休克期切削痂在儿童大面积烧伤的应用

目的阻止大量血浆丢失,减轻坏死组织对机体的毒性反应,降低大面积深度烧伤儿童的死亡率以及缩短住院时间。方法对20例大面积烧伤儿童施行了休克期切痴植皮术(A 组)。年龄5个月至12岁,烧伤总面积28％±11.4％,Ⅲ度面积23.1％±6.2％,开始手术时间平均伤后33小时,一次切痂面积16.1％±4.6％。为评价休克期切痂效果,随机选择18例非休克期切痂植皮大面积烧伤儿童作为对照(B 组)。结果两组比较,休克期切痂组治疗过程相对平稳,所用抗生素种类少、时间短,输血量少,平均每例少输血780 ml,创面换药次数少,愈合时间明显缩短,且内脏并发症减少。结论儿童大面积深度烧伤休克期切痂植皮可提高大面积深度烧伤儿童治愈率,减少住院经费。休克期切痂植皮术不仅可在较大医院及研究所实旋,也可在基层医院内实施。     

Burn resuscitation: The results of the ISBI/ABA survey

Introduction

There are valid concerns that burn shock resuscitation is inadequate; a tendency to over-resuscitate the patient seems to exist which may increase complications such as compartment syndrome. The purpose of this study was to survey members of the ISBI and ABA to determine current practices of burn resuscitation.

Methods

A survey asking for practices of burn shock resuscitation was provided to all participants of a recent ABA meeting. Around the same time, the survey was sent to all members of the ISBI through the internet. The results of the 101 respondents (ABA – 59, ISBI – 42, approximately a 15% response rate) are described.

Results

Surveys were returned from all the continents except Africa. Respondents included directors (48%), staff physicians (19%), nurses (23%) and others. Most programs admitted adults (87%) and children (75%) with a mean of 289 admissions per year. The cut off to initiate resuscitation was 15% TBSA and most preferred peripheral IVs (70%) and central lines (47.5%). The Parkland formula was preferred (69.3%) while others were used: Brooke – 6.9%, Galveston – 8.9%, Warden – 5.9%, and colloid 11.9%. Lactated Ringer's (LR) was the preferred solution (91.9%), followed by normal saline – 5%, hypertonic saline – 4%, albumin – 20.8%. FFP – 13.9%, and LR/NaHCO₃ – 12.9%. Approximately half (49.5%) added colloid before 24 h. Urine output is the major indicator of success (94.9%) while 22.7% use other monitors. Most (88.8%) feel their protocols work well with 69.8% feel that it provides the right amount of fluid (24% – too much, 7% – too little). Despite this feeling, they still feel that they give more fluid than the formula in 55.1%, less than formula in 12.4% and the right amount in 32.6%. Approximately 1/3 use an oral resuscitation formula and 81.8% feel that an oral formula works for burns < 15% TBSA.

Conclusion

Large variations exist in resuscitation protocols but the Parkland formula using LR is still the dominant method. Most feel that their resuscitation protocol works well.     

严重烧伤或伴吸入性损伤患者休克期输液问题及死亡原因探讨

的　探讨严重烧伤或伴吸入性损伤患者休克期输液问题以及死亡原因。　方法在 1991～ 2 0 0 0年间收治的严重烧伤或伴吸入性损伤患者 112例 ,对这些患者休克期的诊断、输液情况、死亡情况进行了总结。　结果　休克期的输液情况可归纳为 :第 1个 2 4h总入量 2 2ml/ (%TBSA·kg) ,其中胶体 0 5ml/ (%TBSA·kg) ,晶体 1ml/ (%TBSA·kg) ,其余为水分。第 2个 2 4h总入量 1 8ml/(%TBSA·kg) ,其中胶体 0 4ml/ (%TBSA·kg) ,其余为晶体、水分各半。单纯烧伤与烧伤伴吸入性损伤的输液情况 ,两者并无差异。休克期 7例患者死亡 ,原因均为呼吸衰竭 ,其中 3例休克未能纠正。　结论　各种输液公式均可为休克期补液提供参考 ,最重要的是应根据病人具体情况进行输液 ,以保证病人平稳渡过休克为最终目的。单纯烧伤和烧伤伴吸入性损伤患者休克期输液量并无不同。     

The prognostic factors regarding long-term functional outcome of full-thickness hand burns

The treatment of the burned hand has always been a subject of special interest. In order to obtain a better understanding of the parameters involved in the long-term functional outcome of hand burns a retrospective study was performed on 88 consecutive patients with hand burns (143 hands), treated according to a standardised protocol. Patients were followed for at least 12 months postburn. Hand function was assessed by the seven objective test criteria (7-OTC) described by Jebsen. Logistic regression analysis produced five parameters that were found to have a significant predictive value for long-term hand function. In order of predictive value, these were finger amputations, age on admission, impaired autograft take, the full-thickness hand burn surface area and the full-thickness total body burn surface area. By fitting these five variables into an equation, a probability model was obtained, which could be applied to estimate a prognosis concerning the final hand function of an individual patient with a hand burn.

