Transfusion requirements in burn patients undergoing primary wound excision: effect of tranexamic acid.

BACKGROUND: Early excision of burn wounds is the standard approach for burns, but it is usually associated with the need of allogeneic blood transfusion. Our aim was to determine if intravenous administration of tranexamic acid (TXA) was able to reduce packed red blood cell (pRBC) transfusion requirements in burn patients. METHODS: We conducted a retrospective cohort study of 2 consecutive series of severely burned patients (≥20% total body surface are) admitted for primary burn surgery. We searched for differences in pRBC transfusion occurrence and requirements during surgery and up to 24 hours after surgery. RESULTS: A total of 107 patients were included in the study, and 48.6% (52 patients) received TXA during primary excision. The use of TXA exhibited an absolute risk reduction in the need for transfusion during surgery of 24.2% (95% CI: 7.1-41.4%). In total, patients receiving TXA required 1.6 units of pRBC in the perioperative period vs. 2.6 units in those not receiving TXA (P=0.017). CONCLUSIONS: The intraoperative use of TXA in burn patients undergoing primary burn excision reduced the incidence of allogeneic transfusion and the total number of pRBC transfused.

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort study.

INTRODUCTION: The use of urinary output and vital signs to guide initial burn resuscitation may lead to suboptimal resuscitation. Invasive hemodynamic monitoring may result in over-resuscitation. This study aimed to evaluate the results of a goal-directed burn resuscitation protocol that used standard measures of mean arterial pressure (MAP) and urine output, plus transpulmonary thermodilution (TPTD) and lactate levels to adjust fluid therapy to achieve a minimum level of preload to allow for sufficient vital organ perfusion. METHODS: We conducted a three-year prospective cohort study of 132 consecutive critically burned patients. These patients underwent resuscitation guided by MAP (>65 mmHg), urinary output (0.5 to 1 ml/kg), TPTD and lactate levels. Fluid therapy was adjusted to achieve a cardiac index (CI) >2.5 L/minute/m² and an intrathoracic blood volume index (ITBVI) >600 ml/m2, and to optimize lactate levels. Statistical analysis was performed using mixed models. We also used Pearson or Spearman methods and the Mann-Whitney U-test. RESULTS: A total of 98 men and 34 women (mean age, 48 ± 18 years) was studied. The mean total body surface area (TBSA) burned was 35% ± 22%. During the early resuscitation phase, lactate levels were elevated (2.58 ± 2.05 mmol/L) and TPTD showed initial hypovolemia by the CI (2.68 ± 1.06 L/minute/m²) and the ITBVI (709 ± 254 mL/m²). At 24 to 32 hours, the CI and lactic levels were normalized, although the ITBVI remained below the normal range (744 ± 276 ml/m²). The mean fluid rate required to achieve protocol targets in the first 8 hours was 4.05 ml/kg/TBSA burned, which slightly increased in the next 16 hours. Patients with a urine output greater than or less than 0.5 ml/kg/hour did not show differences in heart rate, mean arterial pressure, CI, ITBVI or lactate levels. CONCLUSIONS: Initial hypovolemia may be detected by TPTD monitoring during the early resuscitation phase. This hypovolemia might not be reflected by blood pressure and hourly urine output. An adequate CI and tissue perfusion can be achieved with below-normal levels of preload. Early resuscitation guided by lactate levels and below-normal preload volume targets appears safe and avoids unnecessary fluid input.

Risk factors for outbreaks of multidrug-resistant Klebsiella pneumoniae in critical burn patients.

The objective of this study is to identify the risk factors related to colonization or infection in an outbreak of multidrug-resistant Klebsiella pneumoniae in a burn patient unit. The authors studied the risk factors associated with colonization or infection using a case-control study design involving patients with multidrug resistant K. pneumoniae (n = 26) and controls (n = 50). They describe the outbreak and provide a retrospective analysis that encompasses patient demographics, microbiological isolation, culture sites, burn features, inhalation injury, biomarkers (lactate and N-terminal probrain natriuretic peptide), general illness severity scores (Acute Physiology and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment), burn-specific severity scores such as the Abbreviated Burn Severity Index (ABSI), length of stay, and mortality. Patients colonized with multidrug-resistant K. pneumoniae were older (55 vs 42 years), presented with larger burns (32 vs 18% of BSA), and more frequently had full-thickness burns (53 vs 22%). They also had higher ABSI, Acute Physiology and Chronic Health Evaluation II, and Sepsis-related Organ Failure Assessment scores, and they required more days of mechanical ventilation and longer stays in the critical burn unit. Multivariate analysis showed that the factors most significantly related to the development of infection or colonization with K. pneumoniae were burns located on head and neck (odds ratio, 4.81) and the ABSI score (odds ratio, 1.66). Control of the outbreak was achieved by enforcing contact precautions and extensive cleaning. An elevated ABSI score and burns located on the head and neck were the risk factors most significantly related to colonization or infection in an outbreak of multidrug-resistant K. pneumoniae in a critical burn patient unit.

Immediate breast reconstruction (IBR) with direct, anatomic, extra-projection prosthesis: 102 cases.

There are different methods described until now for immediate breast reconstruction. Despite the use of autologous flaps considered by many authors, implants are considered as an option by others. A prospective study of 102 clinical cases was designed, including a 1-year follow-up in which glands were reconstructed by immediate breast reconstruction (IBR) with direct, extra projection, anatomic prostheses located in a submuscular pocket after a skin-sparing mastectomy. The prosthesis coverage was made by the muscle in its upper two thirds and by using the skin from the mastectomy in its lower third. The cosmetic results obtained were evaluated according to the volume, form, and symmetry achieved using a linear numeric analogical score. This evaluation had an averaged value of 2.79 +/- 0.8 in our scale from poor (0) to excellent result (4). The overall rate of complications was 15.7% of the cases, with seroma being the most frequent. In conclusion, this preliminary study demonstrates that immediate breast reconstruction with a direct, extra projection, anatomic prosthesis is a good alternative. Nevertheless, more long-term studies with a higher number of patients and using an SF-36 for patient satisfaction are needed to confirm these results.