大剂量乌司他丁对大面积烧伤患者凝血功能的影响及意义

目的：观察大剂量乌司他丁对大面积烧伤患者凝血功能的影响。方法：4例大面积烧伤患者入院后第3天起每天给予大剂量乌司他丁(60万U,4次/d),用药前及用药后1d、3d、7d、10d、14d,抽血观察血浆纤维蛋白原含量(Fib-c)、凝血酶原时间(PT)、凝血酶时间(TT)、部分凝血活酶时间(APTT)及血浆D-二聚体含量的变化。结果：用药前血浆D-二聚体及纤维蛋白原含量明显升高,PT时间显著延长;给予大剂量乌司他丁1d后,血浆D-二聚体及纤维蛋白原含量明显减低,PT时间迅速恢复。结论：大面积烧伤患者早期应用大剂量乌司他丁可显著改善凝血功能,预防播散性血管内凝血的发生。     

Impact of allogeneic blood transfusions on clinical outcomes in severely burned patients

BackgroundAllogeneic blood transfusions are common in the treatment of severely burned patients as surgery may lead to major blood loss. However, transfusions are associated with a number of adverse events. Therefore, the purpose of our study was to investigate the impact of allogeneic blood transfusions on clinical outcomes in severely burned patients.MethodsThis retrospective study included all adult patients admitted to the burn center of the University Hospital Zurich between January 2004 and December 2014, with burn injuries greater than 10% of total body surface area and receiving both surgical and intensive care treatment. Primary Endpoints were infectious or thromboembolic complications and mortality and secondary endpoints were length of hospital and ICU stay. Simple and multivariable logistic and linear regression models, adjusted for injury severity and confounders, were applied.Results413 patients met inclusion criteria of which 212 patients (51%) received allogenic blood products. After adjustment for injury severity and confounders, red blood cell transfusion was independently associated with wound infection (OR 13.5, 95% CI 1.7–107, p = 0.014), sepsis (OR 8.3, 4.2–16.3; p < 0.001), pneumonia (OR 4.7, 2.2–10.0; p < 0.001), thrombosis (OR 3.0, 1.2–7.4; p = 0.015), central line infection (OR 34.7, 4.6–260; p = 0.001) and a longer ICU and hospital stay (difference 17.7, CI 12.1–23.4, p < 0.001 and 22.0, 15.8–28.2, p < 0.001, respectively). Fresh frozen plasma transfusion was independently associated with a longer ICU and hospital stay (difference 13.7, 95% CI 5.5–21.8, p = 0.001 and 13.5, 4.6–22.5, p = 0.003, respectively). Platelet transfusion was independently associated with systemic inflammatory response syndrome (OR 4.5, 1.3–15.5; p = 0.018) and mortality (OR 5.8, 2.1–16.0; p = 0.001).ConclusionTransfusion of allogeneic blood products is associated with an increased infection rate and thromboembolic morbidity and a longer hospital stay in severely burned patients.     

大面积烧伤患者血清透明质酸浓度检测的临床意义

目的探讨大面积烧伤患者血清透明质酸(HA)浓度变化与肝细胞损伤的关系.方法采用放射免疫和酶联免疫吸附等技术,检测烧伤严重程度不同及其并发全身性炎症反应综合症(SIRS)、多脏器功能障碍综合症(MODS)、多脏器功能衰竭(MOF)和死亡患者各组血清HA、肿瘤坏死因子α(TNFα)和临床常规肝肾功指标.结果烧伤后2周内,血清HA浓度一直维持高水平,并随烧伤严重程度增加和SIRS,MODS的产生,其数值逐步升高、相差显著(P＜0.001),但在MODS向MOF发展、至残废前后,血清HA值又由高限急剧降低;直线相关分析显示,血清HA浓度变化与烧伤严重程度和SIRS等并发症的发生发展密切相关(P＜0.01),与血清TNFα和谷草转氨酶、总胆红素值呈正相关(P＜0.05～0.01),而与血浆白蛋白、白蛋白/球蛋白比值呈负相关(P＜0.05).结论血清HA浓度中、重度升高可能与TNFα等持续损伤肝内皮细胞的降解功能有关,可将其作为临床大面积烧伤患者肝损伤、病情严重程度和预后判断的敏感指标.     