No relationship was found between the postburn day of operation and the long-term hand function. This finding is inconsistent with the current consensus that functional outcome is improved by early excision and grafting. In practice, it suggests that hand function is well preserved when burns of uncertain depth are treated expectantly, followed by selective debridement and grafting. Advantages include reduced blood loss, no loss of vital tissue and a reduction of the need for donor sites.     

Management of burns of over 80% of total body surface area: a comparative study

The aim of this retrospective, comparative study was to analyse the management of extensive burns so as to decrease morbidity and mortality. Over 1987-1996, 24 people with burns >80% of total body surface area and >50% full-thickness burn were admitted to the burn unit of Anhui Medical University Hospital (group A); 30 similar admissions over 1997-2006 formed group B. No significant difference was found in age, male:female ratio, % total body surface or full-thickness burn area between the two groups. Severe shock developed in 19/24 cases in group A and 23/30 cases in group B, following inadequate fluid resuscitation, although group B received a higher mean resuscitation fluid volume during the first 24h after burn. Early excision and grafting was performed for 8/24 people in group A and 23/30 in group B. Inhalation injury was seen in 18/24 cases in group A and 28/30 cases in group B. Prophylactic tracheotomy was undergone by 8/24 casualties in group A and 22/30 in group B. Mortality in group A was significantly higher than in group B (95.8% vs. 63.3%, p<0.05) and survival was longer in group B. These results showed that refinements in burn shock resuscitation, and advances in early wound excision, skin grafting and respiratory management were associated with decreased morbidity and mortality after severe burn.     

严重烧伤后早期大鼠肝脏细胞内外钠离子分布和化学状态的变化

目的观察大鼠严重烧伤后肝脏细胞内、外Na 在分布和化学状态上的改变,为烧伤后早期液体复苏方案的选择提供理论指导。方法选取成年雄性SD大鼠19只,随机分为对照组(12只)、烧伤组(7只),采用钠-23磁共振(23NaNMR)波谱技术和位移试剂,测定两组大鼠肝脏细胞内、外Na 的纵向弛豫时间(T1)和横向弛豫时间(T2)的变化。结果输注位移试剂后,烧伤组大鼠肝脏细胞外Na 浓度降低17%,其快T2所占百分比较对照组有所增加(P<0.01),提示细胞外可与Na 结合或可影响Na 的位点增加;细胞内Na 浓度升高了59%,但其弛豫行为却未发生变化。结论烧伤后早期细胞外的Na 可因向细胞内流失或受其周围大分子可逆性结合位点的影响,使瞬时可发挥渗透粒子作用的Na 相对不足,提示烧伤后第1个24h选择适量高钠溶液复苏较合理。     

The Alfred pre-hospital fluid formula for major burns

Background

The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg) × %TBSA burnt = mls in the first 2 h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration.

Methods

A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period.

Results

There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22–0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04–0.26) mL/kg/%TBSA administered in the prior period (p = 0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24 h, the volume of fluid administered in patients when The Alfred formula was used was 4.9 ± 1.6 mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8 ± 2.2 mL/%TBSA/kg (p = 0.802).

Discussion

The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current ‘gold standard’.     

糖尿病患者烧伤46例的临床特点及治疗体会

目的 探讨糖尿病患者烧伤的临床特点和治疗体会,提高糖尿病患者烧伤的治愈率.方法 对甘肃省人民医院烧伤整形科近5年来收治的46例糖尿病烧伤患者的一般资料,以及补液抗休克、控制血糖、手术和对症支持的综合疗法进行回顾性分析.结果 所有患者经3～7d空腹血糖均下降至10 mmol/L以下,28例手术患者空腹血糖下降至8 mmol/L以下;除1例病情较重并发多器官功能障碍综合征死亡外,其余均治愈,治愈率达97.8％;46例中26例出现并发症,发病率为56.5％.结论 糖尿病患者烧伤病情复杂,全身结合局部的综合性治疗是治愈糖尿病烧伤患者的有效方法.     

