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Responsiveness during resuscitation of severe burns using the Parkland formula
S16
Burns 3 5 S ( 2 0 0 9 ) S1–S47
settings. This investigation was conducted to describe the safety of intraosseous infusion of hydroxocobalamin for suspected smoke inhalation cyanide poisoning. Methods: A 9-month-old female infant with suspected cyanide poisoning from
OC062 Split-thickness skin harvesting from the scalp—Long-term cosmetic results夽
smoke inhalation was sedated, intubated, and administered hydroxocobalamin
R. Zgraggen ∗ , K. Schaeffer, M. Meuli, C. Schiestl Pediatric Burn Center, Plastic and Recon-
2.5 g1 intraosseously with a Bone Injection Gun at the scene of a house fire. Just
structive Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
before treatment, the infant was tachycardic (200 bpm) with a blood pressure of 120/70 mmHg, Glasgow Coma Scale score of 8, and oxygen saturation of 92%. Results: Hemodynamic parameters stabilized after prehospital treatment with hydroxocobalamin. The patient was transported to the intensive care unit of the burn center of the Trousseau Hospital in Paris. The patient was extubated on the second day of hospitalization. Nine days after treatment, the patient was discharged from the intensive care unit with no neurological or other sequelae. Conclusion: Intraosseous administration of hydroxocobalamin for the treatment of suspected cyanide poisoning from smoke inhalation did not appear to be associated with any safety risks. The intraosseous route of administration of hydroxocobalamin warrants further exploration given the potential of this route to improve upon ease and speed of treatment and to support earlier intervention, especially in mass-casualty incidents. 1
In France, the recommended pediatric dosage is 70 mg/kg (repeated if necessary
depending on clinical status).
Rationale: Several studies have proven the scalp to be a reliable donor site in pediatric burns with low healing complications, but sufficient information concerning the long-term cosmetic results is still missing. The present study provides information about long-term results of pediatric burns up to 30 years after skin harvesting. Methods: All patients (n = 71) with ≥1 skin harvest from the scalp due to burn injury in childhood with a current age of ≥30 years were included in the study. History and clinical data of these patients were extracted from their charts and they were contacted and informed about the study. 32 former patients (18 male and 14 female) were finally identified and agreed to participate in the study. A thorough clinical examination of their scalp with regard to abnormal pigmentation, hypertrophic scars, disturbance of the texture and irregular hair growth was performed. They were interviewed about negative perceptions concerning their scalp and their general health status was evaluated by using a standardized questionnaire. Results: Percentage of total body surface area burned was 7–55 percent and the number of scalp donor site harvests ranged from 1 to 5 times per person. The
doi:10.1016/j.burns.2009.06.061
results of the current sample showed that 100 percent of the examined patients (n = 20) had normal age-related hair growth, comparable to those of close family members. Two patients presented areas with hypopigmentation, none of them had
OC061 Responsiveness during resuscitation of severe burns using the Parkland formula夽
hypertrophic scars. One patient showed disturbance of the texture and another
Z. Bak 1,∗ , I. Steinvall 2 , B. Janerot-Sjoberg 3 , F. Sjöberg 1 1 Department of Intensive Care
on any personal complaints.
and Burn Intensive Unit, University Hospital, Linkoping, Sweden 2 Burn Intensive Unit, University Hospital, Linkoping, Sweden 3 Department of Clinical Physiology, University Hospital, Linkoping, Sweden
Conclusion: Although the final results are still open – as it is a work in progress and
Rationale: Predicting fluid responsiveness is vital during the first hours after a severe
once more that the scalp is a reliable donor site in pediatric burns and could help
burn. Burn injuries are characterized by continuous, not only fluid replacement
to disburden parents’ fears of additional deformations in adulthood. It also reveals
caused changes in preload, afterload, heart rate (HR), and arterial and venous
that even repeated skin harvesting from the scalp does not have a negative impact
compliance. This makes decision-making based on immediate responsiveness to
on the cosmetic long-term results at the donor site.
fluid challenge using both static and dynamic hemodynamic-endpoints difficult.
doi:10.1016/j.burns.2009.06.063
patient had a round alopecic spot at the back of the head. Not one patient reported
there are 12 former patients still to be examined – this present study indicates
We hypothesized that using transesophageal echocardiography (TEE) 12, 24 and 36 h after a burn to investigate the association of fluid replacement, to increasing left ventricular end diastolic area (LVEDA), and to stroke volume (SV) using the Parkland formula would support a finding of a relative hypovolemia at the 12 h
OC063 Assessment of blood loss during burn surgery夽
measurement.
