SUMMARY. Continuous elimination methods are part of complex therapeutic methods used in critically ill patients after burn injuries. We have been using CVVH (continual vane -venous hemofiltration) in our center since 1995.
We use CVVH in patients after burn injury who present with systemic inflammatory syndrome multiorgan dysfunction or multiorgan failure. From 1995 till 2001, elimination was performed under the supervision of an intensive care unit nephrologist. In recent years we have provided CVVH to burn patients independently.
A nurse places sets in the device, flushes the sets with saline with heparine and subsequently drains this off into a collecting bag. After the device is tested it is ready to be used on a patient. The nurse calls a MD and under his supervision begins the elimination.
Elimination parameters are set by the attending MD, and the nurse has a full written record of this throughout the elimination. The MD is informed of any complications during the elimination If an alarm goes off the nurse initiates correction in co-operation with the MD During the whole procedure the patient is clinically observed, and changes of his status are noted in a shock record and elimination protocol.
Since 1995. 60 eliminations have been performed, occupying a total time of 7,400 hours. The work is very demanding and interesting: the patient's status improves significantly.
Key words: CVVH, nursing diagnoses, elimination
Numerous works have been published regarding the increased metabolic demands of burnt children and adults (2-6). In 2000 King published a report on the reduced requirements for protein and energy Supply in an l 1-year-old boy with 60% of burnt surface area and burns of respiratory paths, involving the use of Integra artificial skin after free rectomy. as compared with the values suggested by tile calculations based on this extent of injury (1). We decided to verify this knowledge in the child we treated.
In the University Hospital in Ostrava a 7-month- girl was hospitalised who had been scalded by her mother (while cooking goulash), on 26°l° of TBSA on lower limbs, loins, back and hips, belly and chest. The shock phase of the burn condition was complicated by development of ARDS, and the child was under artificial ventilation for 17 days. In this period the burnt areas on 16% of TBSA worsened to 3,d degree. To improve the pulmonary finding, a tangential necrectomy was performed on the 8th day after the accident, and Integra artificial skin was applied on the left lower limb; 6 days later it was also applied to the loins, back and hips. Integra healed without complications. On the 251h post-operation day the silicone layer was removed and neodermis was autotrans- first on the lower limb and 6 days later in other locations. During the healing the scar on the back of the popliteal area contracted. After healing of all burnt and donor-site areas and completion of rehabilitation, the child - from a poor social background-was released into outpatient care 12 weeks after the accident.
Having evaluated the nutrition condition, we chose the period of 25 days from the 1" necrectomy and application of the Integra© artificial skin to the first autotransplantation of neodermis (Fig. 1). During the first 9 post-operation days the child was under artificial ventilation, and 85% of nutrition was provided by parental method, the volume of which was limited by residual pulmonary complication. Enteral nutrition formed 15%r, of the energy supplied. The child was extubated on the 10t], postoperation day and gradually, according to her tolerance, both enteral and peroral nutrition was increased, so that in the second half of the monitored period they formed 75% of the energy supplied. Protein intake increased substantially after the increase of peroral intake in the last third of the monitored period. The average supply of 2.2 g/kg per day represented a supply of 19.8 g of proteins per day for the child, who had a body mass of 9 kg (Fig. 2). Calorific intake grew after increase of peroral intake as well, reaching in average 570 kcal/day, i.e. 63 kcal/kg/day (Fig. 3).
Recommended supply of proteins to a burnt child ranges (according to various authors) front 2.4 to 4.8 g/kg per day, which would represent for this child a supply of 22-43 g proteins per day (2, 8, 10). The energy supply recommended by calculations for a child with body mass of 9 kg and body surface of 0.43 m2, with burns on 16% of the body surface (after healing of other areas) in the monitored period, according to the calculations of various authors, ranges from 840 to 1400 kcal per day (5, 8, 9, 10). From a comparison of actual and recommended supply of proteins and energy it is obvious that the actual supply of proteins was lower and the energetic intake was 3060% lower than recommended (Table 1). As to nutrition indicators. we monitored the levels of albumin, total protein, plasmatic cholinesterases for favourable price of this examination, and praealbumin level - for its short half-life period. We monitored the child's weight as well. The albumin level in the first 4 days after operation was influenced by application of plasma, but it was within normal limits all through the remaining monitored period, ranging from 37 to 48 g/1 (Fig. 4). The level of total protein after the P necrectomy and application of Integra slowly increased, achie- the standard level on the 9th post-operation day (Fig. 5). The level of plasmatic cholinesterase was at standard level from the 1 It post-operation day all through the remaining monitored period. The level of pracalbumin after necrectomy and application of Integra© slowly increased, achieving the standard levels on the 15th post-operation day (Fig. 6). The weight of the child prior to the operation was influenced by generalised edema, as the child was weighed only on the 2nd post-accident day, (9.85 kg). After- the 2°d necrectomy and application of the artificial skin, her weight decreased by 400 g. The weight increased from the 811, postoperation day, and upon expiry of the monitored period of 25 days the child's weight was 70 g more than before the operation (Fig. 7).
<% immagine "Fig. 1","gr0000040.gif","Type of nutrition changes during the treatment period ",230 %> <% immagine "Fig. 2","gr0000041.gif","Protein intake in monitored period ",230 %> <% immagine "Fig. 3","gr0000042.gif","Energy intake in monitores period ",230 %> <% immagine "Fig. 4","gr0000043.gif","Plasma concentration of albumin in monitores period ",230 %> <% immagine "Fig. 5","gr0000044.gif"," Plasma concentrationof proteins in monitored period",230 %> <% immagine "Fig. 6","gr0000045.gif","Plasma concentrations of cholinesterase in monitored period ",230 %> <% immagine "Fig. 7","gr0000046.gif","Plasma concentration of preaealbumin in monitored period ",230 %> <% immagine "Table 1.","gr0000047.gif","Required and raccomended protein and energy intake for burne child (7 months, 16% TBSA) ",230 %>In a 7-month-old child burnt on 26% of her body surface, of which 16% was treated by necrectomy and application of the Integrao) artificial skin, selected nutrition parameters were monitored at intervals of 3-5 days within a 25-day period from the P necrectorny and application of Integra to the 15t autotransplantation of neoder- By this time the other burnt areas were essentially healed. The average supply of proteins in this period was lower than recommended (19.8 g/1 against 22 g/I) and the energy supply was 30-t0 % lower than the recommended supply (570 kcal/day against 840-1400 kcal/day). This finding is explained firstly by the fact that artificial pulmonary ventilation in the first 9 post-operation days reduced energetic demand: the child was hospitalised in an air-conditioned box with temperature of 28°ł C, which reduced thermal loss and power demand. In the monitored period, the child had no donor-site areas, the healing of which would also increase the energy intake demand. It has been proved that leak of liquids through the silicone layer is the same as that one through the epidermis (7) and alt assumption has been made that Integra it reduces albumin loss by exudation (1). Early enteral nutrition, which was commenced 8 hours after the accident, is specified as a factor having favourable effect upon metabolic response as well (3, 4).
According to our observations, application of the Integra artificial skin on necretomised surfaces in the monitored child reduced energy and protein demands with the achievement of the normal values of monitored nutrition parameters.
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