烧伤后血睾酮改变及临床意义

目的 探讨烧伤后血睾酮变化的规律及意义。方法 分组动态观测了21名中度以上男性烧伤病人伤后血睾酮浓度及促性腺激素(LH)变化。结果 中度以上烧伤病人伤后血睾酮水平均有明显的持续性降低，其程度与烧伤的严重性有关。促性腺素(LH)在伤后变化无明显规律性，同时LH的变化对睾酮水平无明显影响。结论 烧伤后性腺损伤所致睾酮持续性降低，导致体内蛋白合成类激素的缺乏和不足，可能是伤后蛋白合成受阻抑的重要原因，使用调理措施纠正伤后睾酮缺乏，可能有助于改善伤后蛋白合成代谢及正氮平衡的恢复。     

Prognostic significance of early cardiac index measurements in severely burned patients

Invasive monitoring during early resuscitation was performed. To compare the haemodynamic results of severely burned patients, the results of 38 patients hospitalized between 1988 and 1991 in the burn centre of Lyon were retrospectively reviewed. Survivors and non-Survivors' data were compared. No difference existed between the two groups in age, unit burn score, fluid requirement and dose of dobutamine. Survivors had a significantly higher cardiac index, O₂ delivery and systolic blood pressure index than non-survivors. It is suggested that the ability to sustain a high cardiac index in response to the burn injury plays a role in the outcome of the patients. There is an indication that dobutamine could have a beneficial effect in this way. Further studies are needed to confirm the benefit of the maintenance of high cardiac index levels by the pressors.     

Impact of diabetes on clinical outcome in severely burned patients

IntroductionAccording to the International Diabetes Federation, approximately 425 million people worldwide suffer from diabetes mellitus, a figure that will double in the next 20 years. Data on the ratio of treated diabetics in burn intensive care units remain scarce and the effects on the mortality rate are poorly defined.MethodsOur retrospective, single-centre study aimed to evaluate differences in the risk factors due to diabetes mellitus, the clinical outcome and the patient population of diabetic patients after severe burn injuries over a time period of 21 years.ResultsDespite increasing numbers of diabetic patients, the ratio of burn patients suffering from diabetes remained stable during the study period. The risk factors for mortality were higher age (OR 1.03, 95% confidence interval (CI), 1.02–1.04, p < 0.0001), female sex (OR 1.56, 95% CI, 1.06–2.29, p = 0.025), higher % total body surface area (TBSA) (OR 3.88, 95% CI, 2.81–5.46, p < 0.0001), full thickness burns (OR 8.58, 95% CI, 3.84 – 23.60, p < 0.0001) and the presence of inhalation injuries (OR 4.68, 95% CI, 3.15–7.02, p < 0.0001) Patients with diabetes had a smaller extent of burned areas with a median TBSA of 30% (quartiles: 22–50%, p = 0.036) compared to non-diabetic patients (35% (25–55%)) but had a similar length of stay with a median of 29 (quartiles: 13–44) days vs. 23 (10–48) days. Outcome analysis showed an overall mortality of 35.6%. Diabetes was not associated with higher mortality rate after burn injury in a univariate model (OR 1.80, 95% CI 0.92–3.51). After correction for %TBSA, the effect of diabetes on mortality was significant (OR 2.80, 95% CI, 1.33–5.90).ConclusionOur data indicate higher mortality rates (50–100%) of diabetic patients with TBSA greater than 40% in severely burned patients compared to non-diabetic patients without a significant outcome due to the low number of cases in the subgroup analyses.     

