Evaluation of soluble CD14 subtype (presepsin) in burn sepsis

Background

Diagnosing sepsis is difficult in burn patients because of the inflammatory mediators that alter postburn metabolic profile. Here, we compare a new marker presepsin with procalcitonin (PCT), c-reactive protein (CRP) and white blood cell (WBC) in diagnosis and follow up of sepsis in burn patients.

Methods

Patients admitted to burn center of our institute were prospectively investigated. Presepsin, PCT, CRP and WBC levels were measured at admission and every 6 h for first day and daily thereafter. At all timing samples, patients were classified as sepsis or non-sepsis according to the current American Burn Association Consensus Criteria (ABA) 2007.

Result

37 adult patients were evaluated. A total data of 611 time points were supplied. Sepsis time points differ significantly from non-sepsis in presepsin (p < 0.0001), PCT (p = 0.0012) and CRP (p < 0.0001) levels. Non-surviving patient results differ significantly from survivors in presepsin (p < 0.0001), PCT (p = 0.0210) and CRP (p = 0.0008). AUC-ROC % values for diagnosing sepsis were 83.4% for presepsin, 84.7% for PCT, 81.9% for CRP and 50.8% for WBC. Sepsis patients had significantly different presepsin, CRP and WBC but not PCT levels on their first day of sepsis compared to previous days.

Conclusion

Plasma presepsin levels have comparable performance in burn sepsis.     

Neutrophil gelatinase associated lipocalin as an indicator of acute kidney injury and inflammation in burned children

Introduction

Neutrophil gelatinase associated lipocalin (NGAL) is a novel predictor of acute kidney injury (AKI), which increases with inflammation. We aimed to assess whether serum NGAL (SNGAL) and urine NGAL (UNGAL) can predict AKI in burned children.

Methods

Patients were referred within the 12 h of burn to our center. Serum samples for SNGAL, C-reactive protein (CRP), procalcitonin (PCT) and urine for UNGAL, microalbumine (Umalb), creatinine (Ucr) were obtained at both admission and the 5th day after burn. Blood urea nitrogen (BUN) and serum creatinine (Scr) were examined daily.

Results

Twenty-two subjects were enrolled and six (27.2%) of them developed AKI within the 48 h of injury. Burn size and abbreviated burn severity index (ABSI) were significantly increased in patients with AKI. CRP, PCT, SNGAL and UNGAL levels at admission and day 5 were significantly higher in patients with AKI than in those without AKI and controls. Scr was not significant between AKI and non-AKI groups at hospital days 1 and 5. A SNGAL level of 315 ng/ml and a UNGAL level of 100 ng/ml were determined as predictive cut-off values of AKI at admission (sensitivity and specificity: 71.4%, 83.3% and 93.3%, 93.7%, respectively). SNGAL and UNGAL were positively correlated with CRP, PCT, ABSI and Umalb/Ucr.

Conclusion

SNGAL and UNGAL are good early predictors of AKI in children with severe burn. NGAL might reflect the severity of burn insult and also could be used as an indicator of inflammation in burn children.     

Chemical burns

Objectives

To report a burn unit’s experience with chemical burns and to discuss the fundamental principles in managing chemical burns.

Design

A chart review.

Setting

A burn centre at a major university-affiliated hospital.

Patients

Twenty-four patients with chemical burns, representing 2.6% of all burn admissions over an 8-year period at the Ross Tilley Regional Adult Burn Centre. Seventy-five percent of the burn injuries were work-related accidents. Chemicals involved included hydrofluoric acid, sulfuric acid, black liquor, various lyes, potassium permanganate and phenol.

Results

Fourteen patients required excision and skin grafting. Complications were frequent and included ocular chemical contacts, wound infections, tendon exposures, toe amputation and systemic reactions from absorption of chemical. One patient died from a chemical scald burn to 98% of the body surface area.

Conclusions

The key principles in the management of chemical burns include removal of the chemical, copious irrigation, limited use of antidotes, correct estimation of the extent of injury, identification of systemic toxicity, treatment of ocular contacts and management of chemical inhalation injury. Individualized treatment is emphasized.     

