Überinfusion von Verbrennungsopfern: häufig und schädlich [Over infusion in burn victims: frequent and injurious]

Major burns are characterized by an initial capillary leak, which requires fluid resuscitation for hemodynamic stabilization. While under resuscitation was the major cause of death until the 1980s, over resuscitation has become an important source of complications, including abdominal compartment syndrome, escharosis, impaired gas exchange with prolonged mechanical ventilation and hospital stay. Fluid over infusion started in the 1990s with an increasing proportion of the fluid delivered within the first 24 h being well above the 4 ml/kg/% burn surface area (BSA) according to the Parkland formula. The first alerts were published in the form of case reports of increased mortality due to abdominal compartment syndrome and respiratory failure. This paper analyses the causes of this fluid over infusion and the ways to prevent it, which include rationing prehospital fluid delivery, avoiding early administration of colloids and prevention by permissive hypovolemia.

Risk factors of sunburns from occupational sun exposure in outdoor workers

Question: Outdoor workers can be exposed to intense ultraviolet (UV) solar radiation likely to results to sunburns. As sunburn is an important risk factor for skin cancer, in particular melanoma, we investigated the causes of occupational sunburns (OS) in French outdoor workers. Methods: A population-based survey was conducted in May-June 2012 through computer-assisted telephonic interviews in population 25 to 69 years of age. History of sunburn from occupational exposure within the year preceding interview was collected. We analysed the risk of OS in multivariate logistic regression. Results: Out of 1442 individuals who declared having an occupational exposure to solar UV radiation, 403 (27.9%) reported a sunburn from occupational exposure in the year preceding the interview. Sunburns were more frequent in women (30% vs. 26.4% in men although not significant p = 0.14), in younger workers (p = 0.0099), in sensitive phototype (40% in phototype I/II vs. 23% in phototype III/IV, p < 0.001) and in workers taking lunch outdoor (p = 0.0355). Some occupations were more associated with OS (more than 30%): health occupations, managing, research/engineering, construction workers and culture/art/social sciences workers. In multivariate analysis, risk factors for OS are phototype (I vs. IV, OR = 4.30 95% CI [2.65-6.98]), sunburn during leisure time (OR = 3.46 95% CI [2.62-4.59]), seasonality of exposure (seasonal vs. constant exposure OR = 1.36 95% CI [1.02-1.81] and annual UVA exposure (OR for 10J/m² daily average increment 1.08 95% CI [1.02-1.14]). In multivariate analysis the type of occupation was not associated with increased OS. Conclusion: Sunburns from occupation was also observed in non sensitive population, phototype IV, which shows that outdoor workers are potentially exposed to intense UV radiations. This study suggests that prevention should target UV sensitive outdoor workers as well as those cumulating intense UV exposure.

Targeting burn prevention in the pediatric population : a prospective study of children's burns in the Lausanne area

Rapport de synthèse : But de l'étude : Les accidents domestiques représentent un problème significatif en médecine pédiatrique. Le but de cette étude est de mieux comprendre les mécanismes et causes des brûlures afin de pouvoir cibler la prévention. Méthode : Il s'agit d'une étude prospective d'une durée d'une année, d'Août 2004 à Août 2005. Les patients ayant consulté pour des brûlures à l'Hôpital de l'Enfance de Lausanne (HEL) ou au CHUV ont été répertoriés. Le mécanisme et les circonstances des brûlures ont été analysées, de même que l'environnement et les données psycho-sociales. Résultats : huitante-neuf patients ont été inclus dans l'étude, âgés de 2 mois à 15 ans. Septante-huit pour cent des patients avaient moins de 5 ans. Plus de la moitié étaient des garçons. Les brûlures par échaudement prédominaient. Nous n'avons pas pu mettre en évidence d'incidence augmentée de brûlures chez des patients de familles immigrées ou de niveau social bas. Dans la majorité des cas, un adulte était présent au moment de l'accident. Conclusion : Si l'on devait établir un profil type de l'enfant à risque de se brûler dans notre région, il s'agirait d'un garçon âgé de 15 mois-5ans, se brûlant en se versant une tasse de liquide chaud sur la main, à son domicile, en présence de l'un ou de ses deux parents. Le message de prévention devrait donc s'adresser directement aux parents, toutes nationalités et niveau social confondus afin de leur expliquer les dangers de brûlures présents au quotidien à leur domicile. A chaque contrôle, les pédiatres devraient parler des accidents domestiques aux parents. En insistant sur les dangers que représentent les tasses de café, la porte du four et la plaque de la cuisinière, qui sont des éléments du quotidien et qui méritent une attention à chaque utilisation. Les brûlures chez le petit enfant pourraient ainsi être fortement réduites.

