Bromelain-based enzymatic burn debridement: Spanish multidisciplinary consensus.

Background: Bromelain-based enzymatic debridement is gaining increased interest from burn specialists in the last few years. The objective of this manuscript is to update the previous, first Spanish consensus document from 2017 (Martínez-Méndez et al. 43:193-202, 2017), on the use of enzymatic debridement with NexoBrid® in burn injuries, adding the clinical experience of a larger panel of experts, integrating plastic surgeons, intensivists, and anesthesiologists. Methods: A consensus guideline was established by following a modified Delphi methodology of a 38-topic survey in two rounds of participation. Items were grouped in six domains: general indication, indication in critical patients, pain management, conditions for NexoBrid® application, NexoBrid® application technique, and post-debridement wound care. Results: In the first round, experts established consensus (strongly agree or agree) on 13 of the 38 statements. After the second round, a consensus was reached on 24 of the 25 remaining statements (97.2%). Conclusions: The present updated consensus document provides recommendations on the use of bromelain-based enzymatic debridement NexoBrid®, integrating the extensive clinical experience of plastic surgeons, intensivists, and anesthesiologists in Spain. Further clinical trials and studies are required to corroborate, modify, or fine tune the current statements.

Soluble suppression of tumorigenicity-2 predicts pneumonia in patients with inhalation injury: Results of a pilot study.

INTRODUCTION: Several mechanisms play a role in the development of pneumonia after inhalation injury. Our aim was to analyze whether higher concentrations of inflammatory markers or of biomarkers of epithelial injury are associated with a higher incidence of pneumonia in patients with inhalation injury. MATERIAL AND METHODS: Secondary analysis of a single-center prospective observational cohort pilot study, performed over a two-year period (2015-2017) at the Burns Unit of the Plastic and Reconstructive Surgery Department of Vall d'Hebron University Hospital. All patients aged 18 with suspected inhalation injury undergoing admission to the Burns Unit were included. Plasma biomarkers of the lung epithelium (RAGE and SP-D), inflammation markers (IL6, IL8), and IL33, as well as soluble suppression of tumorigenicity-2 (sST2) levels, were measured within the first 24 h of admission. RESULTS: Twenty-four patients with inhalation injury were included. Eight (33.3%) developed pneumonia after a median of 7 (4-8) days of hospital stay. Patients with pneumonia presented higher plasma concentrations of sST2 (2853 [2356-3351] ng/mL vs 1352 [865-1839] ng/mL; p < 0.001), IL33 (1.95 [1.31-2.59] pg/mL vs 1.26 [1.07-1.45] pg/mL; p = 0.002) and IL8 (325.7 [221.6-430.0] pg/mL vs 174.1 [95.2-253.0] pg/mL; p = 0.017) on day 1 of inclusion. Plasma sST2 concentration in the first 24 h demonstrated excellent diagnostic accuracy for predicting the occurrence of pneumonia in patients with smoke inhalation (AUROC 0.929 [95%CI 0.818-1.000]). A cutoff point of ≥2825 ng/mL for sST2 had a sensitivity of 75% and a specificity of 100%. The risk ratio of pneumonia in patients with sST2 ≥ 2825 ng/mL was 7.14 ([95% CI 1.56-32.61]; p = 0.016). CONCLUSIONS: Plasma sST2 in the first 24 h of admission predicts the occurrence of pneumonia in patients with inhalation injury.

Intensive Care to Facilitate Organ Donation: A Report on the 4-Year Experience of a Spanish Center With a Multidisciplinary Model to Promote Referrals Out of the Intensive Care Unit.

