Exploring the similarities and differences of burn registers globally: Results from a data dictionary comparison study.

INTRODUCTION: Pooling and comparing data from the existing global network of burn registers represents a powerful, yet untapped, opportunity to improve burn prevention and care. There have been no studies investigating whether registers are sufficiently similar to allow data comparisons. It is also not known what differences exist that could bias analyses. Understanding this information is essential prior to any future data sharing. The aim of this project was to compare the variables collected in countrywide and intercountry burn registers to understand their similarities and differences. METHODS: Register custodians were invited to participate and share their data dictionaries. Inclusion and exclusion criteria were compared to understand each register population. Descriptive statistics were calculated for the number of unique variables. Variables were classified into themes. Definition, method, timing of measurement, and response options were compared for a sample of register concepts. RESULTS: 13 burn registries participated in the study. Inclusion criteria varied between registers. Median number of variables per register was 94 (range 28 - 890), of which 24% (range 4.8 - 100%) were required to be collected. Six themes (patient information, admission details, injury, inpatient, outpatient, other) and 41 subthemes were identified. Register concepts of age and timing of injury show similarities in data collection. Intent, mechanism, inhalational injury, infection, and patient death show greater variation in measurement. CONCLUSIONS: We found some commonalities between registers and some differences. Commonalities would assist in any future efforts to pool and compare data between registers. Differences between registers could introduce selection and measurement bias, which needs to be addressed in any strategy aiming to facilitate burn register data sharing. We recommend the development of common data elements used in an international minimum data set for burn injuries, including standard definitions and methods of measurement, as the next step in achieving burn register data sharing.

Patient-reported Outcomes Utilizing the Breast-Q Questionnaire After Breast Conserving Surgery With and Without Oncoplastic Breast Surgery: A Systematic Review and Meta-analysis.

Oncoplastic breast surgery (OBS) arose to decrease the deformity following breast conserving surgery (BCS) for breast cancer. In this meta-analysis (MA), we pool Breast-Q™ questionnaire data to compare quality of life (QOL) in breast cancer patients who received BCS alone or in combination with Level I or II oncoplastic breast surgery (BCS+OBS). All relevant databases were searched following the PRISMA and QUOROM guidelines. All prospective or retrospective studies with a BCS or BCS+OBS cohort that reported QOL as assessed with the Breast-Q™ questionnaire were eligible. Fifty-five studies (75 distinct patient cohorts; 11,186 patients) were included in the MA, with 12 studies reporting both pre- and postoperative values and eligible for a pairwise MA. The pairwise MA showed a significant postoperative improvement in the overall satisfaction with the breast (MD +8.0%, p=0.003) and in the psychosocial well-being (MD +9.2%, 3.5-14.8, p=0.001) of the entire cohort (BCS and BCS+OBS). A subgroup MA of proportions highlighted a superiority of BCS+OBS to BCS in terms of overall satisfaction with the breast (72.0%, 68.0-76.1, versus 62.9%, 58.3-67.5; p=0.02) and psychosocial well-being (78.9%, 71.5-86.4, versus 73.3%, 67.3-76.5, p=0.0001). A leave-one-out sensitivity analysis confirmed the results of the pairwise MA and the MA of proportions. Oncoplastic breast surgery effectively improves QoL based on the patient-reported outcomes assessed using the Breast-Q™ questionnaire. The improvements were associated with acceptable complication rates, further supporting the use of BCS followed by OBS where mastectomy would otherwise be necessary.

[Revascularization Prior to Defect Reconstruction of the Lower Limb - Essential Cooperation between Plastic and Vascular Surgery]. / Revaskularisation vor Defektdeckung ­ essenzielle Schnittstelle zwischen plastischer Chirurgie und Gefäßchirurgie.

