Volume XIII

Number 4

December 2000

DOES INHALATION INJURY REALLY CHANGE FLUID RESUSCITATION NEEDS? A RETROSPECTIVE ANALYSIS
(Bollero D., Stella M., Calcagni M., Guglielmotti E., Magliacani G. - Italy)
The optimization of fluid resuscitation is a key point in the treatment of severely burned patients. In order to improve our knowledge of fluid resuscitation, we performed a retrospective analysis of patients admitted to the Turin Bunts Centre, Italy, in the years 1992-96. The patients were divided into two groups: the first group was resuscitated using the Parkland formula, while the second group received 2 ml/kg/% TBSA of Ringer's lactate in the first 24 h and 0.5 ml/kg/%o TBSA of Ringer's lactate plus 0.5 ml/kg/% TBSA of 5% albumin in the subsequent 24 h. Among the 163 patients included in our study on the basis of our admission criteria, we also considered 44 burn patients with inhalation injury. The mean fluid requirement for resuscitation, in all patients, was 4.32 ml/kg/%. No statistically significant differences were observed between the groups. Only patients whose fluid administration was initially inadequate (i.e., patients admitted to our burn centre within 24 h post-burn but already lacking more than 30% of the predicted amount of fluid) received a significantly smaller amount of fluid. With regard to inhalation, inhalation injury did not in our experience alter fluid requirements during the resuscitation phase.

MANAGEMENT OF FLUID AND ELECTROLYTE DISTURBANCES IN THE BURN PATIENT
(Ramos C.G. - Portugal)
A brief description is given of the pathophysiology of the burn patient. indicating the three periods of its evolution: the resuscitation phase. lasting for the first 36 h: the early post-resuscitation phase. betsseen days 2 and 6; and the inflammation/infection phase. from day 7 until wound closure. Each phase is characterized by specific electrolyte imbalances. the management of ssrhich requires a thorough understanding of the changes that occur over time. For each electrolyte abnormality, an indication is given of the major mechanisms responsible and the main signs and symptoms, as well as their management.

EVALUATION OF THE VALIDITY OF THE HAIFA FORMULA FOR FLUID RESUSCITATION IN BURN PATIENTS AT THE RAMBAM MEDICAL CENTRE
(Ullmann Y., Kremer R., Ramon Y., Berger J., Ullmann A., Peled I.J. - Israel)
In order to evaluate the validity of the Haifa formula for the fluid resuscitation of burn victims, we retrospectively evaluated the files of 72 burn patients treated in the burn unit of the Rambam Medical Centre (Israel) during the years 1990-95. According to this formula, the estimated quantity of fluid to be given in the first 24 h is: plasma - 1.5 cc x kg x percentage burned TBSA and Ringer's lactate - 1 cc x kg x percentage burned TBSA. Half of this is given in the first 8 h and the other half in the successive 16 h. The fluid estimation for the next 24 h is half the amount estimated for the first day. We included patients over 15 yr old with burns of 20-80%o TBSA, without smoke inhalation. We divided the patients into three subgroups on the basis of the extent of the burned area - subgroup 1: 20-34% TBSA; subgroup 2: 35-49% TBSA; subgroup 3: above 50%o TBSA. We found a good correlation between the volume of plasma recommended by the formula and the amount actually given. We found a substantial difference between the quantity of Ringer's lactate recommended by the formula and the quantity actually given to patients with less than 50% TBSA, during the first day. Since the hourly urine output per kg was relatively high (1.66 cc/kg/h), we concluded that haemodynamic instability was not the cause of the deviation. Respiratory complications were recorded in 12.5% of our patients and sepsis in 60%; the mortality rate was 5.5%. These data are consistent with those found in the literature, although about 25% less fluid was given to our patients than that recommended by the Parkland formula. Complications attributed to fluid overload, such as ileus and compartment syndromes, were not recorded. It was possible to initiate early enteral feeding in all the patients.

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. - Egypt)
Major advances have been made in the treatment of severely burned patients and improved survival rates are being reported from many bum 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.

LOCAL BURN TREATMENT - TOPICAL ANTIMICROBIAL AGENTS
(Noronha C., Almeida A.)
Effective topical antimicrobial agents decrease infection and mortality in burn patients. Silver sulphadiazine continues to be the antimicrobial agent most often used in burn care facilities. Combined topical use of silver sulphadiazine and other antimicrobials may be a possible solution to bacterial resistance in burn wounds. Other agents seem to be useful in isolated clinical situations. None of the available topical antimicrobials, whether alone or in combination. will however prevent colonization of burn wounds. although invasive infections are infrequent.

