1
|
Lucius J, Jensen JO, Tasar RR, Schleusser S, Stang FH, Mailänder P, Kisch T. Acute Microcirculatory Effects of Remote Ischemic Conditioning in Superficial Partial Thickness Burn Wounds. J Burn Care Res 2023; 44:912-917. [PMID: 36326797 DOI: 10.1093/jbcr/irac166] [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: 07/20/2023]
Abstract
Microcirculation is a critical factor in burn wound healing. Remote ischemic conditioning (RIC) has been shown to improve microcirculation in healthy skin and demonstrated ischemic protective effects on heart, kidney, and liver cells. Therefore, we examined microcirculatory effects of RIC in partial thickness burn wounds. The hypothesis of this study is that RIC improves cutaneous microcirculation in partial thickness burn wounds. Twenty patients with partial thickness burn wounds within 48 hours after trauma were included in this study. RIC was performed with an upper arm blood pressure cuff on a healthy upper arm using three ischemia cycles (5 min inflation to 200 mm Hg) followed by 10-minute reperfusion phases. The third and final reperfusion phase lasted 20 minutes. Microcirculation of the remote (lower/upper extremities or torso) burn wound was continuously quantified, using a combined Laser Doppler and white light spectrometry. The capillary blood flow in the burn wounds increased by a maximum of 9.6% after RIC (percentage change from baseline; P < .01). Relative hemoglobin was increased by a maximum of 2.8% (vs. baseline; P < .01), while cutaneous tissue oxygen saturation remained constant (P > .05). RIC improves microcirculation in partial thickness burn wounds by improving blood flow and elevating relative hemoglobin.
Collapse
Affiliation(s)
- Julia Lucius
- Department of Plastic Surgery, Hand Surgery and Burn Care Unit, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Jan-Oluf Jensen
- Department of Plastic Surgery, Hand Surgery and Burn Care Unit, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Raphael R Tasar
- Department of Plastic Surgery, Hand Surgery and Burn Care Unit, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Sophie Schleusser
- Department of Plastic Surgery, Hand Surgery and Burn Care Unit, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Felix H Stang
- Department of Plastic Surgery, Hand Surgery and Burn Care Unit, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Peter Mailänder
- Department of Plastic Surgery, Hand Surgery and Burn Care Unit, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Tobias Kisch
- Department of Plastic Surgery, Hand Surgery and Burn Care Unit, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| |
Collapse
|
2
|
Burmeister DM, Supp DM, Clark RA, Tredget EE, Powell HM, Enkhbaatar P, Bohannon JK, Cancio LC, Hill DM, Nygaard RM. Advantages and Disadvantages of Using Small and Large Animals in Burn Research: Proceedings of the 2021 Research Special Interest Group. J Burn Care Res 2022; 43:1032-1041. [PMID: 35778269 DOI: 10.1093/jbcr/irac091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Multiple animal species and approaches have been used for modeling different aspects of burn care, with some strategies considered more appropriate or translatable than others. On April 15, 2021, the Research Special Interest Group of the American Burn Association held a virtual session as part of the agenda for the annual meeting. The session was set up as a pro/con debate on the use of small versus large animals for application to four important aspects of burn pathophysiology: burn healing/conversion; scarring; inhalation injury; and sepsis. For each of these topics, 2 experienced investigators (one each for small and large animal models) described the advantages and disadvantages of using these preclinical models. The use of swine as a large animal model was a common theme due to anatomic similarities with human skin. The exception to this was a well-defined ovine model of inhalation injury; both of these species have larger airways which allow for incorporation of clinical tools such as bronchoscopes. However, these models are expensive and demanding from labor and resource standpoints. Various strategies have been implemented to make the more inexpensive rodent models appropriate for answering specific questions of interest in burns. Moreover, modelling burn-sepsis in large animals has proven difficult. It was agreed that the use of both small and large animal models have merit for answering basic questions about the responses to burn injury. Expert opinion and the ensuing lively conversations are summarized herein, which we hope will help inform experimental design of future research.
