[Value of cerebral hypoxic-ischemic injury markers in the early diagnosis of sepsis associated encephalopathy in burn patients with sepsis].

Objective: To explore the value of cerebral hypoxic-ischemic injury markers in the early diagnosis of sepsis associated encephalopathy (SAE) in burn patients with sepsis. Methods: A retrospective case series study was conducted. From October 2018 to May 2021, 41 burn patients with sepsis who were admitted to Zhengzhou First People's Hospital met the inclusion criteria, including 23 males and 18 females, aged 18-65 (35±3) years. According to whether SAE occurred during hospitalization, the patients were divided into SAE group (21 cases) and non-SAE group (20 cases). The gender, age, deep partial-thickness burn area, full-thickness burn area, and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) scores of patients were compared between the two groups. The serum levels of central nervous system specific protein S100ß and neuron specific enolase (NSE) at 12, 24, and 48 h after sepsis diagnosis (hereinafter referred to as after diagnosis), the serum levels of interleukin-6 (IL-6), IL-10, tumor necrosis factor α (TNF-α), Tau protein, adrenocorticotropic hormone (ACTH), and cortisol at 12, 24, 48, 72, 120, and 168 h after diagnosis, and the mean blood flow velocity of middle cerebral artery (VmMCA), pulsatility index, and cerebral blood flow index (CBFi) on 1, 3, and 7 d after diagnosis of patients in the two groups were counted. Data were statistically analyzed with chi-square test, analysis of variance for repeated measurement, independent sample t test, and Bonferroni correction. The independent variables to predict the occurrence of SAE was screened by multi-factor logistic regression analysis. The receiver operating characteristic (ROC) curve was drawn for predicting the occurrence of SAE in burn patients with sepsis, and the area under the curve (AUC), the best threshold, and the sensitivity and specificity under the best threshold were calculated. Results: The gender, age, deep partial-thickness burn area, full-thickness burn area, and APACHE Ⅱ score of patients in the two groups were all similar (χ2=0.02, with t values of 0.71, 1.59, 0.91, and 1.07, respectively, P>0.05). At 12, 24, and 48 h after diagnosis, the serum levels of S100ß and NSE of patients in SAE group were all significantly higher than those in non-SAE group (with t values of 37.74, 77.84, 44.16, 22.51, 38.76, and 29.31, respectively, P<0.01). At 12, 24, 48, 72, 120, and 168 h after diagnosis, the serum levels of IL-10, Tau protein, and ACTH of patients in SAE group were all significantly higher than those in non-SAE group (with t values of 10.68, 13.50, 10.59, 8.09, 7.17, 4.71, 5.51, 3.20, 3.61, 3.58, 3.28, 4.21, 5.91, 5.66, 4.98, 4.69, 4.78, and 2.97, respectively, P<0.01). At 12, 24, 48, 72, and 120 h after diagnosis, the serum levels of IL-6 and TNF-α of patients in SAE group were all significantly higher than those in non-SAE group (with t values of 8.56, 7.32, 2.08, 2.53, 3.37, 4.44, 5.36, 5.35, 6.85, and 5.15, respectively, P<0.05 or P<0.01). At 12, 24, and 48 h after diagnosis, the serum level of cortisol of patients in SAE group was significantly higher than that in non-SAE group (with t values of 5.44, 5.46, and 3.55, respectively, P<0.01). On 1 d after diagnosis, the VmMCA and CBFi of patients in SAE group were significantly lower than those in non-SAE group (with t values of 2.94 and 2.67, respectively, P<0.05). On 1, 3, and 7 d after diagnosis, the pulsatile index of patients in SAE group was significantly higher than that in non-SAE group (with t values of 2.56, 3.20, and 3.12, respectively, P<0.05 or P<0.01). Serum IL-6 at 12 h after diagnosis, serum Tau protein at 24 h after diagnosis, serum ACTH at 24 h after diagnosis, and serum cortisol at 24 h after diagnosis were the independent risk factors for SAE complicated in burn patients with sepsis (with odds ratios of 2.42, 1.38, 4.29, and 4.19, 95% confidence interval of 1.76-3.82, 1.06-2.45, 1.37-6.68, and 3.32-8.79, respectively, P<0.01). For 41 burn patients with sepsis, the AUC of ROC of serum IL-6 at 12 h after diagnosis for predicting SAE was 0.92 (95% confidence interval was 0.84-1.00), the best threshold was 157 pg/mL, the sensitivity was 81%, and the specificity was 89%. The AUC of ROC of serum Tau protein at 24 h after diagnosis for predicting SAE was 0.92 (95% confidence interval was 0.82-1.00), the best threshold was 6.4 pg/mL, the sensitivity was 97%, and the specificity was 99%. The AUC of ROC of serum ACTH at 24 h after diagnosis for predicting SAE was 0.96 (95% confidence interval was 0.89-1.00), the best threshold was 14.7 pg/mL, the sensitivity was 90%, and the specificity was 94%. The AUC of ROC of serum cortisol at 24 h after diagnosis for predicting SAE was 0.93 (95% confidence interval was 0.86-1.00), the best threshold was 89 nmol/L, the sensitivity was 94%, and the specificity was 97%. Conclusions: Serum Tau protein, ACTH, and cortisol have high clinical diagnostic value for SAE complicated in burn patients with sepsis.

