A History of Fluid Management-From "One Size Fits All" to an Individualized Fluid Therapy in Burn Resuscitation.

Fluid management is a cornerstone in the treatment of burns and, thus, many different formulas were tested for their ability to match the fluid requirements for an adequate resuscitation. Thereof, the Parkland-Baxter formula, first introduced in 1968, is still widely used since then. Though using nearly the same formula to start off, the definition of normovolemia and how to determine the volume status of burn patients has changed dramatically over years. In first instance, the invention of the transpulmonary thermodilution (TTD) enabled an early goal directed fluid therapy with acceptable invasiveness. Furthermore, the introduction of point of care ultrasound (POCUS) has triggered more individualized schemes of fluid therapy. This article explores the historical developments in the field of burn resuscitation, presenting different options to determine the fluid requirements without missing the red flags for hyper- or hypovolemia. Furthermore, the increasing rate of co-morbidities in burn patients calls for a more sophisticated fluid management adjusting the fluid therapy to the actual necessities very closely. Therefore, formulas might be used as a starting point, but further fluid therapy should be adjusted to the actual need of every single patient. Taking the developments in the field of individualized therapies in intensive care in general into account, fluid management in burn resuscitation will also be individualized in the near future.

Sepsis in Burns-Lessons Learnt from Developments in the Management of Septic Shock.

After surviving the acute phase of resuscitation, septic shock is the cause of death in the majority of burn patients. Therefore, the management of septic shock is a cornerstone in modern burn care. Whereas sepsis therapy in general has undergone remarkable developments in the past decade, the management of septic shock in burn patients still has a long way to go. Instead, the differences of burn patients with septic shock versus general patients have been emphasized and thus, burn patients were excluded in every sepsis study which are the basis for modern sepsis therapy. However, due to the lack of evidence in burn patients, the standards of procedure for general sepsis therapy have been adopted in burn care. This review identifies the differences of burn patients with sepsis versus other septic patients and summarizes the scientific basis for modern sepsis therapy in general ICU patients and burn patients. Consequently, the results in general sepsis research should be transferred to burn care, which means the implementation of effective screening, early resuscitation, and efficient antimicrobial treatment. Therefore, on the basis of past developments and in the light of the current update of the Surviving Sepsis Campaign guidelines, this review introduces the "Burn SOFA score" and the "3 H's of burn sepsis" as a screening tool for early sepsis recognition in burn patients.

[Danger in the pocket: explosive e-cigarette]. / Gefahr in der Hosentasche ­ explosive E-Zigarette.

INTRODUCTION: Be it as a nicotine replacement or a fashionable seduction for young people or casual smokers with or without nicotine additives - the popularity of e-cigarettes in Europe has increased during the past decade. In addition to the potential of long-term pulmonary damage, which is still largely unknown to date, there is a risk of battery explosion with specific injury patterns. Most users are unaware of the danger in their pockets. MATERIAL AND METHODS: Between February and July 2019, four patients were treated with burns from exploded e-cigarettes in the burn centre at Sana Hospital in Offenbach am Main (Germany). This article describes the cause and extent of the injury and its treatment. RESULTS: In all patients, the cause of the explosion was what is called "thermal runaway" (very rapid discharge of the battery). The average age of the patients, who were exclusively male, was 37 (25-50) years. The combustion depth ranged from grade I to deep grade IIb. The burnt body surface averaged 3 % (0.5-4.5 %) TBSA and affected the body regions that are typically in direct contact with the e-cigarette: thighs, genitals and hands. Conservative treatment was successful in one case and surgical treatment in two cases (two alloplastic covers, one meshed split-skin transplant). One patient discharged himself from hospital against medical advice after initial treatment. The average time in hospital for the three remaining patients was 15.6 days (6-17). CONCLUSION: Burns from an exploding e-cigarette represent a rare new entity. The force of the explosion of the battery body leads to injury patterns that require treatment in specialised centres with the entire spectrum of burn care. Mixed injuries with deep burns occur at the predilection sites due to thermal action, colliquative necrosis due to leaking electrolyte fluid and contamination by foreign bodies (metallic lithium, splinters of the destroyed housing) and require special initial measures. The extinction of fire caused by e-cigarettes also requires special measures. Proper handling of CE-certified devices is essential. Manipulation of the device in the event of defective functions or defective batteries is highly dangerous and should be strictly prohibited. General security requirements must be observed.

