Experiencia en reconstrucción del paciente gran quemado agudo con microcirugía

Introducción: Las quemaduras son un trauma frecuente de ocurrencia en todo el mundo, que ha experimentado importantes aumentos de sobrevida. Su manejo requiere la reposición de la barrera cutánea, lo que se logra en la mayoría de los casos con el uso de injertos dermo-epidérmicos. Sin embargo, existen algunas veces lesiones complejas que no logran sanar mediante injertos, arriesgando la funcionalidad o vitalidad del área comprometida, que requerirán reparaciones complejas con el uso de colgajos microqui- rúrgicos (CM). Metodología: Estudio descriptivo retrospectivo en que incluimos todos los pacientes gran quemados agudos admitidos en Hospital de Urgencia de la Asistencia Pública, Servicio de Quemados y Rehabilitación, desde abril de 2019 hasta diciembre de 2020 los que fueron manejados con colgajo micro- quirúrgico. Revisión de ficha clínica para obtención de variables demográficas y del procedimiento con análisis de frecuencia de ocurrencia. Resultados: En nuestro período de estudio hubo 376 ingresos y 21 pacientes recibieron 25 CM. La mayoría hombres (96%), edad promedio 40 años, superficie comprometida promedio 16%, mecanismo más frecuente electricidad (64%) y fuego (32%). La ubicación más frecuente del colgajo fue en extremidades inferiores (64%) y el colgajo más utilizado fue el anterolateral de muslo (80%). Tiempo medio a reconstrucción fueron 40 días, no hubo pérdida total del colgajo. Discusión: se realizó un CM en 5,6% de nuestros ingresos, la mayoría durante el intervalo primario tardío, sin pérdidas totales. Estos resultados representan la consolidación de la técnica que permite su uso en el paciente gran quemado durante su etapa aguda, permitiendo coberturas complejas y manteniendo riesgo quirúrgico y tasa de complicaciones adecuada con enfoque en rehabilitación precoz.

Introduction: Burns are the fourth most common trauma. Microsurgery has evolved as a valuable tool in the acute setting allowing early closure of complex wounds in order to avoid infection, maintain function or even for limb salvage in one stage reconstruction. We present our experience at our burn center in Chile. Method: We performed a retrospective analysis of all major burn patients admitted in the National Burn Center in Chile who received a microsurgical flap in the period between April 2019 to December 2020. Results: A total of 21 patients had 25 free flaps. All patients but one were male (96%), mean age 40 years (range 20-69 years). Total body surface area means 16% (range 1-64%). Most of the injuries were caused by high voltage electricity (64%) and fire (32%). 64% were performed in lower limbs and 36% in upper limbs. In 80% of the cases, anterolateral thing flap was chosen. Mean time to reconstruction was 40 days. We didn't experience a total flap lost in this series. Discussion: In the acute phase microsurgery proved to be safe and feasible albeit a small surgical indication. We performed a flap in 5.6% of our admissions, mostly during late primary interval with no flaps lost. Our results acknowledge the consolidation of the technique for its use in the acutely burned setting, allowing complex coverage while maintaining the surgical risk and an internationally acceptable rate of losses and complications.

The impact of inhalation injury on fluid resuscitation in major burn patients: a 10-year multicenter retrospective study.

BACKGROUND: It remains unclear whether additional fluid supplementation is necessary during the acute resuscitation period for patients with combined inhalational injury (INHI) under the guidance of the Third Military Medical University (TMMU) protocol. METHODS: A 10-year multicenter, retrospective cohort study, involved patients with burns ≥ 50% total burn surface area (TBSA) was conducted. The effect of INHI, INHI severity, and tracheotomy on the fluid management in burn patients was assessed. Cumulative fluid administration, cumulative urine output, and cumulative fluid retention within 72 h were collected and systematically analyzed. RESULTS: A total of 108 patients were included in the analysis, 85 with concomitant INHI and 23 with thermal burn alone. There was no significant difference in total fluid administration during the 72-h post-burn between the INHI and non-INHI groups. Although no difference in the urine output and fluid retention was shown in the first 24 h, the INHI group had a significantly lower cumulative urine output and a higher cumulative fluid retention in the 48-h and 72-h post-burn (all p < 0.05). In addition, patients with severe INHI exhibited a significantly elevated incidence of complications (Pneumonia, 47.0% vs. 11.8%, p = 0.012), (AKI, 23.5% vs. 2.9%, p = 0.037). For patients with combined INHI, neither the severity of INHI nor the presence of a tracheotomy had any significant influence on fluid management during the acute resuscitation period. CONCLUSIONS: Additional fluid administration may be unnecessary in major burn patients with INHI under the guidance of the TMMU protocol.