胸脐皮瓣修复深度烧伤创面疗效观察

目的观察胸脐皮瓣早期修复深度烧伤创面的临床应用效果。方法笔者应用胸脐皮瓣(分别采用带蒂转移、岛状转移、游离移植以及与多种皮瓣联合转移的方式)修复39例深度烧伤患者创面,观察皮瓣的成活情况、色泽、弹性,有无瘢痕挛缩导致的功能障碍及供瓣区愈合情况。结果创面彻底清创后未发生明显感染。胸脐皮瓣面积最大为55 cm×27 cm,最远达到同侧腋中线,且皮瓣可跨越腹中线,最远达对侧10 cm,皮瓣全部成活。33例患者随访1-46个月,皮瓣色泽及弹性良好,无瘢痕挛缩导致的功能障碍,供瓣区部位隐蔽,无明显瘢痕形成。结论胸脐皮瓣根据创面大小及部位采用不同的转移方式,是早期修复深度烧伤创面较理想的方法。     

Clinical characteristics and treatment of burn wound sepsis in extensive burn patients: successful experience with eight cases

Eight burn wound sepsis patients, in which 6 cases were diagnosed as MODS and two as septic shock, were treated consecutively in our hospital from September 1997 to October 1998. The plasma concentration of IL-6, IL-8, TNFα and LPS were assayed before and after surgical intervention, as well as when the patients' vital signs became stable. The results showed: ①The patients' conditions abruptly deteriorated when the burn wound sepsis emerged;②The major cause related to burn wound sepsis was extensive burn injuries, with large areas of deep burn remaining open; ③Although wound swabs taken on admission revealed the presence of colonization by many pathogenic bacteria, Pseudomonas aeruginosa was one of the most frequent bacteria isolated from the subeschar tissue; ④The plasma concentrations of IL-6, IL-8, TNF and LPS before surgical intervention were significantly higher than that after surgical intervention (P＜0.05) ;⑤The lowest level of the inflammatory mediators was observed when the patients' conditions became stable, as compared with before surgical intervention (P＜0. 001).These findings suggest that the clinical characteristics of burn wound sepsis are abrupt deterioration of the general condition and prominent septic symptoms, often complicated by MODS. The main cause of burn wound sepsis is the presence of a large area of open deep burn wounds, which should be excised and covered early. LPS and pro-inflammatory mediators play an important role in the pathogenesis of burn wound sepsis. Although success in treating these patients is the result of appropriate application of multiple treatments, early, aggressive and thorough surgical excision of invasive burn infectious tissue and closure of wound play a crucial role in the successful treatment of patients complicated by burn wound sepsis. Other treatments are adjuvant but also important.     

Resuscitation fluid volume and abdominal compartment syndrome in patients with major burns

Abdominal compartment syndrome (ACS) is rarely reported as a complication of severe burn. This study clarified the risk of burned patients with and without ACS, especially regarding the resuscitation fluid volume. Extensively burned patients admitted to our burn unit from January 2003, through to June 2004, were examined. Vital signs, blood gas analysis, bladder pressure to estimate intra-abdominal pressure (IAP), peak inspiratory pressure (PIP), resuscitation fluid volume, and urine output (UO) were analyzed. Intra-abdominal hypertension (IAH) was defined as an IAP of more than 30 cm of H2O. Eight of 48 patients suffering from a more than 30% total burn surface area developed ACS in 18.3+/-4.9 h. In these patients, IAP (49+/-12 cmH2O), PIP (50+/-16 cmH2O), heart rate (115+/-8/min), and PaCO2 (54.6+/-10.1 mmHg) were higher than normal, and their resuscitation volume was 0.40+/-0.11 L/kg. Also, a significant correlation between the IBP, PIP and resuscitation volume was observed. Most patients with severe burns required more than 300 mL/kg of resuscitation fluid for the first 24 h after injury that led to ACS and had higher HR, IBP, PIP and PaCO2 despite arterial pressure showing no significant difference.     

Influence of CD14 polymorphism on CD14 expression in patients with extensive burns

