A high voltage electrical burn of lung parenchyma.

High voltage electrical trauma may cause severe visceral injuries. We report a case of direct electrical injury to the lung parenchyma, without evidence of any thoracic wall contact injury, in an electrician who sustained a 20 kV-electrical shock while working in a substation cubicle. The diagnosis of a true electrical burn of the left lower lobe was suggested early on by imaging and then confirmed by surgical exploration, histological findings and the significant improvement of the patient's condition following resection of the infarcted lobe. All possible causes of bronchial and pulmonary pathologies in such a context were ruled out. The fatal outcome of two previous similar cases and the generally high mortality of any electrical visceral injury support early surgical management as the only rational life-saving treatment. Current pathophysiological knowledge substantiates the theory of an isolated visceral injury located far away from the contact wounds. However, the pathogenesis of such severe injuries is not entirely understood.

A randomized controlled trial of the influence of the mode of enteral ornithine alpha-ketoglutarate administration in burn patients.

To investigate appropriate mode and daily dose of enteral ornithine alpha-ketoglutarate (OKG) administration, 54 burn patients (total burn surface area: 20-50%) were included in a randomized controlled trial and assigned to receive either a supplement of OKG (10, 20 or 30 g/d) as bolus or continuous infusion, or a continuous infusion of an isonitrogenous amount of a soy protein mixture (Protil-1: 10, 20 or 30 g/d) in addition to their enteral diet. The influence of these treatments on clinical outcome and biological indices was evaluated. OKG administration significantly improved nitrogen balance and reduced 3-methylhistidine and hydroxyproline urinary elimination. This was associated with a gradual rise in plasma glutamine over time. Given as a bolus, OKG significantly improved wound healing, assessed both clinically [day of last graft: (mean +/- SEM) OKG bolus 23.7 +/- 2.1 d versus Protil-1, 39.9 +/- 9.9 d; P < 0.05] and by hydroxyproline excretion, and biological markers of nitrogen metabolism, and tended to reduce duration of enteral nutrition (P = 0.12). The higher catabolic status in the patients administered 20 g OKG/d at the onset of the study, despite randomization, precludes any definite conclusion (concerning the dose-effect relationship). However, based on 3-methylhistidine elimination, our data indicate a benefit of 30 g OKG/d administration over 10 g/d. This study further supports OKG supplementation in burn patients. In addition, this is the first trial based on objective data that favors bolus over continuous infusion of OKG in critically ill patients.

Ornithine alpha-ketoglutarate metabolism after enteral administration in burn patients: bolus compared with continuous infusion.

Ornithine alpha-ketoglutarate (OKG) has been successfully used as an enteral supplement in the treatment of catabolic states, including burn injury. However, specific questions remain unanswered concerning burn patients, including OKG metabolism and metabolite production, appropriate mode of administration, and dose. We thus performed a kinetic study and followed plasma ornithine and OKG metabolite concentrations on day 7 postburn in 42 (35 men, 7 women) consecutive burn patients aged 33 +/- 2 y with a mean (+/-SEM) total burn surface area (TBSA) of 31 +/- 1%. Patients were randomly assigned to receive OKG as a single bolus (10 g; n = 13) or in the form of a continuous gastric infusion (10, 20, or 30 g/d over 21 h; n = 13) or an isonitrogenous control (n = 16). Plasma pharmacokinetics of ornithine followed a one-compartment model with first-order input (r = 0.993, P < 0.005). OKG was extensively metabolized in these patients (absorption constant = 0.028 min-1, elimination half-life = 89 min), with the production of glutamine, arginine, and proline; proline was quantitatively the main metabolite [in OKG bolus, area under the curve (AUC)0-7h: proline, 41.4 +/- 5.6 mmol.min/L; glutamine, 20.4 +/- 5.7 mmol.min/L; and arginine, 7.3 +/- 1.9 mmol.min/L]. Proline production was dose-dependent and quantitatively similar between modes of OKG administration. Glutamine and arginine production were not dose-dependent and were higher in the bolus group than in the infusion group. Overall, the bolus mode of OKG administration appeared to be associated with higher metabolite production compared with continuous infusion in burn patients, especially for glutamine and arginine.

