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EVALUATION OF PROGNOSTIC FACTORS AFFECTING LENGTH OF STAY IN HOSPITAL AND MORTALITY RATES IN ACUTE BURN PATIENTS
(AbdelWahab M.E., Sadaka M.S., Elbana E.A., Hendy A.A. - Egypt)
Burns are considered mostly a serious illness with devastating consequences and prolonged length of hospital stay. Moreover, burns are among the traumatic lesions with the highest costs for care due to their hospitalization time, treatment required and the need for rehabilitation therapy. This study aims to evaluate the factors affecting length of hospital stay and mortality rates in acute burn patients. The study was conducted on 82 patients who presented with acute burn and were admitted to the Plastic and Reconstructive Surgery Department Burn Unit, Tanta University Hospital, in the period from June 2016 to June 2017. A prospective study was carried out using the data of acutely burned patients, and a statistical analysis conducted with the data collected on different factors affecting burn patient length of hospital stay and mortality. The mean age of our patients was 16.5 years, mean LOS was 24.23 days and mortality rate was 9.8% of the total admitted cases, with half of the cases with inhalation injury dying in hospital. The most influencing factors on prediction of length of hospital stay were: incidence of infection, wound depth, TBSA% and inhalation injury. The most influencing factors on patient mortality were: TBSA%, age of the patient, cause of burn and inhalation injury, therefore these factors should be carefully evaluated in every burn patient.
A COMPARISON OF INJURY SCORING SYSTEMS IN PREDICTING BURN MORTALITY
(Halgas B., Bay C., Foster K. - USA)
The models most widely used to predict burn patient mortality are the revised Baux score, Ryan, Smith, McGwin, Abbreviated Burn Severity Index (ABSI), Belgian Outcome of Burn Injury (BOBI), and the Fatality by Longevity, APACHE II score, Measured Extent of burn, and Sex (FLAMES). Improvements in critical care have reduced mortality resulting from severe burns, which may affect the predictive strength of older models. We conducted a cross-validation study on all burn patients (n = 114) with TBSA greater than 20%, admitted to the Arizona Burn Center between 2014 and 2016. The study compared the accuracy of seven previously validated burn-specific models and one new model derived for our cohort. Data were collected on age, ethnicity, gender, total body surface area burned (TBSA), inhalational injury, associated trauma, and injury severity (ISS, APACHE II). The accuracy of each model was tested using logistic regression, preserving the published regression coefficients. Predictive performance of the models was assessed by Receiving Operator Curve (ROC) curve analyses and Hosmer-Lemeshow (H-L) goodness of fit tests. Age, TBSA and APACHE II score were found to be significant, independent risk factors for patient mortality. The FLAMES model performed best (AUC 0.96) and was comparable to our native model (AUC 0.96). The revised Baux score was both accurate and easy to calculate, making it clinically useful. The older models demonstrated adequate predictive performance compared with the newer models. Even without key burn parameters, the APACHE II score performed well in critically ill patients with moderate to severe burn injuries.
ARE WE BOUND TO OUR SCORES? A 74-YEAR-OLD PATIENT WITH AN ABBREVIATED BURN SEVERITY INDEX OF 14
(Vorstandlechner V., Pauzenberger R., Happak W., Ihra G., Rath T., Muschitz G., Nickl S., Radtke C., Fochtmann-Frana A. - Austria)
We report a case of a 74-year-old female patient who was involved in a car accident. The patient suffered deep dermal and full thickness burns and the probability of survival calculated with the Abbreviated Burn Severity Index (ABSI) was extremely low. The patient showed sufficient cardiorespiratory and renal function for the entire treatment period. An epifascial necrosectomy of all four limbs was performed on day three after admission. Wound coverage was performed using the MEEK technique and split skin grafts. The patient was bedded in a FluidAir bed, which enabled the burn wounds on the back to dry and heal in large part. After four surgical procedures and four months of treatment at the burn ICU, the patient was sufficiently mobilized for transfer to a hospital in her home region. The aim of the following case report is to demonstrate that burn patients with very low chances of survival can be treated successfully.
