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Gaffari J, Akbarzadeh K, Baniardalani M, Hosseini R, Masoumi S, Amiri ZS, Shabani Kordshouli R, Rafinejad J, Dahmardehei M. Larval therapy vs conventional silver dressings for full-thickness burns: a randomized controlled trial. BMC Med 2023; 21:361. [PMID: 37726738 PMCID: PMC10510148 DOI: 10.1186/s12916-023-03063-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/04/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND This is the first clinical trial to investigate the effectiveness of maggot debridement therapy (MDT) for full-thickness burn injuries in comparison to conventional silver dressings. METHODS Thirty-one cases with full-thickness (grade III based on ICD-10 classifications version 2019) burns were assigned into larval therapy (15 cases) and conventional treatment (16 cases) groups. Participants in the MDT group have received loose larvae on days 0, 2, 4, and 6, while controls received a conventional regimen comprised of sharp debridement, silver sulfadiazine, antibiotic therapy, and offloading every day. The primary and secondary outcomes were defined as the time to debridement (from admission to skin autograft) and time to healing (from admission to complete healing post-skin autograft). Patients in two groups were also compared in terms of necrosis resolution, granulation, and granulation/necrosis (g/n) ratio during study time periods. RESULTS Participants who received larvae had significantly decreased necrosis on days 2 (p = 0.028) and 4 (p = 0.023) compared to those who received control treatment. Significant differences (p < 0.001) were also observed for granulation between the two groups in favor of MDT and the fold changes of g/n in the larvae group were 5, 15, and 13 times higher than that for the conventional regimen on days 2, 4, and 6 of treatment, respectively. Strikingly, a subgroup analysis of high necrotic burns (necrosis > 50%) revealed a significant improvement (p < 0.001) for MDT compared to the control treatment. There were also significant differences (p < 0.001) for the time to debridement and time to healing between the two groups. However, bacterial contamination did not show significant changes between the two treatment regimens. CONCLUSIONS Our findings revealed that MDT has a favorable superiority over conventional regimen for the treatment of grade-III burns, and thus further clinical trials with larger sample size are warranted to confirm these results.
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Affiliation(s)
- Jasem Gaffari
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Akbarzadeh
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mozhgan Baniardalani
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Hosseini
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Safdar Masoumi
- Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modarres University, Tehran, Iran
| | - Zahra Sadat Amiri
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Razieh Shabani Kordshouli
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Rafinejad
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
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Care of the Critically Injured Burn Patient. Ann Am Thorac Soc 2022; 19:880-889. [PMID: 35507538 DOI: 10.1513/annalsats.202110-1099cme] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Care of the critically injured burn patient presents unique challenges to the intensivist. Certified burn centers are rare and geographically sparse, necessitating that much of the initial management of patients with severe burn injuries must happen in the pre-burn center setting.1 Severe burn injuries often lead to a wide range of complications that extend beyond the loss of skin integrity and require specialized care. As such, medical intensivists are often called upon to stabilize these critically injured patients. This focused review outlines the clinical care of these medically complex patients, including airway management, post-burn complications, volume resuscitation, nutrition, and end-of-life care.
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Intubation in burns patients: a 5-year review of the Manchester regional burns centre experience. Burns 2020; 47:576-586. [PMID: 32861535 DOI: 10.1016/j.burns.2020.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/16/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
Despite criteria to guide intubation from the American Burn Association (ABA), concerns remain regarding over-intubation of burns patients. The purpose of this study was to review appropriateness of intubation at a UK regional burns centre over a 5-year period. A 5-year retrospective review of adult patients admitted to the Manchester Burns Centre who underwent intubation at or prior to admission was performed. Intubations for non-burn indications or burns >40%TBSA were excluded. Patient demographic and burn characteristics data were extracted from medical records. Indications for intubation were compared to ABA and Denver criteria. 47 patients were identified, of which 40 met inclusion criteria for analysis. 72.5% and 95% of these patients met ABA or Denver criteria respectively. 30.8% of patients were extubated within 48 h. 50% patients extubated within 48 h had ≤1 indication for intubation or negative laryngoscopy. Complications related to intubation and ventilation were noted in 37.5% of patients, with ventilation associated pneumonia (VAP) being the most common occurring in 27.5%. 95% of patients fulfilled recognised criteria for intubation. However, 30% were extubated within 48 h, suggesting potentially avoidable intubation. This study suggests current intubation criteria may over-estimate risk of airway compromise and supports results from non-UK studies that a proportion of patients may be suitable for close observation rather than early intubation.
