IMPLEMENTATION OF A PROCALCITONIN-GUIDED ALGORITHM FOR ANTIBIOTIC THERAPY IN THE BURN INTENSIVE CARE UNIT
(Lavrentieva A., Kontou P., Soulountsi V., Kioumis J., Chrysou O., Bitzani M.)
The purpose of this study was to examine the hypothesis that an algorithm based on serial measurements of procalcitonin (PCT) allows reduction in the duration of antibiotic therapy compared with empirical rules, and does not result in more adverse outcomes in burn patients with infectious complications. All burn patients requiring antibiotic therapy based on confirmed or highly suspected bacterial infections were eligible. Patients were assigned to either a procalcitonin-guided (study group) or a standard (control group) antibiotic regimen. The following variables were analyzed and compared in both groups: duration of antibiotic treatment, mortality rate, percentage of patients with relapse or superinfection, maximum SOFA score (days 1-28), length of ICU and hospital stay. A total of 46 Burn ICU patients receiving antibiotic therapy were enrolled in this study. In 24 patients antibiotic therapy was guided by daily procalcitonin and clinical assessment. PCT guidance resulted in a smaller antibiotic exposure (10.1±4 vs. 15.3±8 days, p=0.034) without negative effects on clinical outcome characteristics such as mortality rate, percentage of patients with relapse or superinfection, maximum SOFA score, length of ICU and hospital stay. The findings thus show that use of a procalcitonin-guided algorithm for antibiotic therapy in the burn intensive care unit may contribute to the reduction of antibiotic exposure without compromising clinical outcome parameters.
PREVALENCE OF BETA LACTAMASE PRODUCING SPECIES OF PSEUDOMONAS AND ACINETOBACTER IN PEDIATRIC BURN PATIENTS
(Sobouti B., Khosravi N., Daneshvar A., Fallah S., Moradi M., Ghavami Y.)
Burn wound infection is a major cause of morbidity and mortality in burn victims. Pseudomonas and Acinetobacter species are among the most common organisms complicating burn wounds. Presence of extended spectrum ß-lactamase (ESBL) and metallo-ß-lactamase (MBL) genes plays an important role in spreading ß-lactam resistant strains of these organisms and is a serious condition in the treatment of the affected patients. As a result, we aimed to determine the prevalence of SHV, TEM, PER and VIM ß-lactamases in Pseudomonas and Acinetobacter species isolates from burn wound swabs of children with burn injury. In this descriptive observational study, 107 Pseudomonas and Acinetobacter isolates collected from burn patients were subjected to PCR assay. Using PCR method and DNA sequencing, the existence of SHV-, TEM-, PER- and VIM-type ß-lactamase encoding genes were determined. Out of the 107 Pseudomonas and Acinetobacter isolates, 66 (77.6%) were ESBL positive, 26.2% were positive for SHV gene, 37.4% were positive for TEM gene, 14% were positive for PER gene and 15.9% of them harbored VIM gene. More than half of the Pseudomonas and Acinetobacter strains in our pediatric burn unit harbor ß-lactamase encoding genes that make them resistant to a wide range of ß-lactam antibiotics. Consequently, it is suggested to choose an appropriate antibiotic regimen based on the antibiogram pattern of the strains.
BLOOD TRANSFUSION TRIGGER IN BURNS: A FOUR-YEAR RETROSPECTIVE ANALYSIS OF BLOOD TRANSFUSIONS IN ELEVEN BURN CENTERS IN UKRAINE
(Fuzaylov G., Anderson R., Lee J., Slesarenko S., Nagaychuk V., Grigorieva T., Kozinec G.)