[Value of renal injury marker protein in early diagnosis of acute kidney injury in burn patients with delayed resuscitation].

Objective: To explore the value of renal injury marker protein in early diagnosis of acute kidney injury (AKI) in burn patients with delayed resuscitation. Methods: The retrospective case-control research was conducted. Forty-three burn patients with delayed resuscitation (27 males and 16 females, with age of 18-75 (35±3) years)who were admitted to Zhengzhou First People's Hospital from May 2018 to May 2020 met the inclusion criteria. The patients were divided into AKI group with 23 patients and non-AKI group with 20 patients according to whether AKI occurred within 7 days after burns. The gender, age, deep partial-thickness burn area, full-thickness burn area, and acute physiology and chronic health evaluation Ⅱ of patients were compared between the two groups.The fluid supplement volume and serum creatinine at 12, 24, and 48 h after burn, serum albumin/fibrinogen ratio (AFR), urinary heat shock protein 70 (HSP70), tissue inhibitor of metalloproteinase-2 (TIMP-2)×insulin-like growth factor binding protein 7 (IGFBP-7), and neutrophil gelatinase associated lipocalin (NGAL)at 12, 24, 48, 72, 120, and 168 h after burn were detected.Data were statistically analyzed with Mann-Whitney U test, analysis of variance for repeated measurement, independent-samples t test, chi-square test and Bonferroni correction. The independent variable to predict the occurrence of AKI was screened by multi-factor logistic regression analysis. The receiver's operating characteristic curve was drawn for predicting the occurrence of AKI in burn delayed resuscitation patients, and the area under the curve (AUC), the best threshold, and the sensitivity and specificity under the best threshold were calculated. Results: The gender, age, deep partial-thickness burn area, full-thickness burn area, acute physiology and chronic health evaluation Ⅱ of patients in two groups were similar (χ(2)=1.98, t=1.98, 1.99, 1.99, 1.99, P>0.05). The fluid supplement volume of patients in AKI group at 24 and 48 h after burn was significantly less than that in non-AKI group (t=15.37, 6.51, P<0.01). The serum creatinine of patients in AKI group at 12, 24, and 48 h after burn was significantly higher than that in non-AKI group (Z=2.16, 5.62, 6.72, P<0.01). The serum AFR of patients in AKI group at 12, 24, 48, 72, 120, and 168 h after burn was significantly lower than that in non-AKI group (t=16.14, 35.35, 19.60, 20.47, 30.20, 20.17, P<0.01). The levels of urinary HSP70 of patients in AKI group at 12, 24, 48, 72, 120, and 168 h after burn were (6.89±0.87), (6.42±0.73), (5.81±0.72), (5.17±0.56), (4.63±0.51), (3.89±0.51) µg/L, which were significantly higher than (3.89±0.75), (3.57±0.63), (2.66±0.41), (1.83±0.35), (1.48±0.19), (1.28±0.19) µg/L in non-AKI group (t=12.00, 13.61, 17.39, 22.98, 26.34, 21.59, P<0.01). Urinary TIMP-2×IGFBP-7 and NGAL of patients in AKI group at 12, 24, 48, 72, 120, 168 h after burn were significantly higher than those in non-AKI group (t=26.94, 101.11, 35.50, 66.89, 17.34, 14.30, 14.00, 13.78, 12.32, 14.80, 21.36, 22.62, P<0.01). Urinary HSP70 and serum AFR at 12 h after burn, urinary TIMP-2×IGFBP-7 and NGAL at 24 h after burn were included into multi-factor logistic regression analysis (odds ratio=2.42, 3.47, 7.52, 5.61, 95% confidence interval=1.99-2.95, 1.86-3.92, 2.87-9.68, 2.14-14.69, P<0.01). For 43 patients with burn delayed resuscitation, the AUC of receiver's operating characteristic curve of serum AFR at 12 h after burn for predicting AKI was 0.739 (95% confidence interval=0.576-0.903), the optimal threshold was 9.90, the sensitivity was 82%, and the specificity was 90%. The AUC of urinary HSP70 at 12 h after burn was 0.990 (95% confidence interval=0.920-1.000), the optimal threshold was 1.40 µg/L, the sensitivity was 98%, and the specificity was 96%. The AUC of urinary TIMP-2×IGFBP-7 at 24 h after burn was 0.715 (95% confidence interval=0.512-0.890), the optimal threshold was 114.20 µg(2)/L(2), the sensitivity was 91%, and the specificity was 95%. The AUC of urinary NGAL at 24 h after burn was 0.972 (95% confidence interval=0.860-1.000), the optimal threshold was 78 µg/L, the sensitivity was 95%, and the specificity was 96%. Conclusions: Urinary HSP70 and NGAL have higher value in early diagnosis of AKI in burn patients with delayed resuscitation.