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Ziegler B, Hundeshagen G, Uhlmann L, Will Marks P, Horter J, Kneser U, Hirche C. Impact of diagnostic bronchoscopy in burned adults with suspected inhalation injury. Burns 2019; 45:1275-1282. [PMID: 31383606 DOI: 10.1016/j.burns.2019.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/05/2019] [Accepted: 07/10/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Inhalation injury is a common complication of thermal trauma. Fiberoptic bronchoscopy (FOB) is regarded as current standard practice in diagnosing and grading inhalation injury. Nonetheless, its predictive value in terms of therapeutic decision-making and clinical outcome is controversial. METHODS Adult burn patients with inhalation injury (InI) were selected from the National Burn Repository of the American Burn Association. Subjects were propensity score pair-matched based on injury severity and grouped based on whether or not FOB had been performed (FOB, CTR, respectively). Mortality, incidence of pneumonia, length of hospitalization, length of ICU stay and dependency on mechanical ventilation were compared between the two groups. RESULTS 3014 patients were matched in two groups with a mean TBSA of 22.4%. There was no significant difference in carboxyhemoglobin fraction at admission. Patients, who underwent FOB on admission had a significantly increased incidence of pneumonia (p < 0.001), mortality (p < 0.05), length of hospitalization (p = 0.002), ICU stay (p < 0.001) and duration of mechanical ventilation (p = 0.006). In a subgroup analysis of patients with TBSA of at least 20%, incidence of pneumonia was significantly higher in the FOB group (p < 0.001) and longer mechanical ventilation was required (p = 0.036). DISCUSSION Diagnosis and grading of InI through FOB is the current standard, although its predictive value regarding key outcome parameters and therapeutic decision-making, remains unclear. The potential procedural risk of FOB itself should be considered. This study demonstrates correlations of FOB with major clinical outcomes in both a general collective of burned adults as well as severely burned adults. Although these findings must be interpreted with caution, they may induce further research into potential harm of FOB and critical review of routine diagnostic FOB in suspected inhalation injury in thermally injured patients.
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Affiliation(s)
- Benjamin Ziegler
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University Heidelberg, Im Neuenheimer Feld 130.3, D-69120 Heidelberg, Germany
| | - Patrick Will Marks
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Johannes Horter
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany.
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Mohamed SAR, Mohamed NN. Efficacy and adverse events of early high-frequency oscillatory ventilation in adult burn patients with acute respiratory distress syndrome. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Badulak JH, Schurr M, Sauaia A, Ivashchenko A, Peltz E. Defining the criteria for intubation of the patient with thermal burns. Burns 2018; 44:531-538. [PMID: 29548862 DOI: 10.1016/j.burns.2018.02.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Recent studies demonstrate that burn patients are undergoing unnecessary intubations. We sought to determine the clinical criteria that predict intubations with benefit. METHODS This was a retrospective review of intubated adults admitted to our center with thermal burns 2008-2013. Criteria for intubation were defined as traditional criteria (suspected smoke inhalation, oropharynx soot, hoarseness, dysphagia, singed facial hair, oral edema, oral burn, non-full thickness facial burns), or ABA criteria as defined by the 2011 ABA guidelines (full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper airway trauma, altered mentation, hypoxia/hypercarbia, hemodynamic instability). Patients with <26days free from mechanical ventilation (ventilator-free days (VFD)) out of 28, were deemed indicated long-term intubations. Those with ≥26 VFD were deemed unnecessary short-term intubations. RESULTS Of 218 patients, 151 had long-term and 67 had short-term intubations. Long-term intubation was strongly associated with ABA criteria (77.5%) compared to traditional criteria (22.5%) (p<0.001). Sensitivity of ABA criteria for long-term intubation was 77% and specificity 46%. Traditional criteria associated with long-term intubation included suspected smoke inhalation (OR 2.45 [95% CI, 1.18-5.11]), and singed facial hair (OR 2.53 [95% CI, 1.25-5.09]). The addition of these to ABA criteria created the Denver criteria, which exhibited an increased sensitivity for long-term intubations (95%), but decreased specificity (24%). CONCLUSIONS Intubation should be considered for patients displaying the Denver criteria, which includes full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper airway trauma, altered mentation, hypoxia/hypercarbia, hemodynamic instability, suspected smoke inhalation, and singed facial hair. Patients lacking these criteria should not be intubated.
