Low-dose hydrocortisone reduces norepinephrine duration in severe burn patients: a randomized clinical trial.

INTRODUCTION: The aim of this study was to assess the effect of low-dose corticosteroid therapy in reducing shock duration after severe burn. METHODS: A placebo-controlled, double-blind, randomized clinical trial (RCT) was performed on two parallel groups in the burn intensive care unit (ICU). Patients were randomized to receive either low-dose corticosteroid therapy or placebo for seven days. A corticotropin test was performed at the time of randomization, before the administration of the treatment dose. Thirty-two severely burned patients with refractory shock (>0.5 µg/kg/min of norepinephrine) were prospectively included in the study. RESULTS: We included 12 patients in the hydrocortisone-treated group and 15 patients in the placebo group in the final analysis. Among these patients, 21 were nonresponders to the corticotropin test. Median norepinephrine treatment duration (primary objective) was significantly lower in the corticosteroid-treated versus the placebo group (57 hours versus 120 hours, P = 0.035). The number of patients without norepinephrine 72 hours after inclusion was significantly lower in the treated group (P = 0.003, log-rank test analysis). The total quantities of norepinephrine administered to patients were lower in the hydrocortisone-treated versus the placebo group (1,205 µg/kg (1,079 to 2,167) versus 1,971 µg/kg (1,535 to 3,893), P = 0.067). There was no difference in terms of ICU or hospital length of stay, sepsis incidence, cicatrization or mortality. CONCLUSIONS: In this placebo-controlled, randomized, double-blind clinical trial, we show for the first time that the administration of low-dose hydrocortisone in burn patients with severe shock reduces vasopressor administration. TRIAL REGISTRATION: Clinicaltrial.gov NCT00149123 . Registered 6 September 2005.

Cultured autologous keratinocytes in the treatment of large and deep burns: a retrospective study over 15 years.

AIM: The aim was to review the use and indications of cultured autologous epidermis (CAE) in extensive burns and to evaluate the efficiency of our strategy of burn treatment. MATERIALS AND METHODS: This retrospective study comprised 15 years (1997-2012). INCLUSION CRITERIA: all patients who received CAE. EXCLUSION CRITERIA: patients who died before complete healing and patients who received exclusively cultured allogeneic keratinocytes. Evaluation criteria were clinical. Time and success of wound healing after CAE graft were evaluated. RESULTS: A total of 63 patients were included with severity Baux score of 107 (from 70 to 140) and mean percentage of TBSA of 71% (from 40% to 97%). The CAE were used as Cuono method, in STSG donor sites and deep 2nd degree burns and in combination with large-meshed STSG (1:6-1:12) in extensively burned patients. Cuono method was used in 6 patients. The final take was 16% (0-30) because of the great fragility of the obtained epidermis. Nine patients with deep 2nd degree burns (mean TBSA 81%, from 60 to 97%) were successfully treated with only CAE without skin grafting. Combined technique (STSG meshed at 1:6-1:12 covered with CAE) was used in 27 patients (mean TBSA 69%, from 49% to 96%) with 85% success rate. Finally, donor sites treated with CAE in 49 patients could be harvested several times thanks to rapid epithelialization (time of wound healing was 7 days (from 5 to 10 days)). CONCLUSION: The CAE allow rapid healing of STSG donor sites and deep 2nd second degree burns in extensively burned patients.

Cultured allogenic keratinocytes for extensive burns: a retrospective study over 15 years.

UNLABELLED: The aim was to review the use and indications of cultured allogenic keratinocytes (CAlloK) in extensive burns and their efficiency. MATERIALS AND METHODS: This retrospective study comprised 15 years (1997-2012). INCLUSION CRITERIA: all patients who received CAlloK. EXCLUSION CRITERIA: patients who died before complete healing. Evaluation criteria were clinical. Time and success of wound healing after CAlloK use were evaluated. RESULTS: The CAlloK were used for 2 indications - STSG donor sites and deep 2nd degree burns in extensively burned patients. A total of 70 patients were included with severity Baux score of 99.2 (from 51 to 144) and mean percentage of TBSA of 63.49% (from 21 to 96%). Fifty nine patients received CAlloK for STSG donor sites with a mean number of applications of 4 and mean surface of 3800 cm(2) per patient. Treated donor sites were re-harvested 2.5 times. The mean time of complete epithelialization was 7 days. In 11 patients, CAlloK were used for deep 2nd degree burns. The mean percentage of burned surface was 73.7%. The mean surface of CAlloK per patient was 2545 cm(2). Complete healing was achieved in 6.4 days. CONCLUSION: The CAlloK allow rapid healing of STSG donor-sites and deep 2nd second degree burns in extensively burned patients.

Antibiotics and the burn patient.

Infection is a major problem in burn care and especially when it is due to bacteria with hospital-acquired multi-resistance to antibiotics. Moreover, when these bacteria are Gram-negative organisms, the most effective molecules are 20 years old and there is little hope of any new product available even in the distant future. Therefore, it is obvious that currently available antibiotics should not be misused. With this aim in mind, the following review was conducted by a group of experts from the French Society for Burn Injuries (SFETB). It examined key points addressing the management of antibiotics for burn patients: when to use or not, time of onset, bactericidia, combination, adaptation, de-escalation, treatment duration and regimen based on pharmacokinetic and pharmacodynamic characteristics of these compounds. The authors also considered antibioprophylaxis and some other key points such as: infection diagnosis criteria, bacterial inoculae and local treatment. French guidelines for the use of antibiotics in burn patients have been designed up from this work.

Methemoglobinemia by cerium nitrate poisoning.

Cerium nitrate is a topical antiseptic used with silver sulfadiazine (Flammacerium) for the treatment of serious burns. This topical agent can induce methemoglobinemia, but no cases have been reported in the recent literature. In this article, we present the case of a 16-year old girl, with third-degree burns over 95% of her body. After daily dressings of Flammacerium, on the sixth day she developed a bluish skin coloring. When tested for methemoglobinemia, levels of 31.8% were found. These returned to normal after classic treatment with Methylene blue.

Arterioesophageal fistula: a rare complication of retroesophageal subclavian arteries.

Formation of a fistula between a retroesophageal subclavian artery and the esophagus is a rare cause of hematemesis that is usually fatal. Several etiologies have been described. The purpose of this report is to describe a case involving successful surgical repair of an arterioesophageal fistula induced by prolonged nasogastric intubation. A preoperative CT scan under emergency conditions allowed tentative diagnosis. Arteriography in the operating room confirmed the presence of a fistula and also allowed temporary hemostasis by tamponade. On the basis of a review of the literature, this case demonstrates the importance of screening patients requiring prolonged nasogastric intubation to rule out the possibility of an aberrant aortic arch system.