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Aijaz A, Vinaik R, Jeschke MG. Large animal models of thermal injury. Methods Cell Biol 2022; 168:191-219. [PMID: 35366983 DOI: 10.1016/bs.mcb.2021.12.015] [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: 11/19/2022]
Abstract
Burn injury results in a triad of inter-related adaptive responses: a systemic inflammatory response, a stress response, and a consequent hypermetabolic state which supports the former two. These pathological responses extend beyond the site of injury to affect distant organs and influence long-term outcomes in the patient. Animal models have proven valuable in advancing our understanding of mechanisms underlying the multifactorial manifestations of burn injury. While rodent models have been unprecedented in providing insights into signaling pathways, metabolic responses, protein turnover, cellular and molecular changes; small animal models do not replicate hypermetabolism, hyperinflammation, and wound healing after a burn injury as seen in humans. Herein, we provide a concise review of preferred large animal models utilized to understand burn pathophysiology based on organ systems and associated dysfunction. Additionally, we present a detailed protocol of contact burn injury in the Yorkshire pig model with a focus on preoperative care, anesthesia, analgesia, wound excision and grafting, dressing application, and frequency of dressing changes.
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Affiliation(s)
- Ayesha Aijaz
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Roohi Vinaik
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, ON, Canada; Department of Surgery, Division of Plastic Surgery, University of Toronto, Toronto, ON, Canada; Department of Immunology, University of Toronto, Toronto, ON, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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2
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Lee KCH, Ko JP, Oh CC, Sewa DW. Managing respiratory complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Int J Dermatol 2021; 61:660-666. [PMID: 34494255 DOI: 10.1111/ijd.15888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 07/29/2021] [Accepted: 08/13/2021] [Indexed: 11/28/2022]
Abstract
In the recently published guidelines by the Society of Dermatology Hospitalists on the management of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), a brief section was included on airway management. These recommendations provide an easy reference on how to manage respiratory complications of the disease. Understanding the evidence that underlies these recommendations would offer physicians greater clarity on the considerations behind every decision and treatment offered. We present a review of the literature on respiratory manifestations associated with SJS and TEN. In addition, we aim to address specific concerns regarding the respiratory management of these patients. These include issues such as the indications and optimal timing of intubation, tracheostomy, role of flexible nasoendoscopy, bronchoscopy, ventilation strategies, and management of chronic respiratory complications.
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Affiliation(s)
- Ken Cheah Hooi Lee
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Joanna Phone Ko
- Nursing Division (Specialty Nursing), Singapore General Hospital, Singapore, Singapore
| | - Choon Chiat Oh
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
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3
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Abstract
A lack of reliable laryngeal thermal injury models precludes laryngeal burn wound healing studies and investigation of novel therapeutics. We hypothesize that a swine laryngeal burn model can allow for laryngeal burn evaluation over time. Twelve Yorkshire crossbreed swine underwent tracheostomy and endoscopically directed laryngeal burns using heated air (150-160°C). Swine larynges were evaluated and sectioned/stained at 12 hours, 1, 3, 7, 14, and 21 days. A board-certified veterinary pathologist assessed anatomic regions (left and right: epiglottis, true/false vocal folds, and subglottis) using a nine criteria histological injury scoring scale. Six swine were euthanized at scheduled endpoints, three prematurely (airway concerns), and three succumbed to airway complications after 16 to 36 hours. Endoscopic and gross examination from scheduled endpoints revealed massive supraglottic edema and tissue damage, particularly around the arytenoids, extending transglottically. Swine from premature endpoints had comparatively increased edema throughout. Microscopic evaluation documented an inverse relationship between injury severity score and time from injury. Inflammation severity decreased over time, nearly resolving by 14 days. Neutrophils predominated early with histiocytes appearing at 3 days. Granulation tissue appeared at 3 days, and early epiglottic and/or subglottic fibrosis appeared by 7 days and matured by 14 days. Edema, abundant initially, decreased by day 3 and resolved by day 7. This approach is the first to provide longitudinal analysis of laryngeal thermal injuries, reflecting some of the first temporal wound healing characteristic data in laryngeal thermal injuries and providing a platform for future therapeutic studies.
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Affiliation(s)
- Gregory R Dion
- Dental and Craniofacial Trauma Research Department, U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas.,Department of Otolaryngology-Head and Neck Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Christian S Pingree
- Department of Otolaryngology-Head and Neck Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Pedro J Rico
- Clinical Investigation and Research Support, 59th Medical Wing, United States Air Force, JBSA-Lackland, Texas
| | - Christine L Christensen
- Clinical Investigation and Research Support, 59th Medical Wing, United States Air Force, JBSA-Lackland, Texas
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4
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Tang JA, Amadio G, Nagappan L, Schmalbach CE, Dion GR. Laryngeal inhalational injuries: A systematic review. Burns 2021; 48:23-33. [PMID: 33814215 DOI: 10.1016/j.burns.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/19/2020] [Accepted: 02/05/2021] [Indexed: 02/07/2023]
Abstract
Laryngeal inhalation injury carries a significant increase in mortality rate and often indicates immediate airway evaluation. This may be difficult in the setting of clinical deterioration necessitating immediate intubation, which itself can synergistically cause mucosal damage. Prior studies do not encompass predictive factors or long-term outcomes for the laryngotracheal complex. This systemic review of PubMed, Embase, and Cochrane identified studies investigating inhalational injuries of the upper airway. Demographic data as well as presentation, physical findings, and delayed sequelae were documented. Laryngotracheal burn patients were divided into two cohorts based on timing of laryngeal injury diagnosis (before- versus after-airway intervention). 1051 papers met initial search criteria and 43 studies were ultimately included. Airway stenosis was more common in patients that were intubated immediately (50.0%, n = 18 versus 5.2%, n = 13; p = 0.57). Posterior glottic involvement was only identified in patients intubated prior to airway evaluation (71.4%, n = 15). All studies reported a closed space setting for those patients in whom airway intervention preceded laryngeal evaluation. Laryngeal inhalational injuries are a distinct subset that can have a variety of minor to severe laryngotracheal delayed sequelae, particularly for thermal injuries occurring within enclosed spaces. Given these findings, early otolaryngology referral may mitigate or treat these effects.
