Annals of the M.B.C. - vol. 1° - n° 2 - September 1988

OUR EXPERIENCE IN TREATMENT OF BURNED PATIENTS

Visentini P., Gozzi., Galla A.

Divisione Chirurgia Plastica, Ospedale di Udine, Italia

SUMMARY. A rapid account is given of the changing in treatment ofextensively burned patients in the last twenty years.
A systematic control of blood composition seems of fundamental importance, with particular regard to protein composition.
Equally important is the appropriate use of antibiotics, an early operation and possibly remedies which increase immunitary defences. Results obtained with 845 patients are reported.

During the last twenty years the treatment of burned patients has been much improved, and owing to this we have been able to reduce mortality and to better healing quality.
Let us consider this evolution by analysing the modifications of our treatment plan.
Using the older methods we introduced liquids according to some particular formulae (1, 9, 10). The operation was carried out when the burned patient had eliminated eschar and was covered with granulation tissue (13).
This kind of treatment had the inconvenience of a quite high mortality, a long period of severe disease and healing with hypertrophic or retracting scars.
The use of lab instruments rapidly making it possible to determine and monitor blood composition has shown the inadequacy of a therapy based on fixed formulae (1,9,10), because it was not possible to keep the haernatic composition near normal values.
A factor which, in our opinion, has not been taken into consideration to the right extent is the proteic composition of the plasma (5, 10, 11). In this relation, one of us (P. Visentini), when in Padua working on the late Prof. Dogo's team, observed that burned patients treated exclusively with electrolytes and plasma substitutes frequently showed a considerable lowering of total proteins (5).
At the beginning we started treating patients in the manner of Batchelor and Birke (2, 3, 10), fundamentally using human plasma for the first two days, and we noticed a considerable lowering of total mortality (10, 11, 12).

Materials and Methods

We started regulating the introduction of plasma in the first two days in order to keep haematocrit and diuresis near normal values. On the following days we introduced the electrolytes, the albumin and gammaglobulins suggested by the monitor control of different parameters (11).
Using this kind of treatment, the haematic proteins remain near normal values, though there is a modest lowering in the first two days.
We noted a second advantage when we introduced, from the beginning, antibiotics, which were changed according to the response of antibiograms on burned tissue and on haernocultures (8).
In our treatment plan we do not use cannula feeding: all patients eat normally according to special diets supplying necessary calories. Thus the patients eat what they are used to.
Normally the patients, even when extensively burned, remained in good general conditions, and we have introduced, as suggested by Prof. Janzekovic and the Ljubljana and Turin schools, early intervention (4, 6, 7, 9, 14). We have not found any increase in mortality but on the contrary perhaps a slight decrease with the advantage of reducing the period of serious disease and achieving a better healing quality.
More or less a year ago we started changing the ways of operating, applying skin grafts either treated with mesh-graft or not, by using fibrin glue (Tissucol), without applying sutures as was used once.
This has allowed us to reduce time of operation and to obtain faster healing.

Results and Conclusions

Re-examining all the patients treated at the Division of Plastic Surgery at Udine Hospital, we noted a mortality of 5.3% (Tab. 1), which could partly be ascribed to diseases the patients suffered from before the burn lesion, but fundamentally because of infections, especially aflecting old people (Tab. 2).

In trying to achieve a further reduction of mortality and to better the general conditions of patients, for some months we have systematically administered a remedy that increases immunitary defences: the TPI, with results that till now seem satisfactory, though not yet statistically significant.
In other words, we have tried to change burning from a long disease, with quite high mortality, to a shorter disease, with the purpose of keeping patients in better general conditions, so as to be able to operate earlier.
Results are to be assessed not only on the basis of survival, which we hope to improve, but on the quality of healing, and in this relation we show some cases.

Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13 Fig. 14 Fig. 15 Fig. 16

RÉSUMÉ. Les auteurs considèrent rapidement le changement dans le traitement des brûlés gravement atteints au cours des vingt dernières années.
Un contrôle systématique de la composition du sang semble d'importance fondamentale, en tenant compte surtout de la composition protéique.
D'égale importance est l'emploi approprié des antibiotiques, une rapide opération et peut-être des remèdes pour accroître les défenses immunitaires.
Les auteurs font état des résultats obtenus sur 845 patients.