[Improvement in burn wound care: summary of the AWMF guideline for the treatment of thermal injuries in adults]. / Optimierung der chirurgischen Behandlung Brandverletzter: Auszüge aus der fachübergreifenden S2k-Leitlinie "Behandlung thermischer Verletzungen des Erwachsenen".

INTRODUCTION: More than half a million patients suffer from minor burns in Germany per year. In 2018, almost 2000 patients needed intensive care for their burn injuries. Despite high standards of burn care, mortality remains high. Burn injuries may lead to long-term sequelae. In order to provide up-to-date burn care, guidelines are available online with public access. METHODS AND RESULTS: This overview presents a summary of the German AWMF guideline for the treatment of thermal injuries in adults (https://www.awmf.org/leitlinien/detail/ll/044-001.html). Experts of eleven different medical organisations and specialties have contributed to this S2k guideline with their expertise. The focus of the article is on acute burn wound assessment, the indication for specialised care in burn centres, the management of the burn wound at the trauma scene and in hospitals as well as scar management and rehabilitation. CONCLUSION: This overview reports on the consensus-based treatment of acute burn wounds in adults in Germany. The article is intended to guide doctors and professional caretakers to perform state-of-the-art burn care. The current guideline aims to improve burn outcome.

[Treatment options for burn injuries of the hand - an update]. / Aktuelle Behandlungsmethoden bei Verbrennungen der Hände.

Burn injuries of the hands happens very often. Up to 80 % of all severe burn victims suffer from a participation of their hands. A meticulous reconstruction of these areas is mandatory due to their important properties in form, function and aesthetic outcome. The treatment options actually are impressed by the efforts to reduce invasiveness, to increase the selectivity of necrectomy as well as the natural capacity of tissue regeneration.

Management of donor site infections in split-thickness skin graft with water-filtered infrared-A (wIRA).

Infection of donor sites in split-thickness skin grafts is one of the complications of skin transplantation. Nutrition status and associated diseases play important roles in healing of donor sites. There are different ways used to treat infected donor sites. Water-filtered infrared-A (wIRA), as a special form of heat radiation with a high tissue penetration and a low thermal load to the skin surface, can improve the healing of acute and chronic wounds both by thermal and thermic as well as by non-thermal and non-thermic effects. Water-filtered infrared-A (wIRA) increases tissue temperature, tissue oxygen partial pressure and tissue perfusion. These three factors are decisive for a sufficient supply of tissue with energy and oxygen and consequently also for wound healing and infection defense. This was confirmed in a case with a late severe healing disturbance of the donor sites after skin transplantation.

Sternal Resection for Breast Cancer Metastases.

BACKGROUND: Sternal infiltration of breast cancer (BC) is a rare but known phenomenon. Sternal resection for this cancer is not completely investigated. For this reason, the aim of this study was to examine long-term survival and prognosticators for prolonged survival of our patients after sternal resection. Also, morbidity and mortality were investigated. MATERIALS AND METHODS: We retrospectively analyzed our prospective database of 20 patients who underwent a sternum resection (partial/complete) for BC in our institution between 2003 and 2014. Furthermore, patients with additional lung metastases were included. All patients received a mesh-methyl methacrylate technique ("sandwich technique") and soft tissue coverage with myocutaneous muscle flap. Long-term outcomes and survival curves were performed by the Kaplan-Meier method. Survival differences and prognosticators were investigated using the log-rank test. RESULTS: Median survival was 32 months (95% confidence interval, 8-56 months). One-, 3-, and 5-year overall survivals were 79, 39, and 39%. There was a low morbidity and mortality with 35% (minor complications 30% and major complications 5%) and 0%. As prognosticators for longer survival, a positive hormone status (estrogen or progesterone) (p = 0.070) showed a trend. Neither age, primary mastectomy, disease-free interval < 24 months, primary N-status, nor preoperative chemotherapy showed a significant influence on survival. Furthermore, additional lung metastases did not influence survival significantly (p = 0.826). CONCLUSION: Sternal resections for BC patients can be associated with promising long-term survival. R0 resection, good functional and cosmetic results are achievable with low morbidity and mortality. Patients with additional lung metastases should not be routinely excluded from resection and should be discussed in interdisciplinary tumor boards.