A. Vichard ∗ , P. Jault, P. Duhamel, L. Bargues Centre de traitement des brules, Hopital instruc-
Methods: Ten consecutive adults (aged 36–89 years, two women) with a burn
tion des armees percy, Clamart, France
injury exceeding 20% total burned body surface area (TBSA), needing mechanical ventilation were studied. Mean Baux index 92.7. Resuscitation was performed according to the Parkland formula. 30 series of TEE examinations, and simultaneous Doppler SV measurements were performed 12, 24 and 36 h after burn. Results: Table 1 shows mean SV and LVEDA measured by TEE at 12, 24 and 36 h after burn. The mean values increased significantly for the group during resuscitation between 12 and 24 h postburn. Nine of the ten patients increased their stroke volume in response to an increased LVEDA.
Rationale: Blood transfusions in burns were associated with morbidity and significant cost. The aim of the study was to evaluate our transfusion practice and measure surgical blood loss. Methods: All patients with burns (>10% TBSA) who required at least one surgical procedure (excision-grafts) were prospectively included in 6 months period. In operating room (operative) and in ICU (postoperative), red cells transfusion (bag 250 ml with hematocrit 60%) was made if haemoglobin was <7 g/dl and after fresh frozen plasma (FFP) was transfused if prothrombin rate was <30%. In case of transfusion, compensated blood loss was = (45 × number of red cells bag/pretransfusion haemoglobin) × 100. In absence of transfusion, noncom-
Table 1 – Hemodynamic parameters using the Parkland formula. Mean values ± SD. LVEDA (cm2 ) SV Doppler (ml)
6.96 ± 2.7 39.76 ± 7.5
11.95 ± 3.9 65.21 ± 25.1
14.61 ± 2.2a,b,c 76.88 ± 17.9a,b
Abbreviations: LVEDA: end-diastolic cross-sectional area of the left ventricular cavity; SV Doppler: stroke volume measured by Doppler echocardiography. Significant change on level p < 0.05. a Significant difference between measurements at 12 and 36 h; b Significant difference between 12 and 24 h; c Significant difference between 24 and 36 h.
pensated blood loss was = body blood volume (70 ml/kg in man, 65 ml/kg in woman) × (initial hematocrit − final hematocrit) × 0.3. Total blood volume losses were the amount of operative and postoperative losses, compensating or not by transfusion. Results: 54 patients were included and required 113 procedures (2.1 procedures/patient; range 1–7). 102 procedures were excision-autografts and 11 were excision-allografts (without donor sites). Results are in mean + SD. Demographics were: age 44.2 ± 18.6 years (range 15–90), burns 29.4 ± 18.2 TBSA (8–80), inhalation injury 35.2% (n = 19), length of stay 18.1 ± 12.8 days (2–62), mortality 11.1% (6 deaths). Total blood loss (plasma and cells) was 2862 ± 1567 ml (0–8292). Operative loss was 1628 ± 1010 ml (0–5273) and postoperative loss was 1233 ± 1103 ml (0–7409). Noncompensated blood loss was 834 ± 1321 ml (0–7409) and compensated blood loss was 2026 ± 1581 ml (0–7253). Red cells bags transfused were operatively 2.1 ± 1.7
Conclusion: We conclude that parallel LVEDA and SV measurements during continuous fluid replacement by the Parkland protocol suggest a relative central circulatory hypovolemia at the 12 h measurement. doi:10.1016/j.burns.2009.06.062
(0–6) and postoperatively 1.3 ± 1.5 (0–8). FFP transfused were operatively 0.1 ± 0.5 (0–2) and postoperatively 0.2 ± 0.6 (0–3). Surgical bleeding represented operatively 1.68 ± 1.75 ml of blood/cm2 autografts (0–10) and an amount of 2.73 ± 2.3 ml of total blood/cm2 autografts (0–14). Conclusion: Surgical blood loss in our burn centre is upper than values published previously. Changes in surgical technique and wound management are necessary to reduce transfusion requirements. doi:10.1016/j.burns.2009.06.064
Burns 3 5 S ( 2 0 0 9 ) S1–S47
settings. This investigation was conducted to describe the safety of intraosseous infusion of hydroxocobalamin for suspected smoke inhalation cyanide poisoning. Methods: A 9-month-old female infant with suspected cyanide poisoning from
OC062 Split-thickness skin harvesting from the scalp—Long-term cosmetic results夽
smoke inhalation was sedated, intubated, and administered hydroxocobalamin
R. Zgraggen ∗ , K. Schaeffer, M. Meuli, C. Schiestl Pediatric Burn Center, Plastic and Recon-
2.5 g1 intraosseously with a Bone Injection Gun at the scene of a house fire. Just
structive Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