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Affiliation(s)
- Jessica A Tang
- Department of Otolaryngology, Head and Neck Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Grace Amadio
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Lavanya Nagappan
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Cecelia E Schmalbach
- Department of Otolaryngology, Head and Neck Surgery, Temple University Hospital, Philadelphia, PA, USA; Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA; Temple Head and Neck Institute, Philadelphia, PA, USA
| | - Gregory R Dion
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, TX, USA.
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5
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Gigengack RK, Cleffken BI, Loer SA. Advances in airway management and mechanical ventilation in inhalation injury. Curr Opin Anaesthesiol 2020; 33:774-780. [PMID: 33060384 DOI: 10.1097/aco.0000000000000929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Airway management, mechanical ventilation, and treatment of systemic poisoning in burn patients with inhalation injury remains challenging. This review summarizes new concepts as well as open questions. RECENT FINDINGS Several life-threatening complications, such as airway patency impairment and respiratory insufficiency, can arise in burn patients and require adequate and timely airway management. However, unnecessary endotracheal intubation should be avoided. Direct visual inspection via nasolaryngoscopy can guide appropriate airway management decisions. In cases of lower airway injury, bronchoscopy is recommended to remove casts and estimate the extent of the injury in intubated patients. Several mechanical ventilation strategies have been studied. An interesting modality might be high-frequency percussive ventilation. However, to date, there is no sound evidence that patients with inhalation injury should be ventilated with modes other than those applied to non-burn patients. In all burn patients exposed to enclosed fire, carbon monoxide as well as cyanide poisoning should be suspected. Carbon monoxide poisoning should be treated with an inspiratory oxygen fraction of 100%, whereas cyanide poisoning should be treated with hydroxocobalamin. SUMMARY Burn patients need specialized care that requires specific knowledge about airway management, mechanical ventilation, and carbon monoxide and cyanide poisoning.
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Affiliation(s)
- Rolf Kristian Gigengack
- Department of Anesthesiology, Amsterdam UMC, VU Medical Center, Amsterdam.,Departments of Intensive Care and Trauma and Burn Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Berry Igor Cleffken
- Departments of Intensive Care and Trauma and Burn Surgery, Maasstad Hospital, Rotterdam, The Netherlands
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Modified abbreviated burn severity index as a predictor of in-hospital mortality in patients with inhalation injury: development and validation using independent cohorts. Surg Today 2020; 51:242-249. [PMID: 32691141 DOI: 10.1007/s00595-020-02085-5] [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: 05/10/2020] [Accepted: 07/05/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The ability to accurately evaluate the severity of inhalation injury can help to optimize patient care. However, there is no accepted severity grading system, especially for inhalation injury. METHODS We screened a multicenter burn registry and included adult patients who required oxygen treatment or mechanical ventilation. After the patient data were divided into development and validation cohorts, missing values were replaced with multiple imputation. Twelve potential predictors were analyzed using multivariate logistic regression to identify prognostic variables for in-hospital mortality and scores were assigned to each predictor based on odds ratios to develop the Modified Abbreviated Burn Severity Index, mABSI. The mABSI was validated using c-statistics and calibration curves. RESULTS We randomly assigned 1377 and 919 patients to the development and validation cohorts, respectively. Age, self-inflicted injury, cutaneous burn area, and mechanical ventilation requirement were identified as independent predictors, and the mABSI (1-17 scale) was, thus, developed. The mABSI has a high discriminatory power (c-statistic = 0.94; 95% CI 0.92-0.97), and both estimated and observed in-hospital mortalities increased from 1% at score ≤ 5 to almost 100% at score ≥ 14 with linear calibration plots. CONCLUSIONS We developed and validated the mABSI which accurately predicts in-hospital mortality.