Intubación orotraqueal en el trauma por quemaduras en Uruguay: rol de la intubación profiláctica / Orotracheal intubation in burn trauma in Uruguay: the role of prophylactic intubation / Intubação orotraqueal no trauma por queimaduras no Uruguai: papel da intubação profilática

Introducción: La Intubación orotraqueal (IOT) profiláctica en pacientes con sospecha de Injuria Inhalatoria (II) es una práctica clínica extendida en nuestro país. La misma puede estar asociada a complicaciones y a un aumento de los costos asistenciales. Objetivo: caracterizar a la población de pacientes que ingresaron con IOT al Centro Nacional de Quemados, determinar la incidencia de Intubación orotraqueal no necesaria (IOTNN) así como las complicaciones vinculadas a la misma. Método: Estudio retrospectivo, observacional, analítico. Se incluyeron todos los pacientes con quemadura térmica ingresados al CENAQUE con vía aérea artificial entre enero de 2015 y julio 2023. Se determinaron características demográficas, circunstancias de la injuria, lugar y técnico que realizo la IOT, porcentaje de superficie corporal total quemada (SCTQ), scores de severidad, días de ARM, estado al alta y diagnóstico de II por fibrobroncoscopía. Se analizaron las complicaciones asociadas a la IOT y ARM. Dichas variables fueron contrastadas entre el grupo extubado exitosamente en las primeras 48 horas (IOTNN) y aquellos extubados luego de las 48 horas (IOTP). Resultados: Se incluyeron 562 pacientes. La incidencia de IOTNN fue 41,7% e II 46,7%. Se observaron diferencias significativas entre IOTNN y IOTP para edad [34 (24-48) versus 45 (30-62); p <0,001, para SCTQ [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], Rev. Baux [48 (33-62) versus 77 (60-99), p <0,001], incidencia de II (32% versus 56,6%, p <0,001). La aspiración de VA (30% versus 20,2% p 0,018), extubación durante el traslado (2% versus 0% p 0,043) e incidencia de NA (Neumonía aspirativa) y NAVP (neumonía asociada a la ventilación mecánica precoz) (56,3% versus 15% p <0,001) fueron mayores en el grupo IOTP. Conclusiones: La IOTNN en los pacientes con quemaduras es frecuente en nuestro medio y se asocia a complicaciones. La misma es realizada por médicos sin formación en el manejo de la vía aérea.

Introduction: Prophylactic Orotracheal Intubation (OTI) in patients with suspected Inhalation Injury (II) is a widespread clinical practice in our country. It can be associated with complications and increased healthcare costs. Objective: To characterize the population of patients admitted with OTI to the National Burn Center, determine the incidence of unnecessary Orotracheal Intubation (UOTI), and the associated complications. Method: Retrospective, observational, analytical study. All patients with thermal burns admitted to the National Burn Center (CENAQUE) with an artificial airway between January 2015 and July 2023 were included. Demographic characteristics, injury circumstances, location, and technician performing the OTI, percentage of total body surface area burned (TBSA), severity scores, days on mechanical ventilation, discharge status, and diagnosis of II by fibrobronchoscopy were determined. Complications associated with OTI and mechanical ventilation were analyzed. These variables were compared between the group extubated successfully within the first 48 hours (UOTI) and those extubated after 48 hours (necessary OTI, NOTI). Results: 562 patients were included. The incidence of UOTI was 41,7% and II 46,7%. Significant differences were observed between UOTI and NOTI in age [34 (24-48) versus 45 (30-62); p <0.001], TBSA [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], Baux score [48 (33-62) versus 77 (60-99), p <0,001], incidence of II (32% versus 56.6%, p <0,001). Aspiration of the airway (30% versus 20,2% p 0,018), extubation during transport (2% versus 0% p 0,043), and incidence of aspiration pneumonia (AP) and early ventilator-associated pneumonia (VAP) (56,3% versus 15% p <0,001) were higher in the NOTI group. Conclusions: UOTI in burn patients is frequent in our setting and is associated with complications. It is performed by physicians without training in airway management.

