Ann. Medit. Bums Club - vol. V11 - n. 3 - September 1994

INTERNATIONAL ABSTRACTS

THE COST OF AN EXPENSIVE BURN SURVIVAL

The question is addressed of the cost of burn therapy, in relation to the case of a young man in Israel who susrained severe burns (95% body surface area) and remained in hospital for 232 days until his discharge, when he was functionally independent. He required 16 surgical operations for excision of burn eschar and skin grafting, 128 units of blood, 899 units of fresh frozen plasma, and enteral hyperalimentation for 175 days. In terms of work, 1000 physician-hours, 3000 nurseThours, 1000 physiotherapy and occupational-therapy hours and 250 dietician-hours were needed. More than 1850 laboratory tests were performed, as well as 120 X-rays. Half a ton of topical antimicrobial solutions and more than 600 kg of ointment and creams were used. Total hospitalization costs were US$ 141750. The costs of treating severely burned patients are discussed in relation to possible ways of reducing them.

Eldad A., Stern Z., Sover H., Neuman R., Ben Meir P.,
Wexler M.R. Burns, 19: 235-8, 1993.

MALIGNANT FIBROUS HISTIOCYTOMA DEVELOPING IN BURN SCAR OF THE EAR

Malignant fibrous histiocytoma'is the commonest of all soft tissue sarcomas. Although it may affect young people it usually occurs between the fifth and seventh decades of life. Most often it develops in the thigh. The case of malignant fibrous histiocytoma described in this~paper is unusual as the affected area was in a burn scar of the ear, a condition hitherto unreported in the literature. The patient was a 74-year-old white-skinned male who had suffered burn injuries in the right car as a child, 71 years previously. He now presented a firm 1 x 0.5 cm nodule in the burn scar in the right external ear near the central portion of the antiheliX. Biopsy showed that this was due to malignant fibrous histiocytorna. The patient was otherwise healthy. A wide local excision of the biopsy site, surrounding soft tissue and cartilage was performed, and the patient made a complete recovery.

Cocke W.M. Jr, Tomlinson J.A. Bums, 19:241-3,1993.

One of the metabolic responses to traurna is an increase in energy expenditure (EE). In this study EE was measured in severely burned patients in both the fasted and the fed states in order to determine the thermogenic response to feeding (TRF) and its relation to the degree of hypermetabolism. EE measurements were made at varying time intervals from the day of injury in order to take into account the changes with time in the metabolic derangements induced by the burn. Results from the fasted measurements were compared with values as calculated with variously commonly used formulae in estimating energy needs. It was found that TRF was present in 10 out of 33 measurements. Fasting EE was not different between the tests with and without TRF, but the percentage of values obtained with the Harris-Benedict formula (%HB) was different between the two groups. TRF was always absent when %HB was higher than 50. It was concluded that TRF is suppressed in burned patients with marked hypermetabolism and that EE measured in the fed state reflects resting expenditure accurately in these patients. Also, it is not possible to predict EE from existing formulae.

Garrel D.R., de Jonge L. Burns, 19: 467-72, 1993.

Following bum injury, the very large quantities of lactate released from the peripheral tissues serve as substrate for hepatic gluconeogenesis. It may be that, because of bum injury, reaction kinetics involving lactate are directly changed within the liver. The metabolic fate Of [U-14C] lactate was examined in vitro in fresh liver slices after a 20% TBSA injury in rats. Glucose and carbon dioxide were produced in vitro by the hepatic tissues post-injury and no differences were observed in the metabolism of these substrates between injured and control animals. These findings would suggest that the intrinsic enzymatic processes within the liver are not directly altered by the injury itself or by any of the associated inflammatory mediators that appear in the early post-bum phase.

Carter E.A., Khalid M.A., Burke J.F., Tompkins R.G. Burns, 19: 475-8, 1993.