Treatment of complex ischemic lower leg defects with exposure of deep anatomic structures represents a considerable challenge to involved specialties. In selected patients, limb salvage can be achieved as an alternative to major amputation by means of a combined approach including arterial reconstruction and subsequent free flap transfer. Arterial reconstruction can be performed either by endovascular or open surgical treatment (bypass reconstruction or implantation of an arteriovenous loop) preliminary to defect reconstruction using microsurgical free flap transplantation. Whereas the aim of the arterial reconstruction comprises the establishment of sufficient perfusion and creation of adequate target vessels for the free flap transfer, the selection of the appropriate flap entity depends on the extent of the wound as wells as on the presence of osteomyelitis. Arterial reconstruction and defect reconstruction can be performed as one-stage or two-stage procedure and has become an established and feasible treatment approach in centers. Evaluation of microperfusion by means of indocyanine green can further increase safety and feasibility of this method. Against this background, combined arterial reconstruction and subsequent free flap transfer provides excellent results in terms of amputation free survival and postoperative mobility. Essential is however an individualized decision making in consideration of patient selection and possible contraindications. This approach may be evaluated in mobile patients with complex wounds prior to major amputation.

Sublesional fat grafting leads to a temporary improvement of wound healing in chronic leg ulcers: A prospective, randomised clinical trial.

Chronic wounds remain a therapeutic and financial challenge for physicians and the health care systems. Innovative, inexpensive and effective treatment methods would be of immense value. The sublesional fat grafting could be such treatment, although effectiveness and safety have only been assessed in a few randomised clinical trials. The fat graft was obtained by liposuction, washed with the Coleman method and then injected sublesional and into the wound margins after surgical debridement. For the control group, saline solution was used instead of fat. The primary endpoint was to determine the wound size reduction in both groups. The wounds were measured preoperatively, intraoperatively and 3, 7, 21 and 60 days after the intervention. A p-value of <0.05 was considered significant. Furthermore, histology and microbiology of the wounds and pain were assessed. A temporary effect of the treatment was observed after 14 and 21 days. The wound size reduction was significantly larger in the intervention group, whereas after 60 days, no significant difference was detected between both groups. No adverse events could be reported and the pain level was almost equal in the control and intervention group. Sublesional fat grafting temporarily enhanced healing of chronic wounds. The procedure was safe and the pain level was low. Repeated interventions could lead to complete wound closure, which should be determined in future studies.

Establishment of the German Burn Registry - five years of prospective data collection.

BACKGROUND: From 1991-2014, all major burn centers of the German-speaking countries participated in a multicenter study in which essentially demographic data were collected. Individual patient data was located at the particular burn centers and only cumulated data were summarized annually for presentation. Retrospective statistical analysis of the entire data collection and identification of subgroups was not possible. In 2015 the German Burn Registry was established for prospective collection of individual patient data as a tool for quality management (QM) and for scientific analyses. METHODS: A working group was formed to ensure the development and administration of the registry. From the official start of the German Burn Registry at the beginning of the year 2015 prospective data collection was realized with an individualized, web-based data collection software in a pseudonymized way. Selected data analysis was performed for the first 5 years of data collection. Severely burned adults and all hospitalized children with burn injuries were documented in the registry. RESULTS: The German Burn Registry was successfully established. 64 burn divisions have already been registered. 18,891 patients were documented over 5 years, of which 58% where children (<16 years). Mean ABSI Score was 4 (children: 3, adults: 6) with a mortality rate of 3.8.0% (children: 0.2%, adults: 9.3%). Children were hospitalized for an average of 7 days, whereas adults were discharged after 18 days. CONCLUSION: A registry is mandatory for quality assurance in burn medicine, since realization of randomized studies is difficult due to the heterogeneity of burn injuries. The German Burn Registry already is one of the biggest burn registries in Europe. Several scientific projects, based on the registry database, are in working process or have already been published.

Preoperative Perforator Mapping in DIEP Flaps for Breast Reconstruction. The Impact of New Contrast-Enhanced Ultrasound Techniques.

