Annals of Burns and Fire Disasters - vol. XIII - n. 2 - June 2000

THE SYSTEM OF ACTIVE SURGICAL MANAGEMENT OF SEVERELY BURNED PATIENTS WITH DEEP BURNS AND COMBINED INJURIES (BURN AND BLOOD LOSS)

Atyasov N. L.

The Republican Burns Centre, Mordovia, Saransk, Russia

SUMMARY. Purpose-oriented infusion therapy and intensive treatment proved to be successful in restoring skin coverage in a cohort of over 3000 severely burned patients prior to the development of irreversible changes. Owing to the enhancement of the body's defensive mechanisms it became possible: to shorten the period of wound cleansing of necrotic tissues; to accelerate the local treatment of wounds in the presence of daily dressings in the pre-operative period and speed up the healing of donor sites by means of improved reparative processes; to shorten the time gap between repeated surgical operations, thus achieving a maximum overall gain in time, which was extremely important for the patient's recovery; to minimize the detrimental effect of autoinununization on graft take by reducing the number of repeated surgical interventions (in the presence of infusions that increase in volume up to a maximum level, as the patient's state improves); and to prevent the increasing threat of peri-operative shock by performing preventive infusions under pressure at the most traumatic moments. It was found opportune to cover the wounds with large-sized, closely adjoining skin flaps, a procedure that yielded better functional and cosmetic results and helped to restrict indications of allogenic and meshed grafts. The system was developed in fifty-two dissertation papers, and its implementation in clinical practice helped to save the lives of patients previously regarded as doomed to die.

The twofold decline in the mortality rate in the early stages of the burn disease achieved in the past few years has had an insignificant impact on the overall mortality rate in patients with deep and extensive skin injuries (IIIb-IV degree, over 30% BSA). At present such patients are mostly observed to die - not in the first days post-burn but after a long-term period - of the burn disease known as septicaemia, death being caused by irreversible changes in the internal organs or by visceral and other severe complications.
The main reason for this is an excessively prolonged conservative therapy course and inactive surgical intervention. This sets up a vicious circle in which the progressive exacerbation of the patient's state aggravates the prospects of plastic surgery, and thus post-operative healing of wounds in donor sites and graft take. Unsuccessful surgery contributes to the severity of the patient's condition and may cause death at some stage of reconstructive surgery. As soon as we became aware of the detrimental effects that such "delaying tactics" may have, we developed a new system for the active surgical management of severely burned patients (authorship licence N 58173, 1966) which "opened up a new era in combustionology" (T.Y. Aryey, 1966). The system obtained the approval of the Presidium of the Scientific Board, of the Ministry of Health Care, RSFSR (1969), and of some research forums held in our country and abroad. The developed system was awarded a bronze V13NH medal (1970) and a VDNH diploma in Ukraine (1987), and it received a state prize from the Republic of Mordovia (1994).
Initial implementation of the system showed that it should be accompanied by general intensive infusion therapy, with due attention to the patient's cardiac activity. Active surgery enabled us to overcome the otherwise unavoidable irTeversible changes in the patient or to halt their development.
Transfusions of blood and its components and of purpose-oriented blood substitutes appeared to be indispensable not only as a means of combating early anaemia in burn diseases, as is commonly thought, but also as an efficient means of preventing the emaciation of the patient as an after-effect of the burn injury that may occur in the septicaemia period. We obtained reliable evidence of the expediency of fibrinolylic blood and plasma transfusions.
Repeated transfusions proved to be most indispensable in the pre-operative phase, the recovery period following skin grafting, and during the healing period of donor sites
The premature cessation of transfusions appeared to impair the patient's condition and to protract the final stage of operative management; not infrequently it led to destruction of incorporated skin grafts
In cases where access to the subcutaneous veins was impeded, transfusions were performed in the venous channels of bones or in the liver through the rechannelized umbilical vein. We thus took into account the beneficial effects of the microvascular channels, which may act as "biological filters".
Our system of active surgical management was successfully tested by the burns centres in Nizimy Novgorod (prior to 1972) and in the Republic of Nordovia (1973-98) in the 3000 severely burned patients involved in the trials. It should be emphasized that its implementation was accompanied by intensive infusiontransfusion therapy.