BACKGROUND: Intensive care to facilitate organ donation (ICOD) has been defined as the initiation or continuation of intensive care measures in patients with a devastating brain injury (DBI) in whom treatment for curative purposes is deemed futile, and who are considered possible organ donors, with the aim of offering donation after brain death (DBD) inside their end-of-life care plans. We describe the effect on the donation and transplantation activity of the implementation of ICOD protocol at a university hospital. METHODS: Retrospective analysis (2015-2018) of demographics and outcomes of all patients with a DBI, in whom ICOD was considered as part of their end-of-life care in Vall d'Hebron University Hospital, Barcelona. RESULTS: Of the 983 possible donors evaluated, ICOD was considered in 206 (21%), of whom 115 (55.8%) were medically unsuitable for donation. Family consent was obtained for 69 (76%) of the remaining patients. Refusal rate was twice as high when nontherapeutic ventilation was required for organ donation (34%) vs patients previously ventilated (13.6%) (P = .02). Patients subject to ICOD died in a median of 2 days (1-3 d) and 88.4% became actual donors (39 after brain death; 22 after circulatory death). Nine (17.6%) donors were finally not utilized. ICOD contributed to 29% (ranging from 27.7% in 2015 to 31.6% in 2018) of the 208 actual donors and 26% of the 603 organs transplanted. CONCLUSIONS: ICOD is well-accepted by families and offers the donation option to an increasing number of patients at our hospital. It provides an important and sustained increment of the organ pool for transplantation.

Soluble Suppression Of Tumorigenicity-2 Predicts Hospital Mortality in Burn Patients: An Observational Prospective Cohort Pilot Study.

BACKGROUND: The IL33/ST2 pathway has been implicated in the pathogenesis of different inflammatory diseases. Our aim was to analyze whether plasma levels of biomarkers involved in the IL33/ST2 axis might help to predict mortality in burn patients. METHODS: Single-center prospective observational cohort pilot study performed at the Burns Unit of the Plastic and Reconstructive Surgery Department of the Vall d'Hebron University Hospital (Barcelona). All patients aged ≥18 years old with second or third-degree burns requiring admission to the Burns Unit were considered for inclusion. Blood samples were taken to measure levels of interleukins (IL)6, IL8, IL33, and soluble suppression of tumorigenicity-2 (sST2) within 24 h of admission to the Burns Unit and at day 3. Results are expressed as medians and interquartile ranges or as frequencies and percentages. RESULTS: Sixty-nine patients (58 [84.1%] male, mean age 52 [35-63] years, total body surface area burned 21% [13%-30%], Abbreviated Burn Severity Index 6 [4-8]) were included. Thirteen (18.8%) finally died in the Burns Unit. Plasma levels of sST2 measured at day 3 after admission demonstrated the best prediction accuracy for survival (area under the receiver-operating curve 0.85 [0.71-0.99]; P < 0.001). The best cutoff point for the area under the receiver-operating curve index was estimated to be 2,561. In the Cox proportional hazards model, after adjusting for potential confounding, a plasma sST2 level ≥2,561 measured at day 3 was significantly associated with mortality (hazard ratio 6.94 [1.73-27.74]; P = 0.006). CONCLUSIONS: Plasma sST2 at day 3 predicts hospital mortality in burn patients.

Does Normobaric Hyperoxia Cause Oxidative Stress in the Injured Brain? A Microdialysis Study Using 8-Iso-Prostaglandin F2α as a Biomarker.

Significant controversy exists regarding the potential clinical benefit of normobaric hyperoxia (NBO) in patients with traumatic brain injury (TBI). This study consisted of two aims: 1) to assess whether NBO improves brain oxygenation and metabolism and 2) to determine whether this therapy may increase the risk of oxidative stress (OxS), using 8-iso-Prostaglandin F2α (PGF2α) as a biomarker. Thirty-one patients with a median admission Glasgow Coma Scale score of 4 (min: 3, max: 12) were monitored with cerebral microdialysis and brain tissue oxygen sensors and treated with fraction of inspired oxygen (FiO2) of 1.0 for 4 h. Patients were divided into two groups according to the area monitored by the probes: normal injured brain and traumatic penumbra/traumatic core. NBO maintained for 4 h did not induce OxS in patients without preOxS at baseline, except in one case. However, for patients in whom OxS was detected at baseline, NBO induced a significant increase in 8-iso-PGF2α. The results of our study showed that NBO did not change energy metabolism in the whole group of patients. In the five patients with brain lactate concentration ([Lac]brain) > 3.5 mmol/L at baseline, NBO induced a marked reduction in both [Lac]brain and lactate-to-pyruvate ratio. Although these differences were not statistically significant, together with the results of our previous study, they suggest that TBI patients would benefit from receiving NBO when they show indications of disturbed brain metabolism. These findings, in combination with increasing evidence that TBI metabolic crises are common without brain ischemia, open new possibilities for the use of this accessible therapeutic strategy in TBI patients.