Physiological response to fluid resuscitation with Ringer lactate versus Plasmalyte in critically ill burn patients

2020 ◽  
Vol 128 (3) ◽  
pp. 709-714 ◽  
Author(s):  
Maïté Chaussard ◽  
François Dépret ◽  
Oriane Saint-Aubin ◽  
Mourad Benyamina ◽  
Maxime Coutrot ◽  
...  
Keyword(s):  
Critically Ill ◽  
Fluid Resuscitation ◽  
Base Excess ◽  
Total Body Surface Area ◽  
Ionized Calcium ◽  
Strong Ion Difference ◽  
Special Focus ◽  
Burn Patients ◽  
Ringer Lactate ◽  
Tertiary Teaching

The metabolic consequences in vivo of various balanced solutions are poorly known in critically ill patients. The main objective of this study was to describe the metabolic consequences of Plasmalyte versus Ringer lactate (RL) in critically ill burn patients, with a special focus on the plasma clearance of buffer anions (i.e., gluconate, acetate, and lactate). We conducted a randomized trial between August 2017 and October 2018 in a tertiary teaching hospital in Paris, France. Patients with burn total body surface area >30% were randomized to receive Plasmalyte or RL. The primary end point was the base excess 24 h after inclusion. The secondary end points were acetate, gluconate, and lactate plasma concentration, the strong ion difference (SID). Twenty-eight patients were randomized. Twenty-four hours after inclusion, plasma BE was not significantly different in the Plasmalyte and RL groups {−0.9 [95% confidence interval (95% CI): −1.8–0.9] vs. −2.1 [95% CI: −4.6–0.6] mmol/L, respectively, P = 0.26}. Plasma gluconate concentration was higher in the Plasmalyte group ( P < 0.001), with a maximum level of 1.86 (95% CI: 0.98–4.0) mmol/L versus 0 (95% CI: 0–0.15) mmol/L. Plasma acetate and lactate were not significantly different. Ionized calcium level was lower in the Plasmalyte group ( P = 0.002). Hemodynamics did not differ between groups. To conclude, the alkalinizing effect of Plasmalyte was less important than expected with no difference in base excess compared with RL, in part due to gluconate accumulation. Acetate and lactate did not significantly accumulate. Plasmalyte led to significantly lower ionized calcium levels. NEW & NOTEWORTHY During fluid resuscitation in burns the alkalinizing effect of Plasmalyte was less important than expected, with no difference in base excess compared with Ringer lactate (RL), in part due to gluconate accumulation. Acetate and lactate did not significantly accumulate. Plasmalyte led to significantly lower ionized calcium levels.

1 The Impact of No Next of Kin Decision Makers on End-of-life Care

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S4-S5
Author(s):  
Ryan K Ota ◽  
Maxwell B Johnson ◽  
Trevor A Pickering ◽  
Warren L Garner ◽  
Justin Gillenwater ◽  
...  
Keyword(s):  
Critically Ill ◽  
Decision Maker ◽  
Total Body Surface Area ◽  
Burn Patients ◽  
Inclusion Criteria ◽  
Next Of Kin ◽  
Medical Decisions ◽  
Comfort Care ◽  
Burn Care ◽  
The Impact

Abstract Introduction For critically ill burn patients without a next of kin (NOK), the medical team is tasked with becoming the surrogate decision maker. This poses difficult ethical and legal challenges for burn providers. Despite this frequent problem, there has been no investigation of how the presence of a NOK affects treatment in burn patients. This study is the first to evaluate this relationship. Methods A retrospective chart review was performed on a cohort of patients who died during the acute phase of their burn care from a single burn center from 2015 to 2019. Inclusion criteria were age ≥18 years and mortality within 4-weeks of admission. Exclusion criteria were death from dermatologic disease or trauma. Variables collected included age, gender, mechanism of injury, length of stay (LOS), total body surface area (TBSA), revised Baux score, and the presence of a NOK. Fisher’s Exact Test and Student’s t-test were used for analysis. Results In total, 67 patients met inclusion criteria. Of these patients, 14 (21%) did not have a NOK involved in medical decisions. Table 1 shows the means and odds ratio between the two groups. Patients without a NOK were younger (p &lt; 0.05), more likely to be homeless (p &lt; 0.01), had higher TBSA (p &lt; 0.01), had shorter LOS (p &lt; 0.01), and were 5 times less likely to receive comfort care (p &lt; 0.05). Gender and ethnicity were not statistically significant. Conclusions Patients without a NOK present to participate in medical decisions are transitioned to comfort care less often despite having a higher burden of injury. This disparity in standard of care between the two groups demonstrates a need for a cultural shift in burn care to prevent suffering of these marginalized patients. Burn providers should be empowered to reduce suffering when no decision maker is present. Applicability of Research to Practice We report that the absence of a NOK has a significant impact leading to a decreased initiation of comfort care in critically ill burn patients. National protocols should be created to allow burn providers to act as a surrogate to prevent prolonged suffering.

