regression analysis revealed that non-survival was linked to age > 65 years (odds ratio (OR) 3.5, 95% CI: 1.27-9.66), inhalation injury (OR 3.57, 95% CI: 1.36-9.36), burned surface area > 60% (OR 5.14, 95% CI 1.57-16.84) and prehospital intubation (5.38, 95% CI: 1.92-15.92). CONCLUSION: We showed that severely burned patients frequently received excessive fluid administration prehospitally and that this was not associated with more hemodynamic stability or outcome. In our cohort, patients were frequently intubated prehospitally, which was associated with increased mortality rates. Further research and emergency medical staff training should focus on adequate fluid application and cautious decision-making on the risks and benefits of prehospital intubation. TRIAL REGISTRATION: German Clinical Trial Registry (ID: DRKS00033516).

Mechanical ventilation as a surrogate for diagnosing the onset of abdominal compartment syndrome (ACS) in severely burned patients (TIRIFIC-study Part II).

Intra-abdominal compartment syndrome (ACS) is a devastating complication in burn patients with a high mortality. Apart from high-volume resuscitation as known risk factor, also mechanical ventilation seems to influence the development of ACS. The TIRIFIC trial is a retrospective, matched-pair analysis. Thirty-eight burn patients with ACS were matched for burned total body surface area (TBSA), age and mechanical ventilation (MV). In contrast to the already published part I addressing fluid resuscitation as a risk factor, the parameters analyzed in part II were maximum and average PEEP and peak pressure levels as well as serum lactate levels and prokinetic therapy. For subgroup-analysis the ACS-group was split up into an early-onset and late-onset ACS-group according to the median time between burn trauma and ACS. The groups were analyzed with a two-sided Mann-Whitney-U-test with significance set at p < 0.05. In the ACS-group all ventilation pressures (maximum and average PEEP and peak pressure levels) were significantly increased compared to control. The subgroup-analysis showed significantly increased maximum PEEP and peak pressure levels in early- and late-onset ACS-groups versus control. However, the average ventilation pressure levels were only increased in the early-onset ACS-group (average PEEP p = 0.0069; average peak pressure p = 0.05). The TIRIFIC trial showed significantly increased ventilation pressures in the ACS group in general as a surrogate parameter to support early diagnostics. Especially, maximum PEEP levels and peak pressures are significantly increased in both, early- and late-onset ACS. As an addition to the actual WSACS guidelines we suggest IAP measurement in mechanically ventilated burn patients if ventilating pressures are rising continuously without a clear pulmonary or otherwise identifiable reason.

Fluid Management as a Risk Factor for Intra-abdominal Compartment Syndrome in Burn Patients: A Total Body Surface Area-Independent Multicenter Trial Part I.

Fluid management is one of the anticipated risk factors for intra-abdominal compartment syndrome (ACS). Since fluid requirements depend on the burned total body surface area (TBSA), an independent analysis is necessary to adapt resuscitation protocols and prevent this life-threatening complication. A retrospective multicenter study with matched-pair analysis was conducted in four German burn centers, including 38 burn patients with ACS who underwent decompressive laparotomy. Potential risk factors were analyzed, such as resuscitation volume, total fluid intake, mean fluid administration per day, fluid balance, and blood transfusion. The ACS group and control were compared with a two-tailed Mann-Whitney U test (P < .05). The ACS group was split up into an early and late ACS group for statistical subgroup analysis. Total fluid intake, fluid balance, and the total volume of colloids showed no significant difference in the ACS group (mean TBSA 50%) versus control (mean TBSA 49%). The subgroup analysis showed significant higher total resuscitation volume, fluid administration per kilogram body weight, and fluid balance in the first 24 hours in the late-onset ACS group. This study shows a different risk factor profile for early-onset ACS in the first 4 days after trauma and late-onset ACS. Herein, fluid therapy is a fundamental risk factor for late-onset ACS. In early-onset ACS, fluid administration contributes significantly to the development of intra-abdominal hypertension, but other risk factors seem to turn the balance for the development of early-onset ACS in burn patients.