Deep inferior epigastric artery flaps (DIEP) represent the gold standard of autologous breast reconstruction. Due to significant variations in vascular anatomy, preoperative perforator mapping (PM) is mandatory in order to ensure the presence of a sufficient perforator within the flap. In this regard, CT angiography (CTA) is currently the method of choice. Therefore, we investigated the value of contrast-enhanced ultrasound (CEUS) techniques for preoperative PM in comparison to CTA. Patients underwent PM, utilizing both CTA and CEUS techniques. Documentation included the course of the vascular pedicle through the rectus muscle (M), fascial penetration (F), the subcutaneous plexus (P) and the skin point (SP) on either side of the abdomen. Thus, contrast-enhanced B-Flow (BCEUS), B-Flow ultrasound (BUS), CEUS, color Doppler ultrasound (CDUS) and CTA were evaluated in terms of the diagnostic consistency and effectiveness of PM. Precision (∆L) was then calculated in relation to the actual intraoperative location. Statistical analysis included Kruskall-Wallis, Levene and Bonferroni tests, as well as Spearman correlations. A total of 39 DIEP flaps were analyzed. Only CTA (∆L = 2.85 mm) and BCEUS (∆L = 4.57 mm) enabled complete PM, also including P and SP, whereas CDUS, CEUS and BUS enabled clear PM throughout M and F only. Regarding the number of detected perforators, PM techniques are ranked from high to low as follows: CTA, BCEUS, BUS, CEUS and CDUS. CTA and BCEUS showed sufficient diagnostic consistency for SP, P and F, while CDUS and CTA had a superior performance for M. BCEUS offers precise image-controlled surface tags and dynamic information for PM without imposing radiation and may, therefore, be considered a feasible add-on or alternative to CTA. However, BCEUS requires an experienced examiner and is more time-consuming.

The ABSI is dead, long live the ABSI - reliable prediction of survival in burns with a modified Abbreviated Burn Severity Index.

OBJECTIVES: The Abbreviated Burn Severity Index (ABSI) is a widely used and simple score to predict mortality after burn injuries. On the one hand, significant improvements in intensive care management and surgical treatment result in an increased survival rate. On the other hand, the aging population might lead to an increased injury-related mortality rate. Therefore, the question arises whether the ABSI still accurately predicts survival. METHODS: Data of 14,984 patients from the German Burn Registry from 2015 to 2018 were analyzed to re-evaluate the variables included in the ABSI, identify discrepancies between the predicted age-related probability of survival and the actual survival rate. Descriptive statistics, univariate analysis and binary logistic regression were used to test the variable impact and to establish a modified score. RESULTS: The original ABSI does not accurately predict the survival in the present cohort. In particular, univariate analysis identified age, total body surface area burned, full thickness burn and inhalation injury as significant impactors on survival. Moreover, sex could not be confirmed as significant and was, therefore, excluded from the modified score. The assumption of a linear relation between age and mortality was not correct. We developed a new age scale representing the actual existing relationship. The resulting modified score was significantly more accurate in predicting the probability of survival for all burn score categories. CONCLUSION: The ABSI does not accurately predict probability of survival. Mortality is overestimated in severely burned patients. A modified version was developed that was significantly more accurate in predicting the probability of survival in this cohort.

Toolbox for Research, or how to facilitate a central data management in small-scale research projects.

BACKGROUND: In most research projects budget, staff and IT infrastructures are limiting resources. Especially for small-scale registries and cohort studies professional IT support and commercial electronic data capture systems are too expensive. Consequently, these projects use simple local approaches (e.g. Excel) for data capture instead of a central data management including web-based data capture and proper research databases. This leads to manual processes to merge, analyze and, if possible, pseudonymize research data of different study sites. RESULTS: To support multi-site data capture, storage and analyses in small-scall research projects, corresponding requirements were analyzed within the MOSAIC project. Based on the identified requirements, the Toolbox for Research was developed as a flexible software solution for various research scenarios. Additionally, the Toolbox facilitates data integration of research data as well as metadata by performing necessary procedures automatically. Also, Toolbox modules allow the integration of device data. Moreover, separation of personally identifiable information and medical data by using only pseudonyms for storing medical data ensures the compliance to data protection regulations. This pseudonymized data can then be exported in SPSS format in order to enable scientists to prepare reports and analyses. CONCLUSIONS: The Toolbox for Research was successfully piloted in the German Burn Registry in 2016 facilitating the documentation of 4350 burn cases at 54 study sites. The Toolbox for Research can be downloaded free of charge from the project website and automatically installed due to the use of Docker technology.

