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  • Title: [Analysis of causes and treatment methods of complication of early acute kidney injury in four severely burned patients].
    Author: Chen B, Kuang F, Li XJ, Zhang Z, Deng ZY, Zhang XH, Zhang T, Zhong XM, Tang WB, Liu CL.
    Journal: Zhonghua Shao Shang Za Zhi; 2019 Feb 20; 35(2):110-115. PubMed ID: 30798577.
    Abstract:
    Objective: To analyze the causes of complication of early acute kidney injury (AKI) in four severely burned patients, and to explore the related treatment methods. Methods: The clinical data of 4 patients with severe burn complicated with early AKI admitted to Guangzhou Red Cross Hospital Affiliated to Medical College of Jinan University (hereinafter referred to as our hospital) from June 2014 to December 2017 were retrospectively analyzed. All the patients were male, aged 23-33 (30±5) years old, with depth of burns ranged from deep partial-thickness to full-thickness, complicated with myofascial compartment syndrome of extremities and varying degrees of striated muscle injury, and treated in other hospitals before transfer to our hospital. The patients were numbered from small to large according to the total burn area. The total burn area of patients No. 1, 2, 3, and 4 was 10%, 80%, 90%, and 95% total body surface area respectively, their occurrence time of early AKI was 48, 11, 29, and 48 hours after injury respectively, and their time of arriving our hospital was 60, 11, 29, and 144 hours after injury respectively. Hypovolemic shock occurred in patients No. 2 and 3 at admission to our hospital. All the patients received continuous renal replacement therapy (CRRT) after admission to our hospital. Under the support of hemodynamic monitoring and organ function monitoring, the limbs complicated with myofascial compartment syndrome were incised, thorough decompression exploration was performed, and necrotic muscle tissue was removed or amputation was performed. After escharectomy and decompression of limbs, fresh granulation wounds were formed by temporarily covering wounds with Jieya dressing skin or pig skin, multiple debridements, and vacuum sealing drainage. Fresh granulation wounds and other wounds underwent staged eschar excision and shaving were covered with autologous Meek skin graft, particulate skin graft, reticular skin graft and small skin graft respectively. The treatment outcome, CRRT time, operation times, time of recovery of serum creatinine and myoglobin, length of hospital stay, and follow-up were recorded. Results: All the 4 patients were cured after transfer to our hospital. Among them, totally 5 limbs of patients No. 1 and No. 4 underwent amputation because of complication of myofascial compartment syndrome and a large amount of necrotic muscle which could not be preserved. Patients No. 1, 2, 3, and 4 were treated with CRRT for 19, 35, 14, and 25 days respectively and performed with operation for 5, 6, 10, 8 times respectively. Serum creatinine of patients No. 1, 2, 3, and 4 returned to normal on 22, 35, 37, and 48 days after transfer respectively, and their serum myoglobin returned to normal on 18, 28, 25, and 30 days after transfer respectively. Patients No. 1, 2, 3, and 4 were hospitalized for 52, 105, 148, and 156 days and discharged after basic wound healing. Follow-up for 1 to 36 months showed no abnormal renal function in 4 patients. Conclusions: The early AKI in patients No. 1 and 4 was caused by rhabdomyolysis after severe burn complicated with myofascial compartment syndrome, while that of the other 2 cases were also related to hypovolemic shock and poor renal perfusion. The success rate of early AKI treatment in severely burned patients can be effectively improved by removing the causes of diseases at the same time of CRRT and actively treating burn wounds under the support of organ function and hemodynamic monitoring. 目的： 分析4例严重烧伤患者并发早期急性肾损伤(AKI)的原因并探讨相关治疗方法。 方法： 回顾性分析2014年6月—2017年12月暨南大学医学院附属广州红十字会医院(下称笔者单位)收治的4例严重烧伤并发早期AKI患者的临床资料。患者均为男性，年龄为23～33(30±5)岁，烧伤深度深Ⅱ～Ⅲ度，并发四肢肌筋膜室综合征和不同程度的横纹肌损伤，均经外院治疗后转入笔者单位。将患者按烧伤总面积从小到大编号，1、2、3、4号患者烧伤总面积分别为10%、80%、90%、95%体表总面积，并发早期AKI时间分别为伤后48、11、29、48 h，转入笔者单位时间分别为伤后60、11、29、144 h。2、3号患者转入院时已出现低血容量性休克。4例患者转入院后均行连续性肾脏替代治疗(CRRT)，在血流动力学监测和器官功能监护的支持下，积极对并发肌筋膜室综合征的四肢行切开、彻底减压探查，清除已坏死的肌肉组织或行截肢术。对四肢焦痂切开减压后创面，采用桀亚敷料皮或猪皮临时覆盖、多次清创并结合负压封闭引流治疗形成新鲜肉芽创面后，和其他分期切削痂创面，分别用自体皮行Meek植皮及微粒皮、网状皮、小皮片移植等覆盖。记录患者治疗结局，行CRRT时间，手术次数，血肌酐、肌红蛋白恢复正常时间，住院时间及随访情况。 结果： 本组4例患者转入笔者单位后均治愈，其中1、4号患者共5个患肢因并发肌筋膜室综合征并有大量肌肉坏死无法保留，行截肢术。1、2、3、4号患者分别行19、35、14、25 d CRRT，行5、6、10、8次手术，于转入院后22、35、37、48 d血肌酐恢复正常，于转入院后18、28、25、30 d血肌红蛋白恢复正常，于住院52、105、148、156 d创面基本愈合后出院。随访1～36个月，4例患者肾功能均无异常。 结论： 1、4号患者早期AKI由严重烧伤并发肌筋膜室综合征导致横纹肌溶解所致，另2例还与低血容量性休克、肾灌注不足有关。在行CRRT的同时积极去除病因，在血流动力学监测和器官功能支持下积极手术治疗烧伤创面等，可有效提高严重烧伤并发早期AKI救治成功率。.
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