1
|
Kruse M, Liesenborghs KE, Josuttis D, Plettig P, Guembel D, Lenz IK, Guethoff C, Gebhardt V, Schmittner MD. Early Autocalibrated Arterial Waveform Analysis for the Management of Burn Shock-A Cohort Study. J Intensive Care Med 2024; 39:655-664. [PMID: 38173245 DOI: 10.1177/08850666231224388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group (P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient's volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.
Collapse
Affiliation(s)
- Marianne Kruse
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Konrad Ernst Liesenborghs
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - David Josuttis
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Philip Plettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Denis Guembel
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, DE, Germany
| | - Ida Katinka Lenz
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Claas Guethoff
- Centre for Clinical Research, Biostatistics, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Volker Gebhardt
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| | - Marc Dominik Schmittner
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin, Berlin, DE, Germany
| |
Collapse
|
2
|
Greenhalgh DG, Hill DM, Burmeister DM, Gus EI, Cleland H, Padiglione A, Holden D, Huss F, Chew MS, Kubasiak JC, Burrell A, Manzanares W, Gómez MC, Yoshimura Y, Sjöberg F, Xie WG, Egipto P, Lavrentieva A, Jain A, Miranda-Altamirano A, Raby E, Aramendi I, Sen S, Chung KK, Alvarez RJQ, Han C, Matsushima A, Elmasry M, Liu Y, Donoso CS, Bolgiani A, Johnson LS, Vana LPM, de Romero RVD, Allorto N, Abesamis G, Luna VN, Gragnani A, González CB, Basilico H, Wood F, Jeng J, Li A, Singer M, Luo G, Palmieri T, Kahn S, Joe V, Cartotto R. Surviving Sepsis After Burn Campaign. Burns 2023; 49:1487-1524. [PMID: 37839919 DOI: 10.1016/j.burns.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.
Collapse
Affiliation(s)
- David G Greenhalgh
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA.
| | - David M Hill
- Department of Clinical Pharmacy & Translational Scre have been several studies that have evaluatedience, College of Pharmacy, University of Tennessee, Health Science Center; Memphis, TN, USA
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eduardo I Gus
- Division of Plastic & Reconstructive Surgery, The Hospital for Sick Children; Department of Surgery, University of Toronto, Toronto, Canada
| | - Heather Cleland
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Alex Padiglione
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Dane Holden
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University/Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Aidan Burrell
- Department of Epidemiology and Preventative Medicine, Monash University and Alfred Hospital, Intensive Care Research Center (ANZIC-RC), Melbourne, Australia
| | - William Manzanares
- Department of Critical Care Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - María Chacón Gómez
- Division of Intensive Care and Critical Medicine, Centro Nacional de Investigacion y Atencion de Quemados (CENIAQ), National Rehabilitation Institute, LGII, Mexico
| | - Yuya Yoshimura
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Folke Sjöberg
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wei-Guo Xie
- Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Paula Egipto
- Centro Hospitalar e Universitário São João - Burn Unit, Porto, Portugal
| | | | | | | | - Ed Raby
- Infectious Diseases Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | | | - Soman Sen
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Chunmao Han
- Department of Burn and Wound Repair, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Moustafa Elmasry
- Department of Hand, Plastic Surgery and Burns, Linköping University, Linköping, Sweden
| | - Yan Liu
- Department of Burn, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Carlos Segovia Donoso
- Intensive Care Unit for Major Burns, Mutual Security Clinical Hospital, Santiago, Chile
| | - Alberto Bolgiani
- Department of Surgery, Deutsches Hospital, Buenos Aires, Argentina
| | - Laura S Johnson
- Department of Surgery, Emory University School of Medicine and Grady Health System, Georgia
| | - Luiz Philipe Molina Vana
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Nikki Allorto
- Grey's Hospital Pietermaritzburg Metropolitan Burn Service, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Gerald Abesamis
- Alfredo T. Ramirez Burn Center, Division of Burns, Department of Surgery, University of Philippines Manila - Philippine General Hospital, Manila, Philippines
| | - Virginia Nuñez Luna
- Unidad Michou y Mau Xochimilco for Burnt Children, Secretaria Salud Ciudad de México, Mexico
| | - Alfredo Gragnani
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Carolina Bonilla González
- Department of Pediatrics and Intensive Care, Pediatric Burn Unit, Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Hugo Basilico
- Intensive Care Area - Burn Unit - Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Fiona Wood
- Department of Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James Jeng
- Department of Surgery, University of California, Irvine, CA, USA
| | - Andrew Li
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Mervyn Singer
- Department of Intensive Care Medicine, University College London, London, United Kingdom
| | - Gaoxing Luo
- Institute of Burn Research, Southwest Hospital, Army (Third Military) Medical University, Chongqing, China
| | - Tina Palmieri
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Steven Kahn
- The South Carolina Burn Center, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine, CA, USA
| | - Robert Cartotto
- Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Denny KJ, Lea RA, Lindell-Innes R, Haupt LM, Heffernan AJ, Harvey NR, Hughes O, Cao VT, Stuart J, Paterson DL, McNamara JF, Ungerer JPJ, Pretorius CJ, Griffiths LR, Lipman J. Diagnosing sepsis in the ICU: Comparison of a gene expression signature to pre-existing biomarkers. J Crit Care 2023; 76:154286. [PMID: 36965223 DOI: 10.1016/j.jcrc.2023.154286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/30/2023] [Accepted: 03/02/2023] [Indexed: 03/27/2023]
Abstract
PURPOSE We aimed to identify a gene signature that discriminates between sepsis and aseptic inflammation in patients administered antibiotics in the intensive care unit and compare it to commonly utilised sepsis biomarkers. METHODS 91 patients commenced on antibiotics were retrospectively diagnosed as having: (i) blood culture positive sepsis; (ii) blood culture negative sepsis; or (iii) aseptic inflammation. Bloods were collected after <24 h of antibiotic commencement for both gene expression sequencing analysis and measurement of previously identified biomarkers. RESULTS 53 differentially expressed genes were identified that accurately discriminated between blood culture positive sepsis and aseptic inflammation in a cohort of patients given antibiotics [aROC 0.97 (95% CI, 0.95-0.99)]. This gene signature was validated in a publicly available database. The gene signature outperformed previously identified sepsis biomarkers including C-reactive protein [aROC 0.72 (95% CI, 0.57-0.87)], NT-Pro B-type Natriuretic Peptide [aROC 0.84 (95% CI, 0.73-0.96)], and Septicyte™ LAB [aROC 0.8 (95% CI, 0.68-0.93)], but was comparable to Procalcitonin [aROC 0.96 (95% CI, 0.9-1)]. CONCLUSIONS A gene expression signature was identified that accurately discriminates between sepsis and aseptic inflammation in patients given antibiotics in the intensive care unit.