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Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T, Lefort H, Louvet N, Losser MR, Lucas C, Pantet O, Roquilly A, Rousseau AF, Soussi S, Wiramus S, Gayat E, Blet A. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med 2020; 39:253-267. [PMID: 32147581 DOI: 10.1016/j.accpm.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children. DESIGN A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion. RESULTS The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations. CONCLUSION Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, San Francisco, United States.
| | - Damien Barraud
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France
| | - Isabelle Constant
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | | | - Nicolas Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Mathieu Fontaine
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Laetitia Goffinet
- Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | | | - Mathieu Jeanne
- CHU Lille, Anaesthesia and Critical Care, Burn Centre, 59000 Lille, France; University of Lille, Inserm, CHU Lille, CIC 1403, 59000 Lille, France; University of Lille, EA 7365 - GRITA, 59000 Lille, France
| | - Jeanne Jonqueres
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Hugues Lefort
- Department of emergency medicine, Legouest Military Teaching Hospital, Metz, France
| | - Nicolas Louvet
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Marie-Reine Losser
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France; Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France; Inserm UMR 1116, Team 2, 54000 Nancy, France; University of Lorraine, 54000 Nancy, France
| | - Célia Lucas
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), BH 08-651, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Antoine Roquilly
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University of Nantes, Nantes, France
| | | | - Sabri Soussi
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Interdepartmental Division of Critical Care, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sandrine Wiramus
- Department of Anaesthesia and Intensive Care Medicine and Burn Centre, University Hospital of Marseille, La Timone Hospital, Marseille, France
| | - Etienne Gayat
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alice Blet
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France; Department of Research, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Matsumura K, Yamamoto R, Kamagata T, Kurihara T, Sekine K, Takuma K, Kase K, Sasaki J. A novel scale for predicting delayed intubation in patients with inhalation injury. Burns 2020; 46:1201-1207. [PMID: 31982185 DOI: 10.1016/j.burns.2019.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score. METHODS We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries. RESULTS Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems. CONCLUSIONS We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.
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Affiliation(s)
- Kazuki Matsumura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Tomohiro Kamagata
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minatoku, Tokyo, 108-0073, Japan
| | - Tomohiro Kurihara
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minatoku, Tokyo, 108-0073, Japan
| | - Kiyotsugu Takuma
- Department of Emergency Medicine, Kawasaki Municipal Kawasaki Hospital, 12-1 Shinkawadori, Kawasakiku, Kanagawa, 210-0013, Japan
| | - Kenichi Kase
- Department of Emergency Medicine, Saiseikai Utsunomiya Hospital, 911-1 Takebayashimachi, Utsunomiya, Tochigi, 321-9574, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Bhullar HK, Aung AK, Graudins L, Ihle J, Gin D, Cleland H, Mei Teh B. Upper airway involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis. Burns 2019; 46:682-686. [PMID: 31591001 DOI: 10.1016/j.burns.2019.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/27/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. The indication for flexible nasoendoscopy (FNE) and overall predictive factors for early intubation are unclear. OBJECTIVES To describe the incidence of airway involvement and the key indicators for intubation in our SJS or TEN patient cohort. To determine the association between FNE findings and early intubation. METHODS A retrospective review of 45 patients with biopsy proven SJS or TEN admitted to an Australian tertiary burns centre from 2010 to 2017. RESULTS Thirty-five patients were diagnosed with TEN (77.8%), followed by overlap syndrome (SJS-TEN) (n = 6, 13.3%) and SJS (n = 4, 8.9%). Twenty (44.4%) patients were intubated; and all 20 had a diagnosis of TEN (100.0%) (p < 0.05). Intubated patients had a higher increase in total body surface area percentage(%) from day 1-3 [10.0% (IQR 0.0-23.8%)] and a longer length of stay [26.0 days (IQR 12.5-34.0)], compared to non-intubated patients [0.0% (IQR 0.0-4.0%)], [10.0 days (IQR 6.0-14.0)] (p < 0.05) respectively. The main indications for intubation were to facilitate operative and dressing management (47.4%) followed by airway involvement (26.3%). FNE was performed on 32 patients (71.1%), however FNE findings did not significantly influence intubation rates. CONCLUSION More than half (n = 20, 57.1%) of the 35 patients diagnosed with TEN underwent intubation, mainly to facilitate operative and dressing management. FNE was performed on most patients, however there was no clear association between FNE findings and early intubation.
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Affiliation(s)
- Harmeet K Bhullar
- Ear, Nose and Throat Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; Central Clinical School, Monash University, Victoria, Australia.
| | - Ar Kar Aung
- Department of General Medicine, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; School of Public Health and Preventative Medicine, Monash University, Victoria, Australia.
| | - Linda Graudins
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Josh Ihle
- School of Public Health and Preventative Medicine, Monash University, Victoria, Australia; Intensive Care Unit, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Douglas Gin
- Department of Dermatology, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Heather Cleland
- Central Clinical School, Monash University, Victoria, Australia; Victorian Adult Burns Services, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Bing Mei Teh
- Ear, Nose and Throat Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; Department of Surgery, Monash University, Victoria, Australia.
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10
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Reid A, Ha JF. Inhalational injury and the larynx: A review. Burns 2019; 45:1266-1274. [DOI: 10.1016/j.burns.2018.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 09/01/2018] [Accepted: 10/31/2018] [Indexed: 12/13/2022]
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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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12
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Abstract
Inhalation injury is a serious consequence of a fire or an explosion, with potential airway compromise and respiratory complications. We present a case series of five patients with inhalational burns who presented to Singapore General Hospital and discuss our approach to their early management, including early evaluation and planning for the upper and lower airway, coexisting cutaneous burns, and monitoring their ICU (intensive care unit) severity of illness, sepsis and acute respiratory distress syndrome. All five patients suffered various grades of inhalation injury. The patients were initially assessed by nasolaryngoscopy, and three patients were prophylactically intubated before being sent to the emergency operating theatre for definitive airway and burns management with fibreoptic bronchoscopy. All patients were successfully extubated and discharged stable. Various complications can arise as a result of an inhalation injury. Based on our cases and literature review, we propose a standardised workflow for patients with inhalation injury.