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Affiliation(s)
- Jenelle H Badulak
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Michael Schurr
- Mountain Area Health Education Center, Division of General Surgery, 121 Hendersonville Road, Asheville, NC 28803, United States.
| | - Angela Sauaia
- University of Colorado, Department of Surgery, 12631 E. 17th Avenue, C-305, Aurora, CO 80045, United States.
| | - Anna Ivashchenko
- University of Colorado, Department of Surgery, 12631 E. 17th Avenue, C-305, Aurora, CO 80045, United States.
| | - Erik Peltz
- University of Colorado, Department of Surgery, 12631 E. 17th Avenue, C-305, Aurora, CO 80045, United States.
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Reducing the Indication for Ventilatory Support in the Severely Burned Patient: Results of a New Protocol Approach at a Regional Burn Center. J Burn Care Res 2018; 37:e205-12. [PMID: 25882516 DOI: 10.1097/bcr.0000000000000238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Initial management of the severely injured routinely includes sedation and mechanical ventilatory support. However, nonjudiciously applied mechanical ventilatory support can itself lead to poorer patient outcomes. In an attempt to reduce this iatrogenic risk, a standardized, in-house, five-point protocol providing clinical guidance on the use and duration of ventilation was introduced and analyzed, and the impact on patient outcomes was assessed. In 2007, a protocol for early spontaneous breathing was introduced and established in clinical practice. This protocol included: 1) early extubation (≤6 hours after admission) in the absence of absolute ventilatory indication; 2) avoidance of "routine intubation" in spontaneously breathing patients; 3) early postoperative extubation, including patients requiring multiple surgical interventions; 4) intensive chest and respiratory physiotherapy with routine application of expectorants; and 5) early active mobilization. A retrospective clinical study compared patients (group A) over a 2-year period admitted under the new protocol with a historical patient group (group B). Patients in group A (n = 38) had fewer ventilator days over the time-course of treatment (3 [1; 5.8] vs 18.5 days [0.5; 20.5]; P = .0001) with a lower rate of tracheostomies (15.8 vs 54%; P = .0003). Patients on ventilation at admission in group A had shorter ventilation periods after admission (4.75 [4; 22.25] vs 378 hours [8.5; 681.5]; P = .0003), and 66.7% of these patients were extubated within 6 hours of admission (vs 9.1% in group B). No patients fulfilling the inclusion criteria required re- or emergency intubation. In the first 5 days of treatment, significantly lower Sequential Organ Failure Assessment scores were recorded in group A. There was also a trend for lower mortality rates (0 [0%] vs 6 [14%]), sepsis rates (24 [63.2%] vs 37 [88.1%]), and cumulative fluid balance on days 3 and 7 in group A. In contrast, group A demonstrated an elevated rate of pneumonia (15 [39.5%] vs 8 [19%]). These trends, however, lacked statistical significance. Our five-point protocol was safe and easily translated into clinical practice. In the authors experience, this protocol significantly reduced the ventilatory period in severely injured. Furthermore, this study suggests that many injured may be over-treated with routine ventilation, which carries accompanying risks.