Collapse
Affiliation(s)
- Kerina J Denny
- Department of Intensive Care, Gold Coast University Hospital, Southport, Queensland, Australia; University of Queensland, St Lucia, Queensland, Australia.
| | - Rodney A Lea
- Genomics Research Centre, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Queensland University of Technology, Queensland, Australia
| | - Ross Lindell-Innes
- Department of Haematology, Canberra Hospital, Woden, Canberra, Australia; John Curtin School of Medical Research, Australian National University, Australia
| | - Larisa M Haupt
- Genomics Research Centre, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Queensland University of Technology, Queensland, Australia; ARC Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology, Australia; Max Planck Queensland Centre for the Materials Sciences of Extracellular Matrices, Queensland, Australia
| | - Aaron J Heffernan
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia
| | - Nicholas R Harvey
- Genomics Research Centre, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Queensland University of Technology, Queensland, Australia; Department of Twin Research and Genetic Epidemiology, King's College London, London, United Kingdom
| | - Oliver Hughes
- Genomics Research Centre, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Queensland University of Technology, Queensland, Australia
| | - Van T Cao
- Genomics Research Centre, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Queensland University of Technology, Queensland, Australia
| | - Janine Stuart
- Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia; ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - John F McNamara
- University of Queensland, St Lucia, Queensland, Australia; Department of Infectious Diseases, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Jacobus P J Ungerer
- Department of Chemical Pathology, Pathology Queensland, Herston, Queensland, Australia; School of Biomedical Science, University of Queensland, Brisbane, Australia
| | - Carel J Pretorius
- Department of Chemical Pathology, Pathology Queensland, Herston, Queensland, Australia; School of Biomedical Science, University of Queensland, Brisbane, Australia
| | - Lyn R Griffiths
- Genomics Research Centre, Centre for Genomics and Personalised Health, School of Biomedical Sciences, Queensland University of Technology, Queensland, Australia
| | - Jeffrey Lipman
- Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; Jaimeson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; Nimes University Hospital, University of Montpellier, Nimes, France
| |
Collapse
|
4
|
Use of procalcitonin as a biomarker for sepsis in pediatric burns. Eur J Pediatr 2023; 182:1561-1567. [PMID: 36752894 DOI: 10.1007/s00431-023-04831-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 12/05/2022] [Accepted: 01/12/2023] [Indexed: 02/09/2023]
Abstract
UNLABELLED Infection and sepsis continue to be the leading cause of morbidity and death in burn injuries. Diagnosing sepsis in burns is challenging as signs and symptoms of sepsis are not specific and overlap with those related to the burn injury. While the use of procalcitonin (PCT) as a biomarker is recommended for diagnosing sepsis in burns, evidence for children with burns is scarce. In this study, we aimed to investigate the role of PCT in distinguishing sepsis in pediatric burns. A prospective observational study was conducted in a single pediatric burn unit. Children hospitalized with burns ≤ 30% of total body surface area were included while patients with chemical burn, inhalation injury, or concomitant chronic diseases were excluded. Patients were classified into three groups for sepsis, systemic inflammatory response syndrome (SIRS), or controls using the American Burn Association (ABA) criteria. The predictive role of C-reactive protein (CRP) and PCT was investigated for distinguishing sepsis. Seventy-two patients were included in the study. The median total body surface area (TBSA) size was 12% (2.0-28.5%), and the median abbreviated burn severity index (ABSI) score was 3 (2-7). The median length of burn unit stay was 9.5 days (1-59 days). Sepsis was diagnosed in 11 patients (15.2%), and SIRS was present in 23 patients (40.0%), whereas 38 patients (52.8%) had neither SIRS nor sepsis (control group). Receiver operating characteristic analysis revealed that CRP and PCT levels distinguished sepsis patients from non-sepsis patients while PCT had a higher positive predictive value (50.0% vs. 45.0%). Optimal cutoff values of CRP and PCT for distinguishing sepsis were 66.75 mg/L and 0.95 ng/mL. CONCLUSIONS PCT levels could distinguish sepsis in children with burn injuries, performing better than CRP levels. Confirmatory studies are needed to evaluate the development of sepsis and the role of PCT in diagnosing sepsis in pediatric burn patients. WHAT IS KNOWN • Even though there are excellent criteria for the diagnosis of infection and sepsis in children and several clinical parameters and biomarkers are being studied, it's difficult to diagnose burn wound sepsis in children. WHAT IS NEW • Data from this study showed that procalcitonin levels performed better than CRP levels as a biomarker for distinguishing sepsis from systemic inflammatory response syndrome (SIRS) in children with burn injuries.
Collapse
|
5
|
Biomarkers for the Early Diagnosis of Sepsis in Burns. Ann Surg 2022; 275:654-662. [DOI: 10.1097/sla.0000000000005198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
6
|
Tan J, Li N, Gong Y, Yuan L, Zhou J, Luo G. Procalcitonin kinetics early after severe burn injury and its value in diagnosis of sepsis. Burns 2021; 47:1802-1809. [PMID: 33685812 DOI: 10.1016/j.burns.2021.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To investigate the clinical significance of procalcitonin (PCT) kinetics early after burn and the perioperative period, and to assess its diagnostic performance for sepsis in major burn patients. METHODS This retrospective study on major burn patents (≥40% total body surface area) admitted from 2014 to 2019 was conducted in Southwest Hospital, Chongqing, China. A total of 321 patients were included. The kinetics of PCT was analyzed during the 1st week after burn, the perioperative period, and at the onset of clinical suspected sepsis. RESULTS Serum PCT concentration rose immediately after burn injury. Factors associated with increased PCT level in the 1st week after burn include greater burn area (>70% TBSA) and lower age (≤14 years). Correlations between PCT kinetics after burn and the risk of early development of sepsis and mortality were observed. At the onset of sepsis, serum PCT increased significantly compared to its basal level in the 48 h before diagnosis. The area under the receiver operating characteristics curve of PCT concentration and its kinetic changes was 0.788 and 0.826, respectively. PCT kinetics showed better accuracy than PCT concentration in discrimination of Gram-positive sepsis. The optimal diagnostic thresholds for PCT concentration and its kinetics were 1.41 ng/mL, and a 1.34-fold elevation compared to the baseline level. CONCLUSIONS PCT kinetics in the early stage after burn was a prognostic factor for sepsis and mortality among major burn patients. Serum PCT levels could be a diagnostic biomarker for sepsis in major burn patients.