MANAGEMENT OF PAIN, ANXIETY, AGITATION AND DELIRIUM IN BURN PATIENTS: A SURVEY OF CLINICAL PRACTICE AND A REVIEW OF THE CURRENT LITERATURE
(Depetris N., Raineri S., Pantet O., Lavrentieva A. - Italy)
Management of pain, agitation and anxiety is crucial in critically ill patients, and has a significant impact on clinical and functional outcome. This study aims to assess current management of analgesia, sedation and delirium in adult burn ICUs, and determine if discrepancies exist between current guidelines and actual practices.An online survey was created and sent to burn specialists worldwide.A total of 40 respondents submitted valuable data. Of all respondents, 20 (50%) were from Europe, 7 (17.5%) from North America, 6 (15%) from Africa and 12 (30%) from other regions. The majority of respondents were from burn centres with more than 60 admissions per year (32 centres, 80%); 36 respondents (90%) were affiliated with a University Hospital. 92.5% reported that they routinely screen severe burn patients for pain, while 27.5% declared that no particular pain assessment tool is used. The most common analgesics were opioids, mainly administered intravenously (90%). 70% affirmed they routinely screen burn ICU patients for sedation, but 30% declared that they do not use a specific sedation scoring scale. The most commonly used sedatives were midazolam (72.5%) and propofol (55%). 70% claimed to assess burn ICU patients routinely for delirium, but 57.5% reported they did not use a specific scoring system. 62.5% stated that they prevent delirium by combining pharmacological and non-pharmacological approaches. Our results indicate that awareness regarding the systematic and correct management of pain, sedation and delirium is increasing among burn specialists. However, a substantial gap between guidelines and clinical practices exist. Efforts should be directed at creating specific burn care guidelines and enhancing the implementation of existing recommendations..
THE USE OF NEXOBRIDTM IN DEBRIDING CHRONIC ULCERS: A PRELIMINARY OBSERVATIONAL STUDY
(Mataro I., Giudice G., D'Alessio R., Maggio G., Vestita M. - Italy)
Nexobrid is a highly selective enzymatic debriding agent used in the acute management of burns to perform escharectomy. From October 2016 to April 2017, we treated 6 patients affected with lower limb chronic ulcers of different etiologies with NexobridTM in order to perform eschar removal by enzymatic debridement. For all patients, a dosage of NexobridTM, calculated as 2gr per 1% TBSA, was applied in a 2-3 mm thick uniform layer on the ulcer eschar and fibrin tissue and left for 4 hours, covered with an occlusive dressing. Patients were assessed in terms of ulcer cleansing 24 hours and 7 days post NexobridTM debridement, by wound bed score (WBS) and % of remaining necrotic tissue. A patient pain VAS was also recorded at 24 hours and 7 days post debridement. Adverse events at these time points were also noted. The results documented a complete removal of necrotic tissue in a time frame of 4 hours. At 24 hours, all lesions were completely debrided. At 7 days, there was a partial recurrence of necrotic tissue, as also documented by decreased WBS. All patients reported none to mild pain, and no adverse events were noted, except for mild erythema along the edges of the lesion on healthy skin in one case. This is a preliminary observation. Optimal dosage and application of NexobridTM in this indication needs to be validated by further controlled data.
SEPSIS CAUSED BY MULTIDRUG-RESISTANT KLEBSIELLA PNEUMONIAE INFECTION IN A 23-YEAR-OLD BURN PATIENT: CASE REPORT AND LITERATURE REVIEW
(Freystätter C., Radtke C., Ihra G., Thalhammer F., Fochtmann-Frana A. - Austria)
Septic complications are a major problem in burn care. Infections caused by multidrug-resistant (MDR) Klebsiella pneumoniae strains represent a growing threat. In particular, Romania has seen rapidly increasing rates of MDR Klebsiella pneumoniae isolates in recent years. The PubMed database was searched with the terms 'Klebsiella pneumoniae', 'multiple drug resistant', 'enterobacteria', 'infection', 'sepsis or septicaemia or blood stream infection', 'surveillance', 'diagnose', 'burn', 'intensive care unit' and 'Romania or Europe'. In addition, the case of a burn patient who suffered from sepsis caused by MDR Klebsiella pneumoniae and who was treated at our burn intensive care unit (ICU) was reviewed. The 23-year-old male was initially treated in Romania, but after 48 hours he was transferred to our burn ICU. Initially, the treatment course was appropriate and sufficient wound healing was achieved by day 27. However, the patient's condition deteriorated rapidly on day 28 and blood culture analysis showed growth of MDR Klebsiella pneumoniae. Despite intensive medical therapy, the patient died as a result of multiple organ failure (MOF) on day 44. Sepsis caused by MDR Klebsiella pneumoniae represents an enormous therapeutic challenge. Burn patients who are transferred from Southeast Europe would likely benefit from an intensified screening for MDR pathogens.
