Influence of brachial plexus blockade on oxygen balance during surgery.

The combined effects of anesthesia, motor blockade, and chemically induced sympathectomy after brachial plexus blockade can have a beneficial impact, when applied in selected, isolated diseased states of the upper limb. With the aim of using the prolonged effects of brachial plexus blockade for a future therapeutic application, we demonstrated a dependable methodology of venous blood gas monitoring and confirmed an improved oxygen balance of the blocked versus nonblocked upper extremity in a controlled, prospective study in healthy patients undergoing elective hand surgery.

Which of the abbreviated burn severity index variables are having impact on the hospital length of stay?

Quality control is an important tool ensuring continuous medical efficacy. Outcome scores, however, are unfavorable from a statistical point of view, are not meaningful for less severely injured patients, and may put the treating physicians under pressure to limit therapeutic efforts. In this study the variables of the abbreviated burn severity index (ABSI), primarily an outcome score, were used to predict length of hospital stay (HLS), a continuous quantitative variable reflecting treatment costs and incidence of complications even in less severely injured patients. For 365 patients a multiple linear regression analysis was used to evaluate the influence of the ABSI variables on HLS. Among survivors, age and total body surface area burned (TBSA) contributed significantly to HLS, whereas for nonsurvivors only TBSA significantly influenced HLS. Neither gender nor presence of full-thickness burn or inhalation injury showed a significant influence on HLS. The impact of age and TBSA on HLS might be used as a benchmarking system to evaluate quality of care. However, although HLS is probably widely dependent on regional health care systems, TBSA and age proved to be the only variables of the ABSI to correlate with HLS.

Evaluation of skin perfusion by use of indocyanine green video angiography: Rational design and planning of trauma surgery.

BACKGROUND: A very important aspect in the treatment of traumatic injuries is to determine the extent of skin involvement. Traditionally, this has involved clinical examinations, a more or less subjective technique. Therefore, various techniques, supplementing the clinical diagnosis, have been suggested, but none has yet achieved widespread clinical acceptance. Experiments have shown that the blood flow in injured tissue indicates the extent of tissue damage. METHODS: The clinical and scientific impact of Indocyanine green (ICG) video angiographies was tested in 40 patients. All kinds of depth and all kinds of causes of injury were included and analyzed. RESULTS: In all cases, it was possible to perform the ICG video angiography. Qualitative and quantitative measurements and observations correlated well with the extent and depth of the skin lesion, which was determined clinically (pre- and intraoperative assessment) and histologically (biopsies). CONCLUSION: Based on our experiences, we think that the ICG video angiography seems to be a very sensible and user-friendly device to detect the vascular patency of the skin. Our results indicate that laser induced ICG fluorescence angiography is a practical, accurate, and effective adjunct to clinical methods for evaluating skin perfusion and thereby, helpful to design and plan surgery.

Postoperative vigilance in patients with total intravenous anaesthesia with ketamine/propofol.

Ketamine is a strong acting analgesic drug, used mainly in trauma and emergency medicine settings, as well as for minor procedures. Its pharmacological properties make it a useful drug for military anaesthesia. Ketamine acts by blocking activation of the spinal and supraspinal NMDA-type glutamate and opioid receptors. It produces dissociative anaesthesia, which means that patients might remain conscious, though insensitive to pain and amnesic (anterograde). Dysphoria and hallucinations are the main side effects in the early recovery period. We studied the incidence of post operative nausea and vomiting, vigilance disturbances and haemodynamic instability during combined ketamine and propofol anaesthesia. No patient suffered from postoperative nausea and vomiting. No haemodynamic instability could be observed in any of the patients. The interesting point is that though there were no unpleasant emergence phenomenons, no patient reached the preoperative state of vigilance within two hours after extubation. These results indicate that for plastic/dermatological surgical procedures, patients undergoing ketamine/propofol anaesthesia do not require excessive haemodynamic monitoring, but do need prolonged personal observation in the postoperative period.

Impact of intraoperative duodenal feeding on the oxygen balance of the splanchnic region in severely burned patients.

Enteral feeding causes an increase of intestinal oxygen demand depending on the amount administered. The aim of this study presented was to evaluate, whether intraoperative duodenal feeding might put patients at risk developing splanchnic O(2)-imbalance due to an intraoperatively compromised intestinal perfusion based on stress and unrecognized hypovolemia. In 18 severely burned patients, the CO(2)-gap between the arterial and gastric CO(2), as a parameter for the intestinal O(2)-balance, was measured during the first operation. All operations were performed on day 3-5 after admission and lasted for 4-5h. Half of the patients (nine patients) were fed intraoperatively, whereas in the other nine patients feeding was suspended beginning 1h prior to surgery until 6h after surgery. CO(2)-gap measurements were carried out prior to surgery, hourly during the operation and 5h postoperatively. Measurements 3 and 4h after beginning of the operation revealed significantly higher CO(2)-gap values in the fasting group. All other measurements showed no significant difference between both groups. Therefore, intraoperative enteral nutrition, at least in the early postburn phase, is not only necessary for reducing caloric deficits, but also seems to have a protective effect on gut oxygen balance.

Active warming of critically ill trauma patients during intrahospital transfer: a prospective, randomized trial.

