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Volume XXI |
Number 2 |
June 2008 |
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SUMMARIES
| 59 |
UNHEALED WOUNDS, HYPOALBUMINAEMIA AND CACHEXIA IN A BURNED CHILD - WHERE IS THE LIMIT?
(Trop M.1, Schintler M.2, Spendel S.2, Stockenhuber A. - Austria)
In our case report we attempt to reconstruct the case of a 10-yr-old boy in Iraq with severe burns who survived almost six months without any adequate treatment, i.e. adequate treatment according to our therapeutic standards. We also highlight the patient's predominant symptoms, such as open wounds, hypoalbuminaemia, and cachexia. |
| 63 |
NUTRITIONAL AND PHARMACOLOGICAL MODULATION OF THE METABOLIC RESPONSE OF SEVERELY BURNED PATIENTS: REVIEW OF THE LITERATURE (part 1)
(Atiyeh B.S., Gunn S.W.A., Dibo S.A. - Lebanon)
Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society. Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field. |
| 73 |
SKIN pH VARIATIONS FROM THE ACUTE PHASE TO RE-EPITHELIALIZATION IN BURN PATIENTS TREATED WITH NEW MATERIALS (BURNSHIELD®, SEMIPERMEABLE ADHESIVE FILM, DERMASILK®, AND HYALOMATRIX®). NON-INVASIVE PRELIMINARY EXPERIMENTAL CLINICAL TRIAL
(Osti E. - Italy)
The aim of this trial was to measure the pH value of the skin of burn patients using a non-invasive method, from the acute phase through to complete re-epithelialization. The research was then completed by treating the patients with new materials and innovative methods to verify whether this had an effect on the skin pH and on re-epithelialization time. In this clinical trial, the patients were medicated repeatedly with hydrogel (Burnshield®) kept in place by a transparent, semipermeable adhesive film with a moisture vapour transmission rate equivalent to 1600 until day 5 or 6 post-burn. In one patient, treated silk (DermaSilk®) was applied several times until re-epithelialization; in another patient, synthetic hyaluronic acid (Hyalomatrix®) was applied. Various studies using Dermasilk® have confirmed that the fibroin in silk stimulates re-epithelialization, in addition to keeping the burned skin disinfected, thanks to the antimicrobial agent contained in the treated silk. Hyalomatrix® was used on the other patient, as in other studies, as a temporary substitute for the skin in deep burns. Late complications (keloids and hypertrophic scars) can give rise, even after prolonged periods of time, to Marjolin's ulcer (carcinoma but also melanoma and sarcoma), which can develop in the course of a year. A recent Danish trial affirms that appropriate burn treatment facilitates re-epithelialization and decreases the incidence of Marjolin's ulcer. For the trial, we used a centimetre-wide strip of reactive paper sensitive to pH variations and an acid test (Duotest® kit) as a reference, applied for more than one minute on the patient's burned and slightly damp skin. We performed control procedures on the patient's normal skin, away from the wound site. The pH was measured from day 1 post-burn and every other day thereafter until complete re-epithelialization. We found alkaline pH values for the burned skin from the day of the burn until day 12, with an alkaline pH peak on day 4 (10.5 in the first patient, 9.5 in the second). The values then gradually returned to normal (pH, 5.5) from day 13 onwards. The mean re-epithelialization time was similar in the two patients, equivalent to 24.5 days (25 days in the first patient, 24 in the second), with a mean follow-up of 21 months (33 months in the first case, 9 in the second). No early or late complications were observed. |
| 78 |
ELECTRICAL BURN - A FOUR-YEAR STUDY
(Haddad S.Y. - Jordan)
This is a retrospective study of 12 male patients with electrical burns out of 362 patients admitted to the burns unit of the Royal Rehabilitation Centre at King Hussein Medical Centre, Jordan, over a period of four years from January 2004 to December 2007. The commonest cause of the burns was related to human error and lack of knowledge. The average total burn surface area was 30.3%. The average percentage of cases involving limb loss was 41.7% and the mortality rate was 25.0%. |
| 81 |
DIFFERENT SURGICAL RECONSTRUCTION MODALITIES OF THE POST-BURN MUTILATED HAND BASED ON A PROSPECTIVE REVIEW OF A COHORT OF PATIENTS
(Saleh Y., El-Shazly M., Adly S., El-Oteify M. - Egypt)