PHARMACOKINETICS AND PHARMACODYNAMICS OF LINEZOLID IN BURN PATIENTS
(Mokline A., Gharsallah L., Rahmani I., Gaies E., Tabelsi S., Messadi A.A. - Tunisia)
Burns induce complex physiological changes such as modification of distribution volume, increased clearance of elements and decrease of protein binding. The pharmacokinetics of many antibiotics may then be modified, which requires dose adjustment. We attempted to evaluate the pharmacokinetics of linezolid in burn patients at a standard dose of 600 mg intravenously thrice a day. A prospective study was conducted in a 20-bed adult burn ICU at a university-affiliated teaching hospital in Tunis. Thirteen adult burned patients with documented and/or suspected multi drug resistant (MDR) gram-positive bacterium-related infections were enrolled in the study. Our study suggests that linezolid dosing at 600mg thrice a day leads to adequate pharmacodynamic/pharmacokinetic exposure to linezolid with a Cmin > 2mg/l in 84.6% of cases, T > MIC in about 87.5% and AUC/MIC > 100 in 61.5% of cases. However, a high variability in linezolid serum concentrations with a substantial percentage of sub-therapeutic levels was observed in a few patients, 15% of cases. Therefore, therapeutic drug monitoring of linezolid might be helpful for adequate dosing of linezolid in burned patients, to avoid the risk of treatment failure or of dose-dependent toxicity.
LA PARTICULARITÉ DE CICATRISATION DES PERTES DE SUBSTANCE CUTANÉES DANS LES BRÛLURES ÉLECTRIQUES: NOTRE EXPÉRIENCE
(Ghorbel I., Abid A., Moalla S., Karra A., Ennouri K. - Tunisie)
Les brûlures électriques représentent une cause de préjudice corporel majeur. Ceci nous a amené à étudier ces lésions et leur prise en charge afin d'en diminuer la morbidité. Nous avons mené une étude rétrospective portant sur 23 patients hospitalisés pour brûlure électrique. La moyenne d'âge était de 25,74 ans. La circonstance de la brûlure la plus observée dans notre série était un accident domestique, dans 13 cas (56,5%), un accident de travail dans 8 cas (34,8%), et un accident de la voie publique dans 2 cas (8,7%). La fasciotomie a été réalisée chez 6 patients dont 5 étaient brûlés par haut voltage. L'excision de la nécrose a été réalisée en moyenne à 8,26 jours ± 5,55 jours. Sept amputations ont été réalisées dont 6 au niveau du membre supérieur. Vingt lambeaux ont été utilisés chez 12 patients. Les lambeaux locorégionaux ont été indiqués pour 15 zones et les lambeaux à distance, utilisés comme solution de secours en cas d'échec de lambeaux locorégionaux, pour 5 zones. Parmi les 5 cas qui ont eu une reconstruction immédiate devant l'exposition d'éléments nobles, 3 ont présenté une nécrose du lambeau. Le délai moyen de cicatrisation a été de 45 jours. Les 7 patients qui ont bénéficié d'une reconstruction par lambeaux ont cicatrisé au-delà de ce délai. Les principaux résultats de l'étude montrent que la décompression classique en urgence ne paraît pas diminuer le taux d'amputation, que l'utilisation des lambeaux locaux et locorégionaux au cours de la phase initiale (< 21 jours) comporte un risque important de souffrance et de nécrose, que la prévention anti-thrombotique et l'utilisation des autoplasties ne paraissent pas avoir un retentissement sur les délais de cicatrisation.
ELECTROPHOTOBIOMODULATION IN THE TREATMENT OF FACIAL POST-BURN HYPERTROPHIC SCARS IN PEDIATRIC PATIENTS
(Elmelegy N.G., Hegazy A.M., Sadaka M.S., Abdeldaim D.E. - Egypt)
Hypertrophic scar continues to be one of the leading reasons for surgical and non-surgical treatments after burn healing. Facial post-burn hypertrophic scars can cause severe functional and emotional disability, as they are usually difficult to conceal. Numerous nonsurgical and surgical therapies have been used for the treatment of hypertrophic scars. This study describes the combination of bipolar radiofrequency, intense pulsed light and cooling (given the collective term 'E-light'), and reports the outcomes of its use in the treatment of post-burn facial hypertrophic scars in a series of sixty-five patients in the pediatric age group. There were no reports in the literature of the use of this modality (E-light) in the treatment of facial post-burn hypertrophic scars in pediatric patients. Results showed that the mean decrease in total VSS score for all patients was 5.8. Regarding the satisfaction of the parents of our patients, 66.15% rated the result excellent, 24.61% rated it good and 9.23% rated it fair. We received no poor ratings for the final result, with a significant reduction in total Vancouver scar scale after treatment (P-value = 0.000). The E-light therapy technique studied in this work is effective, safe and economical if compared to other treatment modalities that can be used in the management of facial post-burn hypertrophic scars.