OBJECTIVE: Hypothermia in trauma victims is a frequently observed phenomenon in acute care. Known complications of hypothermia are impaired wound healing, cardiac complications, hemodynamic instability, impaired immune function and increased blood loss. We compared active warming versus passive warming in hypothermia in critical-care patients undergoing intrahospital transfer from ICU to computer tomography (CT). METHODS: Thirty critically ill patients were randomized either to an actively warmed group, covered with a carbon-fiber heating blanket (set to 42 degrees C) during the entire transport including the time spent in the CT, or to a passively warmed group, covered with a carbon-fiber heating blanket (switched off) during the entire transport and in the CT. The carbon-fiber blanket was covered with a conventional wool blanket in both groups. Vital parameters and core temperatures were recorded. RESULTS: Patients' characteristics and vital parameters were similar in each treatment group. Initial average core temperature in group A was 36.4 degrees C +/- 0.2 degrees C and remained stable at 36.4 degrees C +/- 0.1 degrees C; core temperature in group B started at 36.4 degrees C +/- 0.2 degrees C but decreased to 34.7 degrees C +/- 0.6 degrees C. CONCLUSIONS: Hypothermia is common when critically ill trauma patients require intrahospital transport for diagnostic procedures. Resistive heating during intrahospital transport kept the core temperature stable and assured normothermia in all actively warmed patients. We therefore recommend active warming for critically ill trauma patients during intrahospital transport.

Serum cholesterol and triglycerides: potential role in mortality prediction.

The present study was performed in order to evaluate the diagnostic usefulness of serial cholesterol and triglycerides measurements in patients with severe burns. One of the main objective was to find out if these parameters are clinically relevant to determine the morbidity of a burn patient and thereby the patient's outcome. In 220 patients with thermal injuries, cholesterol and triglyceride concentrations were measured daily. Blood samples were drawn immediately upon admission and thereafter daily until patient's discharge or death. For both parameters, a characteristic course was noted: in the group of non-survivors, a decrease of cholesterol prior to death was noted, while survivors, increased prior to discharge. The time courses of both groups (survivors-non-survivors) differed statistically significantly (P=0.0068). An increase in triglycerides was observed in all non-survivors prior to death, but in the group of survivors triglycerides remained more or less unchanged. These time courses also had statistically significant differences (P=0.0004). In our 220 patients, changes in cholesterol (P<0.0001, hazard ratio 1.02) and triglycerides (P=0.0008, hazard ratio 1.01) had comparable capability to predict the severity of a burn trauma and thereby its outcome than the established parameters in the treatment of burns (total body surface area burned, age, inhalation). We consider the serial measurements of cholesterol and triglycerides as clinically relevant to assess the morbidity of a patient and thereby to estimate the patient's outcome. We think that these serial measurements provide useful information for the clinician treating patients with severe burns.

Nutrition and anabolic agents in burned patients.

PURPOSE OF REVIEW: Much of the morbidity and mortality of severely burned patients is connected with hypermetabolism and catabolism with its accompanying impairment of wound healing and increased infection risks. In order to prevent the erosion of body mass, nutritional support and other strategies to prevent catabolism have become a major focus in the care of severely burned patients. RECENT FINDINGS: Major themes discussed in recent literature are dealing with enteral versus parenteral nutrition and gastric versus duodenal feeding. The possibility of overfeeding is another important aspect of high calorie nutrition as commonly used in burned patients. Specific formulas for enteral nutrition for specific metabolic abnormalities are under evaluation as well as the role of anabolic and anticatabolic agents. SUMMARY: From the clinical literature, total enteral nutrition starting as early as possible without any supplemental parenteral nutrition is the preferred feeding method for burned patients. Using a duodenal approach, especially in the early postburn phase, seems to be superior to gastric feeding. Administration of high calorie total enteral nutrition in any later septic phase should be critically reviewed due to possible impairment of splanchnic oxygen balance. Therefore, measurement of CO(2)-gap should be considered as a monitoring method during small bowel nutrition. The impact on the course of disease of supplements such as arginine, glutamine and vitamins as well as the impact of the use of anabolic and anticatabolic agents is not yet evident. Furthermore, the effect of insulin administration and low blood sugar regimes on wound healing and outcome in burned patients should be evaluated in future studies.

Serum cholinesterase activity in patients with burns.

Serum cholinesterase activities were measured in 300 patients with thermal injuries. The samples were drawn immediately upon admission and thereafter daily until the time of the patients' discharge or death. According to the burn severity a characteristic decrease was noted during the first days. The decline during the first 24 hours as well as its value (measured 24 hours after admission) was found to be correlated with the total body surface area burned. In all patients the decrease in cholinesterase activity persisted for days, but in patients with inhalation trauma this decrease was significantly greater than in patients without lung injury. It seems that serum cholinesterase activity reflects not only the presence of an inhalation trauma. The cholinesterase measurement seems to be also a good method to observe the course of illness after a burn injury. Our data suggest a correlation between cholinesterase activity and morbidity. The inhalation trauma aggravates the thermal trauma.

Impact of duodenal feeding on the oxygen balance of the splanchnic region during different phases of severe burn injury.

Enteral nutrition is recommended in burned patients. Depending on the amount administered, enteral feeding causes an increase of intestinal oxygen-demand. Since intestinal perfusion is decreased after major burns the aim of this study was to evaluate, whether duodenal feeding might be a cofactor for the development of a splanchnic O(2)-imbalance. In 15 severely burned patients during duodenal feeding starting within 6 h after injury the assessment of the CO(2)-gap between arterial and gastric CO(2), as a parameter for the measurement of intestinal O(2)-balance was performed. Beginning prior to enteral nutrition CO(2)-gap measurements were carried out to show when the CO(2)-gap increased above 30 mmHg during the whole critical illness phase of the patients. When the CO(2)-gap increased above 30 mmHg enteral nutrition was reduced by 50% and the CO(2)-gap was measured 1 h later. In none of the patients the CO(2)-gap increased during increase of enteral nutrition. In seven patients, the CO(2)-gap increased between the 6th and 13th day above 30 mmHg and fell significantly 1 h after reduction of enteral nutrition. Contrary to the early postburn phase, enteral feeding might have adverse effects on the oxygen balance of the intestine in the later stages of the critical illness phase.