Volker Gebhardt

Background and Objectives: Severe burn injuries are still associated with high mortality. The length of intensive care stay is strongly influenced by the severity of organ failure, with multi-organ failure being the main cause of death in up to 40% of cases. Liver dysfunction is the second most common organ failure. Conventional diagnosis relies on static laboratory parameters that reflect damage already caused. Measuring the hepatic clearance of indocyanine green (LiMON^®) offers a dynamic, bedside method for detecting liver dysfunction early, enabling timely therapy adjustments. Materials and Methods: In this prospective single-centre observational study, all patients admitted to the Unfallkrankenhaus Berlin Burns Centre from October 2022 to September 2024 with ≥30% TBSA burns were included. Liver function was assessed via LiMON^® within 24 h post-injury and every 48 h until day 14 or ICU discharge. Static liver parameters were measured in parallel. Results: We included a total of 23 patients. An initial measurement was only successful in 18 cases. On admission, six patients (33%) had normal liver function with a plasma duration rate (PDR) > 18% (PDR 30.9 ± 7.3%), while 12 (67%) showed reduced clearance (PDR 14.5 ± 2.6%). In 75% of cases (n = 9), function recovered within 48 h. Based on PDR progression, four liver function patterns were defined: “stable”, “recovery”, “late insufficiency”, and “failure”; a fifth pattern included all patients who were deceased during this study (“death”). These groups differed in fluid therapy, plasma transfusion, and catecholamines administered. PDR correlated well with aminotransferase levels. Conclusions: Dynamic liver function monitoring enables earlier detection of impairment than static markers. Early identification of at-risk patients could guide fluid management and improve outcomes. LiMON^® is a valuable tool in burn care, though alternative methods may be needed in patients with severe systemic hypoperfusion.

Background: Finding the optimal amount of fluid is a major challenge in burn shock. Although there is evidence that a restrictive fluid regime is beneficial, current practice shows fluid resuscitation still well above recommendations. The extent of trauma, pre-hospital care and the patient’s pre-existing conditions influence requirements. Methods: We analysed outcomes and influencing factors of fluid regimes in a retrospective cohort study including 90 severely burnt patients resuscitated with the same protocol. Results: The mean amount of fluids in the first 24 h was 6.5 mL/kg bodyweight (BW)/% total burn surface area (TBSA). A total of 14% received restrictive (6) mL/kgBW/%TBSA fluids. There was no difference regarding mortality, age, complications, organ failure, inhalation injury or full-thickness burns in the groups. Patients with excessive fluid therapy had a significantly lower ABSI score (9 vs. 11, p = 0.05) and TBSA (35 vs. 51%, p < 0.001), while patients with a restrictive fluid therapy needed fewer incidences of surgery to cover burn wounds (3.5 vs. 9.0 vs. 7.0, p = 0.008). History of liver disease or alcohol abuse tended to indicate excessive fluid administration. Patients with pre-existing heart failure received restrictive fluid therapy (23 vs. 3 vs. 4%, p = 0.03). Conclusions: Individualised, timely therapy monitoring is as essential as identifying patients with a higher or lower fluid requirement. Excessive fluid resuscitation had fewer deleterious consequences in complications than expected but seems to influence wound healing. Awareness of circumstances that prompt deviations from recommended fluid rates remains elementary.

Knee arthroscopies are regularly carried out in an outpatient setting. The purpose of this retrospective analysis was to investigate the impact of different local anaesthetics for spinal anaesthesia on operating room efficiency (perioperative process times) and postoperative recovery. This study aims to determine the optimal LA for SPA in patients undergoing knee arthroscopy at a day-surgery centre.

Background: Vasovagal reactions during application of intrathecal anaesthesia (IA) are associated with high anxiety levels. A high percentage of patients undergoing outpatient surgery suffer from anxiety. Anxiolytic premedication in day‐surgery is suspected to delay recovery and discharge and is, therefore, not routinely used. The aim of this retrospective analysis was to detect the influence of anxiolytic premedication on the incidence of vasovagal reactions and time until discharge home.Methods: Anaesthesia records of all patients undergoing outpatient surgery under low‐dose IA from January 2008 to June 2017 were analysed. Incidences of vasovagal reactions with a decrease in blood pressure and/or heart rate and need for cardiovascular activating medications were documented. Patients were categorised as having received an anxiolytic premedication or not. The time from intrathecal injection of the local anaesthetic until readiness for discharge was recorded.Results: The records of 2747 patients were analysed. One thousand two hundred and ninety‐one of them received an anxiolytic premedication of 1‐2 mg midazolam intravenously. Three hundred and fourteen patients had vasovagal incidents during application of IA (no premedication n = 217 [15.0%], premedication n = 97 [7.5%], P < 0.0001). Premedication did not prolong time to achieve readiness for discharge (mepivacaine: P = 0.5886, chloroprocaine: P = 0.1555). However, in the prilocaine group, premedication led to a significantly earlier achievement of readiness for discharge (P = 0.0002).Conclusion: Anxiolytic premedication significantly reduces the incidence of vasovagal reactions during the application of IA and does not affect time until readiness for discharge.

Both general and spinal anaesthesia with short-acting local anaesthetics are suitable and reliable for knee arthroscopy as an ambulatory procedure. Chloroprocaine (CP) 1% seems to be the ideal spinal local anaesthetic for this indication. The aim of this study was to compare spinal anaesthesia using CP 1% with general for outpatient knee arthroscopy with regard to procedure times, occurrence of pain, patient satisfaction and recovery, and also costs. A randomised controlled single-centre trial. University Medical Centre Mannheim, Department of Anaesthesiology and Surgical Intensive Care Medicine, Mannheim, Germany. April 2014 to August 2015. A total of 50 patients (women/men, 18 to 80 years old, ASA I to III) undergoing outpatient knee arthroscopy were included. A contra-indication to an allocated anaesthetic technique or an allergy to medication required in the protocol led to exclusion. Either general anaesthesia with sufentanil, propofol and a laryngeal mask for airway-management or spinal with 40-mg CP 1% were used. We noted procedure times, patient satisfaction/recovery and conducted a 7-day follow-up. Primary outcome was duration of stay in the day-surgery centre. Secondary outcomes were first occurrence of pain, patient satisfaction, quality of recovery and adverse effects. In addition, we analysed treatment costs. Spinal had faster recovery than general anaesthesia with patients reaching discharge criteria significantly earlier [117 min (66 to 167) versus 142 min (82 to 228), P = 0.0047]. Pain occurred significantly earlier in the general anaesthesia group (P = 0.0072). Costs were less with spinal anaesthesia (cost ratio spinal: general 0.57). Patients felt significantly more uncomfortable after general anaesthesia (P = 0.0096). Spinal anaesthesia with 40-mg CP 1% leads to a significantly earlier discharge and is cheaper compared with general. German Clinical Trials Register, www.drks.de, identifier: DRKS00005989.

Perianal procedures are carried out in an outpatient setting regularly. The purpose of this retrospective analysis was to investigate the impact of different local anaesthetics (LA) for spinal anaesthesia (SPA) on operating room (OR) efficiency (perioperative process times, turnaround times) and postoperative recovery. This study aims on the determination of the optimal LA for low-dose SPA in the specific setting of a high-volume day-surgery centre.