Specific aspects of perioperative and intensive care management of burn patients
In Chapter 1, we investigated the changes in mortality, admittance criteria and case-mix over the last 30 years of the burn intensive care of the Maasstad Hospital. We observed a significant decline in ICU mortality from 23% in the first decade (1987-1996) to 7% in the last decade (2007-2016). We hypothesized that the improved mortality rate reflects advances in intensive care and burn treatment. We identified a shift in ICU case-mix, from admissions for major burns to a significant proportion (22%) of patients admitted for “watchful waiting”, for example, in cases of inhalation injury. Documenting these findings provide a good oversight of the positive changes in the last 30 years and provide a foundation for future research. In Chapter 2 we reviewed the current national and international burn guidelines. Overall, the guidelines emphasize decisive airway monitoring and intubation, lung protective ventilation, prompt fluid resuscitation and multi-model pain management. The guidelines lack practical support for the treating physician. For example, a step-by-step approach for observing airway patency and guiding towards intubation lacks. Furthermore, the guidelines differ in the threshold for resuscitation (15% or 20% TBSA), choice of resuscitation fluid (which balanced solution), adjuncts to resuscitation (e.g. the addition of albumin) and lack recommendations for the use of vasopressors during burn shock. We have identified key areas where future guidelines can be improved. In Chapter 3 we reviewed available literature focusing on inhalation injury, airway management and ventilation strategies. We propose a step-by-step approach for guiding intubation decisions in patients with suspected inhalation injury, emphasizing the option of deferred intubation and the consequent need for close and repeated monitoring with, for example, nasolaryngoscopy. Currently, the evidence does not support the use of specialized ventilation strategies than the current state-of-the-arts lung protective ventilation used in non-burn patients. In Chapter 4 we provided novel evidence that reducing the initial resuscitation volume from 4 mL/kg/TBSA (hypertonic solution) to 3 mL/kg/TBSA (isotonic solution) does not adversely affect renal function in severe burn patients. Our direct comparison of these two strategies showed that individualized, goal-directed resuscitation can safely reduce fluid volumes without increasing the risk of acute kidney injury or the need for renal replacement therapy. Our findings support a paradigm shift towards more conservative and tailored fluid resuscitation in burn care. In Chapter 5 we developed and internally validated a clinical prediction model for significant blood loss (>250 mL) during burn excisional surgery. Our model, based on %TBSA excised, length of surgery, and ASA-score, demonstrated excellent discrimination (AUC 0.92) and calibration. In Chapter 6, through a systematic review and meta-analysis, we demonstrated moderate-level evidence that tranexamic acid is able to reduce perioperative blood loss and transfusion. While the meta-analysis solely on RCT-data did not find a statistically significant reduction. Due to de moderate-level of evidence and the need for more RCT-data we have designed the TRANEX-study, which is currently ongoing. In Chapter 7, we described the protocol. Our ongoing TRANEX trial will provide high-quality evidence regarding the efficacy and safety of TXA in this setting, as well as insights into the perioperative coagulation and fibrinolytic response in burn patients. In Chapter 8 we evaluated the feasibility and microbiological safety of cell salvage in burn excisional and found that cell salvage can recover approximately 29% of lost red cell mass. However, all samples showed bacterial contamination despite strict sterile technique. Our findings highlight the need for further research into decontamination strategies, such as antibiotic addition, before cell salvage can be safely implemented in burn surgery.