Annals of Burns and Fire Disasters - vol. XIII - n. 4 - December 2000

IMPACT OF SELECTIVE GASTROINTESTINAL DECONTAMINATION ON MORTALITY AND MORBIDITY IN SEVERELY BURNED PATIENTS

Abdel-Razek S.M., Abdel-Khalek A.H., Allam A.M., Shalaby H., Mandoor S., Higazi M.

Plastic, Reconstructive and Burns Unit, Tanta Faculty of Medicine, Tanta, Egypt

SUMMARY. Major advances have been made in the treatment of severely burned patients and improved survival rates are being reported from many burn centres. This study considers 300 patients with a total burned body surface area of 25%0 or more in adults and 15% or more in children. The patients were randomly allocated to three groups: group 1 (control group) comprised 85 patients; group II (treated with selective gastrointestinal decontamination [SLID]) 112 patients; and group III (treated with SGID + alluprinol). The patient mortality rates were 19.0% in group 1, 5.4% in group fI, and 2.9% in group III. There was reduction in the period of hospital stay in group II and group III patients. SGID played a key role in the improvement of the survival rate and the reduction of hospital stay of severely burned patients.

The marked improvements in survival rates after massive burns that are being reported from many centres have been attributed to a new modality of dealing with burned patients and their wounds.' The concept of the gut as a motor of multiple organ failure in severely burned patients has only recently come to be considered.
Most investigations into the pathophysiology of gutderived sepsis involve the use of animal models; however, some findings are already being corroborated - within certain limits - in human studies. It has been reported that bacterial translocation is a physiological phenomenon in non-compromised animals but that in compromised animals translocation occurs more frequently and the number of translocating organisms is higher.

This study considered 300 patients, after the exclusion of the patients who died within 48 h post-burn (resuscitation period), who were admitted to Tanta University Hospital Burns Centre over a three-year period (March 1997 to March 2000). The patients presented a burned total body surface area (TBSA) of 25% or more in adults and 15% or more in children.
The patients were subjected to the following procedures:

1. Clinical evaluation
2. Resuscitation
3. Oral nutritional support as soon as intestinal sounds were audible
4. Local wound care
5. Systemic antibiotics if indicated, depending on culture and sensitivity tests
6. Bacteriological surveillance twice weekly

All burned patients admitted were randomly allocated to one of three groups:
Group I (control group). This group comprised 85 patients with variable degrees of burn. These patients were treated with local wound care only and systemic broadspectrum antibiotics on the basis of the results of blood or wound bacterial surveillance.
Group II. This group included 112 patients treated (in addition to the control group treatment protocol) with:

1. Colistin sulphate at a rate of 150,000 units/kg/day in four divided doses;
2. Co-trimoxazole in the form of 80 mg trimethoprin + 400 mg sulphamethoxazole twice daily for adults (half dose for children);
3. Nystatin oral suspension (adult dose 500,000 IU six-hourly).

Group III. In this group of 103 patients we added alluprinol as xanthine oxidase inhibitor at an adult dose of 100 mg three times daily (half dose for children).
In groups II and III, prophylactic antibiotics were not given routinely but only on a clinical or bacteriological basis.

A total number of 300 patients were included in this study. The mean age was 22.04 ± 16.36 yr, with no statistical difference between the three groups. The youngest patient was 9 months old and the oldest 75 years old.
The mean TBSA was 35 ± 18.28% (Table I).

The mean full-thickness burn area was 21 ± 17.46% (Table II).

The mortality rate in group I was 19%, in group 115.4%, and in group III 2.9%0 (Table Ill).

There was a statistically significant difference between the control group and other two groups. In the control group, mortality was 100% in children with TBSA equal to or more than 60%, while the rate was only 33.3% if selective gastrointestinal decontamination (SGID) was applied (Table IV).

The period of hospitalization was longer in the control group, with a mean of 30.1 ± 9.7 days, compared with 23.9 ± 9.4 days in the SGID group, with a significant statistical difference between the control group and other two groups (Table V).