Collapse
Affiliation(s)
- Jianglin Tan
- Institute of Burn Research, Southwest Hospital, the Army Medical University (Third Military Medical University), Chongqing 400038, PR China; State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing 400038, PR China.
| | - Ning Li
- Institute of Burn Research, Southwest Hospital, the Army Medical University (Third Military Medical University), Chongqing 400038, PR China.
| | - Yali Gong
- Institute of Burn Research, Southwest Hospital, the Army Medical University (Third Military Medical University), Chongqing 400038, PR China.
| | - Lili Yuan
- Institute of Burn Research, Southwest Hospital, the Army Medical University (Third Military Medical University), Chongqing 400038, PR China.
| | - Junyi Zhou
- Institute of Burn Research, Southwest Hospital, the Army Medical University (Third Military Medical University), Chongqing 400038, PR China; State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing 400038, PR China.
| | - Gaoxing Luo
- Institute of Burn Research, Southwest Hospital, the Army Medical University (Third Military Medical University), Chongqing 400038, PR China; State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing 400038, PR China.
| |
Collapse
|
7
|
Zhang P, Zou B, Liou YC, Huang C. The pathogenesis and diagnosis of sepsis post burn injury. BURNS & TRAUMA 2021; 9:tkaa047. [PMID: 33654698 PMCID: PMC7901709 DOI: 10.1093/burnst/tkaa047] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/20/2020] [Indexed: 02/05/2023]
Abstract
Burn is an under-appreciated trauma that is associated with unacceptably high morbidity and mortality. Although the survival rate after devastating burn injuries has continued to increase in previous decades due to medical advances in burn wound care, nutritional and fluid resuscitation and improved infection control practices, there are still large numbers of patients at a high risk of death. One of the most common complications of burn is sepsis, which is defined as “severe organ dysfunction attributed to host's disordered response to infection” and is the primary cause of death in burn patients. Indeed, burn injuries are accompanied by a series of events that lead to sepsis and multiple organ dysfunction syndrome, such as a hypovolaemic state, immune and inflammatory responses and metabolic changes. Therefore, clear diagnostic criteria and predictive biomarkers are especially important in the prevention and treatment of sepsis and septic shock. In this review, we focus on the pathogenesis of burn wound infection and the post-burn events leading to sepsis. Moreover, the clinical and promising biomarkers of burn sepsis will also be summarized.
Collapse
Affiliation(s)
- Pengju Zhang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, and West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, and Collaborative Innovation Center for Biotherapy, No.17 People's South Road, Chengdu, 610041, China
| | - Bingwen Zou
- Department of Thoracic Oncology and Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu, 610041, China
| | - Yih-Cherng Liou
- Department of Biological Sciences, Faculty of Science, National University of Singapore, 14 Science Drive 4, 117543, Singapore
| | - Canhua Huang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, and West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, and Collaborative Innovation Center for Biotherapy, No.17 People's South Road, Chengdu, 610041, China
| |
Collapse
|
8
|
Dastagir K, Krezdorn N, Bingoel AS, Mett TR, Radtke C, Jokuszies A, Vogt PM. Application of critical care scores in severely burned patients. J Burn Care Res 2021; 42:1176-1180. [PMID: 33539518 DOI: 10.1093/jbcr/irab030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Early detection of sepsis is of crucial importance in patients with severe burn injuries. However, according to the S1-guideline , based on SIRS criteria, the early diagnosis of sepsis in severely burned patients is difficult. The value of the new definition of sepsis based on sequential organ failure assessment (SOFA) according to S3-guidelines for patients with severe burn injuries is not described in detail in literature.We analyzed retrospectively all data during the period 2014-2018 from the electronic patient information system. Using Receiver operating characteristic (ROC) curve the area under the curve (AUC) was calculated for diagnostic value of procalcitonin (PCT), SIRS and SOFA score according to the burned total body surface area (TBSA). 651 patients with burn injuries were admitted to our burn unit, 315 of them had burn injuries affecting more than 10% body surface area with partial to full thickness burn (grade 2-4) . In this group, 59 patients showed one or more septic events in the course of the intensive care treatment, defined by positive blood stream infection. Both S1- and S3- guidelines were inappropriate to diagnose sepsis in patients with severe burn injuries. Due to pathophysiological changes of the body function in severely burned patients, that show features of both SIRS and pathological SOFA scores (> 2 points) at the outset of burn injury, the diagnosis of sepsis associated with burns is intricate in this patient group. Assessing data for potential hallmarks of sepsis in burn patients we found PCT to show significant correlation with sepsis.
