[The question of secondary medical transfer in Belgium: the experience conducted at the University Hospital Center of Liège]. / Problématique Liée aux transferts médicalisés secondaires en Belgique: l'expérience développée au CHU de Liège.

Evaluation of the aid of an emergency mobile unit to transfer monitorized patients to a University hospital, in the political context of regional care network offering highly qualified but restricted tertiary area centres, and an open prospective study conducted over the 5 first months in 2006. The call regulation was assessed by the emergency physician of the transfer team and all missions were concluded with an evaluating report. An amount of 197 requests were taken into account from which 80 % were addressed between 8 am and 8 pm. The mean average time interval for missions was 59 minutes (base to base) and the distance covered was 20.7 km as a mean. In essence, indications for medical secondary transfer regarded patients in need for acute coronary care (42.6%), specific intensive care (26.4%) and neurosurgical interventions (19.3%). We noted that endotracheal intubation occurred in only one case. Mortality during such a transfer activity was absent. Medical transfer unit allows the development of specific high qualified network resources owing to the secondary addressee of patients. However, the weak incidence of complication questions the practice of systematic medical accompanying during such transfers.

[The value of mobile intensive care unit (MICU): does it remain to be proven?]. / A-t-on evalué l'intérêt du SAMU?

Recent international guidelines about emergency situations (ILCOR / ERC) pointed to the need of the whole "chain of survival". ALS, Advanced Life Support (the last and "medical" part of the chain ) is important and influences survival rate. If no doubt exists about "what" and "when" to do in such situations, there is no consensus in industrialized countries about "who" should be in charge of such out-of-hospital acute diagnosis and treatment: emergency physicians, emergency nurses, emergency medical technicians (EMT), other "new" professionals ? ... A description of the MICU system in Belgium is given.

A safety assessment of diaspirin cross-linked hemoglobin (DCLHb) in the treatment of hemorrhagic, hypovolemic shock.

OBJECTIVE: To determine the safety and possible efficacy of diaspirin cross-linked hemoglobin (DCLHb) in the treatment of patients in Class II-IV hemorrhagic, hypovolemic shock. DESIGN: Multicenter, randomized, normal saline-controlled, dose-escalation study. SETTING: Eleven hospitals in the U.S. and Belgium. SUBJECTS: One hundred and thirty-nine (139) hospitalized patients with Class II-IV hemorrhagic, hypovolemic shock within the previous 4 hours who still were requiring therapy for shock. INTERVENTIONS: Beginning with the lowest dose, patients were randomized to receive 50, 100, or 200 mL of either 10% DCLHb or normal saline infused intravenously over 15 minutes. Following infusion of either treatment, further fluid resuscitation could be given, as necessary, to maintain perfusion. Vital signs, laboratory assessments, blood and fluid administration, complications, and adverse events were recorded at various times from the end of infusion through 72 hours after infusion. RESULTS: A total of 29 (13 DCLHb- and 16 saline-treated) patients died during the study period. Adverse events were experienced by 61% of patients in the DCLHb group and 53% of patients in the saline group; serious adverse events occurred in 28% of DCLHb-treated patients and 30% of saline-treated patients. The incidence of prospectively defined, clinical complications, including renal insufficiency and renal failure, was similar between the treatment groups except for the occurrence of dysrhythmias/conduction disorders, which occurred significantly more frequently in the saline-treated patients than the DCLHb-treated patients (p = 0.041). At the highest dose level (200 mL), statistically significant between-group differences were observed with greater increases in serum amylase, LDH, the isoenzymes LD1,2,4 and 5, and CK-MB in the DCLHb group compared to the control group; none were of clinical significance. The volume of blood administered did not differ between the groups. Overall 24- and 72-hour survival rates were similar between treatment groups, although the hospital discharge rate was slightly higher in the DCLHb-treated patients (80%) compared with the saline-treated patients (74%). CONCLUSION: Administration of 50 to 200 mL of DCLHb to patients in hemorrhagic, hypovolemic shock was not associated with evidence of end organ toxicity or significant adverse events. Further studies involving larger doses and, perhaps, earlier administration of DCLHb are warranted.

Measurements of muscular microcirculation by laser Doppler flowmetry in isoflurane and halothane anaesthetised horses.

