Annals of Burns and Fire Disasters - vol. XII - n. 1 - March 1999

INTERNATIONAL ABSTRACTS

A PROGRAMME TO DECREASE HOSPITAL STAY IN ACUTE BURN PATIENTS
In order to reduce the duration of the hospitalization of burn patients, a programme of early excision, increased out-patient care, and aggressive discharge planning was introduced over a 5-year period (1991-1995) in a burns centre in Georgia, USA. Two groups of patients were separately considered: those with burns in less than 25% BSA and those with burns in more than 25% BSA. Two separate 30-month periods were compared. It was found that the programme led to a significant reduction in length of hospital stay of 51.4% for burns under 25%. For burns over 25% the reduction was 23.7%. The early and the late groups presented no significant differences in age, burn size, or mortality.

Still L, Denker K., Law E., Thiruvaiyam D.
Burns, 23: 498-500, 1997.

RECONSTRUCTION OF BURN DEFORMITY USING ARTIFICIAL DERMIS COMBINED WITH THIN SPLIT. SKIN GRAFTING
Artificial dermis combined with thin split-skin grafting was used to treat 12 patients with post-burn contracture in the period January 1994April 1996. After excision of scar contracture tissue, bilayer artificial dermis was grafted onto full-thickness open wounds of the skill. The silicon layer was removed after about 3 weeks, and thin split-skin (8/1000 in. thick) was grafted onto the freshly synthesized dermis-like tissue ill the wound bed. In 11 of the 12 cases, the scalp was selected as the donor site (buttocks ill the twelfth case). The purpose of artificial dermis grafting was to ensure that morbidity at the donor site should be reduced as much as possible in order to prevent burn deformity. The skin grafts were successful in all 12 cases, and post-operative management followed the techniques of conventional skin grafting. Post-operative contraction or hypertrophic scar was observed in three cases, but the other nine had a soft, favourable quality. It is thus concluded that burn deformity can be successfully treated with artificial dermis ill certain cases.

Soejima K., Nozaki M., Sasaki K., Takeuchi M., Negishi N.
Burns, 23: 501-4, 1997.

EARLY WOUND CLOSURE AND EARLY RECONSTRUCTION. EXPERIENCE WITH A DERMAL SUBSTITUTE IN A CHILD WITH 60 PER CENT SURFACE AREA BURN
A four-year old girl suffering from 50% full-thickness and 10% deep partial -thickness burns was treated with a dermal substitute for wound management after early scar release. The biosynthetic substitute (INTEGRA^TM Artificial Skin) consists of an upper silicone film and a lower layer of porous cross-linked collagen. and chondroitin-6-sulphate as a template for dernial regeneration. Eight sheets (4 x 10 in. each) were used to cover the patient's trunk after staged tangential necrectomy. Three to four weeks after application, the silicone layer was removed without difficulty and the freshly formed dermis was covered with widely meshed thin split-thickness autograft. An early neck contracture was released seven weeks after admission and the skin defect was also covered with INTEGRA^TM Artificial Skin. Using the same principle, the thin amnestied autograft was successfully transplanted three weeks later. The good result of handling, final take, apparent initial scar reduction, and early recovery may favourably affect initial treatment and reconstruction planning following extensive full-thickness burns.

Lorenz C., Petracic A., Hohl H.-P., Wessel L., Waag K.-L.
Burns, 23: 505-8, 1997.

A MODIFICATION OF SPLIT-SKIN GRAFT
Sometimes not much healthy skin is available for transplantation in extensively burned patients, and sometimes a machine is not available. This paper presents a simple modification of donor skin so that wider areas can be covered in such situations. The thinnest possible skin graft was taken by hand from the donor site with a knife set to transmit the narrowest wafer of light between blade and guard bar. The skin graft was incompletely divided at opposite borders alternating at right angles to the long axis of graft. The graft was thell stretched, lightly perforated, spread on a carrier tulle gras with the outer surface outenilost, applied to the wound, and fixed with sutures. It was found that a skin graft 5 em long could be extended to 7-9 em. The gain in length is achieved in a very short time and no special instrument is required.

Dasgupta S., Sanyal S., Gupta P., Saha M.L., Sarkar A.
Burns, 23: 509-11, 1997.

HOSPITALMADE DIET VERSUS COMMERCIAL SUP. PLEMENT IN POST-BURN NUTRITIONAL SUPPORT
After burn injury, patients enter a severe catabolic state characterized by elevated metabolic rate, increased protein mobilization, and gluconeogenesis. These changes lead to significant increases in energy and protein needs, unless aggressive nutritional therapy is soon instituted. As weight loss of more than 10% has been shown to increase mortality, it is clear that nutritional support is an important factor in the therapy of burn patients. Nutrition supplementation can be based on either "hospital-made" or "commercial" diets. Commercial diets may be expensive or difficult to obtain, and this paper considers the efficacy and tolerance of a hospital-made diet compared with a commercial diet. The efficacy of diet was assessed by evaluation of nutritional status, graft take,'number of surgical procedures, and duration of hospital stay. Tolerance was assessed by recording side effects (nausea, vomiting, abdominal distension, diarrhoea). It was found that both the commercial and the hospital-made diets were successful, indicating that hospital-made diets have equal efficacy and tolerance to commercial diets but are also more economical. Such hospital-made diets are therefore a good alternative to commercial diets, especially with economically disadvantaged patients.

Dhanraj P., Chacko A., Mammen M., Bharathi R.
Burns, 23: 512-4, 1997.