Collapse
Affiliation(s)
- David M Burmeister
- Uniformed Services University of the Health Sciences, Department of Medicine, Bethesda, MD, United States of America
| | - Dorothy M Supp
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Scientific Staff, Shriners Children's Ohio, Dayton, OH, USA
| | - Richard A Clark
- Stony Brook University, Departments of Dermatology, Biomedical Engineering and Medicine, Stony Brook, NY, USA
| | - Edward E Tredget
- Firefighters' Burn Treatment Unit, Department of Surgery, 2D3.31 Mackenzie Health Sciences Centre, University of Alberta, Edmonton, AB, Canada
| | - Heather M Powell
- Department of Materials Science and Engineering, Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA.,Scientific Staff, Shriners Children's Ohio, Dayton, OH, USA
| | - Perenlei Enkhbaatar
- Department of Anesthesiology, Medical Branch, University of Texas, 301 University Boulevard, Galveston, TX, USA
| | - Julia K Bohannon
- Vanderbilt University Medical Center, Department of Anesthesiology, Department of Pathology, Microbiology, and Immunology, Nashville, TN, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - David M Hill
- Firefighters' Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN, USA
| | - Rachel M Nygaard
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN, USA
| |
Collapse
|
3
|
Wen JJ, Mobli K, Radhakrishnan GL, Radhakrishnan RS. Regulation of Key Immune-Related Genes in the Heart Following Burn Injury. J Pers Med 2022; 12:jpm12061007. [PMID: 35743792 PMCID: PMC9224557 DOI: 10.3390/jpm12061007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/15/2022] Open
Abstract
Immune cascade is one of major factors leading to cardiac dysfunction after burn injury. TLRs are a class of pattern-recognition receptors (PRRs) that initiate the innate immune response by sensing conserved molecular patterns for early immune recognition of a pathogen. The Rat Toll-Like Receptor (TLR) Signaling Pathway RT² Profiler PCR Array profiles the expression of 84 genes central to TLR-mediated signal transduction and innate immunity, and is a validated tool for identifying differentially expressed genes (DEGs). We employed the PCR array to identify burn-induced cardiac TLR-signaling-related DEGs. A total of 38 up-regulated DEGs and 19 down-regulated DEGs were identified. Network analysis determined that all DEGS had 10 clusters, while up-regulated DEGs had 6 clusters and down-regulated DEGs had 5 clusters. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis showed that DEGs were involved in TLR signaling, the RIG-I-Like receptor signaling pathway, the IL-17 signaling pathway, and the NFkB signaling pathway. Function analysis indicated that DEGs were associated with Toll-like receptor 2 binding, Lipopeptide binding, Toll-like receptor binding, and NAD(P)+ nucleosidase activity. The validation of 18 up-regulated DEGs (≥10-fold change) and 6 down-regulated DEGs (≤5-fold change) demonstrated that the PCR array is a trusted method for identifying DEGs. The analysis of validated DEG-derived protein–protein interaction networks will guide our future investigations. In summary, this study not only identified the TLR-signaling-pathway-related DEGs after burn injury, but also confirmed that the burn-induced cardiac cytokine cascade plays an important role in burn-induced heart dysfunction. The results will provide the novel therapeutic targets to protect the heart after burn injury.
Collapse
Affiliation(s)
- Jake J. Wen
- Department of Surgery University of Texas Medical Branch, Galveston, TX 77550, USA;
- Correspondence: (J.J.W.); (R.S.R.); Tel.: +1-832-722-0348
| | - Keyan Mobli
- Department of Surgery University of Texas Medical Branch, Galveston, TX 77550, USA;
| | | | - Ravi S. Radhakrishnan
- Department of Surgery University of Texas Medical Branch, Galveston, TX 77550, USA;
- Correspondence: (J.J.W.); (R.S.R.); Tel.: +1-832-722-0348
| |
Collapse
|
4
|
Peck CT, Strauß S, Stahl GL, Vogt PM, Busche MN. Mannose-binding lectin (MBL) and the lectin complement pathway play a role in cutaneous ischemia and reperfusion injury. Innov Surg Sci 2020; 5:43-51. [PMID: 33506093 PMCID: PMC7798300 DOI: 10.1515/iss-2020-0017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/08/2020] [Indexed: 11/15/2022] Open
Abstract