Collapse
Affiliation(s)
- Khaled Dastagir
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Nicco Krezdorn
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Alperen Sabri Bingoel
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Tobias Roland Mett
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Christine Radtke
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Jokuszies
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Peter Maria Vogt
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| |
Collapse
|
9
|
Rakkolainen I, Elmasry M, Steinvall I, Vuola J. N-Terminal Brain Natriuretic Peptide First Week After Burn Injury. J Burn Care Res 2020; 39:805-810. [PMID: 29931326 DOI: 10.1093/jbcr/irx054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
B-type natriuretic peptide has shown promising results as a biomarker for acute kidney injury in general intensive care patients. It may also indirectly reflect fluid balance of the circulation. Among burn patients, it has been observed to indicate excessive fluid resuscitation and organ dysfunction, although its clinical use to indicate acute kidney injury or guide fluid resuscitation has not been validated. The aim of this study was to evaluate whether the N-terminal pro-brain natriuretic peptide values are related to the amount of fluids given after severe burn injury and whether it can act as a novel biomarker for acute kidney injury in these patients. Nineteen consecutive burn patients were included. Plasma N-terminal pro-brain natriuretic peptide was measured daily during 1 week from admission. Other variables such as laboratory values and intravenous infusions were also recorded. The association between acute kidney injury and N-terminal pro-brain natriuretic peptide values was analyzed with a multivariable panel regression model, adjusted for burned total body surface area, age, body mass index, and laboratory values. N-terminal pro-brain natriuretic peptide values varied between single patients, and even more between the patients who developed acute kidney injury. Older age, lower body mass index, and cumulative infusions were independently associated with higher N-terminal pro-brain natriuretic peptide values, whereas acute kidney injury was not. N-terminal pro-brain natriuretic peptide values correlated with cumulative infusions given during the first week. The authors could not validate the role of N-terminal pro-brain natriuretic peptide as a biomarker for acute kidney injury in burns.
Collapse
Affiliation(s)
- Ilmari Rakkolainen
- Department of Plastic Surgery, Helsinki Burn Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finl
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Surgery Department, Plastic Surgery Unit, Suez Canal University, Ismailia, Egypt
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Jyrki Vuola
- Department of Plastic Surgery, Helsinki Burn Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finl
| |
Collapse
|
10
|
Lang TC, Zhao R, Kim A, Wijewardena A, Vandervord J, Xue M, Jackson CJ. A Critical Update of the Assessment and Acute Management of Patients with Severe Burns. Adv Wound Care (New Rochelle) 2019; 8:607-633. [PMID: 31827977 PMCID: PMC6904939 DOI: 10.1089/wound.2019.0963] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/18/2019] [Indexed: 12/14/2022] Open
Abstract
Significance: Burns are debilitating, life threatening, and difficult to assess and manage. Recent advances in assessment and management have occurred since a comprehensive review of the care of patients with severe burns was last published, which may influence research and clinical practice. Recent Advances: Recent advances have occurred in the understanding of burn pathophysiology, which has led to the identification of potential biomarkers of burn severity, such as protein C. There is new evidence about the potential superiority of natural colloids over crystalloids during fluid resuscitation, and new evidence about components of initial and perioperative management, including an improved understanding of pain following burns. Critical Issues: The limitations of the clinical examination highlight the need for imaging and biomarkers to assist in estimations of burn severity. Fluid resuscitation reduces mortality, although there is conjecture over the ideal method. The subsequent perioperative period is associated with significant morbidity and the evidence for preventing and treating pain, infection, and fluid overload while maximizing wound healing potential is described. Future Directions: Promising developments are ongoing in imaging technology, histopathology, biomarkers, and wound healing adjuncts such as hyperbaric oxygen therapy, topical negative pressure therapy, stem cell treatments, and skin substitutes. The greatest benefit from further research on management of patients with burns would most likely be derived from the elucidation of optimal fluid resuscitation protocols, pain management protocols, and surgical techniques from randomized controlled trials.
Collapse
Affiliation(s)
- Thomas Charles Lang
- Department of Anesthesia, Prince of Wales and Sydney Children's Hospitals, Randwick, Australia
| | - Ruilong Zhao
- Sutton Laboratories, The Kolling Institute, St. Leonards, Australia
| | - Albert Kim
- Department of Critical Care Medicine, Royal North Shore Hospital, St. Leonards, Australia
| | - Aruna Wijewardena
- Department of Burns, Reconstructive and Plastic Surgery, Royal North Shore Hospital, St. Leonards, Australia
| | - John Vandervord
- Department of Burns, Reconstructive and Plastic Surgery, Royal North Shore Hospital, St. Leonards, Australia
| | - Meilang Xue
- Sutton Laboratories, The Kolling Institute, St. Leonards, Australia
| | | |
Collapse
|
11
|
Gómez BI, Harrington BK, Chao T, Chung KK, Dubick MA, Boggs NA, Burmeister DM. Impact of oral resuscitation on circulating and splenic leukocytes after burns. Burns 2019; 46:567-578. [PMID: 31787475 DOI: 10.1016/j.burns.2019.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/07/2019] [Accepted: 08/29/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hemodynamic aberrations after severe burns are treated with aggressive intravenous (IV) fluid resuscitation however, oral resuscitation has been proposed in resource poor scenarios. Previously we have shown that animals receiving oral fluid following burns were able to recover kidney function. However, immune function such as circulating and splenic immune cell populations after oral or intravenous fluid administration was not examined. Herein, we perform a follow up analysis of splenic tissue and plasma from the previous animal study to examine the splenic response following these resuscitation strategies after burn injury. METHODS Eighteen anesthetized Yorkshire swine receiving 40%TBSA contact burns were randomized to receive either: (1) no fluids (Fluid Restricted; negative control), (2) 70 mL/kg/d Oral Rehydration Salt solution (Oral), or (3) 2 mL/kg/%TBSA/d of lactated Ringer's solution IV. Blood was drawn for blood cell analysis, and CT scans were performed before and 48 h post-burn, at which point spleens were harvested for histological, Western blot, and RT-PCR analyses. RESULTS Splenic artery diameter decreased by -0.97 ± 0.14 mm in fluid-restricted animals, while IV led to an increase of 0.68 ± 0.30 mm. No significant differences were detected in white and red pulp. IV fluids reduced the population of splenic monocytes (CD163; P = 0.001) and neutrophils (MPO protein; P = 0.13), as well as cytokines IL-8 (P = 0.003), IFN-γ (P = 0.11) and TNFα (P = 0.05). Additionally, withholding IV fluids consistently decreased the expression of FoxP3, CCR6, and IL17β in spleen, suggesting a shift in T-cell phenotype with IV resuscitation. CONCLUSIONS The route of fluid administration has a minor influence on the changes in circulating and splenic leukocytes post-burn in the acute phase. Further research is needed to help guide resuscitation approaches using immunologic markers of splenic function following burns.