[Plastic Surgical Correction of Buried Penis]. / Plastisch-chirurgische Korrektur des "Buried Penis".

A "buried penis" causes functional problems and embarrassment. In the past, this complex condition was only seen in extremely overweight patients or as a result of severe inflammations in this region. More recently, this problem has also been observed in patients with massive weight loss following bariatric surgery. In these patients there is an abundance of extremely flaccid skin in the suprapubic region, which covers the penis and causes it to "disappear". This leads to balanitis and, in turn, further retraction of the penis. The only solution to this condition is a sophisticated surgical approach in 3 phases: At first, suprapubic tissues must be lifted. Secondly, the penis must be completely denuded and debrided and the correct penopubic/penoscrotal angles must be reconstructed. The last phase includes a strainless coverage of the remaining defect of the penis. This condition has not been widely described in the literature. The general incidence and prevalence in the postbariatric population is unknown, probably due to patients' embarrassment and lack of knowledge on the physicians' end. Nevertheless, the buried penis can be successfully exposed through careful, structured surgical treatment and an interdisciplinary approach between plastic surgeons and urologists.

A Severely Burned Hemophiliac.

Patients suffering from moderate or severe hemophilia A are particularly vulnerable to trauma injury, being on high risk of immediate exsanguination. Due to a rareness of this disease, there are very few reports about the management of severe injuries of the affected patients. No guidelines for the management of burn trauma of hemophiliac patients have been yet established. Since, to our knowledge, this is the first case report about a successful treatment of a severely burned hemophiliac, requiring intensive care, long-time intubation, and multiple epifascial necrosectomies of third grade wounds, the authors are proposing the approach to this condition. The factor VIII has been substituted, enhancing its activity to over 70% during the planned interventions and keeping it above 30% in the intervals between the operations. To minimize the risk of surgical bleeding, our therapeutic strategy consisted of multiple short radical operations. The patient was healed and was dismissed after 68 days. The surgical blood loss was comparable with noncoagulopathic patients with similar burn extension. In case of a vast burn injury of the moderate or severe hemophiliacs, where the trauma-related consumption coagulopathy is expected and deep necrosectomies are required, the authors suggest starting a substitution of the factor VIII immediately after the admission, followed by a structured operative planning.

Development and Characterization of an Engraftable Tissue-Cultured Skin Autograft: Alternative Treatment for Severe Electrical Injuries.

BACKGROUND/AIMS: Optimizing the treatment regimens of extensive or nonhealing defects is a constant challenge. Tissue-cultured skin autografts may be an alternative to mesh grafts and keratinocyte suspensions that are applied during surgical defect coverage. METHODS: Autologous epidermal and dermal cells were isolated, in vitro expanded and seeded on collagen-elastin scaffolds. The developed autograft was immunohistochemically and electron microscopically characterized. Subsequently, it was transplanted onto lesions of a severely burned patient. RESULTS: Comparability of the skin equivalent to healthy human skin could be shown due to the epidermal strata, differentiation, proliferation markers and development of characteristics of a functional basal lamina. Approximately 2 weeks after skin equivalent transplantation the emerging new skin correlated closely to the adjacent normal skin. CONCLUSION: The present study demonstrates the comparability of the developed organotypic skin equivalent to healthy human skin and its versatility for clinical applications.

Evaluation of the McPeek postoperative outcome score in three trials.