Introdução: A intubação orotraqueal (IOT) profilática em pacientes com suspeita de lesão por inalação (LI) é uma prática clínica difundida em nosso país. Esta prática pode estar associada a complicações e ao aumento dos custos assistenciais. Objetivo: Caracterizar a população de pacientes que ingressaram com IOT no Centro Nacional de Queimados, determinar a incidência de intubação orotraqueal desnecessária (IOTD) e as complicações associadas. Método: Estudo retrospectivo, observacional, analítico. Foram incluídos todos os pacientes com queimadura térmica admitidos no CENAQUE com via aérea artificial entre janeiro de 2015 e julho de 2023. Foram determinadas características demográficas, circunstâncias da lesão, local e técnico que realizou a IOT, porcentagem da superfície corporal total queimada (SCTQ), escores de gravidade, dias de ventilação mecânica, estado na alta e diagnóstico de LI por fibrobroncoscopia. Complicações associadas à IOT e à ventilação mecânica foram analisadas. Essas variáveis foram comparadas entre o grupo extubado com sucesso nas primeiras 48 horas (IOTD) e aqueles extubados após 48 horas (IOTP). Resultados: Foram incluídos 562 pacientes. A incidência de IOTD foi de 41,7% e LI de 46,7%. Diferenças significativas foram observadas entre IOTD e IOTP em relação à idade [34 (24-48) versus 45 (30-62); p <0,001], SCTQ [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], índice de Baux [48 (33-62) versus 77 (60-99), p <0,001], incidência de LI (32% versus 56,6%, p <0,001). A aspiração de via aérea (30% versus 20,2% p 0,018), extubação durante o transporte (2% versus 0% p 0,043) e incidência de pneumonia aspirativa (PA) e pneumonia associada à ventilação mecânica precoce (NAVM) (56,3% versus 15% p <0,001) foram maiores no grupo IOTP. Conclusões: A IOTD em pacientes com queimaduras é frequente em nosso meio e está associada a complicações. A mesma é realizada por médicos sem formação no manejo da via aérea.

Extensive Heterotopic Ossification in a Large Incisional Ventral Hernia After a Burn Injury Requiring Transversus Abdominis Release.

Heterotopic ossification (HO) is an atypical complication of burn injuries presenting in 0.2-4% of cases. Usually, HO develops surrounding long bones or joints after orthopedic procedures or trauma. However, on extremely rare occasions, HO can develop from other bones such as the xiphoid. The purpose of this case report is to describe a case of an open retromuscular abdominal wall reconstruction with bilateral transversus abdominis release (TAR) in a patient with extensive abdominal heterotopic ossification following a midline laparotomy in the setting of a large burn injury. The patient was a 42-year-old man with a history of 55% total burn surface area (TBSA) second- and third-degree flame burns who was treated in a large academic hospital with a renowned burn unit. His case in particular was brought to attention for the rare presentation of the aftermath of a burn injury and the technical surgical challenge it posed. Five months after the last surgical intervention, the patient is doing well without further complications or clinical signs of hernia recurrence. Since there are no established guidelines for patients with HO after burn injuries, learning about alternate strategies will expand the armamentarium of abdominal wall reconstruction surgeons in this challenging patient population. Specifically, retromuscular ventral hernia repair with transversus abdominis release and synthetic mesh can be used in complex ventral hernia repair complicated by heterotopic ossification after a major burn.

Comparison of Albumin and Fresh Frozen Plasma as Colloid Therapy in Patients With Major Burns.

BACKGROUND: Burn injuries are one of the main causes of morbidity and mortality throughout the world, and burn patients have higher chances of recovery if they are treated with effective fluid and colloid management. Fresh frozen plasma (FFP) and albumin suspension used as a colloid treatment agent are very useful for the treatment of severe burns. METHODS: This retrospective clinical trial was conducted at the Numune Education and Research Hospital Burn Center, Ankara, Turkey. Two hundred and nine patients who had severe burns that involved more than 30% of their total body surface area (TBSA) were studied. After the first 24 hours, 13 patients were deceased, leaving 196 patients remaining in the study, including 139 patients in the fresh frozen plasma group and 57 patients in the albumin group. Both the fresh frozen plasma and albumin groups received the standard therapy of the burn center, which was based on a standard protocol. Then, these patients were compared according to their clinical findings and mortality. RESULTS: There were no significant differences between the groups with respect to age, gender, and comorbidities. The laboratory findings, blood, urine, and wound culture results were also similar between groups. The mortality rate was higher in the group receiving albumin than in the group receiving fresh frozen plasma (78.9% and 33.8%, respectively; p=0.0007). CONCLUSIONS: According to this study, there was a significant relationship between the improvement in mortality and the mode of colloid treatment in patients with major burns.

Extracorporeal Life Support for Severely Burned Patients with Concurrent Inhalation Injury and Acute Respiratory Distress Syndrome: Experience from a Military Medical Burn Center.