L'hypnose intégrée aux soins de patients brûlés: impact sur le niveau de stress de l'equipe soignante [Hypnosis integrated in burn care: impact on the healthcare team's stress].

Hypnosis for burn care was introduced in 2004 in the CHUV burn center showing great benefit for burned patients. Whereas advantages of hypnosis for the patient are well established, the impact on the medical staff remains poorly assessed. This manuscrit reviews current attested benefits of hypnosis for patients, specially for burned patients. The results of a recent study assessing the impact of hypnosis on the staffs level of stress caused by burn treatment, will also be introduced.

Viewing the Midnight Sun at Tornao in Lapland

Stockton 1789, T.Bewick

Impact of the introduction of real-time therapeutic drug monitoring on empirical doses of carbapenems in critically ill burn patients.

PURPOSE: Adequate empirical antibiotic dose selection for critically ill burn patients is difficult due to extreme variability in drug pharmacokinetics. Therapeutic drug monitoring (TDM) may aid antibiotic prescription and implementation of initial empirical antimicrobial dosage recommendations. This study evaluated how gradual TDM introduction altered empirical dosages of meropenem and imipenem/cilastatin in our burn ICU. METHODS: Imipenem/cilastatin and meropenem use and daily empirical dosage at a five-bed burn ICU were analyzed retrospectively. Data for all burn admissions between 2001 and 2011 were extracted from the hospital's computerized information system. For each patient receiving a carbapenem, episodes of infection were reviewed and scored according to predefined criteria. Carbapenem trough serum levels were characterized. Prior to May 2007, TDM was available only by special request. Real-time carbapenem TDM was introduced in June 2007; it was initially available weekly and has been available 4 days a week since 2010. RESULTS: Of 365 patients, 229 (63%) received antibiotics (109 received carbapenems). Of 23 TDM determinations for imipenem/cilastatin, none exceeded the predefined upper limit and 11 (47.8%) were insufficient; the number of TDM requests was correlated with daily dose (r=0.7). Similar numbers of inappropriate meropenem trough levels (30.4%) were below and above the upper limit. Real-time TDM introduction increased the empirical dose of imipenem/cilastatin, but not meropenem. CONCLUSIONS: Real-time carbapenem TDM availability significantly altered the empirical daily dosage of imipenem/cilastatin at our burn ICU. Further studies are needed to evaluate the individual impact of TDM-based antibiotic adjustment on infection outcomes in these patients.

Do standard burn mortality formulae work on a population of severely burned children and adults?

Accurate prediction of mortality following burns is useful as an audit tool, and for providing treatment plan and resource allocation criteria. Common burn formulae (Ryan Score, Abbreviated Burn Severity Index (ABSI), classic and revised Baux) have not been compared with the standard Acute Physiology and Chronic Health Evaluation II (APACHEII) or re-validated in a severely (≥20% total burn surface area) burned population. Furthermore, the revised Baux (R-Baux) has been externally validated thoroughly only once and the pediatric Baux (P-Baux) has yet to be. Using 522 severely burned patients, we show that burn formulae (ABSI, Baux, revised Baux) outperform APACHEII among adults (AUROC increase p<0.001 adults; p>0.5 children). The Ryan Score performs well especially among the most at-risk populations (estimated mortality [90% CI] original versus current study: 33% [26-41%] versus 30.18% [24.25-36.86%] for Ryan Score 2; 87% [78-93%] versus 66.48% [51.31-78.87%] for Ryan Score 3). The R-Baux shows accurate discrimination (AUROC 0.908 [0.869-0.947]) and is well-calibrated. However, the ABSI and P-Baux, although showing high measures of discrimination (AUROC 0.826 [0.737-0.916] and 0.848 [0.758-0.938]) in children), exceedingly overestimates mortality, indicating poor calibration. We highlight challenges in designing and employing scores that are applicable to a wide range of populations.

