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-Transpulmonary thermodilution parameters. A. Extravascular lung water index; B. Intrathoracic blood volume index: The data are presented as the meansAESD. *One-way analysis of variance, P<0.05 vs. PBD 2.
Source publication
Background:
Increased extravascular lung water (EVLW) correlates with pulmonary morbidity and mortality in critical illness. The extravascular lung water index (EVLWI), which reflects the degree of EVLW in an individual, increases in the fluid reabsorption stage rather than the initial resuscitation stage in severe burn cases. While many factors c...
Contexts in source publication
Context 1
... EVLWI remained within the normal range (3-7ml/kg) during the fluid resuscitation stage (PBD 1 to PBD 2) and then increased beyond the normal from PBD 3 to PBD 9, indicating abnormal EVLWI developed during the fluid reabsorption stage ( Fig. 2A). PVPI decreased continually (Fig. 2B). The ITBVI was substantially lower than its normal value during the fluid resuscitation stage, and increased significantly after PBD 4 compared to PBD 2, reaching its peak on PBD 7 with a level close to the upper limit of normal ( Fig. 2C). CVP increased significantly after PBD 3 compared to PBD 2 ...
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... EVLWI remained within the normal range (3-7ml/kg) during the fluid resuscitation stage (PBD 1 to PBD 2) and then increased beyond the normal from PBD 3 to PBD 9, indicating abnormal EVLWI developed during the fluid reabsorption stage ( Fig. 2A). PVPI decreased continually (Fig. 2B). The ITBVI was substantially lower than its normal value during the fluid resuscitation stage, and increased significantly after PBD 4 compared to PBD 2, reaching its peak on PBD 7 with a level close to the upper limit of normal ( Fig. 2C). CVP increased significantly after PBD 3 compared to PBD 2 ( Fig. 2D). Both the CI and SVI ...
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... abnormal EVLWI developed during the fluid reabsorption stage ( Fig. 2A). PVPI decreased continually (Fig. 2B). The ITBVI was substantially lower than its normal value during the fluid resuscitation stage, and increased significantly after PBD 4 compared to PBD 2, reaching its peak on PBD 7 with a level close to the upper limit of normal ( Fig. 2C). CVP increased significantly after PBD 3 compared to PBD 2 ( Fig. 2D). Both the CI and SVI increased continually (Fig. 2E, F). The CI increased beyond the normal after PBD 4 ( Fig. 2E), whereas the SVI remained within the normal range (Fig. 2F). dPmax was generally within the normal range (Fig. 2G). The SVRI showed a transition from a ...
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... Fig. 2A). PVPI decreased continually (Fig. 2B). The ITBVI was substantially lower than its normal value during the fluid resuscitation stage, and increased significantly after PBD 4 compared to PBD 2, reaching its peak on PBD 7 with a level close to the upper limit of normal ( Fig. 2C). CVP increased significantly after PBD 3 compared to PBD 2 ( Fig. 2D). Both the CI and SVI increased continually (Fig. 2E, F). The CI increased beyond the normal after PBD 4 ( Fig. 2E), whereas the SVI remained within the normal range (Fig. 2F). dPmax was generally within the normal range (Fig. 2G). The SVRI showed a transition from a high vascular resistance on PBDs 1-2 to a low vascular resistance on ...
Context 5
... ITBVI was substantially lower than its normal value during the fluid resuscitation stage, and increased significantly after PBD 4 compared to PBD 2, reaching its peak on PBD 7 with a level close to the upper limit of normal ( Fig. 2C). CVP increased significantly after PBD 3 compared to PBD 2 ( Fig. 2D). Both the CI and SVI increased continually (Fig. 2E, F). The CI increased beyond the normal after PBD 4 ( Fig. 2E), whereas the SVI remained within the normal range (Fig. 2F). dPmax was generally within the normal range (Fig. 2G). The SVRI showed a transition from a high vascular resistance on PBDs 1-2 to a low vascular resistance on PBDs 3-9 (Fig. ...