We sought to investigate the association of CD14 genotype with the risk of mortality after burn, and we also attempted to evaluate whether CD14-159 C/T polymorphism affects the kinetics and extent of CD14 expression as well as its release, and TNF-alpha expression in burned patients. The study involved 64 patients in Chinese Han population incurring burns covering more than 30% of the total body surface area. CD14 polymorphism was determined by polymerase chain reaction (PCR) and subsequent restriction fragment length polymorphism (RFLP) analysis. Meanwhile, leukocyte CD14 mRNA expression and soluble CD14 (sCD14) levels were measured during a 28-day observation period. TNF-alpha mRNA and protein levels were also determined in patients with different genotypes of CD14. On day 21 after burn, CD14 mRNA expression and sCD14 levels were significantly higher in TT homozygotes than in CC genotypes (1.33+/-0.36 microg/ml vs. 0.75+/-0.28 microg/ml and 16.1+/-4.6 microg/ml vs. 9.7+/-3.4 microg/ml, P<0.05), and these values were also higher in non-survivors than in survivors (1.32+/-0.40 microg/ml vs. 0.87+/-0.32 microg/ml and 14.8+/-4.5 microg/ml vs. 11.1+/-4.8 microg/ml, P<0.05). In addition, TNF-alpha mRNA and protein levels were significantly lower in both CC homozygotes and survivors than in TT genotypes or non-survivors during the 28-day observation period (P<0.05). However, TT genotype did not impart an increased risk for burn mortality in this small study. In conclusion, CD14-159 C/T polymorphism might be associated with the kinetics and extent of CD14 expression as well as its release, and it was also related to TNF-alpha expression. However, this study did not confirm CD14-159 C/T polymorphism was associated with the outcome of extensive burns.     

手部电烧伤的皮瓣修复

目的 总结用皮瓣修复手部电烧伤创面的经验与不足,以期不断完善. 方法 收集整理2000年1月-2006年12月武汉市第三医院暨武汉大学同仁医院烧伤研究所收治的425例手部电烧伤患者资料,统计分析其治疗概况及结果,归纳总结行皮瓣移植术患者的皮瓣类型、术后并发症及存在的问题.根据皮瓣修复手术时机,将患者分为受伤7 d内手术组和受伤7 d后手术组,比较2组患者皮瓣成活率及并发症发生率. 结果 425例患者中,348例行手术治疗占90.2%,其中209例行不同类型皮瓣移植共248例次,包括远位带蒂皮瓣202例次占81.5%、局部皮瓣19例次占7.7%、游离皮瓣12例次占4.8%、其他类型组织瓣15例次占6.0%.5例因皮瓣撕脱或坏死改用其他方法治疗.8例皮瓣远端少许坏死,经换药或补植小皮片后愈合.其余皮瓣均完全成活,创面一次修复,功能及外观较满意.受伤7 d内手术组(170例次)和受伤7 d后手术组(78例次)患者,皮瓣成活率分别为98.8%(168/170)及96.2%(75/78),并发症发生率分别为10.6%(18/170)及12.8%(10/78),两指标组间比较,差异均无统计学意义(X~2值分别为0.81、0.27,P值均大于0.05). 结论 可用于修复手部电烧伤创面的皮瓣类型较多.合理选择和设计皮瓣、提高操作的熟练程度及术后正确观察与处理,是取得良好疗效的重要环节.     

口服补液复苏对严重烧伤家兔心肌力学指标的改善作用

目的 了解口服补液复苏对严重烧伤家兔心脏功能的保护作用. 方法 150只家兔随机分为正常对照组(6只)、烧伤组(42只)、立即补液组(42只)、延迟补液组(30只)和延迟快速补液组(30只).正常对照组不致伤不补液.其余4组家兔均造成40%TBSAⅢ度烧伤,烧伤组不补液,余下3组伤后用灌胃的方式进行口服补液复苏.经家兔颈动脉左心室内置管,测量正常对照组及4组致伤家兔伤后2、6、8、12、24、36、48 h的平均动脉压(MAP)、左心室收缩压(LVSP)、左心室舒张末期压(LVEDP)以及左心室压力最大上升/下降速率(LV±dp/dt max),另检测休克期尿量. 结果烧伤组家兔LVSP、LV±dp/dt max较正常对照组显著下降.立即补液组和延迟快速补液组上述指标在伤后24 h内高于烧伤组,其中立即补液组LV+dp/dt max在伤后8 h达峰值[(892±116)kPa/s,1 kPa=7.5 mm Hg],LV-dp/dt max在伤后6 h达峰值[(724±149)kPa/s];伤后8 h,延迟快速补液组LV±dp/dt max均达峰值.延迟补液组伤后各时相点LVSP、LV±dp/dt max与烧伤组接近.各组家兔MAP、伤后第1个24 h尿量的比较情况大致与以上指标相似.烧伤组与其余4组比较,各时相点LVEDP差异无统计学意义(P>0.05). 结论严重烧伤家兔伤后24 h内给予有效的口服补液,可改善心肌力学指标;延迟复苏的家兔按照延迟复苏补液公式预估补液量,才能进行有效复苏.     