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Affiliation(s)
- Suneel Ramesh Desai
- Department of Surgical Intensive Care, Singapore General Hospital, Singapore.,Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Delong Zeng
- Department of Burns and Plastic Surgery, Singapore General Hospital, Singapore
| | - Si Jack Chong
- Department of Burns and Plastic Surgery, Singapore General Hospital, Singapore
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13
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Moshrefi S, Sheckter CC, Shepard K, Pereira C, Davis DJ, Karanas Y, Rochlin DH. Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury. J Burn Care Res 2019; 40:341-346. [DOI: 10.1093/jbcr/irz016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Shawn Moshrefi
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Clifford C Sheckter
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Kimberly Shepard
- Division of Otolaryngology, Santa Clara Valley Medical Center, San Jose, California
| | - Clifford Pereira
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Drew J Davis
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Yvonne Karanas
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Danielle H Rochlin
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
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14
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Chong SJ, Kok YO, Tay RXY, Ramesh DS, Tan KC, Tan BK. Quantifying the impact of inhalational burns: a prospective study. BURNS & TRAUMA 2018; 6:26. [PMID: 30238012 PMCID: PMC6139897 DOI: 10.1186/s41038-018-0126-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 07/16/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Inhalational injury is a major cause of morbidity and mortality in burns patients. This study aims to analyse the clinical outcomes, complications and bacteriology of inhalational burn patients. METHODS A prospective study was done on consecutive admissions to Burn Department, Singapore General Hospital over 15 months from January 2015 to March 2016. Presence of inhalational injury, demographics, complications and outcomes was recorded. Diagnosis of inhalational injury was based on history, symptoms and nasoendoscopy. Diagnosis of acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and infective complications were according to the Berlin criteria, acute kidney injury network (AKIN) classification stage 2 and above and the American Burns Association guidelines. RESULTS Thirty-five patients (17.3%) had inhalational burns out of 202 patients (63.4% male, 57.4% Chinese population). The average age was 43 ± 16.7 years (range 16-86), and percentage of total body surface area (%TBSA) was 12.1 ± 18.0 (range 0-88). In patients with inhalational injury, age was 38.9 ± 17.2 years and %TBSA was 30.3 ± 32.3. In patients without inhalational injury, age was 44.1 ± 12.8 years and %TBSA was 8.3 ± 9.59. Compared to patients with cutaneous injury alone, patients with inhalational burns had more surgeries (3 ± 7.07 vs 1 ± 1.54, p = 0.003), increased length of stay (21 days vs 8 days, p = 0.004) and higher in-hospital mortality rate (17.1% vs 0.6%, p < 0.001). Incidence of ARDS and AKI was 48.6% and 37.1%, respectively, compared to 0.6% and 1.2% in the patients without inhalational injury (p < 0.001). Patients with inhalational injury had increased incidence of bacteraemia (31.4% vs 2.4%, p < 0.001), pneumonia (37.1% vs 1.2%, p < 0.001) and burn wound infection (51.4% vs 25.1%, p = 0.004). Inhalational injury predicted AKI with an adjusted odds ratio (OR) of 17.43 (95% confidence interval (CI) 3.07-98.87, p < 0.001); ARDS, OR = 106.71 (95% CI 12.73-894.53, p < 0.001) and pneumonia, OR = 13.87 (95% CI 2.32-82.94, p = 0.004). Acinetobacter baumannii was the most frequently cultured bacteria in sputum, blood and tissue cultures with inhalational injury. Gram-negative bacteria were predominantly cultured from tissue in patients with inhalational injury, whereas gram-positive bacteria were predominantly cultured from tissue in patients without inhalational injury. CONCLUSIONS Inhalational injury accompanying burns significantly increases the length of stay, mortality and complications including AKI, ARDS, infection and sepsis.
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Affiliation(s)
- Si Jack Chong
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Level 5, Academia, Singapore, 169865 Singapore
| | - Yee Onn Kok
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Level 5, Academia, Singapore, 169865 Singapore
| | - Rosanna Xiang Ying Tay
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Level 5, Academia, Singapore, 169865 Singapore
| | - Desai Suneel Ramesh
- Department of Anaesthesiology, Singapore General Hospital, Level 5, Academia, Singapore, 169865 Singapore
| | - Kok Chai Tan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Level 5, Academia, Singapore, 169865 Singapore
| | - Bien Keem Tan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Level 5, Academia, Singapore, 169865 Singapore
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16
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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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17
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Kot Baixauli P, Morales Sarabia JE, Rovira Soriano L, De Andrés Ibáñez J. Proposal for an algorithm for the management of the patient's airway after smoke inhalation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:170-172. [PMID: 29366494 DOI: 10.1016/j.redar.2017.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 12/05/2017] [Accepted: 12/12/2017] [Indexed: 06/07/2023]
Abstract
Smoke inhalation represents the leading cause of mortality and morbidity in burns patients. Given the injuries that can occur in the airway after this exposure, it is imperative to evaluate the need for orotracheal intubation in the emergency department and even in the place of first assistance by healthcare workers. Since the clinical signs are poor predictors of the severity of the lesion, in selected cases, it is advisable to perform a diagnostic fibroscopy. We present a case report of a patient with a smoke inhalation lesion in which the fibroscopy was determinant to proceed to intubation, and we propose an algorithm of action for the management of the airway in this type of patients.