One focus of improvement of burn care in Ukraine was the management of blood loss and blood transfusions in burn patients. The aim of this project was to analyze blood transfusion triggers in burn patients and outcomes at eleven major burn centers in Ukraine. This multicenter retrospective study reviewed four years of data on blood-transfused burn patients admitted to eleven major burn centers in Ukraine. Data analyzed included: demographics, characteristics of the burns, complications of burn injury, triggers for blood transfusions and outcomes. A total of 928 burn patients who received 2,693 blood transfusions from 11 major burn centers over a four-year period, were studied. Regardless of the total body surface area (TBSA) that was burned, blood transfusions were administered with a hemoglobin (Hb) trigger value of around 9 g/dL. Roughly one third (30.5%) of all transfusions were given in patients with a TBSA ≤ 10%. We demonstrated that Ukrainian doctors were using the same Hb trigger for blood transfusions for all Ukrainian burn patients, which suggested a need to change blood transfusion policy.
IMPROVED SURVIVAL WITH AN INNOVATIVE APPROACH TO THE TREATMENT OF SEVERELY BURNED PATIENTS: DEVELOPMENT OF A BURN TREATMENT MANUAL
(Morisada S., Nosaka N., Tsukahara K., Ugawa T., Sato K., Ujike Y.)
The management of severely burned patients remains a major issue worldwide as indicated by the high incidence of permanent debilitating complications and poor survival rates. In April 2012, the Advanced Emergency & Critical Care Medical Center of the Okayama University Hospital began implementing guidelines for severely burned patients, distributed as a standard burn treatment manual. The protocol, developed in-house, was validated by comparing the outcomes of patients with severe extensive burns (SEB) treated before and after implementation of these new guidelines at this institution. The patients included in this study had a burn index (BI) ≥30 or a prognostic burn index (PBI = BI + patient's age) ≥100. The survival rate of the patients with BI ≥30 was 65.2% with the traditional treatment and 100% with the new guidelines. Likewise, the survival rate of the patients with PBI ≥100 was 61.1% with the traditional treatment compared to 100% with the new guidelines. Together, these data demonstrate that the new treatment guidelines dramatically improved the treatment outcome and survival of SEB patients.
RESPONSE OF KEL OID FIBROBLASTS TO VITAMIN D3 AND QUERCETIN TREATMENT - IN VITRO STUDY
(Mathangi Ramakrishnan K., Babu M., Lakshmi Madhavi M.S.)
Keloid scars continue to pose a challenge to clinicians as the treatment armamentarium lacks a formidable agent to tackle them. We have undertaken an in vitro study based on the mechanism of action of Vitamin D3 and quercetin on isolated keloid fibroblasts. Dose-dependent action on the reduction of cellular proliferation, collagen synthesis and induction of apoptosis by Vitamin D3 and quercetin are analyzed and probable mechanism of action is elaborated. This study thus opens up newer avenues in tackling keloid scars effectively.
QUELLE PLACE POUR L'ANESTHÉSIE LOCORÉGIONALE CHEZ LES BRÛLÉS?
(Chaibdraa A., Medjelekh M.S., Saouli A., Bentakouk M.C.)
La pratique de l'anesthésie locorégionale chez les brûlés est limitée par de nombreux facteurs. Elle est considérée comme marginale dans l'approche multimodale du traitement de la douleur par excès de nociception. Ce travail rétrospectif, sur une période de 3 années, porte sur les anesthésies locorégionales (ALR) réalisées. Les résultats obtenus vont permettre, en regard de la rareté des données de la littérature, de formuler quelques suggestions sur la place de cette technique. Il a été recensé 634 ALR, dont 96% chez des adultes. Les membres inférieurs sont les plus concernés (76%). Des anesthésies rachidiennes ont été pratiquées chez 32 patients dont 4 enfants. Les incidents sont peu fréquents (3%) et sans gravité. L'ALR peut représenter une option utile dans la stratégie multimodale de prise en charge de la douleur, la réhabilitation passive précoce et la chirurgie de recouvrement par la greffe de peau. Elle mérite d'être explorée en ambulatoire, dans la mesure où 95% des brûlés ne sont pas hospitalisés. La place de l'anesthésie-locorégionale chez les brûlés devrait susciter plus d'intérêts, pour permettre d'établir des protocoles fondés sur une réflexion pluridisciplinaire.
TRAITEMENT CHIRURGICAL INITIAL DES BRÛLURES DE LA MAIN DE L'ENFANT. REVUE
(Goffinet L., Breton A., Gavillot C., Barbary S., Journeau P., Lascombes P., Dautel G.)
