Complex approach to skin repair in an extensively burned child: a case study.

The limited amount of donor sites and loss of dermis are major challenges in the therapy of extensively burned patients. Here, we present a complex treatment approach of an eight-year-old boy with full-thickness burns on 90% of the total body surface area, using simple and efficient techniques of tissue engineering. To obtain sufficient skin for grafting we repeatedly harvested the same anatomical areas. Acceleration of donor site healing was achieved by treatment with a suspension of noncultured autologous skin cells (NASC) and acellular porcine dermis (Xe-Derma (XD), Czech Republic). Moreover, such wound management allowed up to six reharvestings, compared with one-to-three procedures following routine treatment. Bilayer Integra template (Integra LifeSciences Corp., US) was used as the dermal substitute in over 60% of full-thickness burns. Following successful vascularisation of the neodermis in 3-4 weeks, the templates were covered with meshed split-thickness skin grafts (STSG), or Meek autografts, and facilitated by NASC/XD. We may conclude that such a 'sandwich' technique approach, combining four biological covers (Integra, STSG, NASC and XD), significantly contributed to the successful skin repair of the patient.

Fluid therapy LiDCO controlled trial-optimization of volume resuscitation of extensively burned patients through noninvasive continuous real-time hemodynamic monitoring LiDCO.

This pilot trial aims at gaining support for the optimization of acute burn resuscitation through noninvasive continuous real-time hemodynamic monitoring using arterial pulse contour analysis. A group of 21 burned patients meeting preliminary criteria (age range 18-75 years with second- third- degree burns and TBSA ≥10-75%) was randomized during 2010. A hemodynamic monitoring through lithium dilution cardiac output was used in 10 randomized patients (LiDCO group), whereas those without LiDCO monitoring were defined as the control group. The modified Brooke/Parkland formula as a starting resuscitative formula, balanced crystalloids as the initial solutions, urine output of 0.5 ml/kg/hr as a crucial value of adequate intravascular filling were used in both groups. Additionally, the volume and vasopressor/inotropic support were based on dynamic preload parameters in the LiDCO group in the case of circulatory instability and oligouria. Statistical analysis was done using t-tests. Within the first 24 hours postburn, a significantly lower consumption of crystalloids was registered in LiDCO group (P = .04). The fluid balance under LiDCO control in combination with hourly diuresis contributed to reducing the cumulative fluid balance approximately by 10% compared with fluid management based on standard monitoring parameters. The amount of applied solutions in the LiDCO group got closer to Brooke formula whereas the urine output was at the same level in both groups (0.8 ml/kg/hr). The new finding in this study is that when a fluid resuscitation is based on the arterial waveform analysis, the initial fluid volume provided was significantly lower than that delivered on the basis of physician-directed fluid resuscitation (by urine output and mean arterial pressure).

Natriuretic peptide proANP (1-98), a biomarker of ALI/ARDS in burns.

INTRODUCTION: Plasma atrial natriuretic peptide levels (proANP (1-98)), a parameter of myocardial dysfunction, have been reported to be increased in critically ill patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). The aim of the study was to examine if proANP is a biomarker of ALI/ARDS as assessed by the Sequential Organ Failure Assessment score (SOFA Lung ≥2) in burn patients, and how it compares to the corresponding values for age, total body surface area percent (TBSA%) and inhalation injury for mortality prediction. METHODS: A group of 22 burn patients with a mean TBSA of 30% (10-75%) and a mean age of 52 years (25-84 years) was investigated during 2010. Organ dysfunction/failure was classified according to the SOFA score. The criteria for ALI/ARDS were based on SOFA Lung ≥2. ProANP (1-98) concentrations (nmoll(-1)) were measured by commercially available enzyme linked immunosorbent assay (ELISA) immunoassays (Biomedica Austria) on post-burn days 2 and 7. RESULTS: ProANP levels on day 7 post-burn positively correlated with a SOFA score day 7 post-burn, c=0.91. The receiver operating curve (ROC) analysis proved a sensitivity of 75% and a specificity of 75% for ALI/ARDS at cut-off values >3.35 nmoll(-1). The ROC value of proANP for ALI/ARDS (SOFA Lung ≥2) was significantly larger than that of age, TBSA% and inhalation injury: 0.90, 0.71, 0.74, and 0.69 (p<0.001). CONCLUSIONS: ProANP levels, as a biomarker of ALI/ARDS, in critically burn patients correlated with SOFA scoring. The inhalation injury did not lead to increase in proANP values.

Bioenergetic gain of citrate anticoagulated continuous hemodiafiltration--a comparison between 2 citrate modalities and unfractionated heparin.

PURPOSE: To determine bioenergetic gain of 2 different citrate anticoagulated continuous hemodiafiltration (CVVHDF) modalities and a heparin modality. MATERIALS AND METHODS: We compared the bio-energetic gain of citrate, glucose and lactate between 29 patients receiving 2.2% acid-citrate-dextrose with calcium-containing lactate-buffered solutions (ACD/Ca(plus)/lactate), 34 on 4% trisodium citrate with calcium-free low-bicarbonate buffered fluids (TSC/Ca(min)/bicarbonate), and 18 on heparin with lactate buffering (Hep/lactate). RESULTS: While delivered CVVHDF dose was about 2000 mL/h, total bioenergetic gain was 262 kJ/h (IQR 230-284) with ACD/Ca(plus)/lactate, 20 kJ/h (8-25) with TSC/Ca(min)/bicarbonate (P < .01) and 60 kJ/h (52-76) with Hep/lactate. Median patient delivery of citrate was 31.2 mmol/h (25-34.7) in ACD/Ca(plus)/lactate versus 14.8 mmol/h (12.4-19.1) in TSC/Ca(min)/bicarbonate groups (P < .01). Median delivery of glucose was 36.8 mmol/h (29.9-43) in ACD/Ca(plus)/lactate, and of lactate 52.5 mmol/h (49.2-59.1) in ACD/Ca(plus)/lactate and 56.1 mmol/h (49.6-64.2) in Hep/lactate groups. The higher energy delivery with ACD/Ca(plus)/lactate was partially due to the higher blood flow used in this modality and the calcium-containing dialysate. CONCLUSIONS: The bioenergetic gain of CVVHDF comes from glucose (in ACD), lactate and citrate. The amount substantially differs between modalities despite a similar CVVHDF dose and is unacceptably high when using ACD with calcium-containing lactate-buffered solutions and a higher blood flow. When calculating nutritional needs, we should account for the energy delivered by CVVHDF.