摘要:

Resuscitation from shock based on oxygen transport criteria has been widely used in trauma and surgical patients, but has not been examined in thermally injured patients. To study the possible efficacy of this type of resuscitation, the oxygen transport characteristics of burn resuscitation were studied in nine adults, of whom six had inhalation injuries, with a mean burn size of 45% total body surface area and a mean age of 33.4 years, who were resuscitated based on oxygen transport criteria. Pulmonary artery balloon flotation catheters were placed and hemodynamic and oxygen transport parameters (Fick method) were measured hourly for 6 hours. Patients received fluid boluses in addition to resuscitation calculated by the Parkland formula, until the pulmonary artery wedge pressure reached 15 mm Hg, after which dobutaminc infusions (5 (μg/kg/min) were initiated. Cardiac index increased from 2.51 to 6.57 L/min/m2(p<0.05), whereas systemic vascular resistance fell from 1534 to 584 dyne sec/cms (p<0.05). Oxygen delivery (Do2I) and oxygen consumption (Vo2I) indexes increased significantly during the study period (573 ± 47 to 1028 ± 57, and 132 ± 8 to 172 ± 16 ml/min/m2, respectively; p<0.05). Vo2I appeared dependent on Do2I at levels of Do2I less than 800 ml/min/m2. In this study, depressed cardiovascular function in patients with burn injuries responded to volume loading and inotropic support much as it does in patients with shock of other etiologies. Whether oxygen transport-based resuscitation is effective in improving survival or the incidence of multiple organ failure is unknown and will need to be evaluated in randomized trials.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Our clinical experience has led to the conclusion, shared by others, that standard vital signs produce inadequate data for the resuscitation of severe burns. We reviewed three groups of burn patients including an index group (N=53) whose resuscitation was guided by means of a pulmonary artery catheter, a control group (N=33) collected from the burn registry for the period just before the index group, and a current group (N=30) resuscitated with hyperdynamic end points defined empirically from surviving patients as guidelines. The mortality rates and organ failures decreased over time; the mortality rate of the control group was 48%, the index group 32%, and the protocol group 10% (p=0.003). We concluded that hyperdynamic resuscitation does improve survival and reduces the incidence of organ failure.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Burn injury induces bacterial transloction (BT) from the gut in multiple animal models. Etiologic factors contributing to BT may be an ischemia-reperfusion injury to the gut, the release of inflammatory cytokines, oxygen metabolites and other mediators, and cytotoxic effects mediated by endotoxin (lipopolysaccharide). Bactericidal, permeability-increasing protein is a neutrophil granule protein with potent bactericidal and lipopolysaccharideneutralizing activities. The use of this protein has not been previously reported in a burninjury model. The purpose of this study was to determine whether recombinant bactericidal, permeability-increasing protein (rBPI23) affects the incidence of BT and myeloperoxidase content in lung tissue (a measure of leukocyte sequestration) in a burninjury model. Mice received a 32% total body surface area, full-thickness, scald burn, and 10 mg/kg body weight rBPI23in saline solution was given by intraperitoneal injection at 0, 3, and 6 hours after the burn. Control animals received intraperitoneal saline solution only. All animals received a total of 1 ml saline solution intraperitoneally immediately after burn injury for fluid resuscitation. At 24 hours after burn injury, mesenteric lymph nodes (MLN) were harvested, homogenized, and plated. Lung tissue was harvested and assayed for myeloperoxidase. Burned mice treated with rBPI23had a significantly (p=0.005, Fisher's Exact Test, two-tailed) decreased incidence of BT, compared to burned mouse controls. Leukosequestration into lung tissues was not affected by rBPI23. Postburn administration of rBPI23reduces but does not abolish the incidence of BT after burn injury in mice, perhaps by reducing intestinal injury during burn shock and the ischemia-reperfusion period by inhibiting the effects of lipopolysaccharide. An alternate explanation may be that rBPI23could increase clearance and lulling of bacteria by host defenses.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Wistar rats were burned over 15% of their total body surface area and suffered hemorrhagic hypotension (mean blood pressure 80 mm Hg) 72 hours after the thermal injury (burn + hypotension group). Rats in other groups were treated in the same way except sham hypotension in burn group, sham burn in hypotension group, and sham hypotension and sham burn in control group. At the end of the study period, the mesenteric lymph nodes (MLN), liver, and spleen were cultured for translocated bacteria. The cecal bacterial burden was not affected by the insults. The number of bacteria translocated to the MLN after the thermal injury was much greater in the burn + hypotension group (156.19 ± 42.29 colony-forming units [CFUs]/gm tissue) rather than in the other groups (5.24 ± 8.34, 9.86 ± 16.56, 40.21 ± 45.8 in the control, hypotension, and burn groups, respectively). This indicates that bacterial translocation (BT) is the result of a two-hit phenomenon. The gut-MLN BT ratio, obtained by dividing the bacterial CFUsin the MLN by those in the cecum, was higher in the burn + hypotension group than in the other groups (p<0.01). This ratio allows standardized measurements of BT to the MLN despite differences in the absolute bacterial load in the gut, and the elevated gut mesenteric lymph nodes BT ratio of the burn + hypotension group suggests that the two-hit phenomenon of BT may be the result of alterations in the gut mucosal barrier function.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Inhaled nitric oxide (NO) is known to selectively reduce pulmonary hypertension and improve the ventilation-perfusion relationship in subjects with lung injury of various origin. However, some forms of lung injury do not react to inhaled NO at all, or show only a reduction in pulmonary arterial pressure. Very little is known about the effects of inhaled NO after smoke inhalation injury. We investigated the effects of inhaled NO in an established model of ovine smoke inhalation injury. Chronically instrumented sheep («=8) had tracheostomies and were insufflated with smoke generated from burning cotton cloth (4 times at 12 breaths each). They were then connected to a ventilator with oxygenenriched air to achieve arterial oxygen tensions within the normal range. After 48 hours, NO was added to the inspired gas in ascending concentrations of up to 100 ppm. Systemic and pulmonary hemodynamics as well as oxygen transport were analyzed. Inhaled NO dose dependently lowered the pulmonary hypertension. Concentrations higher than 20 ppm did not further reduce the pulmonary artery pressure. Right ventricular stroke work index was significantly improved owing to die reduction in pulmonary vascular resistance. Arterial oxygenation, however, was not optimized by inhaled NO, probably because of interstitial edema formation.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