The resulting significant enhancement of the body's defensive mechanisms and the revival of reparative processes led to spontaneous cleansing of the wound surfaces from necrotic scabs in a shorter period (two weeks less - a significant time-saving) in the presence of conservative, preserving therapeutic treatment. As a result, indications for traumatic early incisions and scab necrolysis - which are known for their drawbacks - have become more restricted in their application. Some authors continue to offer indications for these traumatic techniques, which they regard as active surgical measures. They are evidently unaware of the fact that a system of active surgical management in many cases makes their application unnecessary.
The local preparation of actively granulating wounds for subsequent plastic surgery, as also complication~free healing of donor sites, is also observed to take less time
Thorough local treatment of wounds in the presence of daily dressings has been seen to accelerate granulation processes, rendering unnecessary - in most cases - the time-consuming fixation of skin flaps to one another and to wound borders by means of noose sutures. The flaps, split down to half their thickness by dermatomes. appear to lose their contractile abilities owing to the absence of elastic fibres, and they adhere well to the granulation areas. These procedures have made it possible to shorten by a proportion of two to three times the duration of each repeated operation, so indispensable in extensive burns, which in turn reduced the patient's exposure to narcosis.
The reliable and complication-free healing of donor sites within a short-term period enabled us for the first time in our clinical practice to shorten the time intervals between skin-grafting stages by as much as three to five times (in up to 5-7 days), and in this way we succeeded in gaining a maximum overall reduction in time - previously unattainable and so beneficial for our patients' recovery.
With a view to minimizing the detrimental effects of the autoimmunization that is observed to progress with each successive skin graft and to impair the quality of take (the process can even destroy the grafts), we set ourselves the research objective of ensuring that the decreased number of surgical interventions (optimal number, three or four) had a beneficial effect. This proved to be correct, becoming possible when we initiated repeated transfusions, gradually increasing in volume after each successful surgical operation.
The increasing high risk of peri-operative shock, even in the presence of rational general anaesthesia, was observed to lessen after the initiation of a methodology of preventive fractional infusions that was developed by our team for the most traumatic phases of surgical procedures. Infusions of this kind have to be performed together with routine infusions.
Our active surgical strategy, with a rational use of donor site grafts, enabled us to provide all-round continuous coverage of even extensive granulating wounds with large split-skin grafts located close to each other, with better functional and cosmetic results.
This appeared to offer an opportunity for restricting indications for the use of meshed skin grafts in plastic surgery in cases of local deep burns without good reason, as also the use of allogenic skin grafts.
Despite the fact that meshed skin grafts (resembling a drag-net) provide coverage in larger areas of burn wounds (with a two- or three-fold increase) and adhere reliably even in areas with immature granulation thanks to their good drainage capability (they also adapt well to the uneven surface of the wound bed), such grafts proved to be inferior to intact grafts because of their functional and cosmetic characteristics.
The reported system of active surgical management has proved to be efficient in restoring skin (up to 60-70% 13SA) in extensive deep lesions, using the body's own resources. Recent enthusiasm related to the use ot laboratory -grown culture-cultivated allofibroblasts for the coverage of granulating wounds of insignificant extent areas seems hardly justified.
The technique we have developed is highly effective, it does not require any high~cost equipment, and it can be applied in the average surgical unit. There is reliable evidence that it drastically reduces the mortality rate in cohorts of comparable patients as regards the severity of their condition. Many patients previously regarded as doomed were seen to recover; the treatment period was two or three times shorter; the disability rate among convalescent patients was seen to go down; and the functional and cosmetic results turned out to be better. It should also be noted that the implementation of our system did not entail any considerable expenditure on infusion solutions, antibacterial drugs, or other medicines.
Our technique has had a considerable socio-economic effect. Its cost-effectiveness was equivalent to 1.2 million roubles annually owing to the shortening of the therapeutic course alone, according to the estimates of the medical staff in 60 burns centres in Russia in the time period 1970-1975.
Our system helped to eliminate specific odour and blue pyesis infection, which has become a major threat in burns centres throughout the world.