Collapse
Affiliation(s)
- Belinda I Gómez
- United States Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX, 78234 United States
| | - Brenna K Harrington
- United States Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX, 78234 United States
| | - Tony Chao
- United States Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX, 78234 United States
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Michael A Dubick
- United States Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX, 78234 United States
| | - Nathan A Boggs
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States
| | - David M Burmeister
- United States Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX, 78234 United States.
| |
Collapse
|
12
|
From traditional biochemical signals to molecular markers for detection of sepsis after burn injuries. Burns 2019; 45:16-31. [DOI: 10.1016/j.burns.2018.04.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/28/2018] [Accepted: 04/24/2018] [Indexed: 12/22/2022]
|
13
|
Roles of Procalcitonin and N-Terminal Pro-B-Type Natriuretic Peptide in Predicting Catheter-Related Bloodstream Infection in Severe Burn Injury Patients. DISEASE MARKERS 2018; 2018:5607932. [PMID: 30595763 PMCID: PMC6282120 DOI: 10.1155/2018/5607932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/08/2018] [Accepted: 10/31/2018] [Indexed: 11/17/2022]
Abstract
Objective To investigate the characteristics of early catheter-related bloodstream infection (CRBSI) in severe burn injury patients induced by a massive aluminum dust explosion. Methods Sixty-eight severe burn injury patients experienced a massive dust explosion in Kunshan were included in this study. Patients received central venous catheter placement, arterial catheterization to monitor blood pressure and PiCCO cardiac monitoring, tracheostomy, mechanical ventilation, analgesics and sedation treatment, and fluid resuscitation. Clinical data including age, gender, burn surface area, fluid intake and output, urine temperature, and APACHE II score information were collected from each patient. Ultrasound screening was performed to exclude heart failure, which may lead to the change of NT-proBNP. When CRBSI was suspected, 10 ml central venous blood and peripheral arterial blood were sent for testing. For patients with suspected CRBSI, the level of PCT and NT-proBNP were monitored every day until the infection was controlled. Results Among the 68 patients, 29 showed CRBSI. The most common pathogenic bacteria of CRBSI were A. baumannii (39.8%), P. aeruginosa (26.4%), and K. pneumoniae (13.7%). Procalcitonin (PCT) (2.98 ng/ml) and NT-proBNP (355 pg/ml) were significantly associated with CRBSI results. The sensitivity of PCT, NT-proBNP, WBC, and CRP was 94.2%, 89.7%, 88.3%, and 90.5%, respectively (P < 0.05). The area under curve (AUC) of PCT combined with NT-proBNP for prediction of CRBSI was 0.981, and the sensitivity and specificity was 0.812 and 0.857, respectively. Conclusion PCT and NT-proBNP combination improves the diagnosis of CRBSI. PCT and NT-proBNP may be alternative candidates for potential prediction of CRBSI in patients with severe injury.
Collapse
|
14
|
Cabral L, Afreixo V, Meireles R, Vaz M, Frade JG, Chaves C, Caetano M, Almeida L, Paiva JA. Evaluation of Procalcitonin Accuracy for the Distinction Between Gram-Negative and Gram-Positive Bacterial Sepsis in Burn Patients. J Burn Care Res 2018; 40:112-119. [DOI: 10.1093/jbcr/iry058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Luís Cabral
- Department of Plastic Surgery and Burns Unit, Coimbra University Hospital Centre (CHUC), Portugal
- Autonomous Section of Health Sciences (SACS), University of Aveiro, Portugal
| | - Vera Afreixo
- CIDMA—Center for Research and Development in Mathematics and Applications, iBiMED—Institute for Biomedicine, Department of Mathematics, University of Aveiro, Portugal
| | - Rita Meireles
- Department of Plastic Surgery and Burns Unit, Coimbra University Hospital Centre (CHUC), Portugal
| | - Miguel Vaz
- Department of Plastic Surgery and Burns Unit, Coimbra University Hospital Centre (CHUC), Portugal
| | - João-Gonçalo Frade
- Clinical Pathology Department, Coimbra University Hospital Centre (CHUC), Portugal
- Escola Superior de Saúde, Instituto Politécnico de Leiria, Portugal
| | - Catarina Chaves
- Clinical Pathology Department, Coimbra University Hospital Centre (CHUC), Portugal
| | - Marisa Caetano
- Pharmacy Department, Coimbra University Hospital Centre (CHUC), Portugal
| | - Luís Almeida
- MedinUP, Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Portugal
| | - José-Artur Paiva
- Department of Emergency and Intensive Care Medicine, Centro Hospitalar São João, Porto, Portugal
- Grupo de Infecção e Sépsis, Faculty of Medicine, University of Porto, Portugal
| |
Collapse
|
15
|
Abstract
Mid regional pro-adrenomedullin (MR-proADM) has been used as a marker of sepsis, but its dynamics and role in a burn injury setting has not been tested. In a prospective observational study, we included 42 consecutive patients with >15% TBSA. Daily blood specimens collected over the initial 20 days of treatment were submitted for laboratory analysis of MR-proADM and procalcitonin (PCT) via immunoluminometric sandwich assay (Kryptor, BRAHMS, Berlin, Germany). In patients with an absence of sepsis, an initial increase in MR-proADM and PCT levels was noted post-burn injury, peaking on the second day postadmission and thereafter demonstrated a continued decline in MR-proADM and PCT levels. In those patients who went on to develop sepsis (n = 27, 64.3%), the levels of MR-proADM and PCT were significantly higher (P < .001) on days categorized as septic, than on days categorized as nonseptic. The increase in PCT levels was noted on the first day to be categorized as septic. In contrast, the MR-proADM levels demonstrated an increase one day earlier. The optimal relationship between the specificity and sensitivity of MR-proADM and PCT for the detection of sepsis was an increase of 31% and at least 0.015 nmol/L (area under curve 0.76) or of >39% and at least 0.15 µg/L (area under the curve 0.83), respectively. Burn injury is associated with increased levels of MR-proADM. Subsequent increases may be considered as diagnostic of sepsis onset. In this context, PCT displayed higher specificity and sensitivity, while MR-proADM may be more suitable for the early recognition of sepsis (ClinicalTrials.gov number, NCT01055587).