This study covered 40 patients (22 females and 18 males) suffering from post-burn hand deformities admitted to Assiut University Hospital and Luxor International Hospital (Egypt) from June 2004 to May 2006. Their ages ranged between 4 and 45 yr (mean, 24.5 yr). They presented a variety of post-burn hand deformities, e.g. dorsal hand contracture (14 cases), volar contracture (10 cases), first web space contracture (3 cases), post-burn syndactyly (2 cases), wrist deformity (3 cases), skin and tendon affection (2 cases), and complex deformity (6 cases). All the patients underwent a variety of surgical procedures specific to the individual post-burn hand deformity. Post-operative splinting of the hand for 10 days was performed in patients with skin graft to prevent recontracture. The post-operative physiotherapy programme started in the second week in order to achieve good functional results. The follow-up period ranged from 6 to 20 months. The results were satisfactory in most of the cases as regards the quality of coverage, which was achieved in the majority of cases. In one case there was partial loss of the skin graft, which healed by secondary intention; full range of motion was achieved in most patients, but not those with joint affections. On the basis of our results, we can conclude that the management of post-burn hand deformities depends on several factors. Initial treatment of the burned hand is of great importance for the prevention of secondary deformities. In secondary burn management the first step is the release of the contracture, which should be complete and include all contracted structures. The second step is the proper selection of methods of coverage for resultant defects, using either skin grafts or flaps depending on the presence of exposed tendons, nerves, or joints. The third step in order to obtain a very good function is the activation of an intensive physiotherapy programme immediately after the operation. |
| 90 |
L'ATTITUDE CHIRURGICALE DANS LES BRULURES ELECTRIQUES GRAVES PAR HAUT VOLTAGE: À PROPOS DE DEUX CAS
(Moussaoui A., Fejjal N., Achbouk A., Tourabi K., Ribag Y., Bakkali H., Ababou K., Ihrai H. - Maroc)
Devant une brûlure électrique grave, deux attitudes chirurgicales se distinguent: 1. une attitude conservatrice; 2. une attitude d'amputation. A la lumière de deux observations, les Auteurs discutent les avantages et les difficultés de la mise en oeuvre de chaque attitude. |
| 94 |
L'EQUIN DU PIED DANS UN CONTEXTE DE BRULURE GRAVE - INTERET DU BILAN PHOTOGRAPHIQUE
(Girbon J.P., Maligot B., Coiffier E., Gonzalez-Gutierrez L., Gaussorgues C., Lacroix P., Braye F. - France)
The incorrect position of the foot in talipes equinus is common in the framework of prolonged confinement to bed in a patient in deep sedation. In the context of severe burns, this incorrect position is difficult to prevent and its fixation by cutaneous shrinkage, which is often associated with a musculotendinous fibrosis, constitutes an important functional after-effect. The onset of talipes equinus is insidious and progressive, and it is therefore important to be watchful both in detection and in prevention. Regular photographic assessment makes it possible to predict its appearance and to take appropriate preventive or curative action. |
| 102 |
CO-GRAFT OF ACELLULAR DERMAL MATRIX AND AUTOGENOUS MICROSKIN IN A CHILD WITH EXTENSIVE BURNS
(Chen X.L., Xia Z.F., Fang L.S., Wang Y.J., Wang C.H. - People's Republic of China)
A 6-yr-old boy was the victim of a burns accident in a public bathhouse. The burns involved the face, neck, upper and lower extremities, anterior and posterior trunk, and both buttocks, covering 72% of the total body surface area (TBSA). The lesions in the lower extremities and parts of the right upper extremity were deep partial-thickness, comprising 40% TBSA. On day 5 post-burn, the lesions in both lower extremities were excised to the extent of the fascia under general anaesthesia. Meshed J1 Jayya Acellular Dermis®, a kind of acellular allodermal (ADM) matrix, was then placed on the left knee joint. The right knee joint served as control. The wounds in both lower extremities were then overlaid with microskin autografting. At 19 days post-application, the lesions in both lower extremities had almost completely resurfaced. Follow-up at six months revealed well-healed and stable skin of acellular ADM and microskin autografts on the left knee. However, the skin of the right knee was unstable and there was a chronic residual ulcer. Both legs showed some significant hypertrophic scars. The left knee joint (acellular ADM grafted site) showed mild contractures, while the right knee joint developed a significant contracture. The "skin" of the co-graft covered site appeared thicker and more elastic. The movement range of the left knee joint was much larger than that of the right knee joint. These results suggest that co-graft of acellular dermal matrix and autogenous microskin may be an effective way to repair this functional site in children with extensive burns and to improve the functional and cosmetic results. |
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