In-depth research has been and is still being carried out in our clinic's experimental laboratory, the aim of which is to increase the efficacy of our technique in the treatment of combined injuries (burns complicated by blood loss), which have lately tended to increase in number owing to natural disasters, major calamities, and local military conflicts. This research work is part of a series of all-Russian purpose-oriented scientific programmes.
The research data have demonstrated the highly effective beneficial effects of our system of active surgical management in trials using test animals (dogs).
In the course of our research work, observations were made on bone-marrow blood formation, acid-alkali balance, water-electrolyte balance,cardiac activity, haemostasis, haemo- and lymphodynamics, the lung system, liver function, the kidneys, the pancreas, and the DVS-syndrome. Our investigation has provided us. with an in-depth knowledge of the pathogenesis of combined injuries and stimulated the development of efficient therapeutic methods of treatment.
The reported system of intensive therapy in severe burns was successfully applied in the burns centre at Chelyabinsk for the treatment of persons injured in a railway accident that occurred in Bashkiria in 1989. The system aroused interest among Russian and foreign experts and health-care authorities from the Ministry of Health Care. On the proposal of the Health Care Minister A.I. Potapov, the Presidium of the Scientific Board of this Ministry took the decision on 12 September 1989 to set up a Centre of Disaster Medicine in Saransk, the capital of Mordovia.
The development and subsequent implementation of the intensive therapy system in clinical practice has stimulated research work: 52 dissertation theses for the Candidate of Medicine degree and 8 for that of Doctor of Medicine have been successfully discussed.
Eight regional inter-republican conferences were held on this issue in Saransk in 1974, 1975, 1976, 1978, 1981, 1984, 1985, and 1996 (the proceedings of the Conferences have been published). In 1972 a fundamental monograph entitled The System of Active Surgical Management of Severely Burnt Patients (528 pp.) was issued. This volume, written on the request of the Ministry of Health Care (16 August 1968), was highly praised by distinguished scientists in reviews published in Clinical Surgery, 6 (1973), Kazan Medical Journal, 6 (1973), Orthopaedics, Traumatology and Prothesis, 12 (1973), Surgical News, 1 (1974), Surgery, 2 (1974), and Military Medical Journal, 7 (1975). The monograph has become a manual for daily use among burns experts and other clinicians involved in burns treatment.
Various monographs have been published on this issue in the past few years, including Management of Burn Wounds, which was presented at the International Book Exhibition in Moscow in 1979 and later reprinted by the Gulab Vasirani Publishing House in India.
Active surgical management of extensive deep burns and combined injuries aroused interest among the participants in research forums in Russia, the CIS countries, Havana (1974), Sofia (1976, 1980, 1984, 1992, 1993), Prague (1989, 1993), Budapest (1990), Barcelona (1991), Tel-Aviv (1991, 1994), Berlin (1992), Paris (1994), Innsbruck (1994), Jerusalem (1995), Verona (1995), Kosbitse (1995), Ottawa (1997), and Cairo (1997). Some of our publications have been reprinted in Chinese journals (Surgery, 2 (1956) and 3 (1957)) and in the USA (Transfusiology, 3 (1968).
The Mordovian Republican Burns Centre has been transformed into a Clinical Research Centre of Thermal Pathology, which has become affiliated to the Sklifosovsky Moscow Research Institute of Emergency Medicine. All these initiatives have opened up new prospects for the promotion of experimental and clinical research in the field of burns pathology and combined injuries.

RESUME. Les Auteurs ont trouvé que la thérapie infusive et le traitement intensif fonctionnalisés sont utiles dans la restauration de la couverture cutanée dans une série de plus de 3000 grands brûlés avant le développement de modifications irreversibles. A cause de l'amélioration des mécanismes défensifs du corps, ils ont trouvé qui'il est possible: de réduire la période du nettoyage des lésions dans les tissus nécrotiques; d'accelérer le traitement local des lésions en présence de médications quotidiennees dans la période préopératoire et de réduire les temps de la guérison des sites donneurs à la suite des procès améliorés de la réparation; de réduire les intervalles entre les opérations chirurgicales répétées, pour obtenir une réduction complessive optimale du temps nécessaire, ce qui est extrêmement important pour la guérison du patient; de minimiser l'effet préjudiciable de l'autoimmunisation sur la prise de la greffe en réduisant le numéro des opérations chirurgicales répétées avec des infusions de volume qui augmente jusqu'à un maximum à mesure que les conditions du patient s'améliorent; de prévenir le danger potentiel du choc périopératoire en effectuant des infusions préventives sous pression dans les moments les plus traumatiques. L'Auteur a eu la possibilité de recouvrir les lésions avec des lambeaux de grosses dimensions qui si unissent en manière très adhérente; cette procédure donne des résultats fonctionnels et cosmétiques meilleurs et tend à limiter les indications pour les greffes allogéniques et à maille. Ce système a été développé dans 52 présentations de dissertations et sa réalisation dans la pratique clinique a contribué à sauver la vie de certains patients précédemment condannés à la mort.