The cardiovascular function of horses was less depressed during anaesthesia with isoflurane than during anaesthesia with halothane. Muscular microcirculation measured by laser Doppler flowmetry was significantly greater in horses anaesthetised with isoflurane.

Biochemical investigations after burning injury: complement system, protease-antiprotease balance and acute-phase reactants.

Seventeen burned patients were investigated--Group I (n=10) with a mean burned area expressed as unit burn standard (UBS) of 69 +/- 24 and Group II (n = 7) with a mean UBS of 23 +/- 8. Blood samples were collected immediately after admission, 6-12 h after injury, during the morning and evening of day 1, and then daily for 2 weeks. This prospective study demonstrated complement activation in vivo in all burned patients, measured by C3d/C3 ratio index which was not related to the extent of the burned surface. A significant protease-antiprotease imbalance, correlated to the severity of burns, was found, leukocyte elastase was increased throughout the observation period, alpha 2-macroglobulin drastically decreased in severely burned patients, and alpha 1-proteinase inhibitor promptly decreased below the normal level in patients with more than 40 UBS. Finally, there was a delayed but then persistent acute-phase reactant protein response involving C-reactive protein, haptoglobin and alpha 1-acid glycoprotein, the concentrations of which reached a plateau on days 6 or 7.

Laser Doppler flowmetry: muscular microcirculation in anaesthetized horses.

Muscular microcirculation was studied in seven halothane anaesthetised horses in lateral recumbency using a laser Doppler flowmeter. A significant difference between the dependent and the uppermost triceps brachii was recorded. In the dependent muscles, microflow at first decreased and then increased up to the starting value. In the uppermost muscles, a significant rise of the microflow was measured.

[Role of a surgical emergency department in the management of a disaster bringing a great number of patients with burns]. / Rôle d'un service d'urgence chirurgicale dans la prise en charge d'une catastrophe engendrant une grande quantité de patients brûlés.

Definition of a disaster would follow prescriptions from the "International Trauma Foundation" (Brighton 1981, document A). This disaster may be: simple (where the structure of community remains intact), compound (where the structure of community and function of the community are disrupted). The classification of disasters is realized: by cause, by number of casualties, by nature of pathology, by time while cause operating, by time of rescue procedures at site, by affected area, by rural or urban location. Belgian legislation about disaster is described. Disaster related to major technological risks will be characterized by high probability of traumatic and burns injuries. The authors prepare medical responses to this eventually, defining the role of a "base hospital", the role of a medical team at site and the management of different groups of burned patients. Propositions are made to bring together actors of "disaster plan".

Laser doppler flowmetry. A new non-invasive measurement of microcirculation in intensive care?

Laser doppler flowmetry (LDF) is a new non-invasive technique by which microcirculation changes in tissue can be studied. In recent papers, this technique has been used to measure microflow in standardized fluid models, in animals and in human clinical situations. LDF utilizes the doppler shift, i.e. the frequency (wave length) change that light as well as all waves undergo being reflected by moving objects such as, e.g. red blood cells. A beam of low power laser light (2 mW He-Ne at 632.8 nm) is led by an optical fibre to a measuring head. From here it enters the tissue to which it is applied by a hemisphere with a 1 mm radius. Blood cells traversing this volume are struck by the light and reflect it, whereby the light undergoes a doppler shift. The surrounding tissue also reflects the light, but in an unshifted manner. Thus the volume of illumination is a mixture of an unshifted and a doppler shifted component, the magnitude and frequency of the latter being related to the number of moving cells and their velocity. The measured microflow is proportional to an arbitrary scale (0 to 10). Our own experience with some applications in human clinical situations is described: Normal skin in a control group. Normal skin and burned area in burned patients. Patient in hypothermia with general anesthesia. Patient in shock. LDF seems to be an interesting new non-invasive technique, supplying a good definition of the skin microflow. In the future, this technique could be one of the non-invasive techniques used for intensive care, defining the microcirculation state of a patient.

Clinical use of laser Doppler flowmetry in a burns unit.

Laser Doppler Flowmetry (LDF) is a new noninvasive technique by which microcirculation changes in tissue can be studied. This has been done in a Burns Unit on burned as well as non-burned patients (volunteers). There were no infection problems with this device in a Burns Unit. Four kHz was the upper wave length limit analysing the doppler signal from burns. A topical temperature load test was defined and used in different situations. Homogeneous flows in reference points from a control group were demonstrated in unheated and heated skin, in this way standardizing the LDF analyses of skin microflow. Ability of LDF to define different degrees of burns was demonstrated.