scholarly journals Comparative Population Plasma and Tissue Pharmacokinetics of Micafungin in Critically Ill Patients with Severe Burn Injuries and Patients with Complicated Intra-Abdominal Infection

2016 ◽  
Vol 60 (10) ◽  
pp. 5914-5921 ◽  
Author(s):  
A. García-de-Lorenzo ◽  
S. Luque ◽  
S. Grau ◽  
A. Agrifoglio ◽  
L. Cachafeiro ◽  
...  
Keyword(s):  
Critically Ill ◽  
Body Surface ◽  
Candida Parapsilosis ◽  
Total Body Surface Area ◽  
Burn Patients ◽  
Content Type ◽  
Abdominal Infection ◽  
Area Burned ◽  
Total Body ◽  
Intra Abdominal Infection

ABSTRACTSeverely burned patients have altered drug pharmacokinetics (PKs), but it is unclear how different they are from those in other critically ill patient groups. The aim of the present study was to compare the population pharmacokinetics of micafungin in the plasma and burn eschar of severely burned patients with those of micafungin in the plasma and peritoneal fluid of postsurgical critically ill patients with intra-abdominal infection. Fifteen burn patients were compared with 10 patients with intra-abdominal infection; all patients were treated with 100 to 150 mg/day of micafungin. Micafungin concentrations in serial blood, peritoneal fluid, and burn tissue samples were determined and were subjected to a population pharmacokinetic analysis. The probability of target attainment was calculated using area under the concentration-time curve from 0 to 24 h/MIC cutoffs of 285 forCandida parapsilosisand 3,000 for non-parapsilosis Candidaspp. by Monte Carlo simulations. Twenty-five patients (18 males; median age, 50 years; age range, 38 to 67 years; median total body surface area burned, 50%; range of total body surface area burned, 35 to 65%) were included. A three-compartment model described the data, and only the rate constant for the drug distribution from the tissue fluid to the central compartment was statistically significantly different between the burn and intra-abdominal infection patients (0.47 ± 0.47 versus 0.15 ± 0.06 h−1, respectively;P< 0.05). Most patients would achieve plasma PK/pharmacodynamic (PD) targets of 90% for non-parapsilosis Candidaspp. andC. parapsilosiswith MICs of 0.008 and 0.064 mg/liter, respectively, for doses of 100 mg daily and 150 mg daily. The PKs of micafungin were not significantly different between burn patients and intra-abdominal infection patients. After the first dose, micafungin at 100 mg/day achieved the PK/PD targets in plasma for MIC values of ≤0.008 mg/liter and ≤0.064 mg/liter for non-parapsilosis Candidaspp. andCandida parapsilosisspecies, respectively.

13 Macronutrient Intake and Wound Healing in Critically Ill Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S11-S12
Author(s):  
Sarah S Rupert ◽  
Beth A Shields ◽  
Brenda D Bustillos ◽  
Leopoldo C Cancio
Keyword(s):  
Wound Healing ◽  
Logistic Regression ◽  
Enteral Nutrition ◽  
Critically Ill ◽  
Univariate Analysis ◽  
Total Body Surface Area ◽  
Oral Intake ◽  
Nutrition Support ◽  
Burn Patients ◽  
Macronutrient Intake

