Management of pain, anxiety, agitation and delirium in burn patients: a survey of clinical practice and a review of the current literature.

Management of pain, agitation and anxiety is crucial in critically ill patients, and has a significant impact on clinical and functional outcome. This study aims to assess current management of analgesia, sedation and delirium in adult burn ICUs, and determine if discrepancies exist between current guidelines and actual practices.An online survey was created and sent to burn specialists worldwide.A total of 40 respondents submitted valuable data. Of all respondents, 20 (50%) were from Europe, 7 (17.5%) from North America, 6 (15%) from Africa and 12 (30%) from other regions. The majority of respondents were from burn centres with more than 60 admissions per year (32 centres, 80%); 36 respondents (90%) were affiliated with a University Hospital. 92.5% reported that they routinely screen severe burn patients for pain, while 27.5% declared that no particular pain assessment tool is used. The most common analgesics were opioids, mainly administered intravenously (90%). 70% affirmed they routinely screen burn ICU patients for sedation, but 30% declared that they do not use a specific sedation scoring scale. The most commonly used sedatives were midazolam (72.5%) and propofol (55%). 70% claimed to assess burn ICU patients routinely for delirium, but 57.5% reported they did not use a specific scoring system. 62.5% stated that they prevent delirium by combining pharmacological and non-pharmacological approaches. Our results indicate that awareness regarding the systematic and correct management of pain, sedation and delirium is increasing among burn specialists. However, a substantial gap between guidelines and clinical practices exist. Efforts should be directed at creating specific burn care guidelines and enhancing the implementation of existing recommendations.

La prise en charge de la douleur, de l'agitation et de l'anxiété est fondamentale chez les patients de réanimation et joue un rôle significatif dans le pronostic vital et fonctionnel. Cette étude a pour but d'évaluer la gestion actuelle de l'analgésie, de la sédation et de la confusion dans les unités de soins intensifs pour brûlés ainsi que leur adéquation avec les recommandations. Un questionnaire d'évaluation en ligne a été envoyé à des brûlologues du monde entier. Quarante réponses ont pu être analysées dont 20 (50%) d'Europe, 7 (17,5%) d'Amérique du Nord, 6 (15%) d'Afrique et 12 (30%) d'autres continents. La majorité des personnes ayant répondu travaillaient dans des Centres de Traitement des Brûlés recevant plus de 60 patients par an (32, 80%), 36 (90%) travaillant dans un CHU. Trente sept (92,5%) déclaraient évaluer régulièrement la douleur des brûlés mais 11 (27,5%) n'utilisaient pas d'outil d'évaluation. Les analgésiques les plus utilisés étaient les opiacés, le plus souvent (90%) utilisés par voie intraveineuse. Vingt huit (70%) réponses attestaient de l'évaluation de la sédation, 12 (30%) n'utilisant pas d'outil spécifique. Les molécules les plus utilisée étaient le midazolam (29; 72,5%) et le propofol (22; 55%). L'état confusionnel était recherché de manière routinière par 28 médecins (70%), aucune échelle n'étant utilisée par 23 d'entre-eux (57.5%). La prévention de la confusion utilisait une approche à la fois pharmacologique et non pharmacologique 25 fois (62,5%). Cette étude confirme l'attention croissante que portent les brûlologues à l'analgésie, la sédation et la confusion. Cependant, il existe des différences importantes entre la pratique et les recommandations. Des efforts seraient nécessaires pour créer des recommandations spécifiques aux brûlés et améliorer l'adhésion à celles déjà existantes.

Analgesia, sedation and arousal status in burn patients: the gap between recommendations and current practices.

Assessment and treatment of pain, agitation and delirium are integral parts of the management of critically ill patients. The purpose of this review is to describe how pain, delirium and agitation are managed in general intensive care units and in burn units, and to address whether management of these issues is compatible with internationally accepted recommendations. A substantial gap exists between the conception of the guidelines, clinical practice and physicians' statements regarding pain, sedation and delirium management. Specific training programs might be required to increase the implementation rate of guidelines and best practices on sedation, pain and delirium assessment and management in burn units.

L'évaluation et le traitement de la douleur, de l'agitation et du délire font partie intégrante de la prise en charge des patients de réanimation. Cette revue a pour but de décrire la prise en charge de ces paramètres en réanimation générale et en centre de brûlés et de discuter si cette prise en charge correspond aux recommandations internationales. Il existe des différences notables entre ces recommandations, la pratique courante et le point de vue des médecins concernant la prise en charge de la douleur, de l'agitation et de la confusion. Des programmes de formation spécifiques pourraient être utiles pour améliorer la concordance entre la vraie vie et les recommandations dans ces situations.

Monitoring and treatment of coagulation abnormalities in burn patients. an international survey on current practices.

The magnitude of coagulation abnormalities, and the definition and treatment of coagulopathy in burn patients are inadequately understood and continue to be discussed in the literature. We aimed to analyse physicians' views on monitoring and treating coagulation abnormalities in burn patients. A total of 350 questionnaires were distributed electronically to burn ICU physicians. Participation was voluntary and anonymous. Responses were analysed electronically and comparisons were made according to the region of the ICU or the specialty of the physician. Of the 350 questionnaires distributed, 55 (15.7%) were returned. The majority of burn specialists consider sepsis-induced coagulopathy to be the most frequent coagulopathy in burn patients, and 74.5% declare that they do not use any specific definition/scoring system in their department to detect coagulopathy. The majority of specialists (70.8%) use standard coagulation tests. The most frequent indications for plasma transfusion are massive bleeding (32.8%) and Disseminated Intravascular Coagulation syndrome treatment (20%). The main specific factors reported in our study are cryoprecipitate (23.2%) and fibrinogen concentrate (18.9%). 21.1% of respondents state that they do not use any specific coagulation factor substitution in burn patients. Specific coagulation factor substitution is not a routine practice. The low response rate precludes the generalization of our results.