BACKGROUND: Both inhalation injury and acute respiratory distress syndrome (ARDS) are risk factors that predict mortality in severely burned patients. Extracorporeal life support (ECLS) is widely used to rescue these patients; however, its efficacy and safety in this critical population have not been well defined. We report our experience of using ECLS for the treatment of severely burned patients with concurrent inhalation injury and ARDS. METHODS: This was a retrospective analysis of 14 patients collected from a single medical burn center from 2012 to 2019. All patients suffered from major burns with inhalation injury and ARDS, and were treated with ECLS. RESULTS: The median total body surface area of deep dermal or full thickness burns was 94.5%, ranging 47.7-99.0 %. The median revised Baux score was 122.0, ranging 90.0-155.0. All patients developed ARDS with a median partial pressure of arterial oxygen to a fraction of inspired oxygen ratio of 61.5, ranging 49.0-99.0. Indications for ECLS included sustained hypoxemia and unstable hemodynamics. The median interval for initiating ECLS was 2.5 days, ranging 1.0-156.0 days. The median duration of ECLS was 2.9 days, ranging 0.3-16.7 days. The overall survival to discharge was 42.8%. Causes of death included sepsis and multiple organ failure. ECLS-related complications included cannulation bleeding, catheter-related infection, and hemolysis. The incidence of risk factors reported in literature were higher in non-survivors, including Baux>120, albumin < 3.0 g/dL, and lactate > 8 mmol/L. CONCLUSIONS: For severely burned patients with concurrent inhalation injury and ARDS, ECLS could be a salvage treatment to improve sustained hypoxemia. However, the efficacy of hemodynamic support was limited. Identifying definite ECLS indications and rigorous patient selection would contribute to better clinical outcomes.

Aspartate transaminase/alanine transaminase (De Ritis ratio) predicts survival in major burn patients.

BACKGROUND: Although treatment of burn patients has significantly improved in recent decades, major burns remain fatal. Therefore, the evaluation of the death risk of the patients with extensive burns is very important. The ratio between the serum levels of aspartate transaminase and alanine transaminase (De Ritis ratio) was an independent predictor of poor outcomes in patients with acute ischemic stroke, cardiac surgery, non-metastatic renal cell carcinoma, and upper urinary tract urothelial carcinoma. Our aim was to determine whether the ratio between the serum levels of AST and ALT (De Ritis ratio) was useful to assess prognosis in extensively burned patients. METHODS: We conducted a single-center cohort study at the Burns Department of Changhai Hospital. This retrospective observational analysis was performed based on the clinical data of major burn patients admitted between May 1, 2005 and April 30, 2018. Univariate and multivariate logistic regression analyses were performed on variables such as age, sex, total body surface area (TBSA), De Ritis ratio, and serum albumin level, which may affect mortality in major burn patients. We assessed their diagnostic value and found the cut-off value by receiver operative characteristic (ROC) curve analysis. We used the Kaplan-Meier curve to display the impact of the De Ritis ratio and serum albumin level on survival in burn patients. RESULTS: A total of 351 patients with extensive burns were included in the study. The cohort predominantly consisted of males (74.64%), and most of the patients (78.35%) had been burned by a flame. Age, TBSA, inhalation, and the De Ritis ratio were found to be independent risk factors for the 30-days mortality of major burn patients, while age, TBSA, inhalation, and the De Ritis ratio were independent risk factors for 90-day mortality. Further, the De Ritis ratio was a better mortality predictor than serum albumin in severely burned patients, whose area under ROC for 30-day and 90-day mortality was 0.771 (95% confidence intervals [CI], 0.708-0.835) and 0.750 (95% CI, 0.683, 0.818). CONCLUSIONS: The De Ritis ratio was useful as a prognostic indicator for major burn patients, which can be conveniently obtained through blood examination. Regardless of whether the prediction was for 30-day or 90-day mortality, the accuracy remained high. Moreover, compared to serum albumin level, the De Ritis ratio was superior in assessing the prognosis of extensively burned patients.

Usage of intermingled skin allografts and autografts in a senior patient with major burn injury.

Mortality rate in older adults following extensive burn injury is extremely high, and management of these patients is challenging. One of the main problems is that autologous split-thickness skin grafts are scarce and the wounds cannot be covered quickly and effectively. Intermingled skin grafting is a low-tech and economic method, which not only maximizes the use of precious autologous skin but also prevents the wounds from infection and consumption. Herein we present a case of extensive burn injury in a 68-year-old female successfully treated with intermingled skin grafting. The patient was accidentally burned by gas flame, resulting in a major burn injury covering 80% of her total body surface area. Early burn wound excision was performed and the wound was temporarily covered with irradiated porcine skin in the first week after injury. Autologous stamp-like skin grafts were applied to the wound bed 4 weeks after injury. In this operation, the results were not satisfactory. The take rate of the skin grafts is only about 50%. We covered the wounds with intermingled skin allografts and autografts 8 weeks after injury: autografts (0.5 cm × 0.5 cm) + fresh close relative's allografts (1 cm × 1 cm) + cryopreserved allografts (2 cm × 2 cm).

Effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage. / ä¼‘å ‹æœŸå†°å†»è¡€æµ†ä¸Žè¡€æµ†ä»£ç”¨å“è¾“æ³¨æ¯”ä¾‹å¯¹å¤§é¢ç§¯çƒ§ä¼¤æˆå¹´æ‚£è€ é¢„åŽçš„å½±å“.

