[Role of albumins in burnt patients: its efficacy during intensive care. Addendum to the expert guidelines of the Consensus Conference, Paris December 15th 1995]

[Initial shock from burns. Physiopathology: therapeutic principles]

Widespread destruction of the skin induces a large necrotic mass and a break of the skin barrier. It also leads to an intense inflammatory reaction. This activates keratinocytes, endothelial cells and neutrophils. Certain mediators (e.g. endothelin, histamine, bradykinin, serotonin, catecholamines, vasopressin, prostaglandins, cytokines and nitrogen monoxide) are thus released in large quantities and act both at the site of the burns and at a distance. The abnormally high level of albumin in the capillary wall and the increased capacity of absorption of the interstitial areas around the burns are the main abnormalities observed. This results in a hypovolemia associated with a hemoconcentration, hyponatremia, hypoalbuminemia, systemic vasoconstriction and myocardial malfunction, which is difficult to evidence. During the initial phase, the major risk is the appearance of hypovolemic shock, which is rapidly irreversible if early treatment is not administered. Vascular filling with iso- or hyper-osmolar sodium crystalloids, associated with buffer solutions, is the first line. There is still debate regarding the best moment at which to give albumin. A hyperkinetic shock may occur after several hours and despite the filling. The symptoms are tachycardia, increased heart rate and a dramatic decrease in systemic vascular resistance. This may lead to metabolic acidosis and multi-organ failure. Study of the hemodynamic profile of the patient allows the rational use of pressor amines and haemodialysis.

Antioxidant properties of albumin: effect on oxidative metabolism of human neutrophil granulocytes

The present study aims at investigating the effect of bovine serum albumin (BSA) on the trial of oxidative-stress. The antioxidant effects of BSA were determined by human neutrophil granulocytes oxygen free radicals and their by-products (O2-, H2O2, HOCl) productions. BSA interacts with those reactive oxygen species (ROS) in a dose-dependent manner. The 50% inhibitory concentration (IC50) of BSA estimated, after phorbol-12-myristate-13-acetate (PMA) stimulation were: 33.5 mg/ml for O2-, 6.5 mg/ml for H2O2, and 6.85 mg/ml for HOCl. When neutrophils were washed after pre-incubation with BSA, there was no significant decrease of ROS after stimulation of PMA (maximal: 15 +/- 1.2%). In the free cell experiments, IC50 for H2O2 and HOCl were 7.86 mg/ml and 0.67 mg/ml, respectively. The mechanism at which BSA acts may result from a simple chemical interaction with ROS rather than an intracellular mechanism by intervention in PMA oxidative metabolism. These antioxidant activities confer to BSA properties, which might be used to prevent damage inflicted by these ROS during inflammatory disorders.

[Management of severe burns during the 1st 72 hours]

Early and efficient management of severely burned patients facilitates outcome improvement. Pre-hospital care includes fluid loading with 2 mL.kg-1/% burn over the first six hours, sedation and analgesia, prevention of hypothermia and ventilatory support for either critically burned patients or facial, cervical or pulmonary burn injury. The transient stay in a general hospital before transfer to a burn centre allows extension of initial care, the critical investigation for associated injuries (intoxication, multiple trauma) and to perform initial local treatment with sterile coverage or vaseline gauze after a revised assessment of the burned skin area, and possibly escharotomies. The main aim of care in the burn centre is to control hypovolaemia and to obtain maximal tissue perfusion and oxygen delivery to burned tissues, as well as to healthy organs. To manage the burn shock (initially hypovolemic and later on hyperdynamic) catecholamines are often indicated when appropriate fluid loading remains insufficient. Mechanical ventilation is indicated in case of either a deep extensive burn over 60% of total body surface area, or facial and cervical burns or severe pulmonary burn injury from smoke inhalation, carbon monoxide intoxication, tracheobronchial thermal injury and blast injury. Because of the severity of burn-related pain, and the stimulus linked to intensive care, continuous sedation is usually required. Early surgical treatment such as escharotomies, excision and grafting, which cause significant pain as well as blood loss, and hydrotherapy, often require general anaesthesia. Burn injury can modify the volume of distribution and the pharmacokinetics of anaesthetic agents. Finally, chemical or electrical burn, radiation, associated CO intoxication or multiple trauma, as well as burn injury in infants, raise specific problems. With improvement in early intensive care, the survival rate of the most severely burned patients is obviously improving. New techniques in skin substitution will probably further improve the final outcome.