Contribution of molecular typing methods and antifungal susceptibility testing to the study of a candidemia cluster in a burn care unit.

We investigated a cluster of cases of Candida septicemia diagnosed in four burn patients. Twenty clinical isolates of Candida albicans and two of Candida parapsilosis, plus eight isolates of C. albicans recovered from nurses' clothes, were analyzed by antifungal susceptibility testing and three genotyping methods (restriction fragment length polymorphism analysis with EcoRI and HinfI, arbitrarily primed PCR, and karyotyping). The high MICs of the azoles for all of the C. albicans isolates tested suggest either a natural resistance of the endogenous flora or the transmission of isolates with acquired resistance. The genotyping methods demonstrated the involvement of four different strains, cross-infections with one C. albicans strain and one C. parapsilosis strain, and identity between some of the strains from the patients and nurses. The origins of the strains remain unclear. Our results show that the use of a combination of at least two different methods such as those used in the present study is recommended for C. albicans typing.

Using bronchoscopy and biopsy to diagnose early inhalation injury. Macroscopic and histologic findings.

OBJECTIVE: To learn the value of bronchoscopy and biopsy in the early diagnosis of inhalation injury ARDS. SETTING: Burn Center, CHU Saint-Antoine, Paris, France. DESIGN: 130 consecutively admitted burn patients were bronchoscoped on admission. MEASUREMENTS: The appearance of the bronchial tree was recorded, and biopsies were taken from spurs of the proximal and distal branches of the right bronchi. RESULTS: Either bronchoscopy or biopsy was positive in 46 cases. Twenty three of 44 patients with chemical inhalation injury developed ARDS (52%). Of 83 negative cases only 6 developed ARDS (7%). CONCLUSION: Bronchoscopy with biopsy is useful in predicting the development of ARDS in burn patients.

Plasma fibronectin and angiotensin-converting enzyme: markers of primary pulmonary injury in burn patients.

Plasma fibronectin (FBN) and angiotensin I-converting enzyme (ACE) were prospectively measured in 50 burn patients from the day of admission to day 28 after the trauma with the aim of finding biochemical markers of pulmonary injury by smoke inhalation. Patients were divided into three groups on the basis of fiberoptic bronchoscopy results (group I: healthy lungs; group II: burned lungs; group III: infected lungs). A decrease in FBN concentrations was observed in the three groups but was larger in group II than in the other groups, especially at day 2 (P < 0.05). A similar profile was observed for plasma ACE activity. Factors other than lung injury may influence plasma FBN and ACE levels, in particular the burned body surface area, an acute event such as septicemia, or outcome. However, repeated measurements of both markers could help in the assessment of lung injury in the follow-up of burn patients.

Cytokine response to burn injury: relationship with protein metabolism.

Plasma levels of interleukin 1 beta (IL-1 beta), tumor necrosis factor alpha (TNF alpha), interleukin 6 (IL-6), and markers of protein metabolism were determined in 12 burn patients throughout the healing period (day 2 to 21 post-injury) to determine the pattern of variations in plasma cytokine concentration. To establish the relationship between cytokine production and the nutritional status a wide range of severity standpoints (burn surface area ranging from 9% to 82%) was chosen. Interleukin 6 levels were increased in all patients throughout the study period; maximum concentrations (615 +/- 198 pg/mL) were reached on day 4 and correlated (p < 0.01) with the extent of burn injury. Tumor necrosis factor alpha levels were also elevated; they were significantly higher on day 7 in the patients who developed sepsis than in the other patients (67 +/- 21 pg/mL vs. 20 +/- 7 pg/mL; p < 0.05) but did not correlate with the extent of burn injury. Interleukin 1 beta was rarely detected. Cortisolemia on day 7 was inversely correlated with levels of TNF alpha but not with those of IL-6. Interleukin 6 levels correlated positively with protein turnover (phenylalaninemia) and catabolism (3-methylhistidine/creatinine ratio) and negatively with levels of fibronectin and transthyretin. Our data indicate that the systemic cytokine response to burn injury is mainly represented by IL-6. These data also support the hypothesis that IL-6 is a key mediator of the variations in protein metabolism following burn injury.

Fiberoptic bronchoscopy for the early diagnosis of subglottal inhalation injury: comparative value in the assessment of prognosis.