[Successful rescue of one severe burn patient accompanied by asphyxia, sudden cardiac arrest, and acute respiratory distress syndrome].

On March 14, 2017, a thirty years old male severe burn patient accompanied by asphyxia, sudden cardiac arrest, and acute respiratory distress syndrome was admitted to Zhengzhou First People's Hospital. During the shock stage, the pulse contour cardiac output was monitored for the restrictive rehydration, tracheotomy was performed, and fibrobronchoscope lavage was performed for the treatment of inhalation injury and pulmonary infection. An alternate application of suspended bed and turning bed was conducted to balance the treatment of cerebral edema and pulmonary infection; targeted antibiotics were used for anti-infective treatment; multiple operations were performed for eschar excision and skin grafting. At last, the wounds were all healed, the lung infection was cured, and the patient was discharged with severe disturbance of consciousness. Asphyxia and acute respiratory distress syndrome post-cardiopulmonary resuscitation are serious complications in severe burn patients. The clinical treatment of such patients is very difficult and should be highly alerted.

[Occurrence of deep venous thrombosis in adult burn patients and its risk factors].

Objective: To investigate the occurrence and risk factors of deep venous thrombosis (DVT) in adult burn patients. Methods: The clinical data of 1 219 adult burn patients admitted to the Department of Burns of Zhengzhou First People's Hospital from January 1, 2015 to August 31, 2016, conforming to the study criteria, were analyzed retrospectively by the method of case-control study, including 811 males and 408 females, aged 18-102 years. According to whether DVT occurred during hospitalization or not, the patients were divided into group DVT (n=12) and non-DVT group (n=1 207). The incidence of DVT, the diagnosis time of DVT, affected limbs, and DVT classification were counted and recorded. The gender, age, total burn area, D-dimer, lower limb burn, full-thickness burn, femoral vein indwelling central venous catheter (CVC) , inhalation injury, sepsis/infection shock, surgical operation, and infusion of concentrated red blood cells of patients between the two groups were compared with chi-square test, and then the indicators with statistically significant differences between the two groups were processed by multivariate binary logistic regression analysis to screen the independent risk factors of DVT in the adult burn patients. Results: (1) The incidence of DVT of adult burn patients was 0.98% (12/1 219), and DVT was diagnosed 24-138 days after injury, with a median of 61.5 days. DVT occurred in the right lower limb of 2 patients, left lower limb of 8 patients, and bilateral lower limbs of 2 patients, and DVT classification included 6 cases of mixed type and 6 cases of peripheral type. (2) There were no statistically significant differences in gender, age, and full-thickness burn of patients between the two groups ( χ(2)=1.524, 0.021, 3.115, P>0.05). There were statistically significant differences in total burn area, lower limb burn, inhalation injury, sepsis/infection shock, D-dimer, femoral vein indwelling CVC, surgical operation, and infusion of concentrated red blood cells among patients between the two groups (χ(2)=17.975, 6.206, 3.987, 8.875, 5.447, 15.124, 10.735, 14.031, P<0.05 or P<0.01). (3) Total burn area, D-dimer, and femoral vein indwelling CVC were independent risk factors for DVT in adult burn patients (odds ratio=10.927, 4.762, 9.394, 95% confidence interval=3.078-38.789, 1.197-18.934, 2.631-33.540, P<0.05 or P<0.01). Conclusions: The incidence of DVT in adult burn patients is relatively low, and the diagnosis time of DVT is 3 weeks after burn, with DVT classification of mixed type and peripheral type. The total burn area, femoral vein indwelling CVC, and D-dimer are independent risk factors for predicting DVT in adult burn patients.

[Effects of citric acid on patients with severe burn complicated with acute renal injury treated by continuous renal replacement therapy].