The significance of acalculous cholecystitis in prolonged respiratory failure in severely burned patients

Acalculous cholecystitis is a very rare complication in severely burned patients. The correlation between acalculous cholecystitis and the development of a protracted pulmonary failure is demonstrated in 5 patients. Marked improvement of pulmonary function was achieved by cholecystectomy in all patients.     

Acute cholecystitis in severely burned patients

Acute acalculous cholecystitis in burned patients develops due to general disturbances of microcirculation of polyetiological origin. Early laparotomy can facilitate diagnosis of acute acalculous cholecystitis in burned patients. Rapidly developing destruction of the gallbladder walls requires an active surgical tactics.     

Metabolic and nutritional support in severely burned patients

Proper metabolic and nutritional support is an important treatment modality in severely burned patients. We examined the effect of branched-chain amino acid (BCAA) enriched TPN on metabolism of burned rats. A scald injury (30% BSA) was produced in rats. The rats, after resuscitated with saline for 24 hr, were divided into 3 groups. Control group: received saline. Group B: received TPN with BCAA enriched solution (45% BCAA). Group C: received TPN with conventional amino acid solution (21.3% BCAA). Both of these TPN solutions were isocaloric and isonitrogenous. Rats of each group were administered TPN solution or saline for further 48 hr. The metabolites in the liver and muscle were measured. Rapid and marked decrease of levels of metabolites such as adenine nucleotides, glycogen, G-6-P, protein and RNA/DNA was observed in the liver and muscle of the rats during fluid resuscitation. The rats of group B showed significant recoveries in all of these parameters after administration of the TPN, as compared with those of group C. On the other hand, progressive metabolic deterioration was recognized in the rats of control group. These results indicate beneficial effects of BCAA enriched TPN on energy and protein metabolism in scald injury.     

Basophil releasability in severely burned patients.

Thermal injury is known to induce dysregulation of the immune system; however, the precise mechanisms have to be clarified. We investigated the histamine release of basophil granulocytes from severely burned patients (n = 12) after stimulation with anti-IgE or the Ca-ionophore A 23187, respectively. The anti-IgE-induced basophil histamine release of all patients was reduced in comparison to healthy donors beginning at day one postburn (p.b.) (5.0 +/- 2.3% vs. 30.5 +/-3.4%), while the Ca-ionophore-induced release was not decreased before day two p.b. Basophils of patients who finally succumbed to their injuries showed poor responsiveness (to zero levels) over the total time. In contrast, the basophil releasability of surviving patients returned to nearly normal levels (fifth to seventh week p.b.). Already in the second week p.b. there was a significant difference in histamine release between survivors and nonsurvivors [e.g., days 6-9 p.b.: 23.7 +/- 4.0 vs. 6.9 +/- 2.7 (p less than 0.005) after Ca-ionophore stimulation]. The altered basophil histamine release was neither due to a diminished dose- or a delayed time-response to the stimuli nor due to differences in the basophil counts or the cellular histamine content. Our data indicate that the decrease of the basophil releasability, which may be secondary to altered signal transduction pathways in severely burned patients correlates with the clinical outcome.     

Blood platelets in severely injured burned patients

Unbelievable decrease of blood-platelet in the severely burned patients during the treatment of skingrafting caused two patients to unexpected death. From the records of changes of platelet number, a certain ‘platelet curve’ was made. By observing the curve, our treatments of skingrafting were carried out during the stable period and from then on we had no death cases.     