Retrospective analysis on thermal injuries in children-Demographic, etiological and clinical data of German and Austrian pediatric hospitals 2006-2015-Approaching the new German burn registry.

OBJECTIVE: The purpose of this observational, multi-center study was to reveal epidemiologic, etiological and clinical aspects of hospitalized children with thermal injuries in Germany and Austria and the workup of a renewed web-based pediatric burn registry. METHODS: From 2006 to 2015, comprehensive patient data of thermally injured children in Germany and Austria were collected prospectively. Retrospective analysis of age, gender, mechanism of injury, total body surface area burned, way of admission and length of stay was performed, followed by the comparative analysis between designated burn centers and other pediatric hospitals. RESULTS: 32 hospitals participated in the study including data of 13,460 thermally injured hospitalized children. The majority was 12-<36 months of age with a share of 48%. 56.5% were boys. The most frequent cause of injury was scalding representing 74.4%. Designated pediatric burn centers treated 82.2% of all patients. In relation to non-centers, no significant differences were seen concerning the affected total body surface area and the amount of patients <1 year of age in contrast to a significant difference regarding the amount of fire injuries, all being parameters indicating the severity of thermal injuries. Overall mortality was 0.1%. CONCLUSION: This study extends our knowledge about population characterization of thermally injured children, highlights risk factors and serves as a basis for the renewed pediatric burn registry from 2016 on.

Immediate Versus Delayed Breast Reconstruction: Evolving Concepts and Evidence Base.

This article provides information about advantages and disadvantages of immediate and delayed breast reconstruction concepts.

Adipose-derived stem cells and keratinocytes in a chronic wound cell culture model: the role of hydroxyectoine.

Chronic wounds represent a major socio-economic problem in developed countries today. Wound healing is a complex biological process. It requires a well-orchestrated interaction of mediators, resident cells and infiltrating cells. In this context, mesenchymal stem cells and keratinocytes play a crucial role in tissue regeneration. In chronic wounds these processes are disturbed and cell viability is reduced. Hydroxyectoine (HyEc) is a membrane protecting osmolyte with protein and macromolecule stabilising properties. Adipose-derived stem cells (ASC) and keratinocytes were cultured with chronic wound fluid (CWF) and treated with HyEc. Proliferation was investigated using MTT test and migration was examined with transwell-migration assay and scratch assay. Gene expression changes of basic fibroblast growth factor (b-FGF), vascular endothelial growth factor (VEGF), matrix metalloproteinases-2 (MMP-2) and MMP-9 were analysed by quantitative real-time polymerase chain reaction (qRT-PCR). CWF significantly inhibited proliferation and migration of keratinocytes. Addition of HyEc did not affect these results. Proliferation capacity of ASC was not influenced by CWF whereas migration was significantly enhanced. HyEc significantly reduced ASC migration. Expression of b-FGF, VEGF, MMP-2 and MMP-9 in ASC, and b-FGF, VEGF and MMP-9 in keratinocytes was strongly induced by chronic wound fluid. HyEc enhanced CWF induced gene expression of VEGF in ASC and MMP-9 in keratinocytes. CWF negatively impaired keratinocyte function, which was not influenced by HyEc. ASC migration was stimulated by CWF, whereas HyEc significantly inhibited migration of ASC. CWF induced gene expression of VEGF in ASC and MMP-9 in keratinocytes was enhanced by HyEc, which might partly be explained by an RNA stabilising effect of HyEc.

Acute and chronic wound fluids inversely influence adipose-derived stem cell function: molecular insights into impaired wound healing.