Objective: To explore the effects of citric acid on patients with severe burn complicated with acute renal injury treated by continuous renal replacement therapy (CRRT). Methods: Medical records of 83 patients with large area of burn complicated with acute renal injury admitted to intensive care unit (ICU) of our department from January 2015 to December 2018 and meeting the inclusion criteria were analyzed retrospectively. The patients were divided into heparin group [n=43, 25 males and 18 females, aged (35.0±2.5) years] and citric acid group [n=40, 22 males and 18 females, aged (37.0±6.6) years] according to different anticoagulation methods. After admission, routine support treatment and CRRT were performed after being diagnosed with acute renal injury in patients in 2 groups. Patients in heparin group were treated with low molecular weight heparin for anticoagulation with first dosage of 20 U/kg and an increase of 2.5 to 5.0 U per hour, and patients in citric acid group were given citric acid of 0.02 g/mL with dosage of 150~200 mL/h for anticoagulation. The use time of blood filter, recovery time of urine volume, and time of staying in ICU, and platelet count, activated partial thromboplastin time (APTT), prothrombin time (PT), and serum creatinine, urea nitrogen, cystatin C, procalcitonin, C-reactive protein, and neutrophil, leukocyte count, blood sugar, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and heart rate, body temperature, and mean arterial pressure before treatment and post treatment hour (PTH) 24 were recorded. Besides, occurrence of hemorrhage, hypocalcemia, metabolic acidosis, metabolic alkalosis, and death within 28 days post injury were recorded. Data were processed with t test and chi-square test. Results: The use time of blood filter of patients in citric acid group was (28.7±3.2)h, significantly longer than (19.4±2.6) h in heparin group (t=14.139, P<0.01). The recovery time of urine volume and time of staying in ICU of patients in citric acid group were respectively (7.6±0.9) and (9.6±1.3) d, significantly shorter than (9.2±1.5) and (11.2±1.8) d in heparin group (t=5.516, 4.697, P<0.01). Before treatment, there were no statistically significant differences in platelet count, APTT, and PT of patients in 2 groups (t=1.235, 0.515, 1.279, P>0.05). At PTH 24, the platelet count of patients in citric acid group was significantly higher than that in heparin group (t=10.947, P<0.01), and APTT and PT of patients in citric acid group were significantly shorter than those in heparin group (t=7.069, 9.142, P<0.01). Before treatment, there were no statistically significant differences in serum creatinine, urea nitrogen, and cystatin C of patients in 2 groups (t=1.684, 1.878, 1.472, P>0.05). At PTH 24, the serum creatinine, urea nitrogen, and cystatin C of patients in citric acid group were significantly lower than those in heparin group (t=7.778, 9.776, 5.117, P<0.01). Before treatment, there were no statistically significant differences in serum procalcitonin and C-reactive protein of patients in 2 groups (t=1.413, 0.898, P>0.05). At PTH 24, the serum procalcitonin and C-reactive protein of patients in citric acid group were significantly lower than those in heparin group (t=2.635, 2.297, P<0.05). Before treatment, there were no statistically significant differences in neutrophil, leukocyte count, blood sugar, AST, and ALT of patients in 2 groups (t=0.555, 0.816, 0.470, 1.896, 0.982, P>0.05). At PTH 24, the neutrophil, leukocyte count, blood sugar, AST, and ALT of patients in citric acid group were significantly lower than those in heparin group (t=2.054, 3.314, 7.185, 2.151, 3.013, P<0.05 or P<0.01). Before treatment, there were no statistically significant differences in heart rate, body temperature, and mean arterial pressure of patients in 2 groups (t=1.406, 0.474, 0.720, P>0.05). At PTH 24, the heart rate, body temperature, and mean arterial pressure of patients in citric acid group were significantly lower than those in heparin group (t=2.307, 4.498, 2.056, P<0.05 or P<0.01). The incidence of hemorrhage of patients in citric acid group while in hospital was significantly lower than that in heparin group (χ(2)=4.949, P<0.05). There were no statistically significant differences in incidence of hypocalcemia, metabolic acidosis, metabolic alkalosis, and death rate within 28 days post injury of patients in 2 groups while in hospital (χ(2)=3.346, 0.884, 0.297, 0.324, P>0.05). Conclusions: Citric acid has significant anticoagulant effect on patients with large area of burn complicated with acute renal injury treated by CRRT, which can prolong the use time of the blood filter, shorten the recovery time of urine volume and time of staying in ICU, improve renal function indexes, blood biochemical indexes, and inflammation indexes, maintain the stability of internal environment, and reduce the risk of hemorrhage.