Examining perception and actual knowledge change among learners in a standardized burn course

BACKGROUND:

Essential Burn Management (EBM) is a burn training program created for East Africa and aims to meet the needs of low- and middle-income countries. The authors present a report on objective testing of change in knowledge, with pre and post tests, and comparison of this testing with the self perception of knowledge gained to explore course utility.

OBJECTIVE:

To evaluate the ability of EBM to improve knowledge in burn care among course participants; and to explore whether participants’ self-perception of knowledge gained is comparable with their actual change in knowledge.

METHODS:

Twenty health care providers from a variety of disciplines participated in EBM and completed the pre and post course burn care knowledge test. Participants also self-rated knowledge in burn care both pre and post course. All tests and self-rated assessments were anonymous and consent was obtained. Paired t tests were conducted on pre and post test scores. Improvements in pre-post scores according to module or topic area were examined to determine the proportion correct, and then analyzed using Wilcoxon signed-rank tests. Module scores pre-post course were compared with individuals’ self-rating of knowledge both before and after the course for that particular module.

RESULTS:

Pre-post course tests reflected an increase in knowledge. An increase in self-rated knowledge was matched with a significant increase in module test scores for primary survey, burn resuscitation, wound management, infection control and electrical injury, but not inhalation injury and compartment syndrome modules.

CONCLUSION:

Findings support a combination of self-report and objective pre-post testing to evaluate courses designed to teach burn management.     

Soluble CD163: A novel biomarker for the susceptibility to sepsis in severe burn injuries

Objective:

Soluble CD163 (sCD163) has been previously shown to play a role in inflammatory and infectious diseases. This study, for the first time, investigates the characteristics and potential values of sCD163 in burn patients. A first look is taken on the changes of sCD163 levels in burn patients by comparing predefined subgroups at single time points.

Materials and Methods:

Serum samples of 18 patients with burn injuries were collected for biochemical analysis at the time of admission and in a chronological sequence of 12, 24, 48 and 120 h after the injury and were matched to clinical parameters. Statistical analysis was performed using the Mann-Whitney test, Wilcoxon signed rank and Pearson bivariate correlation.

Results:

Patients with sepsis showed a significant increase of sCD163 levels. sCD163 was correlated with leukocytes (P=0.035) over the time course of 120 h. Patients characterized by a burn size exceeding 25% of the total body surface area (TBSA) showed a significant increase of sCD163 between 12 and 48 h after burn injury (P=0.038).

Conclusions:

The first view on the characteristics of sCD163 in the serum of burn patients points out that sCD163 seems to be an early indicator for the susceptibility to sepsis. Furthermore, the changes in sCD163 serum levels within the first hours after burn trauma have great potential for early prediction of organ failure after burn injury.     

Airway complications in traumatic lower cervical spinal cord injury: A retrospective study

Objective

To investigate risk factors for pneumonia in patients with traumatic lower cervical spinal cord injury.

Design

Observational study, retrospective study.

Setting

Spinal cord unit in a maximum care hospital.

Methods

Thirty-seven patients with acute isolated traumatic spinal cord injury at levels C4–C8 and complete motor function injury (AIS A, B) treated from 2004 to 2010 met the criteria for inclusion in our retrospective analysis. The following parameters were considered: ventilation-specific parameters, re-intubation, creation of a tracheostomy, pneumonia, antibiotic treatment, and length of intensive care unit (ICU) stay and total hospitalization.

Results

Among the patients, 81% had primary invasive ventilation. In 78% of cases a tracheostomy was created; 3% of these cases were discharged with invasive ventilation and 28% with a tracheostomy without ventilation. Pneumonia according to Centers for Disease Control criteria occurred in 51% of cases within 21 ± 32 days of injury, and in 3% at a later date. The number of pre-existing conditions was significantly associated with pneumonia. Length of ICU stay was 25 ± 34 days, and average total hospital duration was 230 ± 144 days. Significant factors affecting the duration of ventilation were the number of pre-existing conditions and tetraplegia-specific complications.