before treatment, the infant was tachycardic (200 bpm) with a blood pressure of 120/70 mmHg, Glasgow Coma Scale score of 8, and oxygen saturation of 92%. Results: Hemodynamic parameters stabilized after prehospital treatment with hydroxocobalamin. The patient was transported to the intensive care unit of the burn center of the Trousseau Hospital in Paris. The patient was extubated on the second day of hospitalization. Nine days after treatment, the patient was discharged from the intensive care unit with no neurological or other sequelae. Conclusion: Intraosseous administration of hydroxocobalamin for the treatment of suspected cyanide poisoning from smoke inhalation did not appear to be associated with any safety risks. The intraosseous route of administration of hydroxocobalamin warrants further exploration given the potential of this route to improve upon ease and speed of treatment and to support earlier intervention, especially in mass-casualty incidents. 1
In France, the recommended pediatric dosage is 70 mg/kg (repeated if necessary
depending on clinical status).
Rationale: Several studies have proven the scalp to be a reliable donor site in pediatric burns with low healing complications, but sufficient information concerning the long-term cosmetic results is still missing. The present study provides information about long-term results of pediatric burns up to 30 years after skin harvesting. Methods: All patients (n = 71) with ≥1 skin harvest from the scalp due to burn injury in childhood with a current age of ≥30 years were included in the study. History and clinical data of these patients were extracted from their charts and they were contacted and informed about the study. 32 former patients (18 male and 14 female) were finally identified and agreed to participate in the study. A thorough clinical examination of their scalp with regard to abnormal pigmentation, hypertrophic scars, disturbance of the texture and irregular hair growth was performed. They were interviewed about negative perceptions concerning their scalp and their general health status was evaluated by using a standardized questionnaire. Results: Percentage of total body surface area burned was 7–55 percent and the number of scalp donor site harvests ranged from 1 to 5 times per person. The
doi:10.1016/j.burns.2009.06.061
results of the current sample showed that 100 percent of the examined patients (n = 20) had normal age-related hair growth, comparable to those of close family members. Two patients presented areas with hypopigmentation, none of them had
OC061 Responsiveness during resuscitation of severe burns using the Parkland formula夽
hypertrophic scars. One patient showed disturbance of the texture and another
Z. Bak 1,∗ , I. Steinvall 2 , B. Janerot-Sjoberg 3 , F. Sjöberg 1 1 Department of Intensive Care
on any personal complaints.
and Burn Intensive Unit, University Hospital, Linkoping, Sweden 2 Burn Intensive Unit, University Hospital, Linkoping, Sweden 3 Department of Clinical Physiology, University Hospital, Linkoping, Sweden
Conclusion: Although the final results are still open – as it is a work in progress and
Rationale: Predicting fluid responsiveness is vital during the first hours after a severe
once more that the scalp is a reliable donor site in pediatric burns and could help
burn. Burn injuries are characterized by continuous, not only fluid replacement
to disburden parents’ fears of additional deformations in adulthood. It also reveals
caused changes in preload, afterload, heart rate (HR), and arterial and venous
that even repeated skin harvesting from the scalp does not have a negative impact
compliance. This makes decision-making based on immediate responsiveness to
on the cosmetic long-term results at the donor site.
fluid challenge using both static and dynamic hemodynamic-endpoints difficult.
doi:10.1016/j.burns.2009.06.063
patient had a round alopecic spot at the back of the head. Not one patient reported
there are 12 former patients still to be examined – this present study indicates
We hypothesized that using transesophageal echocardiography (TEE) 12, 24 and 36 h after a burn to investigate the association of fluid replacement, to increasing left ventricular end diastolic area (LVEDA), and to stroke volume (SV) using the Parkland formula would support a finding of a relative hypovolemia at the 12 h
OC063 Assessment of blood loss during burn surgery夽
measurement.