Laser Doppler flowmetry measurements of superficial dermal, deep dermal and subdermal burns.

The microcirculation in burned patients' skin has been studied on day 3 after the accident with Laser Doppler Flowmetry (LDF). A schedule for interpretation of LDF values has been designed.

Water and sodium balance: the effect of the air-fluidized bed on burned patients.

Five patients with burned areas from 20 to 40 per cent BSA were studied in the air-fluidized bed during the first 2-week period post burn. Patients with abnormal renal and intestinal functions and with previous pathological history were not incorporated in the study. The patients were treated by the exposure method, and no surgical procedure was carried out during the study. The water and sodium balances were calculated from intravenous and oral intakes, urine-outflow, urinary sodium excretion and weight changes. In addition measurements of the sodium space were performed in two patients, using Sodium. Evaporative water loss was calculated during the first week, the sodium loss during the first and second weeks. As a result of the study the average daily evaporative water loss could be defined as: 0.81 ml/cm2 burned area +/- 0.07 ml. We compared the actual evaporative water loss with two classical formulas: --Davies, Lamke, Liljedahl (1974) (D.L.L.) min: 0.3 ml X cm2 burned area = ml/day = D.L.L. (0.3) Max: 0.45 ml X cm2 burned area = ml/day = D.L.L. (0.45) --Scott, McDougall, Slade, Pruitt (1978) (S.M.S.P.) (25 + %) X BSA = ml/h = S.M.S.P. --Scott, McDougall, Slade, Pruitt (1978) (S.M.S.P.) (25 + %) X BSA = ml/h = S.M.S.P. The average calculated daily evaporative water was: D.L.L. (0.3) + 5 litre/m2 burned area D.L.L. (0.45) + 3.5 l/m2 burned area S.M.S.P. + 4 litre/m2 burned area. This 'extra' evaporative water loss was closely related to the body burned surface. Correlation coefficient: D.L.L. (0.3) = 0.99 D.L.L. (0.45) = 0.98 S.M.S.P. = 0.97. Day 2 and day 3 showed the most important water loss per cm2 burned area. On the other hand, the sodium loss was found to be as expected: daily average: 0.02 mmol/cm2 burned area.

A ten-year retrospective study of sepsis in severely burned patients treated with or without silver sulfadiazinate.

Three groups of extensive burn patients of the surgical intensive care unit (ICU) have been compared: Group I: twenty patients, who were treated locally without silver sulfadiazinate (1968-1970); Group II: the twenty first patients topically treated with silver sulfadiazinate (1970-1972); Group III: twenty similarly treated patients, with silver sulfadiazinate, six years later (1976-1977). The groups are statistically comparable. All bacteriological samples were computerized; the chi-square method was used for statistical analysis of the data. The main conclusions are: (A) Silver sulfadiazinate treatment reduced Pseudomonas aeruginosa and Proteus sepsis. No change in Coliform bacilli sepsis was observed. After six years, a rise in Klebsiella sepsis and Candida sepsis was noted. (B) A quantitative estimate of infections in each group was made by measuring the percentage of positive samples, taking into account the five above-mentioned strains. In the beginning, silver sulfadiazinate reduced quantitative sepsis, but this benefit decreased after six years; the same evolution was demonstrated for positive blood bacteriology; severe septicaemia showed a parallel pattern.

Severe burn cases : a tentative analysis of the epidemiological, clinical and bacteriological data.

We have computerized the epidemiological, clinical and bacteriological data of 140 serious burn cases, hospitalized in our intensive care unit (I.C.U.). The most relevant conclusions are : Epidemiology : it is imperative to exert a prophylactic action against domestic burns through scalds and explosions. Clinic : the most frequent cause of death, during the phases of sept icemia, is cardiac failure. Lung burns significantly increase the mortality rate and they are impossible to codify in the classical systems of burn descriptions. Bacteriology : preventive antibiotic therapy determines, after three days, the strains which resist the usual antibiotics. An antibiotic loses some of its effect when used intensively in reanimation care. We express our concern with regard to the efficiency of antibiotic therapy in intensive care. We suggest to try and standardize data collection, so that multi-centre studies may help to increase the efficiency of their processing.