Collapse
|
16
|
Gilbert DN. Role of Procalcitonin in the Management of Infected Patients in the Intensive Care Unit. Infect Dis Clin North Am 2018; 31:435-453. [PMID: 28779830 DOI: 10.1016/j.idc.2017.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The combination of molecular pathogen diagnostics and the biomarker procalcitonin (PCT) are changing the use of antimicrobials in patients admitted to critical care units with severe community-acquired pneumonia, possible septic shock, or other clinical syndromes. An elevated serum PCT level is good supportive evidence of a bacterial pneumonia, whereas a low serum PCT level virtually eliminates an etiologic role for bacteria even if the culture for a potential bacterial pathogen is positive. Serum PCT levels can be increased in any shocklike state; a low PCT level eliminates invasive bacterial infection as an etiology in more than 90% of patients.
Collapse
Affiliation(s)
- David N Gilbert
- Infectious Diseases, Providence Portland Medical Center, Oregon Health and Sciences University, 5050 Northeast Hoyt, Suite 540, Portland, OR 97213, USA.
| |
Collapse
|
17
|
Abstract
The objective of this study was to determine whether urine ubiquitin levels are elevated after burns and to assess whether urine ubiquitin could be useful as a noninvasive biomarker for burn patients. Forty burn patients (%TBSA: 20 ± 22; modified Baux scores: 73 ± 26) were included (control: 11 volunteers). Urine was collected in 2-hour intervals for 72 hours, followed by 12-hour intervals until discharge from the intensive care unit. Ubiquitin concentrations were analyzed by enzyme linked immunosorbent assay and Western blot. Total protein was determined with a Bradford assay. Patient characteristics and clinical parameters were documented. Urine ubiquitin concentrations, renal ubiquitin excretion, and excretion rates were correlated with patient characteristics and outcomes. Initial urine ubiquitin concentrations were 362 ± 575 ng/ml in patients and 14 ± 18 ng/ml in volunteers (P < .01). Renal ubiquitin excretion on day 1 was 292.6 ± 510.8 μg/24 hr and 21 ± 27 μg/24 hr in volunteers (P < .01). Initial ubiquitin concentrations correlated with modified Baux scores (r = .46; P = .02). Ubiquitin levels peaked at day 6 postburn, whereas total protein concentrations and serum creatinine levels remained within the normal range. Total renal ubiquitin excretion and excretion rates were higher in patients with %TBSA ≥20 than with %TBSA <20, in patients who developed sepsis/multiple organ failure than in patients without these complications and in nonsurvivors vs survivors. These data suggest that ubiquitin urine levels are significantly increased after burns. Renal ubiquitin excretion and/or excretion rates are associated with %TBSA, sepsis/multiple organ failure, and mortality. Although these findings may explain previous correlations between systemic ubiquitin levels and outcomes after burns, the large variability of ubiquitin urine levels suggests that urine ubiquitin will not be useful as a noninvasive disease biomarker.
Collapse
|
18
|
Association of Heart Rate with N-Terminal Pro-B-Type Natriuretic Peptide in Septic Patients: A Prospective Observational Cohort Study. Shock 2018; 46:642-648. [PMID: 27380528 DOI: 10.1097/shk.0000000000000673] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Excessive sympathetic stress has multiple adverse effects during critical illness including sepsis. Recent studies showed that heart rate control had a significant effect on reducing mortality in septic shock patients. Furthermore, elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in septic patients were reportedly associated with adverse outcome. However, no study has evaluated the relationship between hemodynamic profiles of septic patients and the circulating cardiac biomarker. Our objective was to determine whether hemodynamic profiles, specifically tachycardia and new-onset atrial fibrillation (AF), were associated with NT-proBNP elevation in septic patients. METHODS We consecutively enrolled patients admitted to our intensive care unit (ICU). NT-proBNP levels, heart rate, and rhythm at ICU admission were measured, and all clinical and laboratory data were prospectively collected. Tachycardia was defined as a heart rate of above 100 bpm. RESULTS Ninety-five patients out of 267 patients (35.6%) were diagnosed as sepsis. Of these septic patients, 47 presented with tachycardia and 6 developed new-onset AF. Multivariate Cox regression analysis revealed that tachycardia was an independent predictor of 28-day overall survival in septic patients (hazard ratio, 4.22; 95% confidence interval, 1.10-27.72; P < 0.05), but not in nonseptic patients. Multivariate linear regression analysis demonstrated that the presence of tachycardia was an independent determinant of NT-proBNP elevation (P < 0.05) in septic patients, but not in nonseptic patients. CONCLUSIONS Tachycardia was significantly and independently associated with NT-proBNP elevation and lower survival rate in septic patients, although no association was observed in nonseptic patients. Increased NT-proBNP in sepsis with tachycardia might predict poor outcomes in ICU.
Collapse
|
19
|
Cabral L, Afreixo V, Santos F, Almeida L, Paiva JA. Procalcitonin for the early diagnosis of sepsis in burn patients: A retrospective study. Burns 2017; 43:1427-1434. [DOI: 10.1016/j.burns.2017.03.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/13/2017] [Accepted: 03/29/2017] [Indexed: 02/07/2023]
|
20
|
Nunez Lopez O, Cambiaso-Daniel J, Branski LK, Norbury WB, Herndon DN. Predicting and managing sepsis in burn patients: current perspectives. Ther Clin Risk Manag 2017; 13:1107-1117. [PMID: 28894374 PMCID: PMC5584891 DOI: 10.2147/tcrm.s119938] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Modern burn care has led to unprecedented survival rates in burn patients whose injuries were fatal a few decades ago. Along with improved survival, new challenges have emerged in the management of burn patients. Infections top the list of the most common complication after burns, and sepsis is the leading cause of death in both adult and pediatric burn patients. The diagnosis and management of sepsis in burns is complex as a tremendous hypermetabolic response secondary to burn injury can be superimposed on systemic infection, leading to organ dysfunction. The management of a septic burn patient represents a challenging scenario that is commonly encountered by providers caring for burn patients despite preventive efforts. Here, we discuss the current perspectives in the diagnosis and treatment of sepsis and septic shock in burn patients.