The management of pain and anxiety in pediatric patients with burns includes the challenge of striking a balance between inadequate versus excessive medication. Ketamine provides effective sedative, analgesic, and amnestic properties for children and has been used intravenously with good results. With its recent availability as an elixir, we speculated that ketamine given orally may provide effective analgesia and sedation during wound care procedures with a wide safety margin. To test this hypothesis, 19 pediatric patients with burns undergoing a wound care procedure were randomized to receive either ketamine oral suspension or 300 mg acetaminophen with codeine phosphate and diphenhydramine, our prior standard for analgesia and sedation. Intensity of pain was determined with use of a color slide algometer and demonstrated more than 400% reduction in pain with the use of ketamine (p<0.05). The Ramsey scale was used to quantitate sedation and demonstrated that ketamine improved sedation by 360% (p<0.05). These results substantiate improved analgesia and sedation with oral ketamine as compared to a commonly used narcotic and sedative in facilitating wound care procedures in pediatric patients with burns. These findings suggest that expanded use of ketamine oral suspension may be (J Burn Care Rehabil 1997;18:34-6)

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Sexual dysfunction in patients with burns has received only limited attention in the literature on burn care. We present five patients with burns whose sexual dysfunction responded to an eclectic treatment approach. A more extensive discussion on the relationship between post-traumatic stress disorder, other psychopathology, and sexual dysfunction in patients with burn injuries is presented. Neuroendocrinological, psychopathologic, psychodynamic, and physiological mechanisms that may be at play in patients with burns are proposed. The possible impact of post-traumatic stress disorder on sexuality is discussed. The illustrated cases suggest that sexual side effects of psychotropics, although fairly common, should not get in the way of proper use of antidepressants and antianxiety medications during the initial phase of treatment. Psychotropic and other commonly used medications in patients with burns, and the possible mechanisms of actions on sexuality, are reviewed.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Human cadaver allograft skin (HCAS) is widely used for covering excised burn wounds when limited available skin donor sites or die overall patient condition does not permit immediate grafting with autologous skin. However, recurring problems are associated with HCAS including limited supply, variable quality, ultimate immune rejection, and the potential for bacterial and viral disease transmission. These problems speak for the need for development of a dependable substitute for HCAS. We evaluated the ability of a biosynthetic analogue of human skin to temporarily close excised burn wounds in humans. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) is composed of human neonatal fibroblasts cultured on a synthetic dressing (Biobrane; Dow Hickam, Inc.) that consists of nylon mesh fabric covered with a thin layer of silicone rubber membrane, which provides an epidermal “barrier.” The material is stored frozen and thawed immediately before use. DG-TC is semitransparent, thus facilitating continuous observation of the underlying wound surface. Burn wounds in 10 patients (mean age 33.5 years, mean burn size 39.9% total body surface area) were surgically excised. Two variants of the DG-TC skin analogs were tested: a material that was cryopreserved to maintain fibroblast viability (DG-TC Red) and a material that was frozen without efforts to maintain fibroblast viability (DG-TC Blue). A control site on each patient received cryopreserved HCAS. Each study site was approximately 1% total body surface area. When clinically indicated, patients were returned to the operating room where the skin replacements were removed, the wound bed was evaluated and prepared for grafting, and the wounds were closed with meshed split-thickness autograft skin. The results showed that adherence to the wound and subsequent autograft “take” were excellent with both DG-TC variants and were at least equivalent to HCAS. No evidence of immune rejection of DG-TC was seen, whereas in four patients evidence of epidermal sloughing/rejection was noted in the HCAS control sites, which limited persistence of those grafts on the wound. Further clinical trials with this skin analogue are in progress.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

5 days after application) both skin replacements were removed, and the wound beds were evaluated and prepared for grafting. DG-TC was equivalent or superior to allograft with regard to autograft take at post autograft day 14. DG-TC was also easier to remove, had no epidermal slough, and resulted in less bleeding than did allograft while maintaining an adequate wound bed. Overall satisfaction was better widi DG-TC.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Today's managed care environment has challenged health care institutions to deliver quality cost-effective health care. In the burn community the American Burn Association/American College of Surgeons Burn Center Verification has become an increasingly sought after quality credential. Essential to successful completion of the verification process is the identification of key components that must be in place before an application is submitted. These components must be well documented and present in the application and during the site visit. Adequate burn team preparation is a significant contributor to successful verification. In addition, the process necessitates self-examination and acquires the benefits of validating current practices and identifying opportunities for improved patient care and efficient operation. This article details the preparation process undertaken by one burn center before its successful verification.

ISSN:0273-8481    

出版商:OVID    

年代:1997

数据来源: OVID