La définition, l'importance et le traitement des anomalies de la coagulation chez les patients brûlés sont mal connues et font régulièrement l'objet de controverse dans la littérature. Nous avons analysé le point de vue des praticien sur le monitorage et le traitement de ces anomalies. Trois cent cinquante questionnaires ont été envoyés par voie électronique à des médecins travaillant en USI pour brûlés. La participation était volontaire et anonyme. Les réponses ont été comparées en tenant compte de la géographie et de la spécialité du répondant. Cinquante cinq (15,7%) ont été remplis. La majorité des praticiens considèrent que le sepsis est la cause la plus fréquente de coagulopathie chez les brûlés. Les ¾ n'utilisent pas de définition ni de score spécifiques, 70,8% utilisant les tests standard. Les indication le plus fréquentes de transfusion plasmatique (32,8%) sont le saignement massif et la CIVD (20%). Les facteurs spécifiques le plus souvent utilisés sont les cryoprécipités (23,2%) et le fibrinogène (18,9%), et 21,1% des sondés n'utilisent jamais de tels dérivés du sang. L'utilisation en routine de facteurs de coagulation est donc rare chez les brûlologues. Le faible taux de réponse ne permet pas d'inférer ces résultats à la population brûlologique générale.

Corrosive oesophageal strictures in children: outcomes after timely or delayed dilatation.

BACKGROUND AND STUDY AIMS: Among benign oesophageal lesions, caustic strictures are the most difficult to dilate. In low-income countries, children suffering caustic oesophageal injury are frequently referred to the hospitals late, sometimes weeks after ingestion. Therefore, dilatation may be performed late and in highly fibrotic strictures. Reports about endoscopic and clinical outcome of such delayed dilatations are scanty. The aim of this study was to evaluate the safety and efficacy of late caustic stricture dilatations in children, comparing it with the results of timely dilatations, both performed at the Hospital of the Italian Non-Governmental Organization "Emergency" at Goderich, Sierra Leone. PATIENTS AND METHODS: From December 2005 to May 2007, 78 children (<15 years) complaining alkaline caustic ingestion were submitted to oesophageal dilatation, mainly (97%) using Savary dilators. Two groups were identified: children (group 1) with a late treatment (>6 weeks, 37+/-12 weeks), having arrived to the hospital late after ingestion, and children (group 2) dilated timely, i.e. at <6 weeks (4+/-1.4 weeks) after injury. RESULTS: Strictures were severe in all patients. Twenty-five children were dilated late after injury (6.4 dilatations/patient) with a follow-up of 11+/-2.5 months. A successful clinical outcome was observed in 91.6%. Four perforations (2.6% procedure-related) and one death (4.0%) were observed. Strictures recurred once in 72% of patients, twice in 31.8%. Thirty-one children were dilated timely (4.5 dilatations/patient) with a follow-up of 10+/-2.1 months and a clinical success rate of 96.7%. Procedure-related perforation rate was 0.7% with one death (3.2%). Stricture recurred once in 30% and twice in 3.3%. CONCLUSIONS: Delayed dilatation of caustic oesophageal strictures in children carries a higher risk of perforation and a higher recurrence rate.

Postprandial triglyceride-rich lipoprotein metabolism and insulin sensitivity in nonalcoholic steatohepatitis patients.

Nonalcoholic steatohepatitis (NASH) is a syndrome frequently associated with obesity, diabetes mellitus, and dyslipidemia. Increased fasting insulinemia and blood glucose levels may trigger a reduced catabolism of lipoproteins rich in triglycerides by lipoprotein lipase (LPL) and an increase in their fasting and postprandial levels. An association between postprandial lipemia and coronary heart disease has been observed, and many studies now support this concept. The most important result of our study is the increase in triglyceride-rich lipoproteins response after a fat load in NASH patients, the increase of incremental area under the postprandial curve, and the duration of the hypertriglyceridemic peaks. The persisting postprandial plasma triglyceride elevation in NASH patients was mostly due to the elevated plasma level of large triglyceride-rich particles. These data are coupled with lower plasma HDL2-cholesterol levels. As for lipoprotein analyses, the number of apolipoprotein B100 (ApoB100) particles is not significantly different between the two groups, and the higher content of triglycerides in NASH very low density lipoproteins (VLDL) increases the triglyceride-to-ApoB ratio and the particle size. A decreased enzymatic activity of LPL or a defective assembly and secretion of VLDL from hepatocytes due to a moderate reduction in microsomal triglyceride transfer protein could be involved in the overloading of VLDL. Moreover, the undetectable levels of ApoB48 in triglyceride-rich lipoproteins fraction A could be related to the synthesis of smaller and denser chylomicrons. NASH patients not only are insulin resistant but also tend to present alterations in fatty meal delivery, suggesting that an increase in fasting plasma insulin and glucose, with insulin resistance, joins with depressed metabolism of triglyceride-rich lipoproteins. An increase in postprandial triglyceride levels with production of large VLDL suggests an atherogenic behavior of lipid metabolism, in accordance with the high prevalence of the metabolic syndrome in NASH patients. This paper suggests that a fat load may be useful in early detection of atherogenic risk in the presence of otherwise normal fasting plasma lipids.