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Volume XIX

Number 3

September 2006

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(Al-Kaisy A.A., Salih Sahib A., Al-Biati H.A.H.K.. - Iraq)
Many studies have reported that zinc plasma levels significantly decrease after a burn, leading to zinc deficiency, and that increased free radical generation and decreased natural antioxidant may negatively affect wound healing and burn outcome in general. Targeting of these changes is considered an important strategy in the treatment of burns in an attempt to improve burn outcome in the clinical setting. Zinc was given orally in a nutritional dose (15 mg elemental zinc) as a zinc sulphate capsule to burn patients in order to improve post-burn zinc deficiency and burn outcome. The study was carried out in 58 burn patients of different age groups, sex, and occupation with different burn size. The patients were allocated to two groups: group A patients (43 in number) were treated with topical povidone-iodine ointment for the first four days post-injury followed by topical silver sulphadiazine cream 1% until discharge in addition to other prescribed drugs according to our burn unit policy; group B patients (15) received the same treatment as group A plus a single daily oral dose of zinc sulphate in a 66 mg capsule, equivalent to 15 mg elemental zinc. In each group, using standard methods, we considered plasma zinc and copper levels, oxidative stress parameters, thyroid, liver, and renal function tests, microbiological factors, mortality rate, healing time, and cost effectiveness. The administration of zinc in dietary doses significantly increased the plasma zinc level in burn patients to around normal control levels and improved the antioxidant status, as represented by elevation of the natural antioxidant level (glutathione), in addition to improving healing time, the incidence of eschar formation, and the mortality rate, compared with the zinc-nonsupplemented group. We conclude that dietary zinc supplementation in zinc-deficient burn patients led to great improvements in their outcome and that zinc deficiency was as an important goal to target during treatment; also, that the use of a combination of topical and systemic antioxidants (povidone-iodine ointment and zinc sulphate, respectively) represented a good strategy for improving results in burn patient treatment.
(Ravikumar T., Shanmugasundaram N., Jayaraman V., Ramakrishnan K.M., Babu M. - India)
Low molecular weight heparin (LMWH) appears to be a promising solution for reducing inflammatory post-burn episodes and results in improved healing. The clinical examination presented here includes patients with burn wounds ranging from 20 to 35% total body surface area (TBSA) who were categorized into two groups, of which one received subcutaneous LMWH treatment (10,000 units/day) and the other acted as control. The process of healing was assessed through regular examination of clinical features such as regression of erythema and oedema, eschar formation, and rate of re-epithelialization. Various studies have demonstrated an increase in levels of serum IL-6 indicating the severity of the morbid condition. In the present investigation, LMWH-treated patients exhibited a faster decline in levels of serum IL-6 (within 12 days) than control. Infiltration of inflammatory cells at the local wound site was assessed through a histological analysis of tissue samples taken on various days during the healing process. The LMWH-treated groups exhibited an organized healing pattern with better remodelling in a shorter duration (28 days), while control patients took more than 28 days for complete healing. A slight correlation was observed with TBSA to the inflammatory process, which subsided in patients treated with LMWH, favourably modulating the events involved in the inflammatory process of burn wound healing.
(Ramos G.E., Resta M., Durlach R., Patiņo O., Bolgiani A., Prezzavento G.,Fernandez Canigia L., Benaim F. - Argentina)
Bacteraemias during burn wound manipulation are frequent, especially following burn wound excision. However, these bacteraemias seem not to have any clinical consequences, and their treatment is therefore controversial. Over a 20-month period 35 surgical debridement procedures were recorded prospectively in 18 burn patients. Blood culture samples were drawn before, during, and after surgical excision. Bacteraemias were found in ten out of the 35 patients (28%), and 16 of the 105 blood samples (15%) were positive. All three blood samples were positive in one case ("primary bacteraemia"), while others were "transient bacteraemia". Six positive blood cultures were considered to be "bacteraemias induced by wound manipulation" and seven "bacteraemias of unknown source". Bacteraemias of unknown source were not recorded at any time while "bacteraemias induced by wound manipulation" were recorded after day 5 post-burn. Patients with more than 40% TBSA had 4.3 times more bacteraemic risk than patients with less extensive TBSA. Blood pressure and white blood cell variations were observed in bacteraemic patients but without any clinical relevance. We conclude that bacteraemic rates were high and that there were two different patterns of bacteraemia - both transient and with no clinical relevance.
(Le Floch R., Naux E., Pilorget A, Arnould J.-F. - France)
We report our experience in using remifentanil as sole agent for the analgesia of spontaneously breathing non-intubated burn patients during dressing changes. Sixty procedures were collected and analysed. Remifentanil was used during monitoring of vital functions, with oxygen inhalation throughout the procedure, at the bedside in the intensive care unit ward. Infusion speed was varied by the nurse in charge, depending on pain, analgesia, and adverse effects. The dosage of continuous infusion ranged from 0.125 to 1 (average, 0.42). All patients received intravenously morphine 30 min before the end of the procedure (average, 10 mg). The main side effects were hypoxia and drowsiness, always quickly reversed when the doses were reduced. All patients had low levels of pain during and after the procedure, and were satisfied with the analgesia protocol. We conclude that remifentanil is another possible manner of analgesia in the dressing of burn patients, but that it must be used in an "anaesthesiological" environment.