Conclusions

Our results confirm that patients with traumatic lower cervical spinal cord injuries defined by lesion level and AIS constitute a homogeneous group. This group is characterized by a high rate of pneumonia during the first 4 weeks after injury. The number of pre-existing general conditions and spinal injury-specific comorbidities are the only risk factors identified for the development of pneumonia and/or duration of ventilation.     

Reliability of the sit-up test in individuals with spinal cord injury

Objective

To determine the day-to-day reliability of blood pressure responses during a sit-up test in individuals with a traumatic spinal cord injury (SCI).

Design

Within-subject, repeated measures design.

Setting

Community outpatient assessments at a research laboratory at the University of British Columbia.

Participants

Five men and three women with traumatic SCI (age: 31 ± 6 years; C4-T11; American Spinal Injury Association Impairment Scale A-B; 1–17 years post-injury).

Outcome measure

Maximum change in systolic (ΔSBP) and diastolic (ΔDBP) blood pressure upon passively moving from a supine to seated position.

Results

The average values for ΔSBP were –11 ± 13 mmHg (range –38 to 3 mmHg) for visit 1, and −12 ± 8 mmHg (range −26 to −1 mmHg) for visit 2. The average values for ΔDBP were −9 ± 8 mmHg (range -21 to 0 mmHg) for visit 1, and –13 ± 8 mmHg (range –29 to –3 mmHg) for visit 2. The ΔSBP demonstrated substantial reliability with an intraclass correlation coefficient of 0.79 (P = 0.006; 95% CI 0.250–0.953), while the ΔDBP demonstrated almost perfect reliability with an intraclass correlation coefficient of 0.92 (P < 0.001; 95% CI 0.645–0.983). The smallest detectable differences in ΔSBP and ΔDBP were 7 mmHg and 6 mmHg, respectively.

Conclusion

Blood pressure responses to the sit-up test are reliable in individuals with SCI, which supports its implementation as a practical bedside assessment for orthostatic hypotension in this at risk population.     

Mesh fistulation into the rectum after laparoscopic ventral mesh rectopexy

INTRODUCTION

Laparoscopic ventral mesh rectopexy (LVMR) is an effective method of management of functional disorders of the rectum including symptomatic rectal intussusception, and obstructed defaecation. Despite the technical demands of the procedure and common use of foreign body (mesh), the incidence of mesh related severe complications of the rectum is very low.

PRESENTATION OF CASE

A 63 year old woman presented with recurrent pelvic sepsis following a mesh rectopexy. Investigations revealed fistulation of the mesh into the rectum. She was treated with an anterior resection.

DISCUSSION

The intraoperative findings and management of the complication are described. Risk factors for mesh attrition and fistulation are also discussed.

CONCLUSION

Chronic sepsis may lead to ‘late’ fistulation after mesh rectopexy.     

Specialized Respiratory Management for Acute Cervical Spinal Cord Injury:: A Retrospective Analysis

Background:

In individuals with cervical spinal cord injury (SCI), respiratory complications arise within hours to days of injury. Paralysis of the respiratory muscles predisposes the patient toward respiratory failure. Respiratory complications after cervical SCI include hypoventilation, hypercapnea, reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Ultimately, the patient must use increased work to breathe, which results in respiratory fatigue and may eventually require intubation for mechanical ventilation. Without specialized respiratory management for individuals with tetraplegia, recurrent pneumonias, bronchoscopies, and difficulty in maintaining a stable respiratory status will persist.

Objective:

This retrospective analysis examined the effectiveness of specialized respiratory management utilized in a regional SCI center.

Methods:

Individuals with C1-C4 SCI (N = 24) were the focus of this study as these neurological levels present with the most complicated respiratory status.

Results:

All of the study patients’ respiratory status improved with the specialized respiratory management administered in the SCI specialty unit. For a majority of these patients, respiratory improvements were noted within 1 week of admission to our SCI unit.

