Electrical injury - a dual center analysis of patient characteristics, therapeutic specifics and outcome predictors.

BACKGROUND: Electrical injuries represent life-threatening emergencies. Evidence on differences between high (HVI) and low voltage injuries (LVI) regarding characteristics at presentation, rhabdomyolysis markers, surgical and intensive burn care and outcomes is scarce. METHODS: Consecutive patients admitted to two burn centers for electrical injuries over an 18-year period (1998-2015) were evaluated. Analysis included comparisons of HVI vs. LVI regarding demographic data, diagnostic and treatment specific variables, particularly serum creatinine kinase (CK) and myoglobin levels over the course of 4 post injury days (PID), and outcomes. RESULTS: Of 4075 patients, 162 patients (3.9%) with electrical injury were analyzed. A total of 82 patients (50.6%) were observed with HVI. These patients were younger, had considerably higher morbidity and mortality, and required more extensive burn surgery and more complex burn intensive care than patients with LVI. Admission CK and myoglobin levels correlated significantly with HVI, burn size, ventilator days, surgical interventions, amputation, flap surgery, renal replacement therapy, sepsis, and mortality. The highest serum levels were observed at PID 1 (myoglobin) and PID 2 (CK). In 23 patients (14.2%), cardiac arrhythmias were observed; only 4 of these arrhythmias occurred after hospital admission. The independent predictors of mortality were ventilator days (OR 1.27, 95% CI 1.06-1.51, p = 0.009), number of surgical interventions (OR 0.47, 95% CI 0.27-0.834, p = 0.010) and limb amputations (OR 14.26, 95% CI 1.26-162.1, p = 0.032). CONCLUSIONS: Patients with electrical injuries, HVI in particular, are at high risk for severe complications. Due to the need for highly specialized surgery and intensive care, treatment should be reserved to burn units. Serum myoglobin and CK levels reflect the severity of injury and may predict a more complex clinical course. Routine cardiac monitoring > 24 h post injury does not seem to be necessary.

Regional citrate anticoagulation for continuous renal replacement therapy in severe burns-a retrospective analysis of a protocol-guided approach.

INTRODUCTION: For critically ill patients, the use of regional citrate anticoagulation as part of continuous renal replacement therapy (CRRT) has become increasingly common in recent years. However, there are scarce data on the use of this technique in patients with burns. The aim of this study was to examine the effectiveness, feasibility and complications of regional citrate anticoagulation for CRRT in burn patients, as well as the effects on coagulation and the electrolyte and acid-base balance. METHODS: This retrospective study included all patients who received renal replacement therapy with citrate anticoagulation to treat acute kidney injury (AKI) between January 1, 2004 and December 31, 2009 at the burn unit of St. Georg Hospital GmbH in Leipzig. RESULTS: During the examination period, 18 patients were treated using CRRT with regional citrate anticoagulation (CVVHDF in the pre-dilution mode). The median patient age was 64 years (49.5; 71), with a median TBSA of 42.5% (33.25; 52.5) and a median ABSI score of 10 (9; 10). The CRRT was initiated on a median of 6 days (4; 8.75) after admission to the hospital and continued for a median duration of 7 days (5; 8). The median dialysis dose was 38.2mlkgBW(-1)h(-1) (31.8; 42.1). The median effective filter operation time was 67h (46; 72). No relevant disorders associated with acid-base balance, electrolytes or coagulation occurred, and there were no bleeding complications. CONCLUSION: In terms of bleeding risk and electrolyte and acid-base balance, regional citrate anticoagulation may be considered to be an effective, safe and user-friendly procedure for patients with severe burns and AKI.

Safety of resuscitation with Ringer's acetate solution in severe burn (VolTRAB)--an observational trial.

BACKGROUND: A variety of crystalloids are available during fluid resuscitation of the severely burnt patient. There is a paucity of literature evidence on the comparative influence of these with regard to clinical outcomes. Significant differences in crystalloids may be clinically relevant given the large volumes employed during shock resuscitation. METHODS: The study compared two groups of severely burnt patients (TBSA 20-70%). Prospectively 40 consecutive patients treated with Ringer's acetate (RA group) against a retrospective control group of 40 patients treated with Ringer's lactate (RL group). Outcome parameters analysed included Sequential Organ Failure Assessment (SOFA)-scores at Days 3 and 7 after injury, mortality at 28 and 60 days, electrolyte and renal function, infection rates, cumulative volume administration and duration of ventilator support. RESULTS: Groups RA and RL were comparable w.r.t. age, total body surface area burn size and ABSI. SOFA-scores on Day 1 of admission also showed no significant difference but were significantly lower in RA group between the 3rd and 6th day. By Day 7 these differences could be attributed as a group effect (P=0.019). In particular low cardiovascular organ function scores contributed to this. Total crystalloid use within the first 28 days were equal in both but differed within the RA group having lower observed volumes of colloid and incidence of blood transfusion. Furthermore group RA had distinctly higher levels of platelets throughout treatment. Elevated lactate levels were noted in RL group during the initial three days. Survival rates at 28 days and 60 days showed no significant difference. CONCLUSION: Ringer's acetate solution is a suitable medium for the initial fluid management of the acutely burnt patient. In comparison to Ringer's lactate solution the study revealed lower SOFA-scores for Ringer's acetate solution (ClinicalTrials.gov number, NCT00609700).

A randomized trial of increased intravenous hydration in labor when oral fluid is unrestricted.

BACKGROUND AND OBJECTIVES: Increased intravenous (IV) hydration is associated with decreased labor duration and oxytocin augmentation in nulliparous women when oral fluid is restricted. The objective of this study was to determine the effect of increased IV hydration on the duration of labor when access to oral fluid was unrestricted. METHODS: Term, nulliparous women with uncomplicated singleton pregnancies were randomly assigned to receive lactated ringers at 250 ml per hour (IV fluid group) throughout active labor or usual care. All women were allowed unrestricted access to oral fluids. RESULTS: Eighty women completed the study, 37 in the IV fluid group and 43 in the usual care group. There was no difference in the primary outcome of total duration of labor (9.5 versus 9.4 hours) or in the secondary outcomes of duration of the first stage (7.9 versus 8.0 hours), duration of second stage (1.6 versus 1.4 hours), or rate of oxytocin augmentation (51% versus 44%). CONCLUSIONS: Increased IV hydration does not decrease labor duration in nulliparous women when access to oral fluid is unrestricted.

Hydrops fetalis secondary to parvovirus B19 infections.

BACKGROUND: Fetal infection by human parvovirus B19 is a common cause of fetal anemia, nonimmune hydrops fetalis, and spontaneous abortion and can result in fetal death. Recent improvements in diagnosing parvovirus infections and the availability of intrauterine transfusion have reduced the overall rate of fetal loss after maternal exposure. METHODS: We report two cases of maternal parvovirus infection with classic findings of hydrops fetalis and review various aspects of parvovirus infection with emphasis on the developing management options in pregnancy. RESULTS AND CONCLUSIONS: Different management led to different results. In the first case there was normal neonatal and infantile development, and in the second case, the fetus died. With accurate laboratory testing, obstetric sonography, and fetal transfusion, the fetal mortality from parvovirus infection has been reduced considerably, and most pregnancies complicated by maternal parvovirus infection result in healthy outcomes.