OBJECTIVES: In recent years, it has been reported that the anti-shock effect of plasma substitutes in adult patients with major burn in shock stage is not good. However, due to the shortage of clinical frozen plasma supply, it is impossible to guarantee that frozen plasma is used as colloidal solution for anti-shock treatment. The purpose of this study is to explore the effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage. METHODS: This study enrolled 586 adult patients with major burn by selecting the hospitalization burn patients, who had been hospitalized at the Jiangxi province burn center from September 2014 to April 2019. The patients with the infusion ratio of frozen plasma to plasma substitutes ≥2꞉1 at 48 hours after admission were included in the experimental group, otherwise they were included in the control group. The basic clinical data and clinical prognosis indicator in the 2 groups were compared. Logistic univariate regression analysis was used to screen the influential factors of 30-day mortality in adult patients with major burn, and logistic multivariate regression analysis was used to obtain independent risk and protective factors; Kaplan-Meier method was used to draw the survival curve of the 2 groups, and log-rank test was used to compare the 30-day survival rate of the 2 groups. RESULTS: There were significant differences in the infusion volume of frozen plasma and plasma substitutes between the 2 groups at 48 hours after admission (both P<0.05). The duration of mechanical ventilation in the experimental group was shorter than that in the control group, the percentage of continuous renal replacement therapy (CRRT) in the experimental group was lower than that in the control group, and the in-hospital mortality and 30-day mortality in the experimental group were lower than those in the control group, the differences were statistically significant (all P<0.05). The percentage of burn area and total body surface area (TBSA) was an independent risk factor for 30-day mortality of adult patients with major burn (OR=1.228, 95% CI 1.010 to 1.439, P=0.039), while the infusion ration between of frozen plasma and plasma substitutes 48 hours after admission was an independent protective factor (OR=0.016, 95% CI 0.001 to 0.960, P=0.023). The 30-day survival rate of the experimental group was significantly higher than that in the control group (P<0.001). CONCLUSIONS: Infusion ration between frozen plasma to plasma substitutes at 48 hours after admission is an independent protective factor for 30-day mortality of adult patients with major burn. In the early stage of adult patients with major burn, frozen plasma should be used as the anti-shock therapy as far as possible (frozen plasma꞉plasma substitute ≥2꞉1) to improve the prognosis and reduce the of 30-day mortality.

Colonic perforation following major burns: Experience from a burns center and a systematic review.

BACKGROUND: Major burns complicated by stress ulceration and perforation of the stomach or duodenum is a recognized clinical phenomenon. Colonic perforation in burns patients is not common, and the overall incidence, diagnosis, intervention undertaken and mortality is incompletely described in the literature. METHOD: We performed a systematic review of the literature on severe burns resulting in colonic perforation during the initial admission period. Relevant studies from January 1975 to June 2020 were retrieved from MEDLINE and EMBASE databases. Patient demographics, co-morbidities, total body surface area (TBSA) and anatomical region of burn, site of colonic perforation and management, nutrition, sepsis and microbiology, length of stay and overall outcome were extracted. We present a case series of five burns patients who had colonic perforations in our Specialist Burns Center. RESULTS: We identified 54 studies, of which nine (two case series and seven case reports) met the inclusion criteria. Colonic perforation following burns was most common in middle-aged male patients with a proportion of patients having a history of mental health issues. In most cases, the TBSA associated with a colonic perforation was ≥30% (11/16 patients, 69%). Perforations mainly affected the right side of the colon (12/16 patients, 75%), usually occurring after the second week of admission (13/16 patients, 81%). Right-sided colonic perforations were associated with an increased mortality rate compared to left-sided perforations (42% vs 25%). CONCLUSIONS: The current literature is mainly limited to case series and case reports and confirms that colonic perforations in burns patients are rare. Colonic perforations are related to the systemic effect of burn injuries including sepsis and gastrointestinal stasis. We have identified patients who are at higher risk of developing colonic perforations and have described the common findings in these patients. Through greater awareness early diagnosis and prompt intervention may be achieved to improve outcomes and reduce associated morbidity and mortality.

The contradictory role of androgens in cutaneous and major burn wound healing.

Wound healing is a complex process involving four overlapping phases: haemostasis, inflammation, cell recruitment and matrix remodeling. In mouse models, surgical, pharmacological and genetic approaches targeting androgen actions in skin have shown that androgens increase interleukin-6 and tumor necrosis factor-α production and reduce wound re-epithelization and matrix deposition, retarding cutaneous wound healing. Similarly, clinical studies have shown that cutaneous wound healing is slower in men compared to women. However, in major burn injury, which triggers not only local wound-healing processes but also systemic hypermetabolism, the role of androgens is poorly understood. Recent studies have claimed that a synthetic androgen, oxandrolone, increases protein synthesis, improves lean body mass and shortens length of hospital stay. However, the possible mechanisms by which oxandrolone regulates major burn injury have not been reported. In this review, we summarize the current findings on the roles of androgens in cutaneous and major burn wound healing, as well as androgens as a potential therapeutic treatment option for patients with major burn injuries.

