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Incidence of early burn-induced effects on liver functionas reflected by the plasma disappearance rate of indocyanine green: a prospective descriptive cohort study
Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Plastic Surgery, Hand surgery UHL. Linköping University, Department of Clinical and Experimental Medicine, Plastic Surgery, Hand Surgery and Burns.
Linköping University, Department of Clinical and Experimental Medicine, Occupational and Environmental Medicine. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery UHL. Östergötlands Läns Landsting, Sinnescentrum, Department of Intensive Care UHL.
Linköping University, Department of Clinical and Experimental Medicine, Burn Center. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Plastic Surgery, Hand surgery UHL. Östergötlands Läns Landsting, Sinnescentrum, Department of Anaesthesiology and Surgery UHL.
2012 (English)In: Burns, ISSN 0305-4179, E-ISSN 1879-1409, Vol. 38, no 2, 214-224 p.Article in journal (Refereed) Published
Abstract [en]

Organ dysfunction and failure are important for burned patients as they increase morbidity and mortality. Recent evidence has suggested that organ injuries are occurring earlier after burns, and are more common, than previously thought. In this study we have assessed the extent to which liver function, assessed by the plasma disappearance rate of indocyanine green (PDRICG), is affected in patients with severe burns. This is a prospective, descriptive exploratory study at a national burn centre. Consecutive adult patients with a total burned body surface area (TBSA%) of 20% or more, were examined prospectively by dynamic (PDRICG) and static liver function tests (plasma: bilirubin concentration, prothrombin complex, and alanine aminotransferase and alkaline phosphatase activities). Early liver dysfunction was common, as assessed by both dynamic (7 of 17) and static liver function tests (6-17 of 17). A regression model showed that changes in PDRICG were associated with age, TBSA%, plasma bilirubin concentration, plasma C-reactive protein concentration, and cardiac index. Persistent and advanced hepatic dysfunction was associated with mortality. The PDRICG seems to give a comprehensive assessment of liver function after major burns. Hepatic dysfunction seems to be as common as dysfunction in other organs. We interpret the recorded effects on liver function as part of a multiple organ dysfunction syndrome, primarily induced by the burn itself. However, this needs to be further investigated.

Place, publisher, year, edition, pages
Elsevier, 2012. Vol. 38, no 2, 214-224 p.
Keyword [en]
Burns, organ dysfunction, hepatic dysfunction, plasma disappearance rate of indocyanine green, age, cardiac index, sepsis
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-70059DOI: 10.1016/j.burns.2011.08.017ISI: 000301621500010OAI: oai:DiVA.org:liu-70059DiVA: diva2:435089
Note

On the day of the defence date the status of this article was "Manuscript".

Funding agencies|Department of Hand and Plastic Surgery, Linkoping University Hospital||PULSION Medical Systems AG, Munich, Germany||

Available from: 2011-08-17 Created: 2011-08-17 Last updated: 2017-12-08Bibliographically approved
In thesis
1. Organ dysfunction among patients with major burns
Open this publication in new window or tab >>Organ dysfunction among patients with major burns
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The number of patients who are admitted for in-hospital care in Sweden because of burns is about 12/100,000, and only a small proportion of these have larger burns. Among them, and particularly among those who die in hospital, a condition referred to as “organ dysfunction” is common and an important factor in morbidity and mortality. The fact that the time of the initial event is known, and the magnitude of the insult is quantifiable, makes the burned patient ideal to be studied. In this doctoral thesis organ dysfunction and mortality were studied in a descriptive, prospective, exploratory study (no interventions or control groups) in patients admitted consecutively to a national burn centre in Sweden.

The respiratory dysfunction that is seen after burns was found to be equally often the result of acute respiratory distress syndrome and inhalation injury. We found little support for the idea that this early dysfunction is caused by pneumonia, ventilator-induced lung injury, or sepsis. Acute kidney injury (AKI) was also common, and mortality was associated with severity. Importantly, renal dysfunction recovered among the patients who survived. Pulmonary dysfunction and systemic inflammatory response syndrome developed before the onset of AKI. Sepsis was a possible aggravating factor for AKI in 48% of 31 patients; but we could find no support for the idea that late AKI was mainly associated with sepsis. We found that older age (over 60 years), greater TBSA%, and respiratory dysfunction were associated with increased mortality, but there was no association between the overall mortality and sex. We also found that early transient liver dysfunction was common, and recorded early hepatic “hyper”- function among many young adults. Persistent low values indicating severe liver dysfunction were found among patients who eventually died.

We conclude from this investigation that overall organ dysfunction is an early and common phenomenon among patients with severe burns. Our data suggest that the prognosis of organ dysfunction among these patients is good, and function recovers among most survivors. Multiple organ failure was, however, the main cause of death. The findings of the early onset in respiratory dysfunction and a delay in signs of sepsis are congruous with the gutlymphatic hypothesis for the development of organ dysfunction, and the idea of the lung as an inflammatory engine for its progression. We think that the early onset favours a syndrome in which organ dysfunction is induced by an inflammatory process mediated by the effect of the burn rather than being secondary to sepsis.

Our data further suggest that clinical strategies to improve burn care further should be focused on early interventions, interesting examples of which include: selective decontamination of the gastrointestinal tract to prevent translocation of gut-derived toxic and inflammatory factors; optimisation of fluid replacement during the first 8 hours after injury by goal-directed resuscitation; and possible improvement in the fluid treatment given before admission.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011. 70 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1248
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-70061 (URN)978-91-7393-155-7 (ISBN)
Public defence
2011-09-08, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2011-08-17 Created: 2011-08-17 Last updated: 2012-03-13Bibliographically approved

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Steinvall, IngridFredrikson, MatsBak, ZoltanSjöberg, Folke
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