[Early diagnosis and treatment for burn complicated with severe paroxysmal sympathetic hyper-activity].

Objective: To investigate the early diagnosis and treatment for burn complicated with severe paroxysmal sympathetic hyperactivity (PSH). Methods: Medical records of patients with burn complicated with severe PSH, admitted to our department from April 2016 to March 2019 and meeting the inclusion criteria were analyzed retrospectively. There were 4 males and 1 female, aged 17 months to 39 years, with an average of (21±16) years. During occurrence of PSH, the vital signs of patients were routinely monitored and oxygen were given. Other treatment included central venous catheterization and infusion of electrolyte solution, infusion of plasma according to patients' condition, use of opioid analgesics and benzodiazepine sedatives, physical cooling and drug cooling, and establishment or maintenance of artificial airway and use of ventilator. Heart rate was controlled below 120 beats per minute in adults and 140 beats per minute in children with comprehensive treatment dominated by analgesia and sedation. Besides, single or multiple vasoactive agents, even in large doses were used to maintain normal blood pressure of patients. The occurrence characteristics, time, and treatment outcome of PSH were analyzed. Results: PSH happened rapidly, with a sharp increase in several minutes to dozens of minutes. Five patients were with symptoms such as high body temperature, shortness of breath, very fast heart rate, normal or elevated systolic blood pressure, hyperhidrosis, and dystonia at the onset. The symptoms occurred simultaneously or successively. According to the Clinical Feature Scale, the above-mentioned 6 indexes achieved the highest score of 3 points except of systolic blood pressure. Four patients showed dilated pupils and impaired consciousness. Among the patients, PSH occurred in the acute exudation stage in 3 patients, in the fluid reabsorption stage in 1 patient, and in the late repair stage in 1 patient. PSH of patients lasted for 3 hours to 12 days. The symptoms of 4 patients were effectively controlled, and 1 patient died of deterioration. No PSH occurred in the cured patients during follow-up of 3 to 14 months. Conclusions: Burn complicated with PSH can occur at any time before wound repair and in patients with different injury conditions. The causes of PSH include sudden burn, persistent pain, fright and fear, strange environment, low blood volume, and other adverse stimuli, and PSH is more likely to occur in children with underdeveloped brain function. Intravenous infusion of analgesics sedatives, physical therapy and medication to lower body temperature, stabilizing blood pressure and respiration are effective measures to treat PSH. PSH should be distinguished from the common complications of burns, such as sepsis, cerebral edema, hyperpyretic convulsion, transfusion response, stress disorder, etc.