The aim of this study was to investigate the course of tissue swelling in burn patients with the impression technique, during the first days post-burn, in non-injured sites (the impression technique evaluates tissue oedema by measunng the resistive force of the tissue under compression; this force is thought to be related to the mobility and volume of interstitial fluid translocated as a result of the compression). The fluid translocation parameter was calculated, the force curve parameters analysed and the manner in which the different parameters changed from day to day after the burn injury was studied. Tissue fluid translocation increased significantly (P<0.05) up to a maximum value after 6 days post-burn, declining thereafter, which sug-gested a continuous increase in the generalized postburn oedema for the first 6 days post-burn. Impression force at 3 weeks post-burn was significantly lower (P<0.001) than that of the half-day post-burn value, indicating increased tissue pressure during the first days postburn. Parameter analysis indicated a flux of water-like fluid from the vasculature to the interstitial space during the first 6 days post-burn. However, the spread of the values registered between different measurement sites was large.

Lindahl O.A., Zdolsek L, Sjoberg R, Angquist K-A. Burns, 19: 479-84, 1993.

A new medical instrument is presented which produces a doppler blood flow image from a laser beam in a raster pattern, together with results of a pilot study that indicates that the technique is highly accurate in the assessment of burn depth. The scanner used is controlled by an IBM-type computer which also acts as an image storing and display module. The images are displayed as colours representing a scale of blood flow. This new investigative tool is useful because it is non-invasive and provides a non-contact method of assessing burn depth.

Niazi Z.B.M., Essex T.J.H., Papini R., Scott D., McLean N.R., Black MTM.
Burns, 19: 485-9, 1993.

This prospective study presents a qualitative and quantitative investigation into the mother's response in the early stage following a child's thermal injury. The purpose was to determine the practical psychological and social implications of thermal injury resulting in scarring. Mothers of 57 burned children under five years of age were interviewed while their child was in hospital and at home, at one week, two months and six months after hospital discharge. The burn injuries ranged from I to 41% BSA and all required skin grafting. Two scales were used to assess the results: the Maternal Thermal Injury Response Pattern, which describes a phasic pattern of general response categories, and a General Health Questionnaire, which measured the mothers' psychiatric morbidity. The results shows that the mother of a young thermal injured child is as much a victim of an injury as the child, and her plight needs recognition and support.

Mason S.A. Burns, 19: 495-500, 1993.

This prospective study presents a qualitative and quantitative investigation into the mother's response in the early stage following a child's thermal injury. The purpose was to determine the practical psychological and social implications of thermal injury resulting in scarring. Mothers of 57 burned children under five years of age were interviewed while their child was in hospital and at home, at one week, two months and six months after hospital discharge. The burn injuries ranged from 1 to 41% BSA and all required skin grafting. From the mothers' descriptions, four categories of child behavioural response to thermal injury and hospitalization were identified (normal/improved behaviour, normal/altered behaviour, minor disturbed behaviour and major disturbed behaviour). It was found that in the first week after discharge from the burn unit 56% of the children displayed minor or major disturbed behaviour, reducing to 19.3% by the 6-month interview. The MacGregor Deformity Scale was used to assess the child's appearance. It was also found that children under two years of age seemed to be affected for a more prolonged period.

Mason S., Hillier V.F. Burns, 19: 501-6, 1993.

A report is given of the thermal injury, personal and social factors affecting the short-term outcome responses of burned children under five years of age and their mothers. Serial interviews were conducted with the mothers of 57 burned children while the children were in hospital, and at home at one week, two months and six months following hospital discharge. A relationship was found between the child's behaviour and the mother's outcome response at six months. For the mother the qualitative outcome response of the Maternal Thermal Injury Response Pattern was associated with the severity of the child's thermal injury add the quantitative General Health Questionnaire scores were associated with a previous tendency to depression and increased stress on the mother existing before the accident. In the child, no thermal injury factor appeared to affect behavioural outcome. Children exhibiting disturbed behaviour following a thermal injury were more likely to have a mother with a history of depression and added stress, and also to have a mother who was blamed for the accident. Thus, a mother whose child has a more severe thermal injury will take longer to accept (or "rationalize") the thermal injury, and a mother who was more stressed prior to the accident and had a previous tendency to depression will as a result have more psychiatric morbidity. These two categories of mother require particular support.