Trente cinq revues concernant la prise en charge chirurgicale de la main brûlée de l'enfant sont indexées dans Pub-Med. Elles portent sur l'indication de la cicatrisation dirigée versus chirurgie, les techniques et délais d'instauration des traitements par excision-greffe, le calendrier et la nature du traitement de réadaptation et la surveillance. L'enfant présente un risque accru de brides cicatricielles, nécessitant un suivi médico-chirurgical attentif et prolongé. L'objet de cet article est de rapporter les spécificités chirurgicales de la prise en charge de ces brûlures. Cette revue de la littérature, réalisée au moyen de la base PubMed (publication entre 2005 et 2011) à partir des mots-clés « hand AND/OR child AND/OR burn » retrouve 67 publications utiles au sein de 171 références. Les données rapportées ont été comparées aux ouvrages de références français et américains. Des données contradictoires sont rapportées concernant la délai de l'excision et de la greffe, avec seulement deux études comparatives comportant de nombreux biais. L'état de la science n'apporte pas d'éléments de preuve suffisant en raison d'un manque de puissance statistique des études, mais de nombreux avis d'expert explorant chaque type d'indication permet d'établir une stratégie claire, guidant les indications thérapeutiques. Il apparaît donc indispensable de réaliser des études prospectives incluant ces patients depuis le suivi initial jusqu'au suivi à long terme, pour augmenter le niveau de preuve de cette stratégie.
SURGICAL TREATMENT OF BURNS SEQUELAE. OUR EXPERIENCE IN THE DEPARTMENT OF PLASTIC AND RECONSTRUCTIVE SURGERY, PRISTINA, KOSOVO
(Buja Z., Arifi H., Hoxha E., Duqi S.)
Burn injuries are very frequent in Kosovo, leading to long-lasting physical, functional, aesthetic, psychological and social consequences directly proportional to the time of healing; the longer it takes for the burn wound to heal, the more serious are the sequelae. The objectives of the present study are to review the epidemiological, clinical and therapeutic aspects of burn patients presenting with post-burn sequelae and treated at the Department of Plastic and Reconstructive Surgery, Pristina, Kosovo, from January 2005 until December 2011. This study included 188 patients with burns sequelae. The following variables were considered: age, sex, anatomical location, pathological types, and surgical procedure. There were 82 men (43.6%) and 106 women (56.4%), ranging in age from 0 to 67 years (mean age 33.5 years), most of the patients were children (139 = 73.9%). Burn contractures were observed in 135 (71.8%) patients, hypertrophic scars in 32 (17%), keloids in 10 (5.3%), alopecia in 6 (3.2%), syndactyly in 12 (6.4%), ectropion in 4 (2.1%) and ear deformity in 1 (0.53%) cases. To correct the deformities the most common choice was the Z-plasty technique, used in 31.4% of cases, followed by Z-plasty+full thickness skin grafts in 21.8%, full thickness skin grafts in 18.1%, tissue expansion in 8%, Z-plasty+local flaps in 4.8%, flaps (local, fascio-cutaneous, radial forearm) in 6.9% and direct closure in 6.4%. Timely wound closure and the development of an individual programme for surgical treatment of burns sequelae are crucial for optimal outcomes in patients with burns.
TISSUE EXPANDERS IN POST-BURN ALOPECIA: WITH OR WITHOUT GALEOTOMIES?
(El Sakka D.M.)