The aim of this study was to determine the value of bronchoscopy in the early diagnosis of inhalation injury. A total of 130 burn patients underwent bronchoscopy on admission to a specialized center. In order to validate the method and the bronchoscopist's conclusions, they underwent staged bronchial biopsies. Using the histologic findings as the "gold standard," bronchoscopy proved to be sensitive (sensitivity, 0.79) and highly specific (specificity, 0.94) for the diagnosis of inhalation injury. In addition, it was more reliable than the circumstances of the injury, the clinical findings, and complementary tests. In a one-dimensional analysis, bronchoscopy-proven inhalation injury was one of the most strongly predictive variables for the onset of ARDS and death. The analysis of survival curves confirmed that inhalation injury portends a bad outcome in burn patients. It was used to predict the likelihood of ARDS and death at the time of admission with a view to early specific treatment.

Serum transthyretin levels in patients with burn injury.

We examined serum transthyretin levels after thermal injury in a longitudinal study of 61 patients with burn injury from day 2 to day 28 after trauma. All the patients had a maximal decrease in transthyretin levels between days 6 and 8. Transthyretin values remained lower during the recovery phase in patients who died than in patients who survived. In addition, persistently low transthyretin values were associated with sepsis in the survivors. Finally, transthyretin levels were only slightly dependent on the extent of the burn injury. These results emphasize the interest of transthyretin monitoring in patients with burn injuries.

Burns in the elderly.

This report describes the treatment and prognosis of 37 burned patients over 70 years of age.

Influence of enterally administered ornithine alpha-ketoglutarate on hormonal patterns in burn patients.

Plasma concentrations of glucose, insulin, C-peptide, glucagon, cortisol and hGH were measured in burn patients (mean burn surface area 21 per cent) treated or not with ornithine alpha-ketoglutarate (OKG). An increase in basal values of glucose, insulin, C-peptide and cortisol was demonstrated in both groups, whereas hGH values diminished. OKG modified neither insulin nor hGH values 24 h after its enteral administration nor insulin levels within the first 4 h after intake. On the other hand, 60 min after enteral nutrition was restarted the hyperglycaemia observed in untreated subjects was reduced by OKG whereas a hyperinsulinism was observed in both groups. These results suggest that: (i) the anticatabolic/anabolic action of OKG in burn patients is not mediated by insulin or hGH, (ii) OKG probably induces an increase in glucose tolerance in burn patients, in whom there is a state of insulin resistance. The mechanism of this action requires further study.

Plasma branched-chain keto acids in burn patients.

Plasma branched-chain keto acids (BCKA) and glucose-alanine cycle-related substances were measured in venous and arterial blood following burn injury. It was found that the three BCKA diminished with a minimum on day 7 while pyruvate increased. Alanine and glutamate + glutamine also decreased but plasma branched-chain amino acids (BCAA) did not vary. BCKA and gluconeogenic amino acids were liberated by peripheral tissues whereas BCAA were not. By analogy with the fate of alanine, a reduction in plasma BCKA associated with a high release by peripheral tissues might involve an increase in their hepatic metabolism. The BCKA would then give rise to ketone bodies used by the peripheral tissue. This step would complete the glucose-alanine cycle described by Cahill in hypercatabolic states where energy requirements are intense and similar to those found in burn injuries.

Plasma concentrations of vasoactive intestinal polypeptide in severely burned patients: influence of enteral nutrition.

Plasma vasoactive intestinal polypeptide (VIP) concentrations were measured at different days after burn injury. A significant decrease in VIP levels was observed on days 7 and 10. The influence of enteral nutrition was also investigated: a rise in plasma polypeptide levels was found at 60 min after nutrition restart on days 4 and 7 after injury. In burn patients, VIP may be involved in the multiple metabolic and hormonal responses which lead to an increase in the hypercatabolic state. The decrease in these polypeptide values should reflect enhanced utilisation or complex hormonal regulation. After enteral nutrition, the stimulation of VIP secretion disappeared after day 7 after burn injury. This phenomenon is probably mediated by a process of adaptation to continuous enteral nutrition.

Arterio-venous differences in amino acids, glucose, lactate and fatty acids in burn patients; effect of ornithine alpha-ketoglutarate.

