Marianne Kruse

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.

Adequate fluid therapy is crucial to maintain organ function after burn trauma. Major burns lead to a systemic response with fluid loss and cardiac dysfunction. To guide fluid therapy, measurement of cardiac pre- and afterload is helpful. Whereas cardiac function is usually measured after admission to intensive care unit (ICU), in this study, hemodynamic monitoring was performed directly after arrival at hospital. We conducted a prospective cohort study with inclusion of 19 patients (male/female 13/6, 55 ± 18 years, mean total body surface area 36 ± 19%). Arterial waveform analysis (PulsioFlexProAqt^®, Getinge) was implemented immediately after admission to hospital to measure cardiac pre- and afterload and to guide resuscitation therapy. Cardiac parameters 3.75 (2.67-6.0) h after trauma were normal regarding cardiac index (3.45 ± 0.82) L/min/m², systemic vascular resistance index (1749 ± 533) dyn sec/cm⁵ m², and stroke volume (SV; 80 ± 20) mL. Stroke volume variation (SVV) was increased (21 ± 7) % and associated with mortality (mean SVV survivors vs nonsurvivors 18.92 (±6.37) % vs 27.6 (±5.68) %, P = .017). Stroke volume was associated with mortality at the time of ICU-admission (mean SV survivors vs nonsurvivors 90 (±20) mL vs 50 (±0) mL, P = .004). Changes after volume challenge were significant for SVV (24 ± 9 vs19 ± 8%, P = .01) and SV (68 ± 24 vs 76 ± 26 mL, P = .03). We described association of SVV and SV with survival of severely burned patients in an observational study. This indicates high valence of those parameters in the early postburn period. The use of an autocalibrated device enables a very early monitoring of parameters relevant to burn shock survival.

Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt^® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group ( P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient’s volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.