BACKGROUND: Postoperative outcome of patients is determined by recovery characteristics and self-reported quality of life. The first can be assessed with the McPeek score which values three aspects of recovery: mortality, postoperative critical care and duration of hospitalization. MATERIALS AND METHODS: We calculated the McPeek score of 669 patients in three trials: (1) colorectal cancer surgery, (2) antihistamine/volume loading in various operations, and (3) cholecystectomy. Beforehand, the average of intensive care unit treatment and duration of hospitalization were determined for the different operations to define McPeek score points. The score was tested on reliability, validity, and sensitivity. In addition, clinical applicability was assessed in a survey. RESULTS: The score was reliable with similarly distributed score points in the three trials at different institutions. Inter-rater reliability was high (97% overlap). Validity was proven by moderate high correlation to convergent criteria such as complications (trial I to III r=0.43, r=0.38, r=0.60), preoperative American Society of Anesthesiologists class (ASA) (r=0.24, r=0.28, r=0.57), and age (r=0.23, r=0.32, r=0.31). The score was different between patients with and without neoplasms (P<0.001, trial II) and between elective or emergency patients (P<0.001, trial III). In a survey, investigators reported that the score was easy to assess and more comprehensive than four other scores. CONCLUSIONS: The McPeek score values the postoperative outcome on a nonlinear scale. A priori, the average duration of hospitalization and critical care for a specific operation has to be defined. Our validation suggests that it is a reliable, valid, sensitive, and practical instrument for outcome analysis after anesthesia and surgery.

Vaginoplasty with split skin grafts from the scalp: optimization of the surgical treatment for vaginal agenesis.

With this case study, we propose the use of the scalp as the donor site for vaginoplasty with split skin grafts. Patients with a congenital absence of a vagina should also benefit from the obvious advantages, which made the scalp the preferred donor site in burn patients.

Role of nitric oxide in the mechanism of preclamping and remote ischemic preconditioning of adipocutaneous flaps in a rat model.

The purpose of this study was to determine whether nitric oxide (NO) plays a role in the mechanism of acute ischemic preconditioning (IP). Fifty-eight male Wistar rats were divided into seven experimental groups. An extended epigastric flap was raised in one of the control groups (C, n = 8), and a 3-hr flap ischemia was induced. Another group served as a non-ischemic control (CO, n = 8). The animals of group S (n = 9) received 500 nmol/kg of Spermine/Nitric Oxide Complex (Sper/NO) intravenously 30 min prior to ischemia. The group N+P (L-NAME + preclamping, n = 8) received 10 mg/kg Nomega-Nitro-L-Arginine Methyl Ester (L-NAME) intravenously before preclamping of the flap pedicle (10-min cycle length, 30-min reperfusion). Ten mg/kg L-NAME were administered in group N+T (L-NAME + tourniquet, n = 9) before ischemia of the right hindlimb was induced using a tourniquet for 10 min after flap elevation. Flap ischemia was induced after 30 min of limb reperfusion. A similar protocol was used in the groups N+P+S (L-NAME + preclamping+Sper/NO, n = 8) and N+T+S (L-NAME + tourniquet + Sper/NO, n = 8). In both groups Sper/NO was administered 30 min prior to flap ischemia, additionally to the protocol of the groups N+P and N+T. Mean flap necrosis area was assessed on the fifth postoperative day using a planimetry software. Average flap necrosis area was 67 +/- 16 percent in the control group C, 28 +/- 13.3 percent in the non-ischemic controls (CO), 10 +/- 5.9 percent in group S, 77.5 +/- 10.2 percent in group N+P, 76 +/- 6.9 percent in group N+T, 71.5 +/- 9.4 percent in group N+P+S, and 78 +/- 9.9 percent in group N+T+S. The animals of group S and CO demonstrated a significantly lower area of flap necrosis than all other groups ( p < 0.001). No significant difference could be shown between the groups C, N+P, N+T, N+P+S and N+T+S. Group S showed a significantly lower flap necrosis area than group CO ( p < 0.01). The data showed, that NO plays an important role in the mechanism of IP since the administration of an NO-donor previous to ischemia simulates the effect of IP, while the unspecific blocking of NO synthesis by L-NAME eliminates the protective effect of flap preconditioning by preclamping as well as by remote IP. Exogenous NO application is insufficient to provide protection once the endogenous NO synthesis is blocked.

Acute remote ischemic preconditioning II: the role of nitric oxide.