A. Vichard ∗ , P. Jault, P. Duhamel, L. Bargues Centre de traitement des brules, Hopital instruc-
Methods: Ten consecutive adults (aged 36–89 years, two women) with a burn
tion des armees percy, Clamart, France
injury exceeding 20% total burned body surface area (TBSA), needing mechanical ventilation were studied. Mean Baux index 92.7. Resuscitation was performed according to the Parkland formula. 30 series of TEE examinations, and simultaneous Doppler SV measurements were performed 12, 24 and 36 h after burn. Results: Table 1 shows mean SV and LVEDA measured by TEE at 12, 24 and 36 h after burn. The mean values increased significantly for the group during resuscitation between 12 and 24 h postburn. Nine of the ten patients increased their stroke volume in response to an increased LVEDA.
Rationale: Blood transfusions in burns were associated with morbidity and significant cost. The aim of the study was to evaluate our transfusion practice and measure surgical blood loss. Methods: All patients with burns (>10% TBSA) who required at least one surgical procedure (excision-grafts) were prospectively included in 6 months period. In operating room (operative) and in ICU (postoperative), red cells transfusion (bag 250 ml with hematocrit 60%) was made if haemoglobin was <7 g/dl and after fresh frozen plasma (FFP) was transfused if prothrombin rate was <30%. In case of transfusion, compensated blood loss was = (45 × number of red cells bag/pretransfusion haemoglobin) × 100. In absence of transfusion, noncom-
Table 1 – Hemodynamic parameters using the Parkland formula. Mean values ± SD. LVEDA (cm2 ) SV Doppler (ml)
6.96 ± 2.7 39.76 ± 7.5
11.95 ± 3.9 65.21 ± 25.1
14.61 ± 2.2a,b,c 76.88 ± 17.9a,b
Abbreviations: LVEDA: end-diastolic cross-sectional area of the left ventricular cavity; SV Doppler: stroke volume measured by Doppler echocardiography. Significant change on level p < 0.05. a Significant difference between measurements at 12 and 36 h; b Significant difference between 12 and 24 h; c Significant difference between 24 and 36 h.
pensated blood loss was = body blood volume (70 ml/kg in man, 65 ml/kg in woman) × (initial hematocrit − final hematocrit) × 0.3. Total blood volume losses were the amount of operative and postoperative losses, compensating or not by transfusion. Results: 54 patients were included and required 113 procedures (2.1 procedures/patient; range 1–7). 102 procedures were excision-autografts and 11 were excision-allografts (without donor sites). Results are in mean + SD. Demographics were: age 44.2 ± 18.6 years (range 15–90), burns 29.4 ± 18.2 TBSA (8–80), inhalation injury 35.2% (n = 19), length of stay 18.1 ± 12.8 days (2–62), mortality 11.1% (6 deaths). Total blood loss (plasma and cells) was 2862 ± 1567 ml (0–8292). Operative loss was 1628 ± 1010 ml (0–5273) and postoperative loss was 1233 ± 1103 ml (0–7409). Noncompensated blood loss was 834 ± 1321 ml (0–7409) and compensated blood loss was 2026 ± 1581 ml (0–7253). Red cells bags transfused were operatively 2.1 ± 1.7
Conclusion: We conclude that parallel LVEDA and SV measurements during continuous fluid replacement by the Parkland protocol suggest a relative central circulatory hypovolemia at the 12 h measurement. doi:10.1016/j.burns.2009.06.062
(0–6) and postoperatively 1.3 ± 1.5 (0–8). FFP transfused were operatively 0.1 ± 0.5 (0–2) and postoperatively 0.2 ± 0.6 (0–3). Surgical bleeding represented operatively 1.68 ± 1.75 ml of blood/cm2 autografts (0–10) and an amount of 2.73 ± 2.3 ml of total blood/cm2 autografts (0–14). Conclusion: Surgical blood loss in our burn centre is upper than values published previously. Changes in surgical technique and wound management are necessary to reduce transfusion requirements. doi:10.1016/j.burns.2009.06.064