Procalcitonin kinetics early after severe burn injury and its value in diagnosis of sepsis.

PURPOSE: To investigate the clinical significance of procalcitonin (PCT) kinetics early after burn and the perioperative period, and to assess its diagnostic performance for sepsis in major burn patients. METHODS: This retrospective study on major burn patents (≥40% total body surface area) admitted from 2014 to 2019 was conducted in Southwest Hospital, Chongqing, China. A total of 321 patients were included. The kinetics of PCT was analyzed during the 1st week after burn, the perioperative period, and at the onset of clinical suspected sepsis. RESULTS: Serum PCT concentration rose immediately after burn injury. Factors associated with increased PCT level in the 1st week after burn include greater burn area (>70% TBSA) and lower age (≤14 years). Correlations between PCT kinetics after burn and the risk of early development of sepsis and mortality were observed. At the onset of sepsis, serum PCT increased significantly compared to its basal level in the 48 h before diagnosis. The area under the receiver operating characteristics curve of PCT concentration and its kinetic changes was 0.788 and 0.826, respectively. PCT kinetics showed better accuracy than PCT concentration in discrimination of Gram-positive sepsis. The optimal diagnostic thresholds for PCT concentration and its kinetics were 1.41 ng/mL, and a 1.34-fold elevation compared to the baseline level. CONCLUSIONS: PCT kinetics in the early stage after burn was a prognostic factor for sepsis and mortality among major burn patients. Serum PCT levels could be a diagnostic biomarker for sepsis in major burn patients.

[Current place of cultured epithelial autografts in the management of massive burns and future prospects: Literature review]. / Place actuelle des cultures d'épidermes autologues dans la prise en charge des brûlures étendues et perspective d'avenir : revue de littérature.

Cultured Epithelial Autografts (CEAs), developed at the end of the 1970s from in vitro culture amplification of keratinocytes, have led to a therapeutic revolution in the treatment of major burns. The areas of improvement of the cultures initially involved the manufacturing processes (culture media, support matrices, etc.) and then clinical applications (use of a largely expanded allogeneic or autologous dermal bed). These advances have enabled burn centers (BC) using CEAs to obtain very satisfactory percentages of graft integration and survival of major burns patients. However, since CEAs are not without major drawbacks (fragility, high rate of infection, high cost, unstable scars), these pitfalls have restricted their use worldwide. As of 2014, CEAs produced by Genyzme Tissue Repair are no longer available in Europe, which has considerably reduced an indispensable therapeutic arsenal for severe and extensive burns. To overcome these therapeutic limitations, current research is focusing on techniques combining surgery, tissue engineering and cell therapy. The advent of regenerative medicine, based on the use of stem cells, in particular mesenchymal stem cells (MSC), can contribute to an improvement in the management of these massively burned patients (optimization of the environmental medium, attenuation of the systemic inflammatory response and the immunosuppressive effects of the burn, acceleration of tissue regeneration, etc.). Cell therapy, therefore, offers alternatives to CEAs, which must imperatively retain their place in the therapeutic arsenal, namely an effective emergency coverage technique that can be improved.

Dihydrotestosterone (DHT) Enhances Wound Healing of Major Burn Injury by Accelerating Resolution of Inflammation in Mice.

Androgens have been known to inhibit cutaneous wound healing in men and male mice. However, in children with major burn injuries, a synthetic androgen was reported clinically to improve wound healing. The aim of this study is to investigate the role of dihydrotestosterone (DHT) as a new therapeutic approach in treating major burn injury. In the present study, mice received systemic androgen treatment post major burn injury. Wound healing rate and body weight were monitored over 21 days. The serum level of inflammatory cytokines/chemokines were measured using multiplex immunoassays. In addition, splenocyte enumeration was performed by flow cytometry. Healing phases of inflammation, re-epithelialization, cell proliferation and collagen deposition were also examined. In results, DHT treated mice lost less weight and displayed accelerated wound healing but has no impact on hypermetabolism. Mice, after burn injury, displayed acute systemic inflammatory responses over 21 days. DHT treatment shortened the systemic inflammatory response with reduced splenic weight and monocyte numbers on day 14 and 21. DHT treatment also reduced wound infiltrating macrophage numbers. In conclusion, DHT treatment facilitates local wound healing by accelerating the resolution of inflammation, but not through alterations of post-burn hypermetabolic response.