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Onishi S, Osuka A, Kuroki Y, Ueyama M. Indications of early intubation for patients with inhalation injury. Acute Med Surg 2017; 4:278-285. [PMID: 29123875 PMCID: PMC5674455 DOI: 10.1002/ams2.269] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/13/2017] [Indexed: 12/05/2022] Open
Abstract
Aim For patients with inhalation injury, the indications for early intubation are diverse. The purpose of this study was to identify the most reliable symptoms, physical findings, and medical examinations with which to determine the indications for early intubation in patients with inhalation injury. Methods We retrospectively collected patient data from medical records. Collected data included age, sex, burn size, symptoms, physical findings, carboxyhemoglobin levels (COHb), and bronchial wall thickness (BWT) determined from chest computed tomography images. We analyzed the relationships between these findings and the early intubation. We performed fiberoptic bronchoscopy in all patients, and analyzed the relationships between bronchoscopic severity and other findings. Results Of the 205 patients, 80 patients were diagnosed as having inhalation injury, and 34 patients were intubated. Burn size, facial burns, neck burns, use of accessory respiratory muscles, and COHb seemed to be related with intubation, whereas singed nasal hair was not. If the patients suffered ≥27% total body surface area burn and BWT ≥3.5 mm, the positive predictive value for early intubation was 1.00. If the patients suffered smaller cutaneous burn without neck burn, and their COHb <4.0%, the negative predictive value for early intubation was 0.97. Fiberoptic bronchoscopy findings from above the glottis were mainly related with patients’ symptoms. Findings from below the glottis were mainly related with BWT and COHb. Conclusions Patients’ symptoms, especially use of accessory respiratory muscles, are reliable, and BWT and COHb are also useful tools, for determining the indication for early intubation.
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Affiliation(s)
- Shinya Onishi
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Akinori Osuka
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Yuichi Kuroki
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
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Ziegler B, Hirche C, Horter J, Kiefer J, Grützner PA, Kremer T, Kneser U, Münzberg M. In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland. Burns 2016; 43:318-325. [PMID: 27665246 DOI: 10.1016/j.burns.2016.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines. MATERIAL AND METHODS A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered. RESULTS 17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance. CONCLUSION While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.
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Affiliation(s)
- Benjamin Ziegler
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Johannes Horter
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Jurij Kiefer
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Paul Alfred Grützner
- Department of Trauma and Orthopedic Surgery, Air Rescue Center, BG Trauma Center Ludwigshafen/Rhine, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Thomas Kremer
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Matthias Münzberg
- Department of Trauma and Orthopedic Surgery, Air Rescue Center, BG Trauma Center Ludwigshafen/Rhine, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany.
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Abstract
As a result of continuous development in the treatment of burns, the LD50 (the burn size lethal to 50% of the population) for thermal injuries has risen from 42% total body surface area (TBSA) during the 1940s and 1950s to more than 90% TBSA for young thermally injured patients. This vast improvement in survival is due to simultaneous developments in critical care, advancements in resuscitation, control of infection through early excision, and pharmacologic support of the hypermetabolic response to burns. This article reviews these recent advances and how they influence modern intensive care of burns.
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Affiliation(s)
- Shawn P Fagan
- Sumner Redstone Burn Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Mary-Liz Bilodeau
- Sumner Redstone Burn Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Jeremy Goverman
- Sumner Redstone Burn Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med 2013; 21:31. [PMID: 23597126 PMCID: PMC3653783 DOI: 10.1186/1757-7241-21-31] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 04/11/2013] [Indexed: 01/19/2023] Open
Abstract
Lung injury resulting from inhalation of smoke or chemical products of combustion continues to be associated with significant morbidity and mortality. Combined with cutaneous burns, inhalation injury increases fluid resuscitation requirements, incidence of pulmonary complications and overall mortality of thermal injury. While many products and techniques have been developed to manage cutaneous thermal trauma, relatively few diagnosis-specific therapeutic options have been identified for patients with inhalation injury. Several factors explain slower progress for improvement in management of patients with inhalation injury. Inhalation injury is a more complex clinical problem. Burned cutaneous tissue may be excised and replaced with skin grafts. Injured pulmonary tissue must be protected from secondary injury due to resuscitation, mechanical ventilation and infection while host repair mechanisms receive appropriate support. Many of the consequences of smoke inhalation result from an inflammatory response involving mediators whose number and role remain incompletely understood despite improved tools for processing of clinical material. Improvements in mortality from inhalation injury are mostly due to widespread improvements in critical care rather than focused interventions for smoke inhalation. Morbidity associated with inhalation injury is produced by heat exposure and inhaled toxins. Management of toxin exposure in smoke inhalation remains controversial, particularly as related to carbon monoxide and cyanide. Hyperbaric oxygen treatment has been evaluated in multiple trials to manage neurologic sequelae of carbon monoxide exposure. Unfortunately, data to date do not support application of hyperbaric oxygen in this population outside the context of clinical trials. Cyanide is another toxin produced by combustion of natural or synthetic materials. A number of antidote strategies have been evaluated to address tissue hypoxia associated with cyanide exposure. Data from European centers supports application of specific antidotes for cyanide toxicity. Consistent international support for this therapy is lacking. Even diagnostic criteria are not consistently applied though bronchoscopy is one diagnostic and therapeutic tool. Medical strategies under investigation for specific treatment of smoke inhalation include beta-agonists, pulmonary blood flow modifiers, anticoagulants and antiinflammatory strategies. Until the value of these and other approaches is confirmed, however, the clinical approach to inhalation injury is supportive.