Objectives Cutaneous ischemia/reperfusion (CI/R) injury has shown to play a significant role in chronic wounds such as decubitus ulcers, diabetic foot ulcers, atherosclerotic lesions, and venous stasis wounds. CI/R also plays a role in free tissue transfer in reconstructive microsurgery and has been linked to clinical burn-depth progression after thermal injury. While the role of the complement system has been elucidated in multiple organ systems, evidence is lacking with respect to its role in the skin. Therefore, we evaluated the role of the complement system in CI/R injury. Methods Using a single pedicle skin flap mouse model of acute CI/R, we performed CI/R in wild-type (WT) mice and complement knock out (KO) mice, deficient in either C1q (C1q KO; classical pathway inhibition), mannose-binding lectin (MBL null; lectin pathway inhibition) or factor B (H2Bf KO; alternative pathway inhibition). Following 10 h ischemia and 7 days reperfusion, mice were sacrificed, flaps harvested and flap viability assessed via Image J software. The flap necrotic area was expressed as % total flap area. In another group, mice were sacrificed following CI/R with 10 h ischemia and 48 h reperfusion. Two cranial skin flap samples were taken for gene expression analysis of IL1b, IL6, TNFα, ICAM1, VCAM1, IL10, IL13 using real-time polymerase chain reaction (RT-PCR). Results Following CI/R, MBL null mice had a statistically significant smaller %necrotic flap area compared to WT mice (10.6 vs. 43.1%; p<0.05) suggesting protection from CI/R. A significantly reduced mean %necrotic flap area was not seen in either C1q KO or H2Bf KO mice relative to WT (22.9 and 31.3 vs. 43.1%; p=0.08 and p=0.244, respectively). There were no statistically significant differences between groups for markers of inflammation (TNFα, ICAM1, VCAM1, IL1b, IL6). In contrast, mRNA levels of IL10, a regulator of inflammation, were significantly increased in the MBL null group (p=0.047). Conclusions We demonstrated for the first time a significant role of MBL and the lectin complement pathway in ischemia/reperfusion injury of the skin and a potential role for IL10 in attenuating CI/R injury, as IL10 levels were significantly increased in the tissue from the CI/R-protected MBL null group.
Collapse
Affiliation(s)
- Claas-Tido Peck
- Hannover Medical School, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover, Germany
| | - Sarah Strauß
- Hannover Medical School, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover, Germany
| | - Gregory L Stahl
- Harvard Medical School, Center for Experimental Therapeutics and Reperfusion Injury, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter-Maria Vogt
- Hannover Medical School, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover, Germany
| | - Marc N Busche
- Hannover Medical School, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover, Germany.,Leverkusen Hospital gGmbH, Department of Plastic and Aesthetic Surgery, Burn Surgery, Leverkusen, Germany
| |
Collapse
|
5
|
Choi J, Kim R, Kim J, Jeong W, Park SW, Lee HW, Chung HY. Nicorandil reduces burn wound progression by enhancing skin blood flow. J Plast Reconstr Aesthet Surg 2018; 71:1196-1206. [DOI: 10.1016/j.bjps.2018.03.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/10/2018] [Accepted: 03/30/2018] [Indexed: 10/17/2022]
|
6
|
Singer AJ, Towery H, McClain SA. Effect of tadalafil on reduction of necrosis in the ischemic zone in a rat comb burn model. Burns 2018; 44:1427-1432. [PMID: 29895403 DOI: 10.1016/j.burns.2018.05.013] [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] [Received: 01/24/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES A major goal of burn management is to reduce the progression of necrosis in the zone of ischemia surrounding the central zone of necrosis. A rat comb burn model is often used to assess the progression of necrosis in the zone of ischemia. We compared various combinations of naproxen [NPX], N-acetyl cysteine [NAC], and tadalafil [TD] (a phosphodiesterase-5 inhibitor used as a vasodilator to treat erectile dysfunction) in a rat comb burn model to determine their effects on injury progression. METHODS We created two comb burns on the backs of 40 anesthetized Sprague-Dawley rats using a brass comb with four rectangular prongs preheated in boiling water and applied for 30s, resulting in four rectangular 10×20mm full-thickness burns separated by three 5×20mm unburned interspaces, representing the ischemic zones. We randomized five animals each to daily oral gavage with TD (1mg/kg), NPX (10mg/kg), NAC (500mg/kg), NAC+NPX, TD+NPX, TD+NAC, TD+NPX+NAC, or normal saline [NS]. Wounds were observed daily for gross evidence of necrosis in the unburned interspaces and full-thickness biopsies from the interspaces were evaluated with Hematoxylin & Eosin seven days after injury for histological evidence of necrosis. RESULTS The percentages of interspaces with histological evidence of necrosis at day seven were TD-40%, NPX-93%, NAC-97%, NS-87%, TD+NPX-50%, TD+NAC-40%, TD+NPX+NAC-33%, and NPX+NAC-60% (P<0.001). Repeated measures ANOVA demonstrated reduced gross percentage of interspace area undergoing necrosis in all groups that included TD, compared with all groups not including TD (P<0.001). There were no differences among the various treatments within the groups that did or did not include TD. CONCLUSIONS Daily oral therapy with tadalafil reduces necrosis in the unburned interspaces compared with naproxen, NAC, or their combination in a rat comb burn model. Addition of naproxen or NAC to tadalafil does not further reduce injury progression.