PRESSURE-CONTROLLED VENTILATION FOR THE LONG-RANGE AEROMEDICAL TRANSPORT OF PATIENTS WITH BURNS
Adequate ventilation is extremely important in patients with burns, especially in the first 24 h post-injury, when acute respiratory failure may rapidly develop from smoke inhalation injury. During transport of such patients, a reliable means of supporting ventilation is essential. This paper considers pressure-controlled ventilation in order to achieve adequate oxygenation and ventilation at lower peak inspiratory pressures. A portable pressure-controlled time-cycled transport permits it to be used in the field. The safety and efficacy of this ventilator were assessed for the aeromedical transport of burned patients. Special flight teams transported 146 intubated patients with thermal injuries, covering a total of 86,889 miles without in-flight morbidity, mortality, or failure of ventilation. It was therefore found that pressure-controlled ventilation, as performed by an experienced air transport team with this ventilator, is safe and effective.

Barillo D.J., Dickerson E.E., Cioffi W.R., Mozingo D.W., Pruitt B.A., Jr.
J. Burn Care Rehabil., 18: 200-5, 1997.

EFFECTS OF A RAPIDLY SCANNED CARBON DIOXIDE LASER ON PORCINE DERMIS
A systematic study was made of the effect of varying continuouswave carbon dioxide laser scanning parameters on the resultant tissue effects. An assessment was made of the effects of varying scanning speed, laser power, and laser beam diameter. It was found that residual thermal damage at the centre of the crater was about 120pm, independently of dwell time and laser irradiance. It was also found, however, that thermal damage zones along the sides of the oblation crater increased as laser dwell times exceeded 50 msec. The present study shows that under appropriate conditions a scanned continuouswave carbon dioxide laser can ablate tissue with a zone of residual thennal injury of less than 200pm. It is therefore a useful technique in cutaneous surgery and the debridement of burn wounds before skin grafts are performed.

Qomankevits Y., Nishioka N.S.
J. Burn Care Rehabil., 18: 206-9, 1997.

A HYALURONIC ACID MEMBRANE DELIVERY SYSTEM FOR CULTURED KERATINOCYTES: CLINICAL "TAKE" RATES IN THE PORCINE KERATO-DERMAL MODEL
If no dermal bed is provided, the clinical take rate of cultured keratinocyte autographs is poor in a full-thickness wound. Even when it is provided, the problems remain of the time delay in growing the autografts and the fragility of the grafts. A laser-perforated hyaluronic acid membrane delivery system makes it possible to perform grafting at early confluence without the need of dispase digestion to release grafts from their culture dishes. The purpose of this study was to consider the influence of this membrane on clinical take rates in an established porcine kerato-dermal grafting model. It was found that there was a significant reduction in take as a consequence of halving the keratinocyte seeding density onto the membrane. However, the take rates of grafts grown onto membrane at half or full conventional seeding density and transplanted to a dermal wound bed were comparable with, or better than, those with keratinocyte sheet grafts.

Myers S.R., Brady J., Soranzo C., Sanders R., Green S., Leigh I.M., Navsaria H.A.
J. Burn Care Rehabil., 18: 214-22, 1997.

PROLONGED USE OF PROPRANOLOL SAFELY DECREASES CARDIAC WORK IN BURNED CHILDREN
The stress response to major thermal injury includes hypermetabolism, tachycardia, protein wasting, and lipolysis and it is therefore necessary to limit this response. It is known that propranolol is effective for up to 5 days in massively burned children to reduce heat rate and cardiac work. This article describes the use of propranolol administered for 10 days in order to assess whether the drug remains effective and safe in reducing heart rate and cardiac work for longer periods. A prospective study was carried out of 22 burned children (age, 1-10 yr; burn area, <40 % T13SA). The children were treated with 0.5-1.0 mglkg propranolol orally or intravenously every 8 h for 10 days. In both septic and nonseptic patients, propranolol reduced the daily average heart rate. No significant change in mean arterial blood pressure, plasma urea nitrogen creatinine, or glucose levels was observed. No hypotension, hypothermia, azotaemia, hyperglycaemia or hypoglycaemia, arrhythmia, bronchospasm, or peripheral ischaemia was noted during or after treatment. It is concluded that propranolol can be given to decrease the work of the heart safely and effectively for up to 10 days.

Baron P.W., Barrow R.E., Pierre E1, Herndon D.N.
J. Burn Care Rehabil., 18: 223-7, 1997.

IMMUNOGENICITY OF GLYCEROL-PRESERVED HUMAN CADAVER SKIN IN VITRO
When donor allograft skin is preserved in 85% glycerol it can be used as a temporary coverage for large burn wounds. This treatment does not affect the structural integrity of the skin: the cells are well preserved, but dead. However, it is still possible to observe cells expressing major histocompatibility class 11 molecules. This study investigated the mechanism responsible for the clinical observation that glycerol-treated alloskin is destroyed after a prolonged period. The in vitro immunogervicity of untreated and 85% glycerol-treated human skin cells was compared. Human purified blood T cells did not proliferate when cultivated with allogenic treated skin cells, while untreated cells induced a distinct response. A moderate response was observed after adding T cells and viable antigen presenting cells, such as monocytes, to the allogeneic treated skin cells. The response on untreated skin cells was however much higher. These findings suggest that after the transplantation of glycerol -preserved skin has been transformed, an inflammatory process mediated by infiltrating host cells occurs, rather than a rejection process mediated by T cells.

Richters C.D., Hoekstra M.J., van Baare J., du Pont J.S., Kamperdijk E.W.A.
J. Burn Care Rehabil., 18: 228-33, 1997.