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... fluid resuscitation stage, and increased significantly after PBD 4 compared to PBD 2, reaching its peak on PBD 7 with a level close to the upper limit of normal ( Fig. 2C). CVP increased significantly after PBD 3 compared to PBD 2 ( Fig. 2D). Both the CI and SVI increased continually (Fig. 2E, F). The CI increased beyond the normal after PBD 4 ( Fig. 2E), whereas the SVI remained within the normal range (Fig. 2F). dPmax was generally within the normal range (Fig. 2G). The SVRI showed a transition from a high vascular resistance on PBDs 1-2 to a low vascular resistance on PBDs 3-9 (Fig. ...
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... PBD 4 compared to PBD 2, reaching its peak on PBD 7 with a level close to the upper limit of normal ( Fig. 2C). CVP increased significantly after PBD 3 compared to PBD 2 ( Fig. 2D). Both the CI and SVI increased continually (Fig. 2E, F). The CI increased beyond the normal after PBD 4 ( Fig. 2E), whereas the SVI remained within the normal range (Fig. 2F). dPmax was generally within the normal range (Fig. 2G). The SVRI showed a transition from a high vascular resistance on PBDs 1-2 to a low vascular resistance on PBDs 3-9 (Fig. ...
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... with a level close to the upper limit of normal ( Fig. 2C). CVP increased significantly after PBD 3 compared to PBD 2 ( Fig. 2D). Both the CI and SVI increased continually (Fig. 2E, F). The CI increased beyond the normal after PBD 4 ( Fig. 2E), whereas the SVI remained within the normal range (Fig. 2F). dPmax was generally within the normal range (Fig. 2G). The SVRI showed a transition from a high vascular resistance on PBDs 1-2 to a low vascular resistance on PBDs 3-9 (Fig. ...
Context 9
... 2D). Both the CI and SVI increased continually (Fig. 2E, F). The CI increased beyond the normal after PBD 4 ( Fig. 2E), whereas the SVI remained within the normal range (Fig. 2F). dPmax was generally within the normal range (Fig. 2G). The SVRI showed a transition from a high vascular resistance on PBDs 1-2 to a low vascular resistance on PBDs 3-9 (Fig. ...
Context 10
... a cardiac preload parameter, was another factor showing a strong association with EVLWI variations in our study. The ITBVI was largely lower than normal during the fluid resuscitation stage but subsequently increased in the fluid reabsorption stage (Fig. 2C), which is consistent with other reports [12,14]. Although a larger burn size is correlated with greater fluid resuscitation requirements and greater subsequent fluid reabsorption, ITBVI was identified as an independent factor for a supranormal EVLWI in our study. This result is indirectly supported by the fact that no differences were ...
Citations
... Nevertheless, the volumes of additional fluid for patients with inhalation injury were 500 ml and 300 ml for the 1 st and 2 nd 24 hours after burn, respectively, which were lower than the reports of other studies. This difference might be associated with the restricted fluid resuscitation strategy we took in patients with inhalation injury to avoid the aggravation of pulmonary edema [27]. In this study, the average urine outputs of patients with inhalation injury were 0.79±0.35 ...
Background
The Third Military Medical University (TMMU) formula is widely utilized in the fluid resuscitation in China. However, the actual volume needs usually exceed the prediction provided by the TMMU formula in major burn patients with a high proportion of full-thickness burn wounds.
Method
This retrospective study included 149 adult major burn patients (≥40% TBSA) who were admitted to the Burn Department, Southwest Hospital from 2014 to 2020 and received appropriate fluid resuscitation by the TMMU protocol. The actual volume infused in the first 48 hours post-burn was compared to the estimation by the TMMU formula. A new fluid volume prediction formula was developed by multivariate linear regression analysis.
Result
The mean fluid requirements were 2.35 ml/kg/%TBSA and 1.75 ml/kg/%TBSA in the 1 st and 2 nd 24 hours post-burn, respectively. The TMMU formula underestimated the fluid requirement, and its prediction accuracy was 54.1% and 25.8% for the 1 st and 2 nd 24 hours, respectively. The proportion of full-thickness burn wound was found to be associated with the fluid requirements after burn. A revised multifactorial formula consisting of the burn index, body weight and inhalation injury was developed. Using the revised formula, the prediction reliability of resuscitation fluid volume improved to 65.3% and 61.1% in the 1st and 2nd 24 hours, respectively.