Collapse
Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, NY, United States.
| | - Henry Towery
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, NY, United States
| | - Steve A McClain
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, NY, United States
| |
Collapse
|
7
|
Frame MD, Lin F, Dewar AM, Clark RAF. Vasoactive effect of fibronectin-derived epiviosamine-1 and related peptides in quiescent and stress models. Microcirculation 2018; 24. [PMID: 28296053 DOI: 10.1111/micc.12369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/09/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Following thermal burn injury, plasma fibronectin degrades within the interstitium; one possible product is EVA-1, PSHISKYILRWRPK found within the FNIII1 . EVA-1 ameliorates thermal burn injury progression, and binds to and enhances PDGF-BB in promoting cell metabolism, growth and survival; shorter related peptides lose these abilities. Here we study the effect of EVA-1 and shorter peptides for their vasoactivity under quiescent and stress conditions. METHODS Using the hamster cheek pouch intravital microscopy model, five EVA-1 related peptides were applied to small arterioles via micropipette (10-16 -10-4 mol L-1 ) in quiescent tissue and after defined stress: nitric oxide or heat. RESULTS Peak dilation occurred with nanomolar doses (longer peptides) or below (shorter peptides), blocked by propranolol (beta-adrenergic receptor antagonist). Micromolar doses of the same peptides induced only constriction, not antagonized by phentolamine (alpha-adrenergic receptor antagonist). Scrambled variants of two peptides yielded only constriction, suggesting constriction might be due peptide charge. Each stressor caused a left shift in dilation response, blocked by carazolol. CONCLUSIONS Thus, this important region of FNIII1 contains sequences that have a gradation of biological functions dependent on the length of the peptide sequence, with increased efficacy for dilation following stressors.
Collapse
Affiliation(s)
- Mary D Frame
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA.,Department of Physiology and Biophysics, Stony Brook University, Stony Brook, NY, USA
| | - Fubao Lin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Anthony M Dewar
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Richard A F Clark
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA.,Department of Dermatology, Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
8
|
Kenworthy P, Phillips M, Grisbrook TL, Gibson W, Wood FM, Edgar DW. An objective measure for the assessment and management of fluid shifts in acute major burns. BURNS & TRAUMA 2018; 6:3. [PMID: 30009191 PMCID: PMC6040607 DOI: 10.1186/s41038-017-0105-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/19/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Major burns are life threatening. Fluid resuscitation is required for survival to maintain intravascular volumes and prevent hypovolemic shock. Bioimpedance spectroscopy (BIS) has been recognised as a potential method of monitoring fluid shifts after burn and in other disease states. The aims of this study were to examine the reliability of BIS across different dressing conditions and electrode positions, establish the influence of Acticoat™ on BIS variable measures and determine the validity of whole-body BIS to assess net fluid shift in the presence of moderate to major burns. METHODS An observational longitudinal cohort study was conducted from December 2014 to February 2016. Patients with over 15% total body surface area (TBSA) burns and injury less than 48 h were enrolled in the study. BIS triplicate measures were collected in an open wound and with an ActicoatTM dressing (at 5 half hour intervals). Standard and alternate electrode placements were utilised for the reliability analysis and standard placement only for determining the validity of BIS in moderate to major burns. The ImpediMde SFB7 was used to collect whole-body and segmental BIS measures. Stata statistical software, release 14 was utilised to analyse all results. Descriptive analyses were performed and were reported using the means and standard deviations (SD). RESULTS BIS-repeated measures established BIS raw resistance (R), and predicted volume variables were reliable in any condition (intra-class correlation coefficient (ICC) 0.996-0.999, 95% confidence intervals (CI) 0.996-0.999) without a systematic difference. Acticoat™ dressings significantly influenced all BIS-predicted volumes (p ≤ 0.01) as determined by multilevel mixed effects (MLME) linear regression analysis. Validity of BIS was demonstrated by resistance variables significantly decreasing with increasing net ionic fluid shift and increased TBSA (severity of injury) and calculated fluid volumes increasing with increasing net fluid shift and TBSA. BIS resistance also decreased with time as oedema reduced. For clinical use, a calculator was developed to adjust BIS variables when an Acticoat™ dressing is in situ, thus facilitating BIS variable change estimates in real time, with dressings intact. CONCLUSION BIS may be used clinically to monitor fluid volume change in major acute burns.