Prediction of multiple infections after severe burn trauma: a prospective cohort study.

OBJECTIVE: To develop predictive models for early triage of burn patients based on hypersusceptibility to repeated infections. BACKGROUND: Infection remains a major cause of mortality and morbidity after severe trauma, demanding new strategies to combat infections. Models for infection prediction are lacking. METHODS: Secondary analysis of 459 burn patients (≥16 years old) with 20% or more total body surface area burns recruited from 6 US burn centers. We compared blood transcriptomes with a 180-hour cutoff on the injury-to-transcriptome interval of 47 patients (≤1 infection episode) to those of 66 hypersusceptible patients [multiple (≥2) infection episodes (MIE)]. We used LASSO regression to select biomarkers and multivariate logistic regression to built models, accuracy of which were assessed by area under receiver operating characteristic curve (AUROC) and cross-validation. RESULTS: Three predictive models were developed using covariates of (1) clinical characteristics; (2) expression profiles of 14 genomic probes; (3) combining (1) and (2). The genomic and clinical models were highly predictive of MIE status [AUROCGenomic = 0.946 (95% CI: 0.906-0.986); AUROCClinical = 0.864 (CI: 0.794-0.933); AUROCGenomic/AUROCClinical P = 0.044]. Combined model has an increased AUROCCombined of 0.967 (CI: 0.940-0.993) compared with the individual models (AUROCCombined/AUROCClinical P = 0.0069). Hypersusceptible patients show early alterations in immune-related signaling pathways, epigenetic modulation, and chromatin remodeling. CONCLUSIONS: Early triage of burn patients more susceptible to infections can be made using clinical characteristics and/or genomic signatures. Genomic signature suggests new insights into the pathophysiology of hypersusceptibility to infection may lead to novel potential therapeutic or prophylactic targets.

Moderate glycemic control safe in critically ill adult burn patients: A 15 year cohort study.

INTRODUCTION: Hyperglycemia is a metabolic alteration in major burn patients associated with complications. The study aimed at evaluating the safety of general ICU glucose control protocols applied in major burns receiving prolonged ICU treatment. METHODS: 15year retrospective analysis of consecutive, adult burn patients admitted to a single specialized centre. EXCLUSION CRITERIA: death or length of stay <10 days, age <16years. VARIABLES: demographic variables, burned surface (TBSA), severity scores, infections, ICU stay, outcome. Metabolic variables: total energy, carbohydrate and insulin delivery/24h, arterial blood glucose and CRP values. Analysis of 4 periods: 1, before protocol; 2, tight doctor driven; 3, tight nurse driven; 4, moderate nurse driven. RESULTS: 229 patients, aged 45±20 years (mean±SD), burned 32±20% TBSA were analyzed. SAPSII was 35±13. TBSA, Ryan and ABSI remained stable. Inhalation injury increased. A total of 28,690 blood glucose samples were analyzed: the median value remained unchanged with a narrower distribution over time. After the protocol initiation, the normoglycemic values increased from 34.7% to 65.9%, with a reduction of hypoglycaemic events (no extreme hypoglycemia in period 4). Severe hyperglycemia persisted throughout with a decrease in period 4 (9.25% in period 4). Energy and glucose deliveries decreased in periods 3 and 4 (p<0.0001). Infectious complications increased during the last 2 periods (p=0.01). CONCLUSION: A standardized ICU glucose control protocol improved the glycemic control in adult burn patients, reducing glucose variability. Moderate glycemic control in burns was safe specifically related to hypoglycemia, reducing the incidence of hypoglycaemic events compared to the period before. Hyperglycemia persisted at a lower level.

Mun sieluni sun ylläs väräjää

Soitinnus: lauluääni, orkesteri.

Sun rauhaas lemmin

Soitinnus: lauluääni, orkesteri.