Acute renal failure in severely burned patients

Acute renal failure (ARF) is a well known complication of severe burns and is an important factor leading to an increase in mortality. In order to analyze possible pathogenetic and prognostic factors associated with ARF in burned patients we reviewed in a retrospective study the files of 328 patients with burns > 10% body surface area (BSA), admitted to our burn unit between 01.01.94 and 01.05.98. We found 48 patients with acute renal failure corresponding with an incidence of 14.6%. Patients with ARF had a mean burned surface area of 48% (13-95) and an abbreviated burn severity index score (ABSI) of 9.8 (4-15). Thirty eight (79%) of these patients had an inhalation injury diagnosed. Renal insufficiency was divided in a late and an early form depending on its time of onset and we found 15 (31%) patients with ARF occurring within the first 5 days of the hospital stay and 33 (69%) patients with ARF developing >5 days following the thermal injury. The incidence of myoglobinuria and hypotension during the resuscitation phase was significantly higher in the group with early ARF, whereas patients with late ARF presented sepsis more frequently than patients with early occurring renal failure. Accordingly, potential nephrotoxic antibiotics were administered more often in patients with late ARF. Patients with ARF were treated by continuous arteriovenous hemofiltration (CAVH) for a mean period of 10.5 days (1-47) and CAVH was associated with a complication rate of 10%. Most of the complications were associated with the vascular access in the femoral artery. The mortality rate in patients with ARF was 85% and death was due to multiple organ failure in 83% of the cases. Only burned BSA and inhalation injury proved to be significantly correlated with the development of ARF, whereas age, third degree burn or electric injury were not significantly different between the two groups. Neither age, TBSA, day of onset of ARF nor duration of the renal replacement therapy proved to be significantly different comparing survivors with non-survivors, and thus predictive for the survival rate.     

Respiratory insufficiency in severely burned patients]

The increasing number of respiratory insufficiency, as well as of pulmonary complications after burns and their role in the post-traumatic mortality are pointed out by the author.The pathophysiological processes responsible for the development of post-traumatic pulmonary complications are shortly resumed. In respect of the clinical picture, three groups are distinguished by the author. One case is reported in detail. In the development of post-traumatic respiratory insufficiency important role is attributed by the author to the syndromes of micro-embolism. This supposition is supported by the laboratory examination of 10 patients. Finally the problems of prevention and therapy are discussed and the importance of the iatrogenic damages is emphasized.     

Neutrophil granulocyte functions in severely burned patients

Burns wound sepsis is not only the most common but also the most severe complication following extensive thermal injury. One conceivable explanation of this problem is a reduced capacity of the polymorphonuclear neutrophil leucocytes of these patients to combat the invading microbes. Fifty patients (42 male and 8 female) with deep dermal burns, covering 20-90 per cent of the total body surface area, were investigated from immediately after the injury until death or until healing of the wounds. The following functions of the neutrophil granulocytes were studied: chemotaxis and random migration utilizing a modified Boyden chamber technique, phagocytosis of Staph. aureus and IgG-coated latex particles, bactericidal capacity, e.g. killing of Staph. aureus and the neutrophil granulocyte content of: myeloperoxidase, lactoferrin, and chymotrypsin-like cationic protein. The presence of stimulators and inhibitors of the granulocyte functions was studied using gel filtration of the patient's serum on Sephacryl gel columns. Sera from all patients obtained within the first 1-3 days post-burn contained significantly increased amounts of heat-labile chemokinetic stimulating activity. Sera obtained between days 4 and 10 after injury contained significantly decreased amounts of heat-stable chemokinetic stimulating activity. Reduced chemokinetic activity was found during the third and fourth weeks following major burns (greater than or equal to 40 per cent) due to the presence of one or both heat-stable chemokinetic inhibitory activities. During the second week post-burn patients with burns larger than 40 per cent of the body surface area who showed an inhibition of chemotaxis, also had defects in phagocytosis, and often impaired bactericidal capacity concomitant with lower contents than normal of the granular enzymes. A hyaluronic acid preparation in low concentrations was found to counteract the migration inhibitory effect demonstrated in vitro in sera from patients with severe burns. Based upon these results a series of patients with severe burns and impaired functions of the neutrophil granulocytes have been treated with small amounts of this hyaluronic acid preparation subcutaneously. Very promising results have been noticed, similar to those found in vitro.