Collapse
Affiliation(s)
- Pippa Kenworthy
- Fiona Wood Foundation, Fiona Stanley Hospital, Perth, Western Australia Australia
- Burns Service of Western Australia, Fiona Stanley Hospital, Perth, Western Australia Australia
- School of Physiotherapy, Notre Dame University, Fremantle, Western Australia Australia
- Adult State Burns Service, Fiona Stanley Hospital, Murdoch Drive, Murdoch, Western Australia 6150 Australia
| | - Michael Phillips
- Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Western Australia Australia
| | - Tiffany L. Grisbrook
- Fiona Wood Foundation, Fiona Stanley Hospital, Perth, Western Australia Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia Australia
| | - William Gibson
- School of Physiotherapy, Notre Dame University, Fremantle, Western Australia Australia
| | - Fiona M. Wood
- Fiona Wood Foundation, Fiona Stanley Hospital, Perth, Western Australia Australia
- Burns Service of Western Australia, Fiona Stanley Hospital, Perth, Western Australia Australia
| | - Dale W. Edgar
- Fiona Wood Foundation, Fiona Stanley Hospital, Perth, Western Australia Australia
- Burns Service of Western Australia, Fiona Stanley Hospital, Perth, Western Australia Australia
- Burn Injury Research Node, Notre Dame University, Fremantle, Western Australia Australia
| |
Collapse
|
9
|
D'Arpa P, Leung KP. Toll-Like Receptor Signaling in Burn Wound Healing and Scarring. Adv Wound Care (New Rochelle) 2017; 6:330-343. [PMID: 29062590 PMCID: PMC5649422 DOI: 10.1089/wound.2017.0733] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/19/2017] [Indexed: 12/15/2022] Open
Abstract
Significance: Damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs) emanate from burn-injured tissue and enter systemic circulation. Locally and systemically, they activate pattern-recognition receptors, including toll-like receptors (TLRs), to stimulate cytokine secretion, which in the severest burns typically results in extreme systemic cytokine levels, a dysfunctioning immune system, infection, impaired healing, and excessive scarring. This system-wide disruption of homeostasis can advance to life-threatening, multiorgan dysfunction syndrome. Knowledge of DAMP- and PAMP-TLR signaling may lead to treatments that ameliorate local and systemic inflammation and reduce scarring and other burn injury sequela. Recent Advances: Many PAMPs and DAMPs, the TLRs they activate, and their downstream signaling molecules have been shown to contribute to local and systemic inflammation and tissue damage following burn injury. Critical Issues: Whether TLR-pathway-targeting treatments applied at different times postburn injury might improve scarring remains an open question. The evaluation of this question requires the use of appropriate preclinical and clinical burn models carried out until after mature scar has formed. Future Directions: After TLR-pathway-targeting treatments are evaluated in porcine burn wound models and their safety is demonstrated, they can be tested in proof-of-concept clinical burn wound models.
Collapse
Affiliation(s)
| | - Kai P. Leung
- Dental and Craniofacial Trauma Research and Tissue Regeneration Directorate, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| |
Collapse
|
10
|
Abstract
Fluid resuscitation of burn patients is commonly initiated using modified Brooke or Parkland formula. The fluid infusion rate is titrated up or down hourly to maintain adequate urine output and other endpoints. Over-resuscitation leads to morbid complications. Adherence to paper-based protocols, flow sheets, and clinical practice guidelines is associated with decreased fluid resuscitation volumes and complications. Computerized tools assist providers. Although completely autonomous closed-loop control of resuscitation has been demonstrated in animal models of burn shock, the major advantages of open-loop and decision-support systems are identifying trends, enhancing situational awareness, and encouraging burn team communication.
Collapse
Affiliation(s)
- Leopoldo C Cancio
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234-6315, USA.
