|Annals of Burns
and Fire Disasters - vol. XII - n. 1 - March 1999
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.
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 (INTEGRATM
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 INTEGRATM 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
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
Burns, 23: 512-4, 1997.
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
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.
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.
Hoekstra M.J., van Baare J., du Pont J.S., Kamperdijk E.W.A.
J. Burn Care Rehabil., 18: 228-33, 1997.