Wound healing is a complex biological process that requires a well-orchestrated interaction of mediators as well as resident and infiltrating cells. In this context, mesenchymal stem cells play a crucial role as they are attracted to the wound site and influence tissue regeneration by various mechanisms. In chronic wounds, these processes are disturbed. In a comparative approach, adipose-derived stem cells (ASC) were treated with acute and chronic wound fluids (AWF and CWF, respectively). Proliferation and migration were investigated using 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) test and transwell migration assay. Gene expression changes were analysed using quantitative real time-polymerase chain reaction. AWF had a significantly stronger chemotactic impact on ASC than CWF (77·5% versus 59·8% migrated cells). While proliferation was stimulated by AWF up to 136·3%, CWF had a negative effect on proliferation over time (80·3%). Expression of b-FGF, vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 was strongly induced by CWF compared with a mild induction by AWF. These results give an insight into impaired ASC function in chronic wounds. The detected effect of CWF on proliferation and migration of ASC might be one reason for an insufficient healing process in chronic wounds.

Acute and chronic wound fluids influence keratinocyte function differently.

Wound healing requires a proper functioning of keratinocytes that migrate, proliferate and lead to a competent wound closure. Impaired wound healing might be due to a disturbed keratinocyte function caused by the wound environment. Basically, chronic wound fluid (CWF) differs from acute wound fluid (AWF). The aim of this study was to analyse the effects of AWF and CWF on keratinocyte function. We therefore investigated keratinocyte migration and proliferation under the influence of AWF and CWF using MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] test and scratch assay. We further measured the gene expression by qRT-PCR regarding growth factors and matrixmetalloproteinases (MMPs) involved in regeneration processes. AWF had a positive impact on keratinocyte proliferation over time, whereas CWF had an anti-proliferative effect. Keratinocyte migration was significantly impaired by CWF in contrast to an undisturbed wound closure under the influence of AWF. MMP-9 expression was strongly upregulated by CWF compared with AWF. Keratinocyte function was significantly impaired by CWF. An excessive induction of MMP-9 by CWF might lead to a permanent degradation of extracellular matrix and thereby prevent wounds from healing.

Computer-assisted orthognathic surgery: waferless maxillary positioning, versatility, and accuracy of an image-guided visualisation display.

There may well be a shift towards 3-dimensional orthognathic surgery when virtual surgical planning can be applied clinically. We present a computer-assisted protocol that uses surgical navigation supplemented by an interactive image-guided visualisation display (IGVD) to transfer virtual maxillary planning precisely. The aim of this study was to analyse its accuracy and versatility in vivo. The protocol consists of maxillofacial imaging, diagnosis, planning of virtual treatment, and intraoperative surgical transfer using an IGV display. The advantage of the interactive IGV display is that the virtually planned maxilla and its real position can be completely superimposed during operation through a video graphics array (VGA) camera, thereby augmenting the surgeon's 3-dimensional perception. Sixteen adult class III patients were treated with by bimaxillary osteotomy. Seven hard tissue variables were chosen to compare (ΔT1-T0) the virtual maxillary planning (T0) with the postoperative result (T1) using 3-dimensional cephalometry. Clinically acceptable precision for the surgical planning transfer of the maxilla (<0.35 mm) was seen in the anteroposterior and mediolateral angles, and in relation to the skull base (<0.35°), and marginal precision was seen in the orthogonal dimension (<0.64 mm). An interactive IGV display complemented surgical navigation, augmented virtual and real-time reality, and provided a precise technique of waferless stereotactic maxillary positioning, which may offer an alternative approach to the use of arbitrary splints and 2-dimensional orthognathic planning.

Pseudomonas aeruginosa bacteremia after burn injury: the impact of multiple-drug resistance.

