Challenging problems in a Child-Pugh Class C Cirrhosis and Flame Burn Injury Patient--Our Fluid Management and Reconstructive Methods

一位Child-Pugh C級肝硬化合併火焰燒傷患者的挑戰性問題──我們的體液復甦和重建方法

Yu-Hsiang Huang(黃昱翔) ； Lin-Yin Wang(王淩音) ； Chien-Ju Wu(吳建儒) ； Hao-Yu Chiao(喬浩禹) ； Kuang-Ling Ou(歐冠伶) ； Chih-Hsin Wang(王志信)

《臺灣整形外科醫學會雜誌》 33卷4期 (2024/12) Pp. 412-423

摘要

Background: Decompensated cirrhosis leads to numerous complications, such as ascites, hepatic encephalopathy, bleeding tendencies, renal failure, splenomegaly, coagulopathy, bacterial infections, and spontaneous bacterial peritonitis (SBP). Balanced fluid supplementation and reconstruction are essential in patients with burns. However, managing patients with burns who also have decompensated liver cirrhosis presents challenges during both the initial resuscitation and the reconstructive phases. Aim and Objectives: This case report presents a complex case of a patient with burn with coexisting decompensated liver cirrhosis and describes our fluid management and reconstructive approaches, both of which yielded acceptable outcomes. Additionally, we conducted a literature review to support the strategies employed at our burn center. Materials and Methods: A 58-year-old Taiwanese man with Child-Pugh class C cirrhosis presented to our emergency department following a gas explosion. Emergent endotracheal intubation was performed due to inhalation injury. After hydrotherapy, we assessed the burn wound area, which revealed second to third-degree burns covering 30% of the total body surface area. Utilizing the FloTrac system(Edwards Lifesciences Corp, Irvine, CA), we monitored hemodynamic status and initiated the TSGH Burn Center protocol. On post-burn day 7, surgical debridement was performed, and cadaveric skin coverage was applied to the left lower limb. Additionally, successful burn wound reconstruction with split-thickness skin grafting was completed on the bilateral upper limbs. Results: In our fluid management protocol, we did not encounter abdominal compartment syndrome, although mild acute respiratory distress syndrome occurred throughout the treatment course. The burn wounds healed well with our reconstructive strategy, yielding satisfactory aesthetic and functional outcomes. Conclusion: Early albumin supplementation at the 9th hour alleviated ascites accumulation, particularly in our patient with severe liver cirrhosis undergoing aggressive fluid resuscitation. Additionally, our strategy included early burn wound debridement, utilizing either cadaveric skin as a biological dressing or split-thickness skin grafting, with no observed episodes of burn wound sepsis.

關鍵字

flame burn ； cirrhosis ； ascites ； coagulopathy ； fluid resuscitation ； cadaveric skin

並列摘要

背景：失代償性肝硬化導致許多併發症，包括腹水、肝腦病變、出血傾向、腎衰竭、脾腫大、凝血異常、容易細菌感染以及自發性細菌性腹膜炎。適切的液體復甦與隨後的重建在燒傷患者中至關重要。然而，在失代償性肝硬化的燒傷患者，初期體液復甦和後續重建階段治療都帶來挑戰。目的及目標：我們呈現了這位失代償性肝硬化的火焰燒傷患者治療歷程，整理出我們的體液復甦策略和重建方法。我們作法取得了可接受的結果，並且回顧相關文獻，以強化我們燒傷中心的策略。材料及方法：一位58歲的台灣男性，因氣爆意外送到急診。因為吸入性傷害，我們進行了緊急氣管插管以暢通呼吸道。在水療之後，我們評估了燒傷面積，顯示30%的全身表面積為二至三度燒傷。初期我們應用FloTrac系統監測患者的血液動力狀態，並開始使用燒傷中心的體液復甦流程。之後在一週內安排了清創手術，左下肢使用了大體皮膚覆蓋，後續成功地完成了雙上肢分層皮膚移植的燒傷傷口重建。結果：在我們的體液復甦策略下，沒有腹腔內腔室症候群（ACS），但是有觀察到輕度的急性呼吸窘迫症候群（ARDS）。在後續的重建手術，燒傷傷口良好癒合呈現可接受的美觀和功能結果。結論：我們在第9小時開始早期白蛋白補充，這減輕了腹水積聚，特別是在我們的患有嚴重肝硬化且正在接受積極液體復甦的患者中。此外，我們的策略包括早期燒傷清創，利用大體皮膚作為生物敷料及進行分層皮膚移植。此外，我們沒有觀察到任何燒傷傷口感染的發生及疤痕攣縮的現象。