Conclusion:

Utilization of high tidal volume ventilation, high frequency percussive ventilation, and mechanical insufflation– exsufflation have demonstrated efficacy in stabilizing the respiratory status of these individuals. Optimizing respiratory status enables the patients to participate in rehabilitation therapies, allows for the opportunity to vocalize, and results in fewer days on mechanical ventilation for patients who are weanable.     

PCT as a diagnostic and prognostic tool in burn patients. Whether time course has a role in monitoring sepsis treatment

Objective

To evaluate the diagnostic and prognostic performance of inflammatory markers for septic and non septic (localized) bacterial infections in patients with severe burn.

Methods and results

Data of 145 patients were prospectively included in this study. Serum procalcitonin and other inflammatory markers were measured within 24 h after burn and daily thereafter. Maximum procalcitonin (p = 0.004) was independent predictors of outcome in logistic regression analysis. PCT thresholds of 1.5 ng/ml, 0.52 ng/ml and 0.56 ng/ml had adequate sensitivity and specificity to diagnose sepsis, respiratory tract and wound infections respectively. A threshold value of 7.8 ng/ml in PCT concentration on day 3 was associated with the effectiveness of the sepsis treatment with an AUC of 0.86 (95% CI 0.69–1.03, p = 0.002). C-reactive protein levels and WBCs showed no significant change over the first 3 days in the patients with successfully treated sepsis (p = 0.93).

Conclusion

The maximum procalcitonin level has prognostic value in burn patients. PCT can be used as a diagnostic tool in patients with infectious complications with or without bacteremia during ICU stay. Daily consecutive PCT measurements may be a valuable tool in monitoring the effectiveness of antibiotic therapy in burn ICU patients.     

Systemic inflammatory response syndrome outcome in surgical patients

Introduction

The problems of inflammation and infection as a leading cause of organ dysfunction and failure is a major problem after injury or operations. When systemic inflammatory response syndrome (SIRS) progress to multiple organ failure (MOF), the mortality reach up to 30–80% depending on the number of failed organs. Recent discoveries and improvement in patient care, a reasonable question then arises, are the incidence of MOF decreasing? The literature suggests a decrease in mortality of patients with severe organ failure and a decrease in elective surgical mortality in patients.

Methods

This is prospective study of 50 patients who underwent surgical procedure. They were followed up till date of termination with daily SIRS monitoring, development of MODS and MOF. Risk factors for MOF are addressed.

Results

There are total 31 patients who develop SIRS, of whom 7 patients develop severe sepsis and 4 went into MOF.

Conclusion

Early detection of SIRS helps us to prevent multiple organ dysfunction syndrome (MODS)/MOF, leading to lesser hospital stay and better outcome.     

The cost effectiveness of early management of acute appendicitis underlies the importance of curative surgical services to a primary healthcare programme

Introduction

Appendicitis in the developing world is a cause of significant preventable morbidity. This prospective study from a regional hospital in South Africa constructs a robust cost model that demonstrates the cost effectiveness of an efficient curative surgical service in a primary healthcare-orientated system.

Methods

A prospective audit of all patients with acute appendicitis admitted to Edendale Hospital was undertaken from September 2010 to September 2011. A microcosting approach was used to construct a cost model based on the estimated cost of operative and perioperative interventions together with the associated hospital stay. For cost analysis, patients were divided into the following cohorts: uncomplicated appendicitis, complicated appendicitis with localised intra-abdominal sepsis, complicated appendicitis with generalised intra-abdominal sepsis, with and without intensive care unit admission.

Results

Two hundred patients were operated on for acute appendicitis. Of these, 36% (71/200) had uncomplicated appendicitis and 57% (114/200) had perforation. Pathologies other than appendicitis were present in 8% (15/200) and these patients were excluded. Of the perforated appendices, 45% (51/114) had intra-abdominal contamination that was localised while 55% (63/114) generalised sepsis. The mean cost for each patient was: 6,578 ZAR (£566) for uncomplicated appendicitis; 14,791 ZAR (£1,272) for perforation with localised intra-abdominal sepsis and 34,773 ZAR (£2,990) for perforation with generalised intra-abdominal sepsis without intensive care admission. With intensive care admission it was 77,816 ZAR (£6,692). The total cost of managing acute appendicitis was 4,272,871 ZAR (£367,467). Almost 90% of this total cost was owing to advanced disease with abdominal sepsis and therefore potentially preventable.