Conclusion
The TMMU formula showed low accuracy in predicting fluid requirements among major burn patients. A revised formula based on burn index was developed to provide better guidance for initiative fluid resuscitation for major burns by the TMMU protocol.
... EVLWI is regarded as a significant parameter in the fluid management of the major burns to avoid fluid overload. 13,14 Furthermore, we found that EVLWI is independently influenced by intrathoracic blood volume index, a cardiac preload parameter, in major burns, 15 indicating that EVLWI could probably be reduced to harmless level by proper invitations. Nevertheless, a correlation of EVLWI with the prognosis of early ARDS in burn patients has not been established yet. ...
... Liquid resuscitation in our department refers to the TMMU protocol, as described previously. 15 Tracheotomy, escharoctomy, and digital chest radiographs were performed after admission if necessary. Fibreoptic bronchoscopy was performed in order to determine whether there existed an inhalation injury. ...
An important feature of acute respiratory distress syndrome (ARDS) is fluid lost into the interstitium of lung combined with its compromised reabsorption, resulting in the elevation of extravascular lung water (EVLW). Although ARDS is known as an early, common, and life-threatening complication in major burns, the issue of whether or how the EVLW index (EVLWI) correlates to its prognosis has not been identified yet. In this retrospectively study, 121 severely burned adults with ARDS occurred in two weeks postburn were analyzed and divided into two groups: survivors (73 patients) and non-survivors (48 patients) according to the 28-day outcome after injury. Compared to non-survivors, survivors exhibited bigger EVLWI reduction in day 2 after ARDS onset (ΔEVLWI2), with no differences in ARDS timing and other EVLWI variables. ΔEVLWI2, rather than EVLWI on 2 days after ARDS onset, was identified as an independent prognostic factor even after adjusting other significant factors by Cox proportional hazard analysis. ROC curve analysis showed that ΔEVLWI2 [AUC=0.723, 95% CI= (0.631- 0.816), P<0.001] was a relative predictor for survival on 28-day postburn, with a threshold of 1.9 ml/kg (63.0% sensitivity, 77.1% specificity). Kaplan-Meier survival curve analysis confirmed a significantly higher survival rate on 28-day postburn in patients with ΔEVLWI2 > 1.9 ml/kg (log-rank test: χ2 =14.780, P< 0.001). Taken together, our study demonstrated that ΔEVLWI2 is an independent prognostic factor for early ARDS in severe burns. ΔEVLWI2 higher than 1.9 ml/kg might predict a higher survival rate in those patients.
Background
Burn patients with inhalation injury are at higher risk of developing pneumonia, and yet there is no reliable tool for the assessment of the risk for such patients at admission. This study aims to establish a predictive model for pneumonia risk for burn patients with inhalation injury based on clinical findings and laboratory tests.
Method
This retrospective study enrolled 546 burn patients with inhalation injury. They were grouped into a training cohort and a validation cohort. The least absolute shrinkage and selection operator (LASSO) regression analysis and binary logistic regression analysis were utilized to identify risk factors for pneumonia. Based on the factors, a nomogram for predicting pneumonia in burn patients with inhalation injury was constructed. Areas under the receiver operating characteristic curves (AUC), calibration plots and decision curve analysis (DCA) were used to evaluate the efficiency of the nomogram in both the training and validation cohorts.
Results
The training cohort included 432 patients, and the validation cohort included 114 patients, with a total of 225 (41.2%) patients experiencing pneumonia. Inhalation injury, tracheal intubation/tracheostomy, low serum albumin, and high blood glucose were independent risk factors for pneumonia in burn patients with inhalation injury and they were further used to build the nomogram. The AUC of the nomogram in the training and validation cohorts were 0.938 (95% CI, 0.917-0.960) and 0.966 (95% CI, 0.931-1), respectively. The calibration curve for probability of pneumonia showed optimal agreement between the prediction by nomogram and the actual observation, and the DCA indicated that the constructed nomogram conferred high clinical net benefit.