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Affiliation(s)
- P Kot Baixauli
- Servicio de Anestesia, Reanimación y Terapia del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España.
| | - J E Morales Sarabia
- Servicio de Anestesia, Reanimación y Terapia del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - L Rovira Soriano
- Servicio de Anestesia, Reanimación y Terapia del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J De Andrés Ibáñez
- Servicio de Anestesia, Reanimación y Terapia del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
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Impact of Real-Time Therapeutic Drug Monitoring on the Prescription of Antibiotics in Burn Patients Requiring Admission to the Intensive Care Unit. Antimicrob Agents Chemother 2018; 62:AAC.01818-17. [PMID: 29263079 DOI: 10.1128/aac.01818-17] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/06/2017] [Indexed: 11/20/2022] Open
Abstract
As pharmacokinetics after burn trauma are difficult to predict, we conducted a 3-year prospective, monocentric, randomized, controlled trial to determine the extent of under- and overdosing of antibiotics and further evaluate the impact of systematic therapeutic drug monitoring (TDM) with same-day real-time dose adaptation to reach and maintain antibiotic concentrations within the therapeutic range. Forty-five consecutive burn patients treated with antibiotics were prospectively screened. Forty fulfilled the inclusion criteria; after one patient refused to participate and one withdrew consent, 19 were randomly assigned to an intervention group (patients with real-time antibiotic concentration determination and subsequent adaptations) and 19 were randomly assigned to a standard-of-care group (patients with antibiotic administration at the physician's discretion without real-time TDM). Seventy-three infection episodes were analyzed. Before the intervention, only 46/82 (56%) initial trough concentrations fell within the range. There was no difference between groups in the initial trough concentrations (adjusted hazard ratio = 1.39 [95% confidence interval {CI}, 0.81 to 2.39], P = 0.227) or the time to reach the target. However, thanks to real-time dose adjustments, the trough concentrations of the intervention group remained more within the predefined range (57/77 [74.0%] versus 48/85 [56.5%]; adjusted odd ratio [OR] = 2.34 [95% CI, 1.17 to 4.81], P = 0.018), more days were spent within the target range (193 days/297 days on antibiotics [65.0%] versus 171 days/311 days in antibiotics [55.0%]; adjusted OR = 1.64 [95% CI, 1.16 to 2.32], P = 0.005), and fewer results were below the target trough concentrations (25/118 [21.2%] versus 44/126 [34.9%]; adjusted OR = 0.47 [95% CI, 0.26 to 0.87], P = 0.015). No difference in infection outcomes was observed between the study groups. Systematic TDM with same-day real-time dose adaptation was effective in reaching and maintaining therapeutic antibiotic concentrations in infected burn patients, which prevented both over- and underdosing. A larger multicentric study is needed to further evaluate the impact of this strategy on infection outcomes and the emergence of antibiotic resistance during long-term burn treatment. (This study was registered with the ClinicalTrials.gov platform under registration no. NCT01965340 on 27 September 2013.).
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Pantet O, Stoecklin P, Charrière M, Voirol P, Vernay A, Berger MM. Trace element repletion following severe burn injury: A dose-finding cohort study. Clin Nutr 2018; 38:246-251. [PMID: 29428787 DOI: 10.1016/j.clnu.2018.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 01/04/2018] [Accepted: 01/22/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Major burn patients are characterized by large exudative losses of Cu, Se and Zn. Trace element (TE) repletion has been shown to improve clinical outcome. Having increased the TE doses over time, the study aimed at analysing if our repletion protocol corrected TE plasma concentrations and if the necessity for continuous renal replacement therapy (CRRT) might increase the TE needs. METHODS Retrospective analysis of prospectively collected data in burn patients requiring intensive care (ICU) between 1999 and 2015. INCLUSION CRITERIA Admission on day 1, full treatment, burned surface area (TBSA) ≥20% and ≥1 TE plasma determination during the stay. Four groups were constituted according to protocol changes. Period 1 (P1): 1999-2000, P2: 2001-2005, P3: 2006-2010, P4: 2011-2015. Changes consisted in increasing TE repletion doses and duration. Demographic data, daily TE intakes and weekly plasma concentrations were retrieved for the first 21 ICU-days. Data as median (IQR). RESULTS 139 patients completed the criteria, aged 37 (28) years, burned on 35 (25) % TBSA. As a result of prescription, Cu, Se and Zn intakes increased significantly between P1 and P4, resulting in normalization of plasma Cu (16 μmol/l) since P3 and Zn (13.5 μmol/l) since P2. Median plasma Se were above reference range (1400 nmol/l) during P3 and P4. CRRT patients required higher doses of Cu for maintenance within normal ranges. CONCLUSION This dose finding study shows that the latest repletion protocol is safe and normalizes Cu and Zn concentrations. Se doses result in supra-normal Se concentrations, suggesting prescription reduction. CRRT patients are at high risk of Cu depletion and require specific monitoring.