Conclusions

Early uncomplicated appendicitis treated appropriately carries little morbidity and is relatively inexpensive to treat. As the pathology progresses, the cost rises exponentially. An efficient curative surgical service must be regarded as a cost effective component of a primary healthcare orientated system.     

Predicting multiple organ failure in patients with severe trauma

Objective

Pathophysiological processes in the first days after trauma seem to be important for the development and final outcome in cases of multiple organ failure (MOF). Our objective in this study was to assess the kinetics of C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-10 (IL-10) and phospholipase A₂ group II (PLA₂-II) as predictors of more severe forms of MOF. As well, we sought to assess the criteria for systemic inflammatory response syndrome (SIRS) and Simplified Acute Physiology Score (SAPS II) values and to create predictive models of MOF development.

Methods

This prospective study recruited a sample from 75 patients treated for severe injuries at surgical intensive care units at the Clinical Center of Serbia. Of these patients, a total of 65 met the entry criteria, which included an Injury Severity Score ≥ 18 (severe injury), age range 16–65 years, admission to the hospital within the first 24 hours after injury and survival longer then 48 hours. We excluded patients with primary injury to the central nervous system.

Results

When patients with and without MOF were compared, a statistically significant difference was noted in the average CRP and PLA₂II levels on all days. IL-6 and IL-10 concentrations were significantly different on all days of hospitalization.

Conclusion

According to the results of our study, it is possible to create predictive models with a high level of accuracy for the development of organ failure in traumatized patients. The most important parameters of MOF development are serum IL-6 concentration on the first day of hospitalization and the number of positive SIRS criteria on the fourth day of hospitalization.     

The association of age,pain, and fatigue with physical functioning and depressive symptoms in persons with spinal cord injury

Context/objective

To describe the relationship of pain and fatigue with physical and psychological functioning in adults with spinal cord injury (SCI).

Design

Cross-sectional survey.

Setting

Community-based survey.

Participants

Convenience sample of individuals with SCI.

Intervention

Not applicable.

Outcome measures

Physical functioning (Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Functioning item bank items), depression (Patient Health Questionnaire-9 (PHQ-9)), pain severity (0–10 Numerical Rating Scale (NRS)), and fatigue (0–10 NRS).

Results

Pain and fatigue were independently associated with depression, but only pain was associated with physical functioning. Additionally, depression was more severe among middle-aged participants relative to younger or older participants. Physical functioning declined with increasing age, as well as with higher level of injury.

Conclusions

The findings support the need for continued development of effective treatments for both pain and fatigue in order to prevent and mitigate the negative effects these symptoms can have on functioning.     

Can injury in major junior hockey players be predicted by a pre-season functional movement screen – a prospective cohort study

Background:

The Functional Movement Screen (FMS) is a tool that is commonly used to predict the occurrence of injury. Previous studies have shown that a score of 14 or less (with a maximum possible score of 21) successfully predicted future injury occurrence in athletes. No studies have looked at the use of the FMS to predict injuries in hockey players.

Objective:

To see if injury in major junior hockey players can be predicted by a preseason FMS.

Methods:

A convenience sample of 20 hockey players was scored on the FMS prior to the start of the hockey season. Injuries and number of man-games lost for each injury were documented over the course of the season.

Results:

The mean FMS score was 14.7+/−2.58. Those with an FMS score of ≤14 were not more likely to sustain an injury as determined by the Fisher’s exact test (one-tailed, P = 0.32).

Conclusion:

This study did not support the notion that lower FMS scores predict injury in major junior hockey players.     

Total hip arthroplasty using a combined anterior and posterior approach via a lateral incision in patients with ankylosed hips

Background

For most patients with severely ankylosed hips, traditional surgical approaches do not provide sufficient exposure during THAs. We report our experience with a combined anterior and posterior approach using a lateral incision for total hip arthroplasty (THA) in patients with severe, spontaneous bony hip ankylosis.