This study reports on survival and the length of hospital stay in relation to burn size, age, and SGID in 300 consecutive patients treated in the last three years in the Tanta Burns Unit. The mortality rate in the control group was 19%, compared with 5.4% in patients receiving SGID; when alluprinol was also administered to SGID patients, mortality fell to 2.9% (statistically significant).
Major advances have been made in the treatment of severely burned patients, and improved survival rates are being reported from a number of burns centres.
Between 1983 and 1989, the overall mortality rate in the USA was between 6 and 20%, compared with 20% in the UK.' These figures vary considerably, some being quite high, e.g. a centre in Alexandria reported 21 %,° while Fadaak et al.' reported a mortality of 6.9%. Chen et al.' studied the effect of early escharectomy on intestinal microflora.
Monafo et al.' attributed improved survival to the use of topical silver sulphadiazine while Herek et al."' studied the effects of immunotherapy on bacterial Tanslocation in burn wound infection.
Demling" attributed the improved survival in massive burns to better methods of burn management. Although Gram-negative enteric bacteria are frequently isolated from the burn wound, little attention has been paid to the patient's gastrointestinal tract, while the relationship between the microflora of the digestive tract and the microflora of the burn wound has repeatedly been reported.
The translocation of enteric bacilli, endotoxin, and yeast after major burns has been well demonstrated in experimental models.' In our study we investigated the impact of SGID on mortality and the length of hospital stay in cases of severe burn injury.
Mackie et al." investigated the use of SGID in patients with extensive burns, but the study included only a limited number of cases (33 patients). In the present study, children in the SGID group presented no mortalities when the TBSA was less than 60%, which is consistent with Feller's sigmoid curve. Saffle" reported an overall survival rate of 80%o and 67% in patients aged over 75 yr.In Shanghai, Li et al." reported a mortality rate of 32.7Q in burn patients aged o% er 65 yr. -Mason et a1. reported that there was significantly increased mortality in patients with Gram-negative bacteraemia also in patients with a positive blood culture for yeast but no increase attributed to Gram-positive bacteraernia.
In our study we did not record any mortalitx in nonshocked non-bacteraemic patients. while mortality was 9.1c% in the control group. When the patients were shocked but not bacteraemic the mortality rate was 500~ in the control group: the rate was -1.8c'c in the SLID group. and there was no mortality in the SGID group when alluprinol was added to the SGID regimen.
On admission. if the patients were shocked and bacteraemic. the mortality rate ryas 60.7Cé in the control group, while with SGID it "as 35.717c; when admission shock was associated with enteric bacteraemia the mortality rate "as markedly increased to 73.7~ in the control group, while it was 50c,'c in the SGID group. and the rate was -1?.9c-c if alluprinol was added to the SGID regimen.
In our study the mean hospital stay was 30.11 ± 9.70 days in the control group, compared with 23.86 ± 9.-1? days in the SGID group: this represents a beneficial reduction in financial cost. Itlanson et al.'° in 1987 reported that the mean hospitalization period was 35 days in the SGID group. and in 1992 1flanson" again attributedJthe length of hospital stay to the extent of the burned area. the age of the patient, and also to colonization with enteric bacteria.
Our study indicated that SGID played a key role in the improvement of the survival rate and in the reduction of hospital stay in severely burned patients.

RESUME. Des progrès très importants ont été réalisés dans le traitement des Brands br6lés et beaucoup de centres des br6lds communiquent des taut de survie améliords. Les Auteurs présentent dans cette etude leurs rdsultats avec 300 patients atteints de brîllures de ?Scc ou de plus de la surface corporelle chez leg adultes et IScc ou de plus chez leg enfants. Les patients ont ere divisés au hasard en trois grouper: le groupe I (Qroupe témoinl contenait 85 patients: le groupe II 1 aroupe de decontamination gastrointestinale selective [sigle anglais: SGID] 112 patients: et le groupe III 1 SGID + alluprinol 1. Les taut de mortalite des patients étaient 19.0% dans le aroupe I. 5.5c--c dans le groupe II et 22,9cc dans le groupe III. Les Auteurs ont observe une reduction dans la periode de Fhospitalisation dans leg patients des grouper II et III. La SLID a jour un r61e fondamental dans Famélioration du taux de la survie et dans la rdduction de -'hospitalisation des patients sevèrement br6ld

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