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Affiliation(s)
- Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, University Hospital, Lausanne, Switzerland.
| | - Patricia Stoecklin
- Department of Intensive Care Medicine, Bern University Hospital, Switzerland
| | - Mélanie Charrière
- Service of Adult Intensive Care Medicine and Burns, University Hospital, Lausanne, Switzerland
| | - Pierre Voirol
- Service of Pharmacy, University Hospital, Lausanne, Switzerland
| | - Arnaud Vernay
- Department of Computer Sciences, University Hospital, Lausanne, Switzerland
| | - Mette M Berger
- Service of Adult Intensive Care Medicine and Burns, University Hospital, Lausanne, Switzerland
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20
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Abstract
This article summarizes research conducted over the last decade in the field of inhalation injury in thermally injured patients. This includes brief summaries of the findings of the 2006 State of the Science meeting with regard to inhalation injury, and of the subsequent 2007 Inhalation Injury Consensus Conference. The reviewed studies are categorized in to five general areas: diagnosis and grading; mechanical ventilation; systemic and inhalation therapy; mechanistic alterations; and outcomes.
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21
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Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2017; 120:323-352. [PMID: 29406182 DOI: 10.1016/j.bja.2017.10.021] [Citation(s) in RCA: 437] [Impact Index Per Article: 62.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
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Affiliation(s)
- A Higgs
- Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK(8).
| | - B A McGrath
- Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Manchester, UK(9)
| | - C Goddard
- Anaesthesia & Intensive Care Medicine, Southport and Ormskirk Hospitals NHS Trust, Southport, UK(8)
| | - J Rangasami
- Anaesthesia & Intensive Care Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK(8)
| | - G Suntharalingam
- Intensive Care Medicine and Anaesthesia, London North West Healthcare NHS Trust, London, UK(10)
| | - R Gale
- Anaesthesia & Intensive Care Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK(11)
| | - T M Cook
- Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK(12)
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22
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Yeung JK, Fung Leung LT, Papp A. A survey of current practices in the diagnosis of and interventions for inhalational injuries in Canadian burn centres. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2017. [DOI: 10.1177/229255031302100402] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Justin K Yeung
- Department of Plastic Surgery, University of Calgary, Calgary, Alberta
| | | | - Anthony Papp
- BC Professional Firefighters' Burn Unit, Vancouver General Hospital, Vancouver, British Columbia
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23
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Fournier A, Voirol P, Krähenbühl M, Bonnemain CL, Fournier C, Dupuis-Lozeron E, Pantet O, Pagani JL, Revelly JP, Sadeghipour F, Eggimann P, Que YA. Staphylococcus aureus carriage at admission predicts early-onset pneumonia after burn trauma. Eur J Clin Microbiol Infect Dis 2016; 36:523-528. [PMID: 27815777 DOI: 10.1007/s10096-016-2828-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
Early-onset pneumonia (EOP) is frequent after burn trauma, increasing morbidity in the critical resuscitation phase, which may preclude early aggressive management of burn wounds. Currently, however, preemptive treatment is not recommended. The aim of this study was to identify predictive factors for EOP that may justify early empirical antibiotic treatment. Data for all burn patients requiring ≥4 h mechanical ventilation (MV) who were admitted between January 2001 and October 2012 were extracted from the hospital's computerized information system. We reviewed EOP episodes (≤7 days) among patients who underwent endotracheal aspiration (ETA) within 5 days after admission. Univariate and multivariate analyses were performed to identify independent factors associated with EOP. Logistic regression was used to identify factors predicting EOP development. During the study period, 396 burn patients were admitted. ETA was performed within 5 days in 204/290 patients receiving ≥4 h MV. One hundred and eight patients developed EOP; 47 cases were caused by Staphylococcus aureus, 37 by Haemophilus influenzae, and 23 by Streptococcus pneumoniae. Among the 33 patients showing S. aureus positivity on ETA samples, 16 (48.5 %) developed S. aureus EOP. Among the 156 S. aureus non-carriers, 16 (10.2 %) developed EOP. Staphylococcus aureus carriage independently predicted EOP (p < 0.0001). We identified S. aureus carriage as an independent and strong predictor of EOP. As rapid point-of-care testing for S. aureus is readily available, we recommend testing of all patients at admission for burn trauma and the consideration of early preemptive treatment in all positive patients. Further studies are needed to evaluate this new strategy.
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Affiliation(s)
- A Fournier
- Pharmacy Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - P Voirol
- Pharmacy Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - M Krähenbühl
- Adult Intensive Medicine Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - C-L Bonnemain
- Adult Intensive Medicine Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - C Fournier
- Adult Intensive Medicine Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - E Dupuis-Lozeron
- Unit of Population Epidemiology, Department of Community Medicine, Primary Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - O Pantet
- Adult Intensive Medicine Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - J-L Pagani
- Adult Intensive Medicine Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - J-P Revelly
- Adult Intensive Medicine Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - F Sadeghipour
- Pharmacy Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - P Eggimann
- Adult Intensive Medicine Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Y-A Que
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
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Sturgess DJ, Greenland KB, Senthuran S, Ajvadi FA, van Zundert A, Irwin MG. Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review. Anaesthesia 2016; 72:248-261. [PMID: 27804108 DOI: 10.1111/anae.13668] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2016] [Indexed: 12/17/2022]
Abstract
Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.