Methods

Between January 2004 and December 2008, patients with severe, spontaneous bony hip ankylosis underwent THA via a combined anterior and posterior approach using a lateral incision.

Results

We included 47 patients (76 hips) with a mean age of 53 (range 22–72) years in our study. All surgeries were successful, and no significant postoperative complications occurred. The mean operative duration was 1.5 (range 1.3–1.7) hours, and mean blood loss was 490 (range 450–580) mL. The mean duration of follow-up was 5.5 (range 2–11) years. Harris hip score improved from 53 to 88 points postoperatively, and the outcome was good to excellent in 88.37% of cases. Heterotopic ossification occurred in 6 hips, and infection, which resolved with antibiotics, occurred in 1 patient.

Conclusion

This combined anterior and posterior approach to THA using a lateral incision in patients with severe, spontaneous ankylosis provides very good exposure, protects the abduction unit and results in good to excellent postoperative recovery.     

Palatal and retropharyngeal injury secondary to intubation using the GlideScope? video laryngoscope

Introduction

There are few reports of injury to the soft palate and retropharynx sustained during intubation with the GlideScope® video laryngoscope. Most reports are of isolated injury to the soft palate.

Case History

We describe a patient in whom the retropharynx was injured but the extent of the injury was not observed initially. The patient did not suffer severe sequelae from this injury. However, this injury can cause serious sequelae if it is not recognised (eg development of a retropharyngeal abscess).

Conclusions

We recommend that any patient who sustains injury to the soft palate during intubation (particularly if the endotracheal tube passes through the soft palate) should be reviewed an otolaryngologist before removal of the endotracheal tube.     

Acute compartment syndrome secondary to disruption of the perforating branch of the peroneal artery following an acute inversion injury to the ankle

INTRODUCTION

Although ankle sprain by inversion is common in daily practice, acute compartment syndrome following ankle inversion injury is unusual. Only a few cases of this uncommon entity have been reported.

PRESENTATION OF CASE

This report describes a case of acute compartment syndrome following severe inversion of an ankle injury secondary to disruption of the perforating branch of the peroneal artery 3 h after the trauma. Although emergent fasciotomy was performed, residual weakness of ankle dorsiflexion still presented six months after surgery.

DISCUSSION

To the best of our knowledge, this case is the third in literature on an acute compartment syndrome following severe inversion ankle injury secondary to disruption of the perforating branch of the peroneal artery.

CONCLUSION

This report underscores the importance of considering compartment syndrome when individual has an inversion ankle injury, even when no fracture exists.     

Initial Experience of Laparostomy with Immediate Vacuum Therapy in Patients with Severe Peritonitis

INTRODUCTION

To report our initial experience of laparostomy and immediate intra-abdominal vacuum therapy in patients with severe peritonitis due to intra-abdominal catastrophes.

PATIENTS AND METHODS

Twenty-seven patients underwent emergency laparotomy and laparostomy formation with the application of immediate intra-abdominal TRAC–VAC® therapy (male:female ratio, 1:1.2; median age, 73 years; range, 34–84 years). Predicted mortality was assessed using the P-POSSUM score and compared with clinically observed outcomes.

RESULTS

Ten patients (37%) with a mean predicted P-POSSUM mortality of 72%, died of sepsis and multi-organ failure. Seventeen patients (mean P-POSSUM 48% expected mortality) survived to discharge. One patient with pancreatitis died from small bowel obstruction 1-year post discharge, two patients developed a small bowel fistula. One patient had an allergic reaction to the VAC dressing. Our patients, treated with laparostomy and TRAC VAC therapy, had a significantly improved observed survival when compared to P-POSSUM expected survival (P = 0.004).

CONCLUSIONS

Laparostomy with immediate intraperitoneal VAC therapy is a robust and effective system to manage patients with intra-abdominal catastrophes. There were significantly improved outcomes compared to the mortality predicted by P-POSSUM scores. Damage control surgery with laparostomy formation and intra-abdominal VAC therapy should be considered in patients with severe peritonitis.