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Affiliation(s)
- David J Dries
- Department of Surgery, Regions Hospital, St. Paul, MN 55101, USA.
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12
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Carr JA, Crowley N. Prophylactic sequential bronchoscopy after inhalation injury: results from a three-year prospective randomized trial. Eur J Trauma Emerg Surg 2013; 39:177-83. [DOI: 10.1007/s00068-013-0254-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/05/2013] [Indexed: 11/30/2022]
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Cotte J, Prunet B, Esnault P, Lacroix G, D'aranda E, Cungi PJ, Goutorbe P, Dantzer E, Meaudre E. Early onset pneumonia in patients with severely burned face and neck: a 5-year retrospective study. Burns 2013; 39:892-6. [PMID: 23332161 DOI: 10.1016/j.burns.2012.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/01/2012] [Accepted: 12/04/2012] [Indexed: 11/18/2022]
Abstract
Patients with face and neck burns (FNBs) often undergo prehospital intubation, or sustain inhalation injury which are risk factors for pneumonia in specific populations. Early onset pneumonia (EOP) might be caused by initial management. The primary goal of this study was to find risk factors for EOP in FNB patients. This is a retrospective, single-center trial. We screened all FNB patients for EOP with the Clinical Pulmonary Infection Score. Pneumonia diagnosis was with culture from a mini broncho-alveolar lavage. Potential risk factors for EOP were recorded. We included 152 patients, EOP was diagnosed in 58 (38.2%). EOP patients had a greater burned surface area median (20±17% vs. 10±17%; p<0.001), were more frequently intubated during prehospital care (65.5% vs. 21.3%; p<0.001), had more abnormal fiberoptic bronchoscopy at admission (58.6% vs. 19.1%; p=0.002) and a lower initial PaO2/FiO2 ratio (median 314±118.6 vs. 365±105.7; p=0.01). Multivariate analysis showed that only prehospital intubation was independently associated with EOP (odds ratio 3.6; 95% confidence interval, 1.34-10). Prehospital intubation appears to be an independent risk factor for EOP in severe burn patients. Assessments of the risk-benefit ratios of intubating and of not intubating those patients are indicated.
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Affiliation(s)
- Jean Cotte
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France.
| | - Bertrand Prunet
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre Esnault
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Guillaume Lacroix
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Erwan D'aranda
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre Julien Cungi
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Philippe Goutorbe
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Dantzer
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Meaudre
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
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Huzar TF, Cross JM. Ventilator-associated pneumonia in burn patients: a cause or consequence of critical illness? Expert Rev Respir Med 2012; 5:663-73. [PMID: 21955236 DOI: 10.1586/ers.11.61] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Infectious complications are a constant threat to thermally injured patients during hospitalizations and are a predominant cause of death. Most of the infections that develop in burn patients are nosocomial and of a pulmonary etiology. The bacteria that cause ventilator associated pneumonia (VAP) take advantage of the fact that uniquely among intensive care unit patients endotracheal intubation allows them a 'free' passage to the sterile lower airways; however, the combination of severe thermal injury (systemic immunosuppression) and inhalation injury (local immunosuppression and tissue injury) create an ideal environment for development of VAP. Thus, strategies directed at preventing and treating VAP in burn patients must address not only rapid extubation and VAP prevention bundles known to work in other intensive care unit populations, but therapies directed to more rapid wound healing and restoration of pulmonary patency.