Conclusion
This nomogram can accurately predict the risk of developing pneumonia for burn patients with inhalation injury, and help professionals to identify high-risk patients at an early stage as well as to make informed clinical decisions.
Objective: We conducted a systematic review and meta-analysis to comprehensively estimate the incidence and mortality of acute respiratory distress syndrome (ARDS) in overall and subgroups of patients with burns.
Data sources: Pubmed, Embase, the Cochrane Library, CINAHL databases, and China National Knowledge Infrastructure database were searched until September 1, 2021.
Study selection: Articles that report study data on incidence or mortality of ARDS in patients with burns were selected.
Data extraction: Two researchers independently screened the literature, extracted data, and assessed the quality. We performed a meta-analysis of the incidence and mortality of ARDS in patients with burns using a random effects model, which made subgroup analysis according to the study type, inclusion (mechanical ventilation, minimal burn surface), definitions of ARDS, geographic location, mean age, burn severity, and inhalation injury. Primary outcomes were the incidence and mortality of burns patients with ARDS, and secondary outcomes were incidence for different subgroups.
Data synthesis: Pooled weighted estimate of the incidence and mortality of ARDS in patients with burns was 0.24 [95% confidence interval (CI)0.2–0.28] and 0.31 [95% CI 0.18−0.44]. Incidences of ARDS were obviously higher in patients on mechanical ventilation (incidence = 0.37), diagnosed by Berlin definition (incidence = 0.35), and with over 50% inhalation injury proportion (incidence = 0.41) than in overall patients with burns. Patients with burns who came from western countries and with inhalation injury have a significantly higher incidence of ARDS compared with those who came from Asian/African countries (0.28 vs. 0.25) and without inhalation injury (0.41 vs. 0.24).
Conclusion: This systematic review and meta-analysis revealed that the incidence of ARDS in patients with burns is 24% and that mortality is as high as 31%. The incidence rates are related to mechanical ventilation, location, and inhalation injury. The patients with burns from western countries and with inhalation injury have a significantly higher incidence than patients from Asian/African countries and without inhalation injury.
Systematic Review Registration: identifier: CRD42021144888.
The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic conditions as well as oxygen delivery to the vital organs (DO2) among this patient population, a rapid assessment of cardiac function is essential. In this context, hemodynamic focused echocardiography offers an excellent opportunity to examine the signs of cardiac filling impairment, preload, myocardial contractility, and the function of the heart valves. In this chapter, a practical six-step approach towards a perioperative echocardiographic-based hemodynamic optimization is presented. The summary of all echocardiographic findings and their integration in the clinical context along with the patients’ medical background allows a differentiated assessment of the patient’s cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.
Pulmonary edema (PE) is a hallmark of many life-threatening conditions, frequently overlapping with acute respiratory distress syndrome, heart failure, and overhydration. The accumulation of lung fluid can result from increased microvascular permeability and microvascular outflow pressure (hydrostatic or “cardiogenic” edema). The excessive filtration of water and proteins, as well as migration of inflammatory cells, involves both interstitial and alveolar compartments of the lung tissue and is cleared by various mechanisms including lymphatic drainage and venous backflow. The boundary between cardiogenic and non-cardiogenic PE seems to be not steady since the permeability and hydrostatic components are interrelated and can often coexist. The key technique for the reference bedside quantification and monitoring of PE in critically ill patients is single transpulmonary thermodilution currently integrated into many monitoring systems. In addition, the use of lung ultrasound can be a plausible alternative for screening and semiquantitative assessment of PE.
In the new century, our diagnostic armamentarium has been significantly reinforced by the 'three-dimensional' volumetric haemodynamic monitoring currently available at the bedside in many perioperative and intensive care settings. The volumetric approach has improved our insight into the haemodynamic scenarios of many critical illnesses and surgical interventions, including sepsis, circulatory shock, acute respiratory distress syndrome as well as cardiothoracic and transplantation surgery. However, the influence of volumetric haemodynamic monitoring on clinical outcome is still a subject for debates. This review presents physiological background, technical details, aspects of bedside use, limitations and further perspectives of the volumetric approach to the cardiopulmonary monitoring.