The pig as an experimental model for mid-dermal burns research

This was a novel, prospective and interventional animal study designed to develop and evaluate a new infliction device for the experimental burn model.Four paired sets of contact burns measuring 36 mm diameter were inflicted on the dorsum of an anesthetized pig using a stainless steel round bar heated up to 80–110 °C. The bar was applied using a push–pull force gauge designed to control 1 kgf mechanical force applied to the skin for a period of 20 s. The left dorsum was used for macroscopic observation and the right dorsum was used for histopathological evaluation. A total of eight burns were covered with moist saline dressings and given daily treatments of xylocaine (lidocaine HCl) gel. This procedure was followed for a period of 24 days. Full-thickness biopsies were obtained for histologic analysis to determine the extent of injury.Statistical analysis showed a high correlation between the exposure temperature and histopathological assessment. The results found the depth of injury to the collagen (Seg₁) correlated with the temperature (T_i) at which the burns was inflicted, Seg₁ = 0.038T_i − 2.57 (r = 0.973, P < 0.05). Also, the histological studies show a high correlation between the depth of collagen denaturation in wounds and the exposure temperature, Seg₁ = 0.0268T_i − 0.165 (r = 0.991, P < 0.05). This model is useful to assess more closely the therapeutic agents used for wound healing in experimental burn wounds.     

The Pre-Hospital Initial Fluid Therapy Estimate in Early Nasty Burns (PHIFTEEN B, 15-B) Guideline applied to a retrospective cohort of Intensive Care Unit patients with major burns

BackgroundAppropriate fluid administration in severe burns is a cornerstone of early burns management. The American Burns Association’s (ABA) recommendation is to administer 2 mL–4 mL × burnt Body Surface Area (BSA) × weight in the first 24 h with half administered in the first eight hours. Unfortunately, the calculations involved are complex and clinicians do not estimate the BSA or weight well, which can lead to errors in the amount of fluid administered.To simplify cognitive load to calculate the fluid resuscitation of early burns, the investigators derived the PHIFTEEN B (15-B) guideline. The 15-B guideline estimates the initial hourly fluid for adults ≥ 50 kg to be:15 mL × BSA (to the nearest 10%)

• •If >100 kg add 200 mL/h.

AimsTo model and determine the accuracy of the 15-B calculated based on the characteristics of a retrospective cohort of patients admitted with ≥ 20% BSA to the Royal Brisbane and Women’s Hospital (RBWH) Intensive Care Unit (ICU).MethodsThe 15-B formula was retrospectively calculated on the prehospital BSA estimate on patients admitted to the RBWH ICU. In addition, the 15-B guideline was modelled against a variety of weights and BSAs. The fluid volume was deemed to be clinically significant if it was greater than 250 mL/h outside the ABA’s recommendations.ResultsThe ICU cohort consisted of 107 patients (63.2% male, median age 37 years), with a median ICU estimated BSA of 40% and a median ICU weight estimation of 80 kg. In 43.9% of the cohort, the magnitude of the proportional difference between prehospital and ICU BSA estimate was greater than 25%.The 15-B formula accurately estimated the hourly fluid for all BSA (20%–100%) and weight combinations (50 kg–140 kg) in a BSA- weight matrix.When prehospital BSA estimate was utilized, 15-B guideline accurately estimated the fluid to be given within clinically significant limits for 97.2% of cases.ConclusionsThe 15-B formula is a simple, easy to calculate guideline which approximates the early fluid estimates in severely burned patients despite inaccuracy in prehospital BSA estimates.     

Non-pharmacological nursing interventions for procedural pain relief in adults with burns: a systematic literature review

Adult burn patients experience pain during wound care despite pharmacological interventions. Additional nursing interventions are needed to improve pain management. A systematic review was undertaken in order to examine the implications of previous research for evidence based decisions concerning the use of non-pharmacological nursing interventions and for future research. Twenty-six studies met the inclusion criteria and were discussed. The majority of the included studies concerned behavioural nursing interventions and focussed on promotion of psychological comfort. Although 17 studies showed that the intervention had a positive effect on pain outcomes and no adverse effects of the reviewed interventions were reported, the best available evidence was found for active hypnosis, rapid induction analgesia and distraction relaxation. However, in order to reduce methodological limitations, further research is needed before well-founded evidence based decisions for nursing practice can be made. Aspects that seem important for future research, like the type of the intervention, theoretical framework, manner of giving instruction and guidance, cost, outcomes, measurement instruments and data collection points are considered.     

A systematic review of quantitative burn wound microbiology in the management of burns patients

Background

The early diagnosis of infection or sepsis in burns are important for patient care. Globally, a large number of burn centres advocate quantitative cultures of wound biopsies for patient management, since there is assumed to be a direct link between the bioburden of a burn wound and the risk of microbial invasion. Given the conflicting study findings in this area, a systematic review was warranted.