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Affiliation(s)
- D J Sturgess
- Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - K B Greenland
- Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR
| | - S Senthuran
- School of Medicine, James Cook University, Townsville, Queensland, Australia
| | - F A Ajvadi
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - A van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR
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25
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Mécanismes de toxicité des fumées d’incendie (monoxyde de carbone et cyanures exclus). MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1212-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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26
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Dion GR, Teng S, Bing R, Hiwatashi N, Amin MR, Branski RC. Development of an in vivo model of laryngeal burn injury. Laryngoscope 2016; 127:186-190. [DOI: 10.1002/lary.26123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/09/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Gregory R. Dion
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York U.S.A
| | - Stephanie Teng
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York U.S.A
| | - Renjie Bing
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York U.S.A
| | - Nao Hiwatashi
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York U.S.A
| | - Milan R. Amin
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York U.S.A
| | - Ryan C. Branski
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York U.S.A
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27
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Rech TH, Boniatti MM, Franke CA, Lisboa T, Wawrzeniak IC, Teixeira C, Maccari JG, Schaich F, Sauthier A, Schifelbain LM, Riveiro DFM, da Fonseca DLO, Berto PP, Marques L, Dos Santos MC, de Oliveira VM, Dornelles CFD, Vieira SRR. Inhalation injury after exposure to indoor fire and smoke: The Brazilian disaster experience. Burns 2016; 42:884-90. [PMID: 26975698 DOI: 10.1016/j.burns.2016.02.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 01/14/2016] [Accepted: 02/18/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the pre-hospital, emergency department, and intensive care unit (ICU) care and prognosis of patients with inhalation injury after exposure to indoor fire and smoke. MATERIALS AND METHODS This is a prospective observational cohort study that includes patients admitted to seven ICUs after a fire disaster. The following data were collected: demographic characteristics; use of fiberoptic bronchoscopy; degree of inhalation injury; percentage of burned body surface area; mechanical ventilation parameters; and subsequent events during ICU stay. Patients were followed to determine the ICU and hospital mortality rates. RESULTS Within 24h of the incident, 68 patients were admitted to seven ICUs. The patients were young and had no comorbidities. Most patients (n=35; 51.5%) only had an inhalation injury. The mean ventilator-free days for patients with an inhalation injury degree of 0 or I was 12.5±8.1 days. For patients with an inhalation injury degree of II or III, the mean ventilator-free days was 9.4±5.8 days (p=0.12). In terms of the length of ICU stay for patients with degrees 0 or I, and patients with degrees II or III, the median was 7.0 days (5.0-8.0 days) and 12.0 days (8.0-23.0 days) (p<0.001), respectively. In addition, patients with a larger percentage of burned surface areas also had a longer ICU stay; however, no association with ventilator-free days was found. The patients with <10% of burned body surface area showed a mean of 9.2±5.4 ventilator-free days. The mean ventilator-free days for patients who had >10% burned body surface area was 11.9±9.5 (p=0.26). The length of ICU stay for the <10% and >10% burned body surface area patients was 7.0 days (5.0-10.0 days) and 23.0 days (11.5-25.5 days) (p<0.001), respectively. CONCLUSIONS We conclude that burn patients with inhalation injuries have different courses of disease, which are mainly determined by the percentage of burned body surface area.
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Affiliation(s)
- Tatiana Helena Rech
- Department of Intensive Care Medicine, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, Brazil
| | - Márcio Manozzo Boniatti
- Department of Intensive Care Medicine, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, Brazil.