| | - Jose Salinas
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234-6315, USA
| | - George C Kramer
- Department of Anesthesiology, University of Texas Medical Branch at Galveston, Galveston, TX 77555-1102, USA
| |
Collapse
|
11
|
Song G, Jia J, Ma Y, Shi W, Wang F, Li P, Gao C, Zuo H, Fan C, Xin N, Wu Q, Shao Y. Experience and efficacy of surgery for retaining viable subcutaneous tissue in extensive full-thickness burns. Burns 2015; 42:71-80. [PMID: 26546384 DOI: 10.1016/j.burns.2015.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 06/14/2015] [Accepted: 06/21/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM For adult patients with extensive full-thickness burns (EFTB), a fascial excision is mostly used but it causes a very significant deformity. This study aims to summarize experience and efficacy of surgery for retaining viable subcutaneous tissue in EFTB. METHOD Clinical data were reviewed for 31 consecutive adult patients with full-thickness burn (FTB) over 70% total body surface area (TBSA) and undergoing first tangential excision and skin grafting on subcutaneous tissue wound (TESGSTW) within 7 days post burn at our burn center between 2002 and 2013. RESULTS Average age, total burn area, and FTB area of 31 patients were 32.4 ± 12.8 years, 89.0 ± 6.2% and 80.4 ± 7.6% TBSA, respectively. Of these, 80.6% combined with inhalation injury and 71.0% supervened early shock. Eighteen patients who survived (58.1%) totally underwent 121 times of surgery, of which TESGSTW and autologous skin grafting were 41 and 88 times, respectively. Their average time and area of first tangential excision was 4.1 ± 0.6 days post burn and 33.8 ± 7.6% TBSA, respectively, and accumulated tangential excision area was 58.4 ± 10.8% TBSA. In 39 times of TESGSTW within 14 days post burn, cryopreserved alloskin or fresh young pigskin was applied on 84.6%, and average time and take rate of autologous skin grafting instead of grafted alloskin or xenoskin was 14.6 ± 0.7 days and 89.5 ± 1.4%, respectively. Scalp was the main donor site for autologous skin, especially microskin grafting. Systemic wound healing time roughly was 67.3 ± 1.9 days post burn, meanwhile, viable subcutaneous tissue was retained. Healed wounds were plump, and their extensibility and sensitivity were better by follow-up. CONCLUSION The surgical treatment in EFTB is practicable and effective.
Collapse
Affiliation(s)
- Guodong Song
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Jun Jia
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Yindong Ma
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Wen Shi
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Fang Wang
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Peilong Li
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Cong Gao
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Haibin Zuo
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Chunjie Fan
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Naijun Xin
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Qiuhe Wu
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| | - Yang Shao
- Department of Burns, Jinan Central Hospital Affiliated to Shandong University, 105 Jiefang Road, Jinan, Shandong 250013, PR China.
| |
Collapse
|
12
|
Abstract
Controversy remains over appropriate endpoints of resuscitation during fluid resuscitation in early burns management. We reviewed the evidence as to whether utilizing alternative endpoints to hourly urine output produces improved outcomes. MEDLINE, CINAHL, EMBASE, Cochrane Library, Web of Science, and full-text clinicians' health journals at OVID, from 1990 to January 2014, were searched with no language restrictions. The keywords burns AND fluid resuscitation AND monitoring and related synonyms were used. Outcomes of interest included all-cause mortality, organ dysfunction, length of stay (hospital, intensive care), time on mechanical ventilation, and complications such as incidence of pulmonary edema, compartment syndromes, and infection. From 482 screened, eight empirical articles, 11 descriptive studies, and one systematic review met the criteria. Utilization of hemodynamic monitoring compared with hourly urine output as an endpoint to guide resuscitation found an increased survival (risk ratio [RR], 0.58; 95% confidence interval, 0.42-0.85; P < 0.004), with no effect on renal failure (RR, 0.77; 95% confidence interval, 0.39-1.43; P = 0.38). However, inclusion of the randomized controlled trials only found no survival advantage of hemodynamic monitoring over hourly urine output (RR, 0.72; 95% confidence interval, 0.43-1.19; P = 0.19) for mortality. There were conflicting findings between studies for the volume of resuscitation fluid, incidence of sepsis, and length of stay. There is limited evidence of increased benefit with utilization of hemodynamic monitoring, however, all studies lacked assessor blinding. A large multicenter study with a priori-determined subgroup analysis investigating alternative endpoints of resuscitation is warranted.
Collapse
|
13
|
Toussaint J, Singer AJ. The evaluation and management of thermal injuries: 2014 update. Clin Exp Emerg Med 2014; 1:8-18. [PMID: 27752547 PMCID: PMC5052819 DOI: 10.15441/ceem.14.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 08/21/2014] [Accepted: 08/28/2014] [Indexed: 11/23/2022] Open
Abstract
Burns are among the most common injuries presenting to the emergency department. While burns, especially large ones, may be associated with significant morbidity and mortality, most are minor and can be managed by emergency practitioners and discharged home with close follow-up. In contrast, patients with large burns require aggressive management of their airway, breathing and circulation in order to reduce mortality and morbidity. While early endotracheal intubation of patients with actual or impending airway compromise and aggressive fluid resuscitation have been emphasized, it appears that the pendulum may have swung a bit too far towards the extreme. The current review will briefly cover the epidemiology, pathogenesis and diagnosis of burn injuries with greater emphasis on airway and fluid management. We will also discuss the local management of the burn wound, which is all that is required for most burn patients in the emergency department.