[One case of severely burned patient complicated by acute hemorrhagic necrotizing enteritis and fungal infection].

One severely burned patient, caused by heat lead slag and combined with shock, was hospitalized in our burn unit on 2nd June, 2016. The patient received treatments including anti-shock, intensive care, anti-infection, and organ protection. On post injury day 16, the patient suffered outbreak of acute hemorrhagic necrotizing enteritis after eating dumplings. Plasma and albumin were given, octreotide was intravenously infused to inhibit the secretion of intestinal fluid, the broad-spectrum antibiotics were used for anti-infection, abdominal puncture and drainage were performed, sodium tanshinone ⅡA sulfonate was applied to improve the intestinal microcirculation, ulinastatin was applied to alleviate inflammatory reaction, somatostatin was given to reduce intestinal bleeding, and voriconazole was given for antifungal treatment. The patient gradually recovered and was finally cured and discharged. Among critically ill patients, gastrointestinal tract is not only the initiating organ of sepsis, but also one of the target organs which can be easily damaged during sepsis. This case reminds us the importance of gastrointestinal management in severely burned patients.

[Effect of continuous plasma filtration adsorption on treatment of severely burned patients with sepsis].

Objective: To investigate effect of continuous plasma filtration adsorption on treatment of severely burned patients with sepsis. Methods: In January 2014 to September 2017, 86 severely burned patients with sepsis, conforming to the study criteria, were admitted to our hospital and divided into into routine treatment group and continuous plasma filtration group according to the random number table method, with 43 patients in each group. Patients in routine treatment group were treated with routine treatment after admission. Patients in continuous plasma filtration group were treated with blood filter, blood purification machine, and plasma separator for continuous plasma filtration adsorption on the basis of the routine treatment group on the second day after admission. The course of treatment in the 2 groups was 7 d. The total effective treatment rate, changes of leukocyte count (WBC), usea nitrogen, serum creatinine, neutrophile CD64, procalcitonin, and C reactive protein (CRP) before and after treatment, and mortality on 28 days after treatment of patients in 2 groups were analyzed and compared. Results: (1) The total effective treatment rate of patients in continuous plasma filtration group was 88.37% (38/43), which was significantly higher than that of the routine treatment group [65.12% (28/43), χ(2)=6.515, P=0.018]. (2) After treatment, WBC, urea nitrogen, serum creatinine, neutrophils CD64, procalcitonin, and CRP of patients in continuous plasma filtration group were significantly lower those in routine treatment group (t=6.305, 4.420, 18.537, 13.435, 12.975, 14.234, P<0.05). WBC, urea nitrogen, serum creatinine, neutrophile CD64, procalcitonin, and CRP of patients in 2 groups after treatment were significantly lower than those before treatment (t=9.459, 9.130, 25.438, 35.467, 23.471, 23.601, 3.802, 5.662, 12.067, 25.694, 20.720, 12.437, P<0.05). (3) On 28 days after treatment, mortality of patients in continuous plasma filtration group was 6.98% (3/43), which was significantly lower than that in routine treatment group [25.58% (11/43)], χ(2)=5.460, P=0.023. Conclusions: Continuous plasma filtration adsorption is effective in treating severely burned patients with sepsis, which can alleviate inflammatory reaction mediated by inflammatory cytokine with good prognosis.