Evaluation of Tp-e interval and Tp-e/QT ratio in major burn patients.

INTRODUCTION: Major burn injury is an acute stress reaction with systemic effects. Major burn injury has been associated with a number of cardiovascular dysfunctions, including ventricular arrhythmias. The mechanism of increased ventricular arrhythmias in burn patients uncertain. The aim of the present study was to evaluate the ventricular repolarization by using the Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio as candidate markers of ventricular arrhythmias in patients with major burn patients. In addition, the relationship between the repolarization parameters and the CRP(C-reactive protein) and ABSI(Abbreviated Burn Severity Index) score was investigated. METHODS: 55 major burn patients, 55 age and sex matched healthy subjects were included in the study between January 2017 and September 2019. The risk of ventricular arrhythmias was evaluated by calculating the electrocardiographic Tp-e and QT interval, corrected QT(QTc), Tp-e/QT and Tp-e/QTc ratios. ABSI score was calculated in burn patients. Left ventricular functions were evaluated by echocardiography. RESULTS: Tp-e interval (80.7 ±â€¯5.7 vs. 67.4 ±â€¯5.7; p < 0.001), Tp-e/QT ratio (0.21 ±â€¯0.01 vs. 0.18 ±â€¯0.01; p < 0.001) and Tp-e/QTc ratio (0.20 ±â€¯0.01 vs.0.17 ±â€¯0.01; p < 0.001) were significantly higher in major burn patients than the control group. There was a significant positive correlation between Tp-e interval, Tp-e/QTc ratio and ABSI score in major burn patients (r = 0.870, p < 0.001, r = 0.312, p = 0.020 consecutively). CONCLUSION: Our study showed for the first time in literature that the Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio, which were evaluated electrocardiographically in major burn patients, were prolonged compared with normal healthy individuals. A positive correlation was determined between repolarization parameters and ABSI score. Whether these changes increase the risk of ventricular arrhythmia deserve further studies. TAKE-HOME MESSAGE: Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio, which were evaluated electrocardiographically in major burn patients, were prolonged compared with normal healthy individuals and a positive correlation was found between these repolarization parameters and burn severity.

Pharmacokinetic analysis investigating gentamicin dosing in a major burned patient complicated by septic shock.

Profound pharmacokinetic alterations involving volume of distribution and clearance may impair the achievement of adequate antimicrobial serum concentrations in major burn patients. Gentamicin pharmacokinetic analysis was performed in a major burn victim with 90% of total body surface area affected and complicated by septic shock due to Serratia marcescens (minimum inhibitory concentration [MIC] = 2 mg/L). Gentamicin 240 mg was administered as a 30-min intravenous infusion, and plasma samples were obtained at 0-, 0.5-, 1-, 3- and 6-hour time points after the start of infusion. Gentamicin peak concentrations (CMAX) were 11.9 mg/L, providing for the achievement of an inadequate CMAX/MIC target. Volume of distribution was more than double as compared to healthy volunteers (0.44 vs. 0.18 L/Kg), while clearance was quite similar (5.21 vs. 5.42 L/h). Higher dosage (7-10 mg/Kg) coupled with adaptive therapeutic drug monitoring should be implemented in order to maximize gentamicin dosing schedule in critical challenging situations.

Review of Emergency Response Management of 33 Major Burn Victims of the Formosa Fun Coast Dust Explosion Disaster in a Regional Hospital Without Burn Units.

BACKGROUND: The Formosa Fun Coast Dust Explosion is one of the major national disasters in Taiwan. The Taipei City Hospital (TCH), a regional hospital without a burn unit, received 33 patients out of 499 casualties in the initial response period. This retrospective study aimed to review the primary response of TCH and the outcome and mortality of the patients who were initially managed at TCH. METHODS: Basic profi les, total body surface area (TBSA) with burn injury, facial burn injury, vital signs, laboratory data, intubation rate and clinical outcomes, such as urine output and mortality, were analyzed. Moreover, the emergency department (ED) response faculties, who were involved in the initial response, were interviewed about the critical decision-making processes during the patient surge in the ED. RESULTS: The average initial estimated TBSA with burn injury in ED was 34.2%, and the average final TBSA assessed in the intensive care unit was 41.0%. The patients with facial burn injury were 38.7%, and the intubation rate was 22.6%. When comparing the result of TCH to the patient group transferred directly to Chang Gung Memorial Hospital (CGMH), and the group received by CGMH from other hospital, the mortality rate was 0.0, 5.7, 9.1%; and the delayed intubation rate was 3.0, 14.3, 27.3%, respectively. The key elements for effi cient initial response were the multidisciplinary response team cooperated as a production line, using the clipboards for orders recordings, and the plastic surgeons ED-operating room (OR) direct transferring. CONCLUSIONS: Regarding airway complications, and mortality, patients who were initially managed in TCH had comparable results with patients directly sent to the burn centers. This study supports the notion that immediate resuscitation in multiple level of hospitals, even without burn units but with adequate recruited response personnel, provided the best chance for the survival of casualties during such national disasters.