5-FU FOR PROBLEMATIC SCARRING: A REVIEW OF THE LITERATURE
(Ibrahim A., Chalhoub R.S. - Lebanon)
Keloids and hypertrophic scars represent a common complaint for plastic surgeons. These scars often leave patients with severe morbidity due to their resistance to therapy. A variety of therapeutic options exist, yet none seem to offer a permanent solution, and scars frequently reoccur. The antineoplastic drug 5-fluorouracil (5-FU) has been shown to inhibit fibroblast proliferation in vitro and has been used as a treatment modality for these pathologic and problematic scars. We present a review of literature on treatment protocols, and on the efficacy and safety profile of this drug in the treatment of problematic scarring in terms of size reduction and symptom resolution. Current evidence suggests that 5-FU is effective in treating keloids and hypertrophic scars, but further research must be done to correlate therapeutic response with the age of the scar. In addition, larger randomized control trials must be conducted with longer follow up periods to assess recurrence rates with better accuracy.
KNOWLEDGE ON EMERGENCY MANAGEMENT FOR BURN AND MASS BURN INJURIES AMONGST PHYSICIANS WORKING IN EMERGENCY AND TRAUMA DEPARTMENTS
(Lam N.N., Huong H.T.X., Tuan C.A - Vietnam)
A survey was conducted on 397 physicians working in Emergency and Trauma Departments of district and provincial hospitals in Vietnam. The contents of the survey were emergency care for burn and mass burn injuries. Results showed that only 39.8% of participants gave more than 50% correct answers. In the case of mass burn injuries, only 10.3% of participants gave correct answers for triage, and 71.8% of participants considered oral fluid resuscitation to be an appropriate method. In addition, intubation for suspected inhalational injury was indicated by 51.9% of doctors. Bivariate analysis showed that working experience did not remarkably affect knowledge level. A significantly higher knowledge level was recorded among doctors working at provincial hospitals compared to those working at district hospitals (47.9 ± 13.5% correct answers vs. 42.2 ± 14.8% respectively, p = .0001). Moreover, physicians who had attended training courses in the past had a significantly higher knowledge level compared to the others (53.1 ± 13.6% vs. 44.5 ± 14.2% respectively; p = .0003). Multivariate logistic analysis indicated that both these variables were independent factors that affect the knowledge of healthcare providers with p < .01. Further continuing medical education on burn management and mass burn injury response needs to be conducted for physicians, especially doctors working at primary hospitals.
TREATMENT OF THIRD-DEGREE BURN WOUNDS IN ANIMAL SPECIMENS: ACELLULAR DERMIS OR PARTIAL-THICKNESS SKIN GRAFT
(Fatemi M.J., Momeni M., Tavakoli A., Bagheri T., Hosseini A., Araghi S., Ranjpoor F., Zavareh A. - Iran)
Several dermal products have been introduced to substitute dermal tissues. In this study we review the effects of these products on repairing third-degree burn wounds and managing complications in animal specimens. Using an interventional approach, rats were randomly assigned to four groups (G1 to G4). Two wounds were created on the back of each rat. An open wound was left on the back of rats in G1; in G2, wounds were covered with a thick rat derived-ADM product and overlying thin skin graft; on G3 rats, similar third degree ulcers were made with one ulcer covered with harvested thin skin graft. In G4, ulcers were covered with a thin rat derived-ADM product and thin graft. Factors such as take rate, histopathological score, wound contracture and graft contracture were compared on the 7th, 15th, 21st and 30th day. Mean graft take rate on the 30th day in the thick ADM, thin ADM and graft group showed a significant difference (p=0.015). Histopathological score on the 30th day in the thin ADM, thick ADM and graft group showed no considerable difference. Mean graft take rate was significantly better in the thin ADM and graft group than in the thick ADM group. Wound contracture was significantly more severe in the thick ADM and control group than in the thin ADM and graft group.
COMPTE-RENDU DES TABLES RONDES, JEUDI 7 JUIN 2018, 38ÈME CONGRÈS DE LA SFB, LILLE
(Voulliaume D., Le Floch R - France)
Les sujets abordés en 2018 étaient « brûlure du membre supérieur, main exceptée » et « nouveauté en analgésie et sédation ». Les rapporteurs se sont servis des notes prises en séance et de la captation vidéo pour rédiger ce compte rendu. Le lecteur pourra, s'il souhaite creuser le sujet, se rapprocher de l'auteur de la communication.
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