The purpose of this study was to determine whether nitric oxide (NO) plays a role in the mechanism of acute "classic" as well as acute remote ischemic preconditioning (IP). Thirty-two male Wistar rats were divided into five experimental groups. The rat cremaster flap in vivo microscopy model was used for assessment of ischemia/reperfusion injury. In the control group (CG, n = 8), a 2-hr flap ischemia was induced after preparation of the cremaster muscle. The animals of group NO (n = 6) received 500 nmol/kg of the NO-donor spermine/nitric oxide complex (Sper/NO) intravenously 30 min prior to ischemia. The group LN + P (L-NAME + preclamping, n = 6) received 10 mg/kg Nomega-nitro-L-arginine methyl ester (L-NAME) intravenously before preclamping of the flap pedicle (10-min cycle length, 30-min reperfusion). L-NAME (10 mg/kg) was administered in group LN + T (L-NAME + tourniquet, n = 6) before ischemia of the right hindlimb was induced, using a tourniquet for 10 min after flap elevation. The limb was then reperfused for 30 min. Thereafter, flap ischemia was induced in each group as in group CG. In vivo microscopy was performed after 1 hr of flap reperfusion in each animal. Group NO demonstrated a significantly higher red blood cell velocity (RBV) in the first-order arterioles and capillaries, a higher capillary flow, and a decreased number of leukocytes adhering to the endothelium (stickers) of the postcapillary venules by comparison to all other groups (P < 0.05). The average capillary RBV and capillary flow were still higher in the CG than in the groups receiving L-NAME (P < 0.05). The data show that NO plays an important role in the mechanism of both acute "classic" as well as acute remote IP, since the administration of a NO-donor previous to ischemia simulates the effect of IP, whereas the nonspecific blocking of NO synthesis by L-NAME abolishes the protective effect of flap preconditioning.

Ischemic preconditioning by brief extremity ischemia before flap ischemia in a rat model.

Ischemic preconditioning is a protective endogenous mechanism to reduce ischemia/reperfusion injury and is defined as a brief period of ischemia the authors term "preclamping." This is followed by tissue reperfusion and is believed to increase the ischemic tolerance. The objective of this study was to determine whether acute remote ischemic preconditioning, which has been reported to be successful for other organs, such as the heart, kidney, intestine, and liver, will also result in an enhancement of survival in flaps, and whether remote ischemic preconditioning is as effective as preclamping. Forty male Wistar rats were divided into four experimental groups. An extended epigastric adipocutaneous flap (6 x 10 cm) was raised, based on the left superficial epigastric artery and vein. In the control group, a 3-hour flap ischemia was induced. In the preclamping group, a brief ischemia of 10 minutes was induced by clamping the flap pedicle, followed by 30 minutes of reperfusion. Ischemia of the right hind limb was induced in the femoral ischemia group by clamping the femoral artery and vein for 10 minutes after flap elevation. The limb was then reperfused for 30 minutes. Thereafter, flap ischemia was induced as in the control group. A similar protocol was used in the tourniquet group. A tourniquet was used to induce hind-limb ischemia. The experiment was then performed as in the femoral ischemia group. Mean flap necrosis area was assessed for all groups on the fifth postoperative day using planimetry software. Average flap necrosis area was 68.2 +/- 18.1 percent in the control group, 11 +/- 8.38 percent in the preclamping group, 12.5 +/- 5.83 percent in the femoral ischemia group, and 24 +/- 11.75 percent in the tourniquet group. All preconditioned animals demonstrated a significantly lower area of flap necrosis than the control group (p < 0.001, one-way analysis of variance, post hoc Tukey's test). The data show that ischemic preconditioning and enhancement of flap survival can be achieved not only by preclamping of the flap pedicle but also by induction of an ischemia/reperfusion event in a body area distant from the flap before harvest. These findings indicate that remote ischemic preconditioning is a systemic phenomenon, leading to an enhancement of flap survival. The exact mechanism is not yet completely understood. The data suggest that remote ischemic preconditioning could be performed simultaneously with flap harvest in the clinical setting, resulting in an improved flap survival without prolongation of the operation. This may decrease the rate of partial flap loss or fat necrosis, especially in high-risk groups such as smokers, those with irradiated tissues, and obese patients.