To evaluate the clinical impact of multiple-drug resistance in burn patients with Pseudomonas aeruginosa (Pa) bacteremia. A retrospective cohort study in a 10-bed burn intensive care unit (BICU) was performed. Univariate and multivariate analyses were used to analyze the influence of multiple-drug resistance on mortality and length of BICU stay in Pa bacteremic patients. During a 21-year study period (1989-2009), 87 patients with Pa bacteremia were identified; 45 patients had multiple-drug resistant (MDR) strains and 42 susceptible strains. On comparison of the two populations, one with multiple-drug resistant strains and the other with the susceptible strains, the following parameters were found to be significantly different in the univariate analysis: age (32.7 vs 43.6 years; P = .013), sex (males: 91.1 vs 66.7%; P = .005), intubation status on admission (75.6 vs. 54.8%; P = .041), escharotomy (57.8 vs 33.3%; P = .022), burn size (51.0 vs 35.3% of TBSA; P = .002) and Abbreviated Burn Severity Index score (9.2 vs 8.1; P = .048). In terms of outcome parameters, multiple-drug resistance was not significantly related to mortality (adjusted odds ratio 1.076; 95% confidence interval [CI] 0.356-3.254; P = .897) and length of BICU stay after Pa bacteremia (Kaplan-Meier analysis log-rank test P = .945; Cox's proportional hazards regression hazards ratio, 0.994; 95% CI 0.513-1.925; P = .985) in the univariate and multivariate analyses. The data from this study suggest that multiple-drug resistance is not associated with significant increases in mortality and length of BICU stay among burn patients with Pa bacteremia.

Staphylococcus aureus bacteremia after thermal injury: the clinical impact of methicillin resistance.

OBJECTIVE: To evaluate the impact of methicillin resistance in Staphylococcus aureus bacteremia (SAB) on mortality and length of stay in burn patients. DESIGN: Retrospective cohort study. SETTING: A 750-bed tertiary care university hospital in Cologne, Germany. PATIENTS: Patients registered in the database of the burn intensive care unit (BICU) between 1989 and 2009 with complete data sets (n=1688). RESULTS: Over the 21-year study period, 74 patients with SAB were identified; 33 patients had methicillin-resistant S. aureus (MRSA) and 41 methicillin-susceptible S. aureus (MSSA). Comparing the MRSA with the MSSA population the following parameters were significantly different in the univariate analysis: BMI (27.2 kg/m(2) vs. 23.6 kg/m(2); P=0.05), extent of deep partial thickness burns (17.8% vs. 9.0% of total body surface area; P=0.007), antibiotic requirement on admission (45.5% vs. 22.0%; P=0.046), median length of hospitalization prior SAB (24 days vs. 7 days; P<0.001), packed red blood cells administration (47.6 units vs. 26.1 units; P=0.003), intubation requirement (100% vs. 80.5%; P=0.007), intubation period (43.5 days vs. 26.8 days; P=0.008), catecholamine requirement (90.9% vs. 61.0%; P=0.004), sepsis (60.6% vs. 34.1%; P=0.035) and organ failures (81.8% vs. 39.0%; P<0.001). Regarding outcome parameters, methicillin resistance was not significantly related with mortality (adjusted OR 1.55, 95% CI 0.56-4.28; P=0.40) and length of BICU stay after SAB (Kaplan-Meier analysis log-rank test P=0.32; Cox's proportional hazards regression HR 1.22, 95% CI 0.65-2.27, P=0.535) in the univariate and multivariate analyses. CONCLUSION: Our data suggest that methicillin resistance is not associated with significant increases in mortality and length of BICU stay among burn patients with SAB.

Early single-shot intravenous steroids do not affect pulmonary complications and mortality in burned or scalded patients.