Collapse
Affiliation(s)
- Jimmy Toussaint
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
14
|
Abstract
For the physician or surgeon practicing outside the confines of a burn center, initial assessment and fluid resuscitation will encompass most of his or her exposure to patients with severe burns. The importance of this phase of care should not be underestimated. This article provides a review of how to perform initial resuscitation of patients with significant burns and/or inhalation injury, while arranging for transfer to a regional burn center.
Collapse
Affiliation(s)
- Leopoldo C Cancio
- Medical Corps, U.S. Army, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA, Fort Sam Houston, TX 78234-6315, USA.
| |
Collapse
|
15
|
Indocyanine green dye angiography accurately predicts survival in the zone of ischemia in a burn comb model. Burns 2013; 40:940-6. [PMID: 24231464 DOI: 10.1016/j.burns.2013.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/01/2013] [Accepted: 10/18/2013] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Surgical evaluation of burn depth is performed via clinical observation, with only moderate reliability. While perfusion analysis has been proposed to enhance accuracy, no perfusion study has attempted to predict burn extension into the area of ischemia surrounding the original insult. We examined whether laser Doppler imaging (LDI) and indocyanine green (ICG) angiography predicted survival in the zone of ischemia in a porcine hot comb burn model. METHODOLOGY Six full-thickness wounds were created on 5 female Yorkshire swine using a validated porcine hot comb burn model. 4 full-thickness burns were created separated by 3 unburned interspaces that represent the zone of ischemia. The interspaces between each comb burn were monitored using LDI and ICG Angiography at 1, 4, 24, and 48 h after burn. Interspace survival was assessed via gross observation and blinded histological readings 7 days after injury. RESULTS ICG Angiographic assessments of burn perfusion were significantly different in viable vs. non-viable interspace perfusion at 1 h, 4 h, and 48 h. Temporal plotting of a trend-line derived from quantitative perfusion measurements rendered two distinct graphs, allowing for the derivation of a predictive algorithm to separate viable and non-viable interspaces. LDI revealed no such prognostic trend. CONCLUSION Results from a validated porcine burn comb model suggest that ICG angiography has significant potential in the prediction of burn progression early after burn. However, the full potential of this technology cannot be determined until completion of clinical trials.
Collapse
|
16
|
Retrospective analysis of photographic evaluation of burn depth. Burns 2011; 37:69-73. [DOI: 10.1016/j.burns.2010.05.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Revised: 05/21/2010] [Accepted: 05/25/2010] [Indexed: 11/21/2022]
|
17
|
|
18
|
Critical review of burn depth assessment techniques: part II. Review of laser doppler technology. J Burn Care Res 2010; 31:151-7. [PMID: 20061851 DOI: 10.1097/bcr.0b013e3181c7ed60] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The judgment of which wounds are expected to heal within 21 days is one of the most difficult and important tasks of the burn surgeon. The quoted accuracy of 64 to 76% by senior burn surgeons underscores the importance of an adjunct technology to help make this determination. A plethora of techniques have been developed in the last 70 years. Laser Doppler imaging (LDI) is one of the most recent and widely studied of these techniques. The technology provides an estimate of perfusion through the burn wound, the assumption being that a lower perfusion correlates with a deeper wound and, therefore, a longer time to heal. Although some reports suggest accuracy between 96 and 100% and that it does this 2 days ahead of clinical judgment, others have questioned its applicability to clinical practice. This article, the second of a two-part series, has two objectives: 1) a review of the Doppler principle and how the LDI uses it to estimate perfusion; and 2) a critical assessment of the burn literature on the LDI. Part I provides a historical perspective of the different technologies used through the last 70 years to assist in the determination of burn depth. Laser Doppler has brought technology closer to provide a reliable adjuvant to the clinical prediction of healing, yet, caution is warranted. A clear understanding of the limitations of LDI is needed to put the current research in perspective to find the right clinical application for LDI.