Collapse
Affiliation(s)
- Omar Nunez Lopez
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA
| | - Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Ludwik K Branski
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA
| | - William B Norbury
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch.,Shriners Hospitals for Children, Galveston, TX, USA.,Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, USA
| |
Collapse
|
21
|
Dries DJ, Marini JJ. Management of Critical Burn Injuries: Recent Developments. Korean J Crit Care Med 2017; 32:9-21. [PMID: 31723611 PMCID: PMC6786736 DOI: 10.4266/kjccm.2016.00969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 12/25/2016] [Indexed: 12/28/2022] Open
Abstract
Background Burn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve vital organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage problems related to thermal injury, including lightning and electrical injuries. Methods A selected review is provided of key management concepts as well as of recent reports published by the American Burn Association. Results The burn-injured patient is easily and frequently over resuscitated, with ensuing complications that include delayed wound healing and respiratory compromise. A feedback protocol designed to limit the occurrence of excessive resuscitation has been proposed, but no new “gold standard” for resuscitation has replaced the venerated Parkland formula. While new medical therapies have been proposed for patients sustaining inhalation injury, a paradigm-shifting standard of medical therapy has not emerged. Renal failure as a specific contributor to adverse outcome in burns has been reinforced by recent data. Of special problems addressed in burn centers, electrical injuries pose multisystem physiologic challenges and do not fit typical scoring systems. Conclusion Recent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury has been generally adopted, but new standards for description of burn-related infections have been presented. The value of the burn center in care of the problems of electrical exposure, both manmade and natural, is demonstrated in recent reports.
Collapse
Affiliation(s)
- David J Dries
- Department of Surgery and Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - John J Marini
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
22
|
The Use of Procalcitonin (PCT) for Diagnosis of Sepsis in Burn Patients: A Meta-Analysis. PLoS One 2016; 11:e0168475. [PMID: 28005932 PMCID: PMC5179235 DOI: 10.1371/journal.pone.0168475] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 12/01/2016] [Indexed: 01/15/2023] Open
Abstract
The continuous development of resuscitation techniques and intensive care reduced the mortality rate induced by the initial shock in burn patients and, currently, infections (especially sepsis) are the main causes of mortality of these patients. The misuse of antimicrobial agents is strongly related to antimicrobial and adverse patient outcomes, development of microbial resistance and increased healthcare-related costs. To overcome these risks, antimicrobial stewardship is mandatory and biomarkers are useful to avoid unnecessary medical prescription, to monitor antimicrobial therapy and to support the decision of its stop. Among a large array of laboratory tests, procalcitonin (PCT) emerged as the leading biomarker to accurately and time-effectively indicate the presence of systemic infection. In the presence of systemic infection, PCT blood levels undergo a sudden and dramatic increase, following the course of the infection, and quickly subside after the control of the septic process. This work is a meta-analysis on PCT performance as a biomarker for sepsis. This meta–analysis showed that overall pooled area under the curve (AUC) is 0.83 (95% CI = 0.76 to 0.90); the estimated cut-off is 1.47 ng/mL. The overall sepsis effect in PCT levels is significant and strong (Cohen's d is 2.1 and 95% CI = 1.1 to 3.2). This meta–analysis showed PCT may be considered as a biomarker with a strong diagnostic ability to discriminate between the septic from the non-septic burn patients. Thus, this work encourages the determination of PCT levels in clinical practice for the management of these patients, in order to timely identify the susceptibility to sepsis and to initiate the antimicrobial therapy, improving the patients’ outcomes.
Collapse
|
23
|
Zhang X, Li N, Meng Y, Zhang R, Bian J, Yao Y, Li J, Deng X. High-Level Expression of Toll-Like Receptors on Dendritic Cells in Adult Patients with Burns on ≥90% of Total Body Surface Area (TBSA). Med Sci Monit 2016; 22:3493-3499. [PMID: 27686145 PMCID: PMC5047034 DOI: 10.12659/msm.897433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background As a serious clinical problem, severe burn injury disturbs the immune system, resulting in progressive suppression of immune response. TLRs are associated with immune system activation, but the effect of TLRs levels on circulating cDCs of severe burn injury patients has not been fully assessed. Material/Methods Ten patients with total body surface area (TBSA) burned >90% admitted to our institution were enrolled in this study. We analyzed TLR2, TLR4, and TLR9 expression on the circulating cDCs by using multicolor flow cytometric analysis in patients at 14 days to 28 days after burn injury according to mortality, and We also assessed Demographics, clinical outcomes, organ function, and inflammatory and acute-phase responses. Results No difference in TBSA, sex, age, or number of operations before the first 14 days after injury were observed between surviving and non-surviving burn patients. The levels of TLR2, TLR4, and TLR9 in circulating cDCs were significantly and consistently elevated in all patients compared to age-matched healthy volunteers, and survivors exhibited higher TLR2 and TLR4 values than non-survivors. Of the survivors, TLR2 and TLR4 levels were higher at 28 days than at 14 days after injury, while the difference in TLR9 levels was not significant. TLR2 levels of non-survivors at 28 days after injury decreased, and the TLR4 and TLR9 levels showed no significant difference. Conclusions TLRs levels in circulating cDCs are highly activated in severe burn injury patients up to 28 days after injury. The low expression of TLR2 in cDCs may be useful as a potential marker predicting the poor prognosis of severe burn patients.
Collapse
Affiliation(s)
- Xu Zhang
- Department of Anesthesiology and Intensive Care, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Na Li
- Department of Anesthesiology and Intensive Care, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Yan Meng
- Department of Anesthesiology and Intensive Care, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Renjing Zhang
- Department of Anesthesiology and Intensive Care, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Jinjun Bian
- Department of Anesthesiology and Intensive Care, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Ying Yao
- Department of Anesthesiology and Intensive Care, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Jinbao Li
- Department of Anesthesiology and Intensive Care, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Xiaoming Deng
- Department of Anesthesiology and Intensive Care, Changhai Hospital, Second Military Medical University, Shanghai, China (mainland)
| |
Collapse
|
24
|
Abstract
Management of burn injuries requires treatments and interventions from many disciplines. Worldwide, burn patients suffer from physical and psychological challenges that impact their lives socially and economically. In this review, we will highlight a handful of the numerous articles published in multiple areas of burn care. The areas of burn care addressed in the article are: epidemiology; burn resuscitation, critical care, and infection; nutrition and metabolism; pain and rehabilitation; prevention and firefighter safety; psychology; and reconstruction and wounds.