BIBLIOGRAPHY (dissertation papers)

1. Abramova S.V.: Acid-base condition of blood at an early restorative period in acute blood loss combined with burns. Saransk, p. 17,1997
2. Anoshkin l.A.: Local changes in bone tissue following intraosscous drip-injections of blood and drugs. Chelyabinsk, p. 12, 1972.
3. Aralbaev T.A.: Burn disease in mountainous areas and the principles of infusion therapy. Moscow, p. 21, 1986.
4. Atyasov N.I: Intraosseous infusions in traumatology and orthopaedics. Gorky, p. 33, 1965.
5. Begoulov N.I: Efficacy of blood-restitution methods in combined injuries (burn and acute blood loss). Minsk, p. 20, 1986.
6. Belyacv AX: Ways of improving infusion therapy in combined injuries (burn and blood loss). N. Novgorod, p. 30, 1996.
7. Bril E.V.: The effect of narcosis on cholinesterase activity in burn patients in the septicaemia period. Kharkov, p. 22, 1982.
8. Bugrova K.P.: General anaesthesia in active surgical tactics in burn patients. Moscow, p. 17, 1969.
9. Vereshagina E.S.: Clinicophysiological grounding for the methodology of operative management in severe chest burns in paediatric patients. Gorky, p. 16, 1988.
10. Gasin.I.K.: Acid-base balance and oxygen depot in blood in the management of combined injuries with volecam and ozonotherapy.Saransk, p. 16, 1988.
11. Galustov G.N.: Pilot study of active surgical management in burn patients in Checheno-Ingushetia. Chelyabinsk, p. 21, 1976.
12. Gorbunov S.N.: Acid-alkaline balance of blood and outer breath in the pre-operative period and inhalatory narcosis. Gorky, p. 18,1975.
13. Guzeev V.A.: Transfusion therapy in severe burns. Alma-Ata, p. 48,1971.
14. Denisov V.M.: Transfusion of cadaver blood to patients with extensive, deep burns. Orenburg, p. 18, 1967.
15. Dmitriev G.I: Reconstructive-restorative surgery in rehabilitation of patients with burns sequelae. Perm, p. 32, 1986.
16. Eliseeva L.P.: Fluid- and electrolyte-balance at an early restorative period in acute blood loss and burns. Saransk, p. 17, 1998.
17. Ionicheva L.V.: Adaptive abilities of the haemopoietic system at an early restorative period in deep burns and blood loss. Saransk, p.not communicated, 1999.
18. Karpushin A.A.: Acid-alkaline balance of blood in burn injury and its dynamics in complex management of burn disease. Moscow,CITO, p. 16, 1971.
19. Kildyushov AX: Haemostatic disorders at an early restorative period in burns complicated by acute blood loss. Saransk, p. 17,1994.
20. Kiselyev S1: The role of donor skin grafts in the choice of rational surgical management in severely burned patients. Ryazan, p. 17,1971.
21. Klevtsova TX: The functional state of the cardiovascular system 42 in burn patients. Leningrad, VMOLA, p. 15, 1988.
22. Korablyov S.B.: Pilot study of autoimmune responses and their influence on graft take in repeated skin autoplasty. Kujbishev, p. 21, 1982.
23. Kotlov I.S.: Intrahepatic circulation and some hepatic functions in burns complicated by blood loss - various ways of its restitution. Gorky, p. 20, 1986.