Collapse
|
19
|
Meyerholz DK, Piester TL, McNamara AR, Sokolich JC, Jaskille AD, Orion KC, Zamba KD, Light TD. Pharmacologic modification to resuscitation fluid after thermal injury--is drotrecogin alfa the answer to arrest burn depth progression? THE JOURNAL OF TRAUMA 2009; 67:996-1003. [PMID: 19901660 DOI: 10.1097/ta.0b013e3181b83b3b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HYPOTHESIS The addition of drotrecogin alfa (DA), an anti-inflammatory useful in septic shock, to standard burn shock resuscitation fluids will protect burned, injured skin from further injury. METHODS Anesthetized animals were subjected to a standardized burn pattern by applying a branding iron to 10 different locations on the back of the rat for 1 seconds to 14 seconds, creating a range of burn depths and severities. DESIGN Animal burn shock and resuscitation model. PARTICIPANTS Thirty-one male adult Sprague-Dawley rats. INTERVENTIONS Control animals were resuscitated with lactated Ringer's solution (LRS) at 2 mL/kg/percent total body surface area/24 h; experimental animals received LRS plus DA 24 microg/kg/h (LRS + DA). OUTCOME MEASURES Perfusion to each burned area was assessed using a laser Doppler imaging technology. Punch biopsies at each burned area were stained with hematoxylin and eosin and assessed for burn depth and for inflammation using previously reported measures. Samples from 14 animals were stained for terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling and caspase-3 (apoptosis markers). RESULTS Increasing branding iron contact times worsened perfusion, burn depth, and apoptotic ratios. There was no correlation between inflammatory markers and burn contact time. The addition of DA leads to worse perfusion, deeper burns, worse inflammation, and decreased apoptotic ratios. CONCLUSIONS Laser Doppler imaging is a useful technology to assess burn depth. The addition of DA to traditional resuscitation fluids for burn shock is deleterious to the injured, burned skin. Modifying the traditional burn shock resuscitation fluids, although intellectually attractive, needs to be rigorously studied.
Collapse
Affiliation(s)
- David K Meyerholz
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, Iowa 52242, USA
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Cutaneous microcirculatory assessment of the burn wound is associated with depth of injury and predicts healing time. Burns 2009; 36:477-82. [PMID: 19854578 DOI: 10.1016/j.burns.2009.06.195] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Revised: 06/24/2009] [Accepted: 06/24/2009] [Indexed: 01/07/2023]
Abstract
RATIONALE Current trends for the treatment of deep partial thickness and full-thickness burns include early excision and skin grafting. In this study we retrospectively evaluated the ability of Laser Doppler Flowmetry (LDF), taken within 24h of the burn to predict: (1) burn wound depth and (2) wounds which would heal in less than 21 days. METHOD The Laser Doppler Flowmeter (O2C, LEA Medizintechnik, Germany) was employed to non-invasively measure the cutaneous microcirculation of 173 selected areas on 28 patients who suffered burns. RESULTS A distinct association between initial flow (<24h after burn injury) and the clinical assessment of depth of burn wounds was observed. Wounds demonstrating an initial blood flow of >100 AU were, in 93.1% of cases, correctly (positively) predicted for spontaneous healing within 21 days. A blood flow of <100 AU (negatively) predicted in 88.2%, those wounds which would not go on to heal within 21 days. Sequential measurement analysis (<24h, 3 days after injury and 6 days after injury) revealed no significant decrease in skin perfusion velocity or flow rate. CONCLUSION LDF can provide immediate results for early determination of burn wound depth and is useful in selecting patients for conservative treatment of their burn wounds.
Collapse
|
21
|
Abstract
In the year 2007, approximately 1000 original burn research articles were published in scientific journals using the English language. This article reviews approximately 90 of these which were deemed by the author to be the most important in terms of clinical burn care. Relevant topics include epidemiology, wound characterisation, critical care physiology, inhalation injury, infection, metabolism and nutrition, psychological considerations, pain management, rehabilitation, and burn reconstruction. Each selected article is mentioned briefly with editorial comment.
Collapse
Affiliation(s)
- Steven E Wolf
- Department of Surgery, University of Texas Health Science Center, San Antonio and the United States Army Institute of Surgical Research, San Antonio 7703 Floyd Curl, TX 78229-3600, USA.
| |
Collapse
|
22
|
Improved Markers for Burn Wound Perfusion in the Severely Burned Patient: The Role for Tissue and Gastric Pco2. J Burn Care Res 2008; 29:49-55. [DOI: 10.1097/bcr.0b013e31815f59dc] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
Base deficit and lactate: Early predictors of morbidity and mortality in patients with burns. Burns 2007; 33:973-8. [DOI: 10.1016/j.burns.2007.06.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Accepted: 06/29/2007] [Indexed: 11/17/2022]
|