(Adeleke O.E.1, Olaitan P.B. - Nigeria)
Pseudomonas aeruginosa has a notorious characteristic of resistance to most antimicrobial compounds. This characteristic was subjected to verification in the present study, whereby 50 human isolates of the organism from different pathological sources were subjected to sensitivity tests against honey from three different sources by the agar-cup diffusion method. Gentamicin, an aminoglycoside antibiotic normally with activity against Gram-negative bacteria, was used alongside honey. The 50 isolates of P. aeruginosa showed 100% sensitivity to each of the three types of honey tested in their undiluted form. This was not the case with gentamicin used in 8 and 4 ĩg/ml concentrations, both of which varied in their antipseudomonal activity, like the 1:2 aqueous dilution of each honey which failed to appreciably inhibit a lower number of pseudomonal isolates than either of the two concentrations of gentamicin. Honey is suggested as an effective natural product in overcoming the widespread antibiotic resistance of P. aeruginosa.
(Lohana P., Potokar T.S. - United Kingdom)
A variety of dressings are used for the management of paediatric burns. Aquacel AgŪ is a silver-impregnated hydrofibre that releases silver within the dressing for up to two weeks. It has been reported in the literature that it is a beneficial dressing for the management of partial-thickness burns. It promotes an appropriate environment for re-epithelialization of the burn wound. The aim of this study was to evaluate the use and outcomes of Aquacel AgŪ dressing in paediatric burn patients. This was a prospective audit carried out in the period January-July 2005. The healing time was satisfactory. The dressing normally adheres to the burn wound for up to two weeks and thus requires less frequent changes. In our study, patients required three to four outer dressing changes. However, Aquacel AgŪ has not been compared with other dressings. Overall pain requirements were reduced during subsequent dressing changes. It was also easy to apply the dressing in the majority of our patients. Non-adherence was one of the problems encountered but, overall, Aquacel AgŪ appeared to be a safe, effective, and comfortable dressing.
(Abdel-Razek S.M. - Saudia Arabia)
Perineal or genital burns are mostly part of large body surface injuries, and isolated burns to the genitalia are not common. Nevertheless, they are of major concern to the patient and clinician. Highly concentrated solutions of sulphuric acid are available to unclog drains. We have noted a substantial number of both accidental and intentional cutaneous burns caused by these agents and we therefore conducted a study on the incidence and treatment of isolated chemical burns in the genitalia. The study was performed in the Burns Unit, King Saud Hospital, Al-Qassim, Kingdom Saudi Arabia, from April 2001 to December 2004. During this period we received 12 patients with isolated chemical burns in the genitalia, representing 3.4% of all cases of burns treated between 2001 and 2004 (350 patients with different causes and variable percentages of burns). Of these 12 patients, 11 were males and one female. The patients' ages ranged from 9 to 75 yr. The mean burn size was 2% of the total body surface area. The cause of the burn injury was sulphuric acid, which is famous in this area for water closet cleaning. Eight patients (66.7%) required skin grafting, one healed with minimal scarring, and three (25%) healed with minimal contractures treated with multiple Z-plasty. We concluded that conservative management of perineal and genital chemical burns was recommended until the demarcation zone became clear. Split-thickness skin grafts were durable, safe, and technically easy, with satisfactory cosmetic and functional results.
(Kritikos O., Tsangaris H., Tsoutsos D.A., Papadopoulos S., Karabinis A., Ioannovich J. - Greece)
Inhalation injury is one of the main causes of death in patients with severe burns. Administration of exogenous surfactant appears promising for the treatment of acute respiratory failure. We report our clinical experience with this approach. A 35-yr-old man was admitted to our burns unit after an industrial accident. He had sustained a 60% total body surface area full-thickness burn combined with severe inhalation injury. Fiberoptic bronchoscopy confirmed the diagnosis, demonstrating severe blisters and ulcers of the bronchial mucosa. Refractory hypoxaemia (PaO2/FiO2 56 mm Hg, where PaO2 is oxygen tension in arterial blood and FiO2 is the fraction of inspired oxygen) was treated with optimal mechanical ventilatory support; additionally, an initial dose of natural bovine surfactant (Alveofact) of 50 mg/kg body weight was administered by intrabronchial instillation on day 3 post-burn. A significant improvement in oxygenation was observed 12 h after administration (from 56 mm Hg initially to 194 mm Hg), followed by an improvement in dynamic compliance (from 26 ml/cm H2O initially to 41 ml/cm H2O) and inspiratory resistance (from 14 cm H2O/lps initially to 11 cm H2O/lps). The same dose of surfactant was repeated 48 h later to prevent potential deterioration, resulting in maintenance of gas exchange and lung mechanics at the above levels. No complication associated with the surfactant administration was observed. However, the patient died on day 9 post-burn owing to extrapulmonary causes. Our results demonstrate a significant improvement in gas exchange and lung mechanics in a burn patient with severe inhalation injury after repeated administration of exogenous surfactant. Further study is needed in order to elucidate the clinical impact of surfactant administration and the complications associated with its use in cases of inhalation injury.
(Castana O., Makrodimou M., Mantzaris G., Tsandoulas Z., Prigouris S., Alexakis D. - Greece)
The co-existence of an extensive burn with a systemic disease negatively affects the outcome of the burn as well as the progress of the disease. A case report is presented regarding a 70-yr-old female patient with 45% total body surface area burns and ulcerative colitis under treatment. The outcome of the burns is described and it is pointed out that the healing process of the burns and the remission of the ulcerative colitis were related.
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