Collapse
|
25
|
Abstract
OBJECTIVES In this review, we discuss the physiology, pathophysiology, and clinical role of troponin, lactate, and B-type natriuretic peptide in the assessment and management of children with critical cardiac disease. DATA SOURCE MEDLINE, PubMed. CONCLUSION Lactate, troponin, and B-type natriuretic peptide continue to be valuable biomarkers in the assessment and management of critically ill children with cardiac disease. However, the use of these markers as a single measurement is handicapped by the wide variety of clinical scenarios in which they may be increased. The overall trend may be more useful than any single level with a persistent or rising value of more importance than an elevated initial value.
Collapse
|
26
|
Denny KJ, Cotta MO, Parker SL, Roberts JA, Lipman J. The use and risks of antibiotics in critically ill patients. Expert Opin Drug Saf 2016; 15:667-78. [PMID: 26961691 DOI: 10.1517/14740338.2016.1164690] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The altered pathophysiology in critically ill patients presents a unique challenge in both the diagnosis of infection and the appropriate prescription of antibiotics. In this context, the importance of effective and timely treatment needs to be weighed against the individual and community harms associated with antibiotic collateral damage and antibiotic resistance. AREAS COVERED We evaluate the principles of antibiotic use in critically ill patients, including dose optimisation, use of combination antibiotic therapy, therapeutic drug monitoring, appropriate antibiotic therapy duration, de-escalation, and utilisation of sepsis biomarkers. We also describe the potential risks associated with antibiotic therapy including antibiotic resistance, delayed treatment, treatment failure, and collateral damage. EXPERT OPINION Prescribing teams must be aware of the impact of critical illness on their patients and tailor antibiotic therapy appropriately to prevent the significant harms associated with suboptimal antibiotic administration.
Collapse
Affiliation(s)
- Kerina J Denny
- a Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,b Burns, Trauma and Critical Care Research Centre, School of Medicine , The University of Queensland , Brisbane , Australia
| | - Menino O Cotta
- a Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,c School of Pharmacy , The University of Queensland , Brisbane , Australia
| | - Suzanne L Parker
- b Burns, Trauma and Critical Care Research Centre, School of Medicine , The University of Queensland , Brisbane , Australia
| | - Jason A Roberts
- a Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,b Burns, Trauma and Critical Care Research Centre, School of Medicine , The University of Queensland , Brisbane , Australia.,c School of Pharmacy , The University of Queensland , Brisbane , Australia
| | - Jeffrey Lipman
- a Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,b Burns, Trauma and Critical Care Research Centre, School of Medicine , The University of Queensland , Brisbane , Australia.,d School of Nursing , Queensland University of Technology , Brisbane , Australia
| |
Collapse
|
27
|
Ruiz-Castilla M, Roca O, Masclans JR, Barret JP. Recent Advances in Biomarkers in Severe Burns. Shock 2016; 45:117-25. [DOI: 10.1097/shk.0000000000000497] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
28
|
Honore PM, Spapen HD. The struggle to differentiate inflammation from infection in severely burned patients: time to send better biomarkers into the arena? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:13. [PMID: 26786789 PMCID: PMC4719695 DOI: 10.1186/s13054-016-1194-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Patrick M Honore
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Herbert D Spapen
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
29
|
Honoré PM, Jacobs R, De Waele E, Van Gorp V, Spapen HD. Biomarkers of inflammation during continuous renal replacement therapy: sensors, players, or targets? A reply to the letter by Villa et al. Blood Purif 2014; 38:102-3. [PMID: 25342457 DOI: 10.1159/000363498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Patrick M Honoré
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | |
Collapse
|
30
|
McLean AS, Huang SJ. Brain not processing: is finding a role for BNP in sepsis like fitting a square peg into a round hole? Crit Care 2014; 18:161. [PMID: 25042534 PMCID: PMC4095610 DOI: 10.1186/cc13960] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Since its introduction to the intensive care setting a decade ago, B-type natriuretic peptide has been the focus of studies in different areas (in particular, sepsis). With this biomarker, as with many newly identified biomarkers, its diagnostic performance was pursued initially and then its ability to predict outcomes. Despite all the efforts, results have not been consistent and the applications of B-type natriuretic peptide in the intensive care setting remain by and large academic. Will such studies one day become clinical practice? Or are we too obsessed with finding a place for every biomarker?
Collapse
|
31
|
Rydell-Törmänen K, Uller L, Erjefält JS. Allergic airway inflammation initiates long-term vascular remodeling of the pulmonary circulation. Int Arch Allergy Immunol 2009; 149:251-8. [PMID: 19218818 DOI: 10.1159/000199721] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 10/07/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Asthma and allergic airway inflammation are associated with persistent structural alterations in the bronchi, i.e. airway remodeling. Previous studies have shown that during allergic airway inflammation, similar structural alterations may also be evoked in the pulmonary circulation. However, it remained unknown whether remodeling of the pulmonary circulation is as persistent as airway remodeling. The aim of this study is to investigate the reversibility and resolution of vascular remodeling, induced by allergic airway inflammation. METHODS A validated mouse model of allergic airway inflammation, utilizing ovalbumin as allergen, was employed. Animals were sacrificed 1 day, 1 week or 1 month after the last allergen exposure, and different parameters of remodeling (smooth muscle mass, proliferation of smooth muscle cells and endothelial cells as well as number of myofibroblasts and procollagen-I-producing cells) were investigated and quantified histologically. RESULTS Allergen exposure resulted in allergic airway inflammation characterized by a transient leukocyte infiltration and in structural alterations in both airway and vascular compartments. The increase in vascular smooth muscle mass and endothelial proliferation persisted at 1 month after the last allergen exposure. The other parameters and cellular inflammatory response returned to baseline within 1 month after the last allergen challenge. CONCLUSIONS Based on the findings in this study, we conclude that acute allergic airway inflammation, although being initiated from the airways, is able to evoke similar long-term structural alterations in pulmonary vessels as described for bronchi.
Collapse
Affiliation(s)
- Kristina Rydell-Törmänen
- Division of Vascular and Airway Research, Department of Experimental Medical Science, Lund University, Lund, Sweden.
| | | | | |
Collapse
|