| | - Cristiano Augusto Franke
- Department of Intensive Care Medicine, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, Brazil
| | - Thiago Lisboa
- Department of Intensive Care Medicine, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, Brazil
| | - Iuri Christmann Wawrzeniak
- Department of Intensive Care Medicine, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, Brazil
| | - Cassiano Teixeira
- Department of Intensive Care Medicine, Hospital Moinhos de Vento, Ramiro Barcelos, 910, Porto Alegre, Brazil
| | - Juçara Gasparetto Maccari
- Department of Intensive Care Medicine, Hospital Moinhos de Vento, Ramiro Barcelos, 910, Porto Alegre, Brazil
| | - Felipe Schaich
- Department of Intensive Care Medicine, Hospital Moinhos de Vento, Ramiro Barcelos, 910, Porto Alegre, Brazil
| | - Angelica Sauthier
- Department of Intensive Care Medicine, Hospital de Pronto Socorro de Porto Alegre, Largo Teodoro Herzl, Porto Alegre, Brazil
| | - Luciele Medianeira Schifelbain
- Department of Intensive Care Medicine, Hospital de Caridade Dr. Astrogildo de Azevedo, Presidente Vargas, 2291, Santa Maria, Brazil
| | | | | | - Paula Pinheiro Berto
- Department of Intensive Care Medicine, Santa Casa de Misericórdia, Professor Annes Dias, 295, Porto Alegre, Brazil
| | - Leonardo Marques
- Department of Intensive Care Medicine, Santa Casa de Misericórdia, Professor Annes Dias, 295, Porto Alegre, Brazil
| | - Moreno Calcagnotto Dos Santos
- Department of Intensive Care Medicine, Hospital Nossa Senhora da Conceição, Francisco Trein, 596, Porto Alegre, Brazil
| | - Vanessa Martins de Oliveira
- Department of Intensive Care Medicine, Hospital Nossa Senhora da Conceição, Francisco Trein, 596, Porto Alegre, Brazil
| | | | - Sílvia Regina Rios Vieira
- Department of Intensive Care Medicine, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, Brazil
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Vo E, Kurmis R, Campbell J, Greenwood J. Risk factors for and characteristics of dysphagia development in thermal burn injury and/or inhalation injury patients: a systematic review protocol. ACTA ACUST UNITED AC 2016; 14:31-43. [DOI: 10.11124/jbisrir-2016-2224] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Stoecklin P, Delodder F, Pantet O, Berger MM. Moderate glycemic control safe in critically ill adult burn patients: A 15 year cohort study. Burns 2015; 42:63-70. [PMID: 26691869 DOI: 10.1016/j.burns.2015.10.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/25/2015] [Accepted: 10/23/2015] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Hyperglycemia is a metabolic alteration in major burn patients associated with complications. The study aimed at evaluating the safety of general ICU glucose control protocols applied in major burns receiving prolonged ICU treatment. METHODS 15 year retrospective analysis of consecutive, adult burn patients admitted to a single specialized centre. EXCLUSION CRITERIA death or length of stay <10 days, age <16 years. VARIABLES demographic variables, burned surface (TBSA), severity scores, infections, ICU stay, outcome. Metabolic variables: total energy, carbohydrate and insulin delivery/24h, arterial blood glucose and CRP values. Analysis of 4 periods: 1, before protocol; 2, tight doctor driven; 3, tight nurse driven; 4, moderate nurse driven. RESULTS 229 patients, aged 45 ± 20 years (mean ± SD), burned 32 ± 20% TBSA were analyzed. SAPSII was 35 ± 13. TBSA, Ryan and ABSI remained stable. Inhalation injury increased. A total of 28,690 blood glucose samples were analyzed: the median value remained unchanged with a narrower distribution over time. After the protocol initiation, the normoglycemic values increased from 34.7% to 65.9%, with a reduction of hypoglycaemic events (no extreme hypoglycemia in period 4). Severe hyperglycemia persisted throughout with a decrease in period 4 (9.25% in period 4). Energy and glucose deliveries decreased in periods 3 and 4 (p<0.0001). Infectious complications increased during the last 2 periods (p=0.01). CONCLUSION A standardized ICU glucose control protocol improved the glycemic control in adult burn patients, reducing glucose variability. Moderate glycemic control in burns was safe specifically related to hypoglycemia, reducing the incidence of hypoglycaemic events compared to the period before. Hyperglycemia persisted at a lower level.
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Affiliation(s)
- Patricia Stoecklin
- Service of Intensive Care Medicine & Burns, University Hospital (CHUV), 1011 Lausanne, Switzerland.
| | - Frederik Delodder
- Service of Intensive Care Medicine & Burns, University Hospital (CHUV), 1011 Lausanne, Switzerland.
| | - Olivier Pantet
- Service of Intensive Care Medicine & Burns, University Hospital (CHUV), 1011 Lausanne, Switzerland.
| | - Mette M Berger
- Service of Intensive Care Medicine & Burns, University Hospital (CHUV), 1011 Lausanne, Switzerland.
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30
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Cheng W, Ran Z, Wei L, La-na D, Xiao-zhuo Z, Yan-hua R, Fang-gang N, Guo-an Z. Pathological changes of the three clinical types of laryngeal burns based on a canine model. Burns 2014; 40:257-67. [DOI: 10.1016/j.burns.2013.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 03/24/2013] [Accepted: 06/03/2013] [Indexed: 11/17/2022]
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Oscier C, Emerson B, Handy JM. New perspectives on airway management in acutely burned patients. Anaesthesia 2014; 69:105-10. [DOI: 10.1111/anae.12565] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- C. Oscier
- Chelsea and Westminster NHS Foundation Trust; London UK
| | - B. Emerson
- St Andrews Centre for Plastic Surgery and Burns; Mid Essex Hospitals NHS Trust; Chelmsford UK
| | - J. M. Handy
- Chelsea and Westminster NHS Foundation Trust; London UK
- Imperial College London; London UK
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Abstract
Approximately 2457 research articles were published with burns in the title, abstract, and/or keyword in 2012. This number continues to rise through the years; this article reviews those selected by the Editor of one of the major journals in the field (Burns) and his colleague that are most likely to have the greatest likelihood of affecting burn care treatment and understanding. As done previously, articles were found and divided into these topic areas: epidemiology of injury and burn prevention, wound and scar characterization, acute care and critical care, inhalation injury, infection, psychological considerations, pain and itching management, rehabilitation, long-term outcomes, and burn reconstruction. Each selected article is mentioned briefly with comment from the authors; readers are referred to the full papers for further details.
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Affiliation(s)
- Steven E Wolf
- Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas - Southwestern Medical Center, Dallas, TX 75390-9158, United States.
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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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