静吸复合麻醉对特重度烧伤患者凝血功能障碍的影响

目的收集特重度烧伤(总TBSA50%以上或三度TBSA20%以上或伴有严重并发症者)患者围术期凝血指标(APTT、PT、FIB、DD和PLT)，分析静吸复合麻醉对患者凝血功能的影响及其临床意义。 方法选取近3年内蒙古医科大学第三附属医院烧伤外科收治的特重度烧伤患者148例，根据入院14 d内的预后分为死亡组和生存组，生存组男性129例，女性9例；年龄24~59岁，平均(43.30±12.90)岁。死亡组男性8例，女性2例；年龄26~63岁，平均(46.19±15.41)岁。收集入院时(T0)，术前(早晨入手术室前，T1)，术毕(送至PACU未拔除气管导管前，T2)及术后2 d(T3)4个时间点的凝血指标，比较两组凝血指标动态差异。 结果死亡组休克期输液量、累计血浆、红细胞输入量显著高于生存组(P<0.01)。T0时，生存组的FIB(1.78±0.32)显著高于死亡组(1.26±0.07)(P<0.05)；T2时，两组APTT、PT均显著缩短(P<0.05)，生存组的FIB(3.86±0.40)显著高于死亡组(2.45±1.02)(P<0.05)；T3时，死亡组PLT显著低于生存组(P<0.01)。 结论特重度烧伤患者在围手术期易出现高凝状态，并且这可能导致患者死亡。静吸复合麻醉和围术期大量液体复苏会促进患者的高凝状态。     

Butane detection after long-term treatment of burns in two autopsy cases

A man and a woman were rescued from a room that had exploded. Many empty cassette gas cylinders were found in the room. The man and woman were hospitalized immediately for the treatment of burns. The woman died 6 days later, and the man died 31 days later without regaining consciousness. Carbonization and hardening of the frontal facial skin and parts of the left and right fingers were observed on the man's body. In both cases, systemic burns had led to progressive systemic edema and markedly suppressed circulation. Analytical samples for butanes obtained from their bodies at autopsy were stored at −20 °C for 14 and 25 days, respectively, before analysis. Normal butane and isobutane were quantified in the brain and subcutaneous adipose tissue of the woman. Only the isobutane was quantified in the adipose tissue of the man. The evidence suggests that the man lit a cigarette while breathing gas and the entire room exploded. Our results also suggest that butane can be detected in the adipose tissue of autopsy cases long after inhalation even under the present storage conditions, and isobutane may remain in adipose tissue longer than n-butane.     

Trends and risk factors for mortality in elderly burns patients: A retrospective review

IntroductionThe elderly experience higher mortality rates and poorer outcomes compared to younger burn survivors with similar injuries.MethodsThis epidemiological study reviewed records of all admitted elderly burn patients collected from five burns facilities in Israel between 1997–2016. Collected data was limited to the population aged 20+, focused on the population aged 60+.ResultsMortality rates for elderly patients increased with TBSA and increases with age. Regression analyses demonstrated a decrease in mortality of 2.9% (p = 0.013) per 5 years, an overall decrease of 11.6% over the 20-year study period, with the decline more significant for older age groups. This decrease in mortality was much larger than that observed for all burns patients over this period. The most common cause of injury in the elderly population was fire, with mortality rate highest for this cause. There was no effect of gender on mortality rate. Mortality increased when smoke inhalation was present for TBSA<20%, with mortality unaffected by the presence of smoke inhalation for higher TBSA. The need for surgery correlates with high mortality rates.ConclusionThis study identified key factors that impact mortality and demonstrated a large decrease in mortality in the elderly patients over the study period.     

A randomized controlled trial: Comparison of one-per-mil tumescent technique and tourniquet in surgery for burn hand contracture in creating clear operative field and assessment of functional outcome