Analysis of factors associated with mortality in major burn patients.

OBJECTIVES: Major burn injury is a type of trauma with high morbidity and mortality rates at all age groups. There is no consensus on the provided guidelines regarding the prediction of severity of the victims. Not being accessible to sophisticated clinical and blood monitoring in developing countries, it remains a challenge for them. The aim of the present study was to analyze the factors that have an effect on mortality and serve as a guide for burn treatment. Factors affecting mortality in major burn patients treated in a burn treatment center of a third step hospital with over 30% of burns of the total body surface area were evaluated, and parameters indicating severity were specifically determined. MATERIAL AND METHODS: Medical records and follow-up notes of patients hospitalized in Ankara Numune Education and Research Hospital Burn Center between 2008 and 2014 were evaluated retrospectively. Data on age, gender, comorbidities, burn percentage, locality, type of burn, process of the burn (suicide or accident), presence of inhalation injury, results of blood hemogram and biochemical tests, length of hospitalization, type of surgical procedures performed, presence of multitrauma, and ventilatory support requirement were analyzed to determine the factors affecting mortality. White blood cell count, hemoglobin count, platelet count, and lactate dehydrogenase level were examined at admission, at the middle of the clinical course, and at the end of treatment (at both exitus date or discharge date). RESULTS: A total of 224 patients were hospitalized with burns ≥ 30% total body surface area. Of the 224 patients, 81.7% were males, and 18.4% were females. In the mortality group, 41.3% were males, and 58.5% were females. Gender (female, p <0.041), age (p <0.001), age group (0-14/15-59/> 60 years, p <0.001), total body surface area (p <0.001), type of burn (flame, p <0.002), presence of inhalation injury (p <0.001), process of the burn (p <0.002), time spent between the event and admission to the hospital (p <0.001), length of hospitalization (p <0.001), presence of comorbidity (p <0.038), diabetes mellitus (p <0.05), ventilation support (p <0.001), lactate dehydrogenase values (lactate dehydrogenaseadmission, p <0.001; lactate dehydrogenasemiddle, p <0.015; lactate dehydrogenaselast, p <0.001), white blood cell count (p <0.001), and platelet count (p <0.043) were found to be significant for univariate analyses. These parameters were further evaluated using multivariate analyses. Lactate dehydrogenaselast level (p <0.001), age (p <0.001), length of hospitalization (negative odds ratio), p <0.001), presence of inhalation injury (p <0.029), total body surface area burned (p <0.029), and leukocytosis (p <0.006) were found to be significantly associated with mortality; however, leukocytosis and length of hospitalization did not pose risk for mortality with regard to odds ratios. CONCLUSION: Early recognition of the factors affecting morbidity and mortality in patients and taking preventive measures, in addition to earlier detection and prevention of complications in long-time intensive care unit patients, could reduce complication and mortality rates in major burn trauma patients. Parameters for the indication of severity and mortality are important; however, lactate dehydrogenase is an easily studied parameter and is found to have a predictive value on prognosis.

Cadaver skin allograft may improve mortality rate for burns involving over 30% of total body surface area: a propensity score analysis of data from four burn centers.

Cadaver skin is used for temporary wound covering, but there is insufficient evidence regarding its clinical usefulness in patients with major burns. We aimed to analyze the effect of cadaveric skin allograft on mortality rates in patients with burns involving > 30% of total body surface area (TBSA). Our study included 1282 patients with > 30% of TBSA burned admitted to four hospitals in Korea between June 1, 2008 and December 31, 2016. Of these, 698 patients underwent cadaver skin allograft (cadaver group), and 584 were treated with conventional treatment (non-cadaver group). We corrected the differences between the two groups using propensity score matching, and generated 474 propensity score-matched pairs. Overall 90-day in-hospital mortality rate among all patients was 35.3% (453/1282). There was a significant difference in 90-day in-hospital mortality between the two groups for both unmatched [cadaver vs. conventional, 31.7 vs. 39.7%; difference, 8.0; 95% confidence interval (CI) 2.8-13.3] and propensity-matched groups (37.8 vs. 47.3%; difference, 9.5; 95% CI 3.2-15.8). Logistic regression analyses showed a significant association between cadaver skin allograft and lower 90-day in-hospital mortality in the propensity-matched groups (odds ratio, 0.42; 95% CI 0.29-0.62). Patients with major burns who underwent cadaver skin allograft had a lower mortality rate compared to those who did not. Cadaver skin allograft may improve the survival of patients with major burns, especially in the early phase of injury.