The tissue expansion technique is part of the reconstructive surgeon's armamentarium. It provides donor skin that is an optimal match in terms of skin colour, texture, sensation and hair-bearing characteristics. Tissue expansion of the scalp is one of the methods used for the management of alopecia. This method allows the expansion of normal hair-bearing scalp to cover the area of alopecia. Unfortunately, the tough galeal layer prevents easy and fast expansion of the scalp and increases the rate of expander extrusion. A prospective and retrospective comparative analysis of the use of subgaleal expanders with or without galeotomies to manage post-burn alopecia was conducted in the Burn Unit of the Menofia University Hospital, in the period from September 2010 to November 2014. Thirty expanders in 30 patients with alopecia were included in the study. These constitute the experience of a single surgeon. Twenty expanders were applied to the subgaleal plane without galeotomies and 10 were applied with galeotomies. Indications for scalp expansion were mainly post-burn alopecia and scarring. Complications and failures were recorded. Adding galeotomies to subgaleal tissue expander placement for scalp alopecia decreases the time of expansion, allows a larger amount of fluid to be injected each time without inducing pain, and decreases the rate of expander extrusion. Adding galeotomies to subgaleal tissue expander placement for post-burn alopecia ensures preservation of galeal blood supply for easier and faster expansion of the scalp and fewer expander extrusion complications.
THE COST OF POST-BURN SCARRING
(Mirastschijski U., Sander J.T., Zier U., Rennekampff H.O., Weyand B., Vogt P.M.)
Deep burns lead to scarring and contractures for which there is little or no published data on treatment costs. The purpose of this study was to fill this gap by analysing treatment costs for burn sequelae. To do this, German-DRG for in-patient treatment was collected from the Burn Centre Lower Saxony. DRG-related T95.-coding served as a tool for burn-associated sequelae. Data on scar occurrence, plastic-reconstructive surgery and sick leave were collected by a questionnaire. The findings showed that 44.6% patients reported post-burn scarring and 31% needed surgical intervention. The expected risk for readmission was significantly higher (p=0.0002) with scars compared to without. Significantly higher costs for pressure garments were noted for scarred patients (p=0.04). No differences were found for ointments, silicone dressings or pain medication. Treatment costs for patients with scars were 5.6 times higher compared with no scar assessed by G-DRG. No differences were stated subsuming multiple readmissions for post-burn treatment per individual. Significantly higher costs (p=0.03) were noted for patients with burn sequelae other than scars with regard to individual readmissions. It has been revealed that treatment of scars causes higher costs than for other burn sequelae because of multiple surgical interventions. To reduce post-burn scarring and costs, specialized burn centres provide optimal and state-of-the-art treatment. As well as this, more emphasis should be laid on promoting research for the development of novel anti-scarring therapies.
IS A SELF-INFLICTED BURN PART OF A REPEATED SELF-HARM PATTERN?
(Joory K., Farroha A.,* Moiemen N.)
Self-inflicted burns (SIB) consistently account for a small proportion of burn injuries. There is a wide spectrum of SIB, from minor burns through to major life threatening burn injuries in suicidal patients who have committed self-immolation. Non-fatal deliberate self-harm (DSH) is a common reason for presenting to hospital. This occurs in many forms including wounding, burning and poisoning to name a few. Such behaviours are commonly repeated, sometimes with increasing severity. DSH is a major risk factor for subsequent suicide. We had observed patterns of repeated self harm behaviours in patients presenting to our centre with SIB. Patterns of repeated DSH in those presenting with self-inflicted burns have not previously been described in the literature. In a five-year period (2008 to 2012) 84 patients presented to our burns centre with SIB. Within this population, 39 patients (46%) were identified on a national database as having been admitted to an acute National Health Service (NHS) trust somewhere in the UK with sequelae of deliberate self-harm. There had been a total of 128 additional hospital admissions. In the majority of cases (85%) another admission preceded the presentation to our service with SIB. Only four out of the 17 SIB patients (24%) who died of their injuries had previous hospital admissions with DSH. This lends weight to the need for thorough holistic assessment of any patient admitted to hospital with sequelae of deliberate self-harm in order to try and provide appropriate support and interventions for these vulnerable individuals to prevent recurrent self-harm or suicide.
HOW FAST CAN A NATUROPATHIC MEDICINE CAUSE SKIN BURN? A CASE REPORT OF GARLIC BURN
(Keles M.K., Bayram Y., Durmus M.)
This paper presents a case in which a chemical burn resulted from the use of garlic as a naturopathic medicine for knee pain.
FIRES IN HISTORY: THE CATHAR HERESY, THE INQUISITION AND BRULOLOGY