BackgroundThis study aims to compare the use of one-per-mil tumescent solution (a mixture of epinephrine and 0.2% lidocaine in a ratio of 1:1,000,000 in normal saline solution) and tourniquet to create clear operative fields and to evaluate the functional outcomes after post burn hand contracture surgery.MethodsThe subjects of this randomized controlled trial were divided into one-permil tumescent technique and tourniquet group for a similar surgical procedure. Three independent assessors evaluated the clarity of the operative fields through recorded videos for the first 15 min and the first 10-minute of each hour of the surgery. Functional outcome was evaluated at least three months postoperatively using total active and passive motion (TAM and TPM) of each digit. Malondialdehyde (MDA) and tumor necrosis factor alpha (TNF-α) were tested during baseline (5 min before the procedures), ischemia phase, and reperfusion phase (a phase when the blood flow returned to the tissue).Results35 subjects were included in this study: 17 in the tumescent group and 18 in the tourniquet group. We found a significant difference in the clarity of operative field between tumescent and tourniquet groups, 5 vs 35 bloodless operative fields, respectively (p < 0.05). TAM and TPM of each digit before surgery and 3 months postoperatively showed no significant difference between both groups (p > 0.05). Furthermore, we found no difference in MDA and TNF-α levels between both groups at their respective phases.ConclusionsThe use of one-per-mil tumescent technique does not replace tourniquet use to create bloodless operative fields in burned hand contracture surgery. However, the postoperative functional results were similar in both groups showing that tumescent technique can be used as an alternative to tourniquet without compromising outcomes. The MDA and TNF-α examinations do not provide conclusive outcomes regarding ischemia and reperfusion injury.     

Surgical management and epidemiological trends of pediatric electrical burns

Electrical burns are an uncommon yet devastating class of burn injuries. Shriners Hospitals for Children — Boston a pediatric burn center in New England and cares for both domestic and international patients. We utilized our experience over the past 13 years to review surgical management and evaluate historical trends for this unique patient group. A retrospective chart review was conducted on 68 patients aged 0–18 years admitted to our pediatric center with an electrical burn from January 2005 to December 2018. We collected and analyzed data pertaining to patient demographics, burn characteristics, clinical course, and surgical interventions. Our cohort included 31 patients from the US (46%) and 37 transferred from a variety of international countries (54%). The majority of US patients were admitted with low voltage burns (81%), whereas the majority of international patients were admitted with high voltage burns (95%). Acute and reconstructive surgical interventions were performed mainly for high voltage burns (94% and 89%). Based on our experience, epidemiology and surgical intervention varied based on voltage of the burn injury and residence of the patient. We have seen a reduction in US pediatric high voltage injuries over the past two decades, likely due to enhancement of electrical safety. It may be possible to use a similar strategy to reduce the frequency of severe high voltage electrical burn injuries in developing countries.     

Inflammatory and infectious complications of laser therapy in treatment of hypertrophic burn scars: Correlations in literature review & case reports

IntroductionHypertrophic burn scars contribute to morbidity through secondary symptoms of pain, pruritus, and scar contracture. Traditional treatment methods are now augmented by the use of monochromatic light therapies, which are generally accepted as safe and effective. However, little literature is available regarding the complications of laser treatments of hypertrophic burn scars and even less regarding inflammatory and infectious complications.MethodsA literature search using PubMed was performed to identify literature pertaining to infectious and inflammatory complications of cutaneous laser treatments. Additionally, we reviewed cases of inflammatory and infectious complications occurring at our institution after laser treatment of hypertrophic burn scars.ResultsWe identified 1 publication related to complications of laser therapy in the treatment of burn scars. In this series of 163 laser sessions, the reported incidence of adverse events was 25.1%, of which 6 cases 3.7% were related to inflammatory and infectious processes. In the 391 laser sessions performed at our institution (December, 2015 and July, 2016) 9 cases of inflammatory and infectious complications were noted yielding an incidence of 2.3%. Cases included 3 each of cellulitis, Systemic Inflammatory Response Syndrome (SIRS), and complicated SIRS.ConclusionWe found the most common inflammatory complication was SIRS with MSSA positive wound cultures. Three cases underwent hospitalization along with fluids and vasopressors, despite negative blood cultures. In light of the high prevalence of MSSA in the natural skin flora and negative blood cultures, the inability to establish a true source of infection lead to declaring these cases “complicated SIRS” and not sepsis. Correlative factors that may have led to complications reported in our cases were: preoperative evidence of infection, no preoperative antibiotics administered, no postoperative antibiotic dressings, combined procedures, and large treatment areas. The true mechanism of inflammatory and infectious complication is yet to be determined, but we postulate that these factors place a greater challenge on an already burdened immune system. Determining whether this is a true causal mechanism, leading to an aggravated inflammatory response, benefits from further investigation.Applicability of research to practiceWe urge institutions preforming such procedures to advise patients on preoperative wound preparation. We recommend that each individual with a preexisting history of infection and/or preoperative culture evidence of infection receive antibiotics, particularly when undergoing combined procedures or procedures involving higher surface areas. Although complications are rare, the benefits of these precautionary measures outweigh the risks when it comes to prevention and management.