BACKGROUND AND OBJECTIVES: Inhalation injury, especially in combination with cutaneous burns, is the major cause of morbidity and mortality in patients admitted to burn care centers. Either with or without the presence of a cutaneous burn, inhalation injury contributes to high risk for developing severe pulmonary complications. Steroids may reduce a prolonged and destructive inflammatory response to toxic or allergic substances. The objective of this study was to evaluate the effect of early single-shot intravenous steroids on pulmonary complications and mortality in burned or scalded patients with or without inhalation injury. METHODS: Retrospective analysis of a prospective single center database of patients registered between 1989 and 2011 who were admitted to the intensive care unit of our burn care center after burn or scald injury. Uni-variate statistical analysis was performed comparing two groups (steroid treated vs. non steroid treated patients) with regard to clinical outcome. Main parameters were sepsis, mortality and pulmonary complications such as pneumonia, ALI and ARDS. Multi-variate analysis was used by logistic regression with mortality and pulmonary complications as the dependent variables to identify independent risk factors after burn or scald injuries. RESULTS: A total of 1637 patients with complete data were included in the present analysis. 199 (12.2%) received single-shot intravenous steroids during the prehospital phase of care. In 133 (66.8%) of these patients, inhalation injury was diagnosed via bronchoscopy. Steroid treated patients had sustained a significantly higher severity of burn than non-steroid treated patients (Abbreviated Burn Severity Index 7.1±3 vs. 6.0±2.9; p<0.001). In a multivariate analysis using a logistic regression model early intravenous steroid treatment had no significant effect on pulmonary complications and mortality. CONCLUSIONS: In our single center cohort of burned and scalded patients single-shot intravenous steroids during the pre-hospital phase of care was not associated with pulmonary complications or mortality.

Epidemiology and risk factors of sepsis after multiple trauma: an analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery.

OBJECTIVES: The objectives of this study were 1) to assess potential changes in the incidence and outcome of sepsis after multiple trauma in Germany between 1993 and 2008 and 2) to evaluate independent risk factors for posttraumatic sepsis. DESIGN: Retrospective analysis of a nationwide, population-based prospective database, the Trauma Registry of the German Society for Trauma Surgery. SETTING: A total of 166 voluntarily participating trauma centers (levels I-III). PATIENTS: Patients registered in the Trauma Registry of the German Society for Trauma Surgery between 1993 and 2008 with complete data sets who presented with a relevant trauma load (Injury Severity Score of ≥ 9) and were admitted to an intensive care unit (n = 29,829). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over the 16-yr study period, 10.2% (3,042 of 29,829) of multiply injured patients developed sepsis during their hospital course. Annual data were summarized into four subperiods: 1993-1996, 1997-2000, 2001-2004, and 2005-2008. The incidences of sepsis for the four subperiods were 14.8%, 12.5%, 9.4%, and 9.7% (p < .0001), respectively. In-hospital mortality for all trauma patients decreased for the respective subperiods (16.9%, 16.0%, 13.7%, and 11.9%; p < .0001). For the subgroup of patients with sepsis, the mortality rates were 16.2%, 21.5%, 22.0%, and 18.2% (p = .054), respectively. The following independent risk factors for posttraumatic sepsis were calculated from a multivariate logistic regression analysis: male gender, age, preexisting medical condition, Glasgow Coma Scale score of ≤ 8 at scene, Injury Severity Score, Abbreviated Injury ScaleTHORAX score of ≥ 3, number of injuries, number of red blood cell units transfused, number of operative procedures, and laparotomy. CONCLUSIONS: The incidence of sepsis decreased significantly over the study period; however, in this decade the incidence remained unchanged. Although overall mortality from multiple trauma has declined significantly since 1993, there has been no significant decrease of mortality in the subgroup of septic trauma patients. Thus, sepsis has remained a challenging complication after trauma during the past 2 decades. Recognition of the identified risk factors may guide early diagnostic workup and help to reduce septic complications after multiple trauma.

Alveolar recruitment strategy and high positive end-expiratory pressure levels do not affect hemodynamics in morbidly obese intravascular volume-loaded patients.

We evaluated the effect of the alveolar recruitment strategy and high positive end-expiratory pressure (PEEP) on hemodynamics in 20 morbidly obese (body mass index 50 +/- 9 kg/m2), intravascular volume-loaded patients undergoing laparoscopic surgery. The alveolar recruitment strategy was sequentially performed with and without capnoperitoneum and consisted of an upward PEEP trial, recruitment with 50-60 cm H2O of plateau pressure for 10 breaths, and a downward PEEP trial. Recruitment and high PEEP did not cause significant disturbances in any hemodynamic variable measured by systemic and pulmonary artery catheters. Transesophageal echocardiography revealed no differences in end-diastolic areas or evidence of segmental abnormalities in wall motion.