24. Krizhanovskaya N.A.: Changes in the peripheral blood and bone marrow blood formation in patients with deep burns - the effect of intensive transfusion therapy. Moscow, p. 21, 1972.
25. Kupriyanova B.A.: Antibacterial treatment of granulating wounds in burns patients in the pre-amodermatoplastic period. Chelyabinsk, p. 15, 1972.
26. Kupriyanova T.S.: Aerosol treatment of burn wounds with antibacterial drugs. Ivanovo, p. 22, 1975.
27. Lazarev V.A.: Pathogenic grounding of regional (intra-umbilical) infusion-transfusion therapy in severely burned patients. Moscow, p. 33, 1988.
28. Levin S.A.: Haemocoagulatory properties and clinical use of plasma and blood platelets from cadaver blood. Moscow, p. 3, 1997.
29. Liyaskina A.V.: Study of the haemopoictic system at an early restorative period in deep burns complicated by blood loss. Saransk, p. 21, 1999.
30. Matchin E.N: Active surgical management of deep burns in Donskaya City Hospital, Tulskaya Region. Ryazan, p. 17, 1975.
31. Matchin EX: Ways of improving the surgical treatment of severelyburned patients. Moscow, p. 36, 1997.
32. Makhrov V1: Lymphodynamics and biochemical changes in blood and lymph and various ways of blood restitution in burns complicated by blood loss. Chelyabinsk, p. 19, 1986.
33. Ogoltsova V.A.: Clinico-morphologic results of skin restoration with meshed grafts in severely burned patients. Kharkov, p. 16, 1982.
34. Okunev N.A.: Renal function in burns complicated by acute blood loss - various ways of its restitution. Chelyabinsk, p. 18, 1985.
35. Pakhomov S.P.: Active surgical management of extensive deep burns. Moscow, p. 19, 1977.
36. Ponomaryeva N.A.: Methodology and functional outcomes of therapy in deep burns of shoulder joints. YaroslavI, p. 18, 1968.
37. Pilaeva S.I.: Dynamics of the data in nonspecific immunological reactivity in burn diseases. Gorky, p. 19, 1972.
38. Ryazantsev E.V.: Correction of acute kidney failure at an early restorative stage in burns complicated by blood loss (a pilot study). Saransk, p. 20, 1995.
39. Saushev I.V.: Disorders in transcapillary exchange of fluid and in lung surfactant activity in burns complicated by acute blood loss - some ways of their correction. Saransk, p. 19, 1995.
40. Semyonov A.V.: Corrections of disorders in acid-base balance of blood with sodium oxybutyrate and dimephosphone in burns complicated by blood loss. Saransk, p. 21, 1998.
41. Sovo E.R.: Prevention of operational shock in burns patients by active surgical management. Chelyabinsk, p. 15, 1969.
42. Sokolov LX: Early free skin grafting in deep burns. Gorky, p. 12, 1964.
43. Tarasova L.F.: Haernotransfusional therapy in children suffering from burn exhaustion. Ivanovo, p. 14, 1972.
44. Taratinov I.B.: Disorders in haemostasis system and their correction in combined injuries. Saransk, p. 20, 1996.
45. Tyukin A.A.: Experimental grounding and clinical experience in necrolysis of deep wounds. Gorky, p. 34 1973.
46. Tyagusheva M.N.: The use of spongy substance of bone tissue as a biological microfilter. Saransk, p. 16, 1997.
47. Usanova A.A.: Phase analysis of cardiac activity and some data relating to central haemodynamics in burns complicated by blood loss. Saransk, p. 11, 1994.
48. Utkina I.V.: Functional and morphological changes in kidneys and their correction in combined injury. Saransk, p. 21, 1999.
49. Chistyakov S.l.: Changes in proteolytic activity of blood in burns complicated by blood loss - some ways of their correction. N. Novgorod, p. 17, 1991. Sheremetyev J.A.: Pathogenic role of proteolytic enzymes in the development of early burn anaemia - ways of its correction. Moscow, p. 20, 1980.
50. Shifrina G.A.: Functional state of the heart in burn patients.Ivanovo, p. 17, 1974.
51. Yakushev S.A.: Pilot study of active surgical management of burn patients in a city hospital. Smolensk, p. 18, 1974.