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Affiliation(s)
- Todd F Huzar
- Department of Surgery, University of Texas Medical School, Houston, TX, USA.
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Oppeltz RF, Rani M, Zhang Q, Schwacha MG. Burn-induced alterations in toll-like receptor-mediated responses by bronchoalveolar lavage cells. Cytokine 2011; 55:396-401. [PMID: 21696980 DOI: 10.1016/j.cyto.2011.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 04/26/2011] [Accepted: 05/02/2011] [Indexed: 01/09/2023]
Abstract
UNLABELLED Burn is associated with profound inflammation and activation of the innate immune system in multiple organ beds, including the lung. Similarly, toll-like receptors (TLR) are associated with innate immune activation. Nonetheless, it is unclear what impact burn has on TLR-induced inflammatory responses in the lung. METHODS Male C57BL/6 mice were subjected to burn (3rd degree, 25% TBSA) or sham procedure and 1, 3 or 7 days thereafter, bronchoalveolar lavage (BAL) fluid was collected and cells were isolated and cultured in vitro with specific TLR agonists as follows: Zymosan (TLR-2), LPS (TLR-4) and CpG-ODN (TLR-9). Supernatants were collected 48 h later and assayed for inflammatory cytokine levels (IL-1β, IL-6, IL-10, IL-17, TNF-α, KC, MCP-1, MIP-1α, MIP-1β and RANTES) by Bioplex. RESULTS BAL fluid from sham and burn mice did not contain detectable cytokine levels. BAL cells, irrespective of injury, were responsive to TLR-2 and TLR-4 activation. Seven days after burn, TLR-2 and TLR-4 mediated responses by BAL cells were enhanced as evidenced by increased production of IL-6, IL-17, TNF-α, MCP-1, MIP-1β and RANTES. CONCLUSIONS Burn-induced changes in TLR-2 and TLR-4 reactivity may contribute to the development of post-burn complications, such as acute lung injury (ALI) and adult respiratory distress syndrome (ARDS).
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Affiliation(s)
- Richard F Oppeltz
- Department of Surgery, The University of Texas Health Science Center, San Antonio, TX 78229, USA.
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Abstract
The purpose of this study was to determine whether 26S proteasome is detectable in human bronchoalveolar lavage fluid (BALF) and whether burn and inhalation injury is accompanied by changes in BALF proteasome content or activity. BALF was obtained on hospital admission from 28 patients with burn and inhalation injury (controls: 10 healthy volunteers). Proteasome concentrations were quantified by enzyme-linked immunosorbent assay, and their native molecular mass was assessed by gel filtration. Proteasome peptidase activity was measured using a chymotryptic-like peptide substrate in combination with epoxomicin (specific proteasome inhibitor). BALF protein was increased in patients (P<.001) and correlated positively with the degree of inhalation injury. The 20S/26S proteasomes were detectable in all BALF by enzyme-linked immunosorbent assay. Gel filtration confirmed the presence of intact 20S and 26S proteasome that was stable without soluble ATP/Mg. In all BALF chymotryptic-like activity was detectable and could be inhibited with epoxomicin by 60 to 70% (P<.01). Absolute amounts of 20S/26S proteasomes and proteasome activity were increased in patients (P<.001 for all). The relative BALF composition after injury was characterized by increased concentrations of 20S proteasome/mg protein (P=.0034 vs volunteers), decreased concentrations of 26S proteasome/mg protein (P=.041 vs volunteers), and reduced specific proteasome activity (P=.044 vs volunteers). The 26S proteasome per milligram and specific proteasome activity were even further reduced in patients who developed ventilator-associated pneumonia (P=.045 and P=.03 vs patients without ventilator-associated pneumonia). This study supports the novel concept that extracellular proteasomes could play a pathophysiological role in the injured lung and suggests that insufficient proteasome function may increase susceptibility for pulmonary complications.
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