Abstract Introduction Nutrition support is an important component of the care of the critically ill burn patient. The European Society for Parenteral and Enteral Nutrition recommends less than 35% of calories from fat and less than 60% from carbohydrate (CHO); however, favorable clinical outcomes have been found in randomized controlled trials when burn patients were given 12–27% fat and 46–65% CHO. These benefits include lower rates of pneumonia and mortality. The purpose of this research was to examine macronutrient intake of critically ill burn patients and the association with wound healing. Methods A retrospective study was approved by the Institutional Review Board and included patients admitted to our burn intensive care unit over an 11 year period who were ≥18 years of age, had ≥20% total body surface area burns. Subjects who required hospitalization for ≥8 days and required nutrition support were included in this analysis. Subjects who were admitted over a week after injury and those who underwent limb amputations were excluded. Caloric intake from CHO, fat, and protein was obtained from enteral nutrition, parenteral nutrition, and oral intake for the first eight days following hospitalization. Wound healing was defined as achieving &lt; 10% TBSA open wound. Univariate analysis was used to identify factors significantly associated with wound healing. Variables found to be significant (p&lt; 0.05) were subjected to logistic regression. Results A total of 309 patients (89% male) were included. Patients were 37 ± 17 years old and had 46 ± 18% TBSA burns. Wound healing was achieved by 77% of patients, with 26% mortality. Those who healed were significantly younger (34 ± 15 vs. 47 ± 19 years, p&lt; 0.001), were taller (70 ± 3 vs. 68 ± 4 inches, p&lt; 0.001), with smaller burns (44 ± 16% vs. 54 ± 20% TBSA, p&lt; 0.001), predominantly male (92% vs. 77%, p&lt; 0.001), received a higher amount of CHO (1166 ± 465 vs. 902 ± 494 kcals, p&lt; 0.001), and received a higher amount of fat (455 ± 234 vs. 360 ± 220 kcals, p=0.003). After logistic regression, factors negatively associated with wound healing included increased age (p&lt; 0.001), female gender (p=0.032), and larger burn size (p&lt; 0.001); a positive association was seen with 8-day average calories from CHO (p=0.027). Conclusions This study identified several factors significantly associated with healing in burn patients; however, higher CHO intake was the only modifiable factor. Further research is needed to determine the optimal CHO intake to improve patient outcomes. Applicability of Research to Practice Consideration should be made for high-CHO enteral nutrition in critically ill burn patients.

Preserving Vision: Rethinking Burn Patient Monitoring to Prevent Orbital Compartment Syndrome

2020 ◽  
Vol 41 (5) ◽  
pp. 1104-1110
Author(s):  
Anthony P Mai ◽  
Christopher R Fortenbach ◽  
Lucy A Wibbenmeyer ◽  
Kai Wang ◽  
Erin M Shriver
Keyword(s):  
Risk Factors ◽  
At Risk ◽  
Compartment Syndrome ◽  
Fluid Resuscitation ◽  
Vision Loss ◽  
Total Body Surface Area ◽  
Treatment Center ◽  
Burn Patients ◽  
Calculated Volume ◽  
Parkland Formula

Abstract Burn patients receiving aggressive fluid resuscitation are at risk of developing orbital compartment syndrome (OCS). This condition results in elevated orbital pressures and can lead to rapid permanent vision loss. Risk factors and monitoring frequency for OCS remain largely unknown. A retrospective review was therefore conducted of admitted burn patients evaluated by the ophthalmology service at an American Burn Association verified Burn Treatment Center. Demographic, burn, examination, and fluid resuscitation data were compared using two-sided t-tests, Fisher’s exact tests, and linear regression. Risk factors for elevated intraocular pressures (IOPs; a surrogate for intraorbital pressure) in patients resuscitated via the Parkland formula were found to be total body surface area (% TBSA) burned, resuscitation above the Ivy Index (&gt;250 ml/kg), and Parkland formula calculated volume. Maximum IOP and actual fluid resuscitation volume were linearly related. Analysis of all patients with elevated IOP found multiple patients with significant IOP increases after initial evaluation resulting in OCS within the first 24 hours postinjury. While %TBSA, Ivy Index, and resuscitation calculated volume are OCS risk factors in burn patients, two patients with facial burns developed OCS (25% of all patients with OCS) despite not requiring resuscitation. Orbital congestion can develop within the first 24 hours of admission when resuscitation volumes are the greatest. In addition to earlier and more frequent IOP checks in susceptible burn patients during the first day, the associated risk factors will help identify those most at risk for OCS and vision loss.

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