ENHANCEMENT OF BURN HEALING BY GROWTH FACTORS AND IL-8
(Blumenfeld I., Ullmann Y., Laufer D., Livne E. - Israel)
The aim of the present study was to evaluate the ability of interleukin-8 (IL-8) to enhance wound healing and to compare this with the effect of transforming growth factor-(31 (TGF-(31) + basic fibroblast growth factor (bFGF) applied in combination. Inflicted burn injury was used as the model for wound healing. Deep partial-thickness burns were inflicted using aluminium templates. IL-8 and growth factors were applied topically using measured volumes (40 pd) and the wound was covered by non-adherent absorbent dressings and then bandaged. Treatment was repeated every two days for up to 13 days. Wound areas were recorded and photographed and tissue biopsies were obtained on the last day for general morphology. The results indicated that treatment with IL-8 enhanced epithelialization and reduced contraction and the open area values of inflicted wounds. IL-8 appeared to be the most significant in this respect compared with TGF-(31 + bFGF or control groups. Morphology obtained from tissue biopsies on the last day of the experiment also revealed that re-epithelialization was most significant in IL-8 treated wounds. It is concluded that the topical application of IL-8 enhanced the wound healing process in experimental animals

ADJUNCTIVE HYPERBARIC OXYGEN TREATMENT OF SEVERE ELECTRICAL INJURIES: A COMPARATIVE STUDY IN HUMANS
(Colic M. M - Yugoslavia)
The action of hyperbaric oxvaenation (HBO) on high-tension electrical injuries as an adjunctive treatment is presented in this report, as applied in 30 patients compared " ith 67 patients treated in a standard way. The results were compared using as parameters overall mortality, the number of amputations. and the time necessary before final coverage of the defects and discharge from hospital. Exposure to hyperbaric oxygenation permitted faster and better healing of the affected areas with no secondary infections, a lower amputation rate. and better reconstructive possibilities in the HBO group than in the group of patients treated conventionally.

SURGICAL MANAGEMENT OF THE BURNED HAND: AN UPDATE AND REVIEW OF THE LITERATURE
(Atiyeh B.S., Ghanimeh G., Nasser A.A., Musharrafieh R. S. - Lebabon)
In wartime or following mass accidental casualties characterized by large numbers of burn victims, and whenever hand burns are associated with a life-threatening extensive burn or other injury, hand burns are often neglected. Although it is generally accepted that the management of critical burn patients should be primarily directed towards the patients' survival, burned hands should also be regarded seriously since the majority of cases of post-burn morbidity, as well as the most devastating sequelae of thermal injuries, are related to hand burns. It is difficult to adhere to strict management protocols, except in isolated, relatively minor hand burns, and there is an urgent need to formulate easily applicable guidelines and develop simple treatment modalities and dressings that are practical to use in most situations, without compromising the final outcome. The "Moist Exposed Burn Therapy" (MEBT) principle seems to be very promising in this regard. It offers the advantages of a moist environment for wound healing, which promotes rapid infection-free re-epithelialization, in addition to the advantages of the open treatment technique, avoiding cumbersome, bulky, and expensive dressings and allowing early and frequent range-of-motion exercises.

APPORT D'UN DOUBLE LAMBEAU INTEROSSEUX "GÉANT" DANS LE TRAITEMENT DE DEUX MAINS SÉQUELLAIRES CHEZ UN PATIENT BROLÉ
(Chafiki N., Terrab S., Diouri M., Bouchta A., Bahechar N., Boukind E.H. - Maroc)
Burned hand sequlae may be very difficult to manage. This case report of complex hands sequelae in a patient describes the positioning and the technical refininements of a large posterior interessoeus flap. Prevention remains the best way of preventing undesiderable sequelae in the deeply burned hand. Early excision plays an important role.

COMPLEX TREATMENT AND PROPHYLAXIS OF POST-BURN CICATRIZATION IN CHILDHOOD
(Dyakov R. - Bulgaria)
During the 10-yr period 1989-98, 2261 burned children were observed at the Clinic of Paediatric Burns and Plastic Surgery of the N.I. Pirogov Medical Institute, Sofia, Bulgaria. Out of the total number of burned children, 1401(61.96%) underwent a surgical intervention. Of these 1401 children, 1149 (82.01 %o) were covered with free flaps after chemical escharectomy or spontaneous biological detachment of the necroses. Surgical escharectomy was performed in only 213 cases (17.99%), with the patients being autografted in one or more stages. Out of all the cases (whether operated upon or not) with IIB degree burns who epithelialized spontaneously, 1843 developed hypertrophic scars and keloids. Surgical procedures were undertaken in 1415 (76.77%) of the cases. We recommend the following steps in order to prevent pathological cicatrization: 1. adequate infusion therapy; 2. appropriate local treatment with preparations containing silver sulphadiazine or 10% povidone-iodine (this stops bacterial contamination, which is an important factor in the prevention of the formation of severe cicatrices in donor sites as well as spontaneously epithelialized sites); 3. early surgical treatment on day 1-8; 4. early and timely rehabilitation. The injection of corticosteroids under and marginally to the grafts prevented cicatrization. Plate devices were used to compress the scars and reduce blood flow. Elastic bandages and underwear also exerted compressive action. All three methods were applied during the whole period of scar maturation, e.g. 8-10 months, and in some cases longer. Reviewing the effects of the complex treatment implemented and the extended prophylaxis model, we can define the results as very good in 941 children (51.05%), good in 812 (44.07%0), and unsatisfactory in 90 (4.88%).