The study concerns two groups of seven burn patients matched for age, weight and total burn surface. Both groups received conventional enteral nutrition, while one was given a 10 g/day alpha-ketoglutarate ornithine (OKG) supplement. Femoral venous and arterial blood was taken from day 2 to day 13 post-burn in order to determine levels of amino acids, nonesterified fatty acids (NEFA), glucose and lactate. In the control group large negative arterio-venous differences (DeltaA-V) were observed in amino acid and lactate levels whereas they were significantly lower with regard to Hyp, Gly, Lys and Ala in the OKG-treated group. DeltaA-V was near zero for glucose and NEFA in both groups. These results support the view that OKG-therapy limits the output of amino acids in the leg and that glucose and NEFA do not constitute the main fuel in muscle.

Myoglobinemia after burn injury: relationship to creatine kinase activity in serum.

Myoglobin is released into the blood after burn injury. We measured it and other analytes in blood collected from 22 burn patients two to seven times during their recovery. There was a significant correlation between myoglobinemia and creatine kinase (CK) activity in serum (r = 0.764; p less than 0.001). In a group of 14 thermal-burn subjects a correlation was found between burn depth (clinically expressed as Unit Burn Surface) and both myoglobinemia (r = 0.825; p less than 0.01) and CK activity (r = 0.686; p less than 0.01). In eight thermal-burn patients who were recovering satisfactorily, myoglobin and CK activity measured on days 2, 4, 7, 10, and 13 after injury were significantly increased (p less than 0.05) on days 2, 4, and 7. Evidently myoglobinemia and CK activity are good biological markers of burn depth, and reflect muscle damage equally well.

Rhabdomyolysis and acute renal failure in a patient with thermal injury.

We report a case of rhabdomyolysis with acute renal failure during recovery from thermal burn injury. The late occurrence of this unusual complication is emphasized and possible etiological factors are discussed.

Origins of hyperphenylalaninemia in burn patients.

Plasma phenylalanine concentrations were measured on the seventh postburn day in patients with burn surface areas ranging from 1 to 39%. Hepatic function (glutamate-pyruvate transaminase, prothrombin time) and protein breakdown (nitrogen balance, urine 3-methylhistidine/creatinine ratio) were evaluated in parallel. Plasma phenylalanine concentrations in patients with normal hepatic function and those with hepatic failure were similar. A correlation was shown between phenylalaninemia and nitrogen balance for all patients but phenylalaninemia only correlated with the urine 3-methyl-histidine/creatinine ratio in patients with burn surface areas under 20%. Taken as a whole, the data suggest that the determination of plasma phenylalanine concentration is a valuable test to assess the nitrogen balance in burn patients. This test, when performed on day 7, is particularly relevant in patients with normal hepatic function and either slight or moderate burn injury.

Plasma amino acid pattern in burn subjects: influence of septicemia.

A comparison of plasma amino acid levels was made between two groups of burn subjects, septic and non-septic. On day 4 after injury, results do not show any differences between patients who later went on to develop sepsis on day 7 and those who remained non-septic. Similarly, no differences between these two groups were discernable on day 7. Thus metabolic variations induced by septicemia do not seem to modify the usual burn-induced amino acid variations; consequently, plasma amino acid determination in burn patients do not appear to predict septicemia.

Effect of enterally administered ornithine alpha-ketoglutarate on plasma and urinary amino acid levels after burn injury.

Eight severely burned patients received 10 grams twice a day of enterally administered ornithine alpha-ketoglutarate. Variations in their plasma and urinary amino acid levels were compared with those from six severely burned control patients. The study covered the period from the fourth day to the twenty-eighth day after injury. Essential differences between the two groups were that plasma ornithine and proline increased until day 13 in the treated group, plasma phenylalanine levels were higher in the control group except on day 13, the peak, on the twenty-first day, in plasma concentrations of valine, leucine, isoleucine, tyrosine, lysine, proline, and ornithine, in the control group was not found in treated subjects, and urinary amino acids were lower on day 28 in the treated group. These results suggest that ornithine alpha-ketoglutarate administration lowered protein catabolism after injury, probably through a process mediated by increased secretion of insulin and human growth hormone.