Mason S., Hillier VT. Burns, 19: 507-10, 1993.

A partial-thickness bum wound 20 mm in diameter was produced on the dorsum of rats. Half the wound area was left untreated while the other half was painted with elastic collodion, in order to prevent dehydration. On day 10 after this procedure it was found that the prevention of dehydration saved a good proportion of thermally damaged tissue. It was also observed that prevention of dehydration causes a marked delay in wound healing.

Smahel J. Burns, 19: 511-2, 1993.

The purpose of this study was to examine the feasibility and success of initiating enteral. feeding very early in the post-burn course via a nasogastric feeding tube instead of a feeding tube placed across the pylorus. Forty-five patients (divided into three groups with average burns in respectively 24.4%, 38.2% and 56.3% TBSA) were fed as early as possible after admission. The mean caloric intake corresponded to nutritional goals beginning on the second day post-burn, and in the most severely burned group the mean caloric intake was over 2500 kcal by the second day. The initiation of intragastric feeding within hours of burn injury results in the provision of high daily levels of nutrition and may obviate the necessity of inserting a transpyloric feeding tube in the majority of burn patients.

Hansbrough W.B., Hansbrough LF. J. Burn Care Rehabil., 14: 512-6, 1993.

Gastrointestinal ulcerations occur in some 80% of critically ill patients with thermal injuries unless some form of prophylactic therapy is performed. A commonly accepted modality for prophylaxis consists of the buffeting of intragastric pH, which is measured on the basis of gastric aspirate specimens. However, it has been found that the measurement techniques involving these specimens present a number of flaws. The purpose of this study was to compare gastric pH measurements with the use of a nasogastric sensor, meter system, and pH-sensitive paper. A total number of 1500,Paired seiial measurements ofintragastric pH were obtained in 19 bum patients (age range: 23 to 79-years; bum range: 25-80% TBSA). A double-lumen tube containing an antimory/graphite pH sensor incorporated into the tip of the tube was inserted using standard techniques. Tubes remained in position for an average of 5.7 days (range 1-15 days). Patients were randomized into two groups. Group I (six patients) received nonacid-buffering prophylaxis therapy, while Group 2 (13 patients) received standard antacid or antacid/H2 histamine-blocking agent combination prophylaxis therapy. The study established a weak correlation between the probe/meter and pl-l-sensitive paper techniques for obtaining gastric pH measurements. It was not estabfished which technique provides the more accurate measurement, but the probe/meter system appears to have greater advantages than the test paper technique in reducing potential errors in prophylactic treatment decisions, reducing material and personnel costs, and in increasing staff safety through. decreased exposure to gastric aspirate.

Driscoll D.M., Cioffi W.G., Molter N.C., McManus W.F., Mason A.D., Pruitt B.A. Jr
J. Burn Care Rehabil., 14: 517-24, 1993.

MANAGEMENT OF BURNS OF THE PENIS

This report considers bums of the penis, which can be physically and psychologically devastating, especially in young paediatric patients who have to contend with growth as well as with the problems of adolescence and die development of self-image. A successful management technique is described for burns in this area, where grafting is made difficult by the problems associated with the unique character of this anatomical structure, and standard principles are less useful. Ten cases are reviewed of young patients (mean age: 10.2 years; age range: 16 months to 16 years) with full-thickness penis bums. The grafting technique consisted 'of excision and grafting with sheet grafts in a one- or two-stage setting. After grafting,. the penis was, placed in traction. with ~ a weighted Foley catheter. Grafts were left open or stented. The traction apparatus did not cause any complications and graft take was excellent. Short-term results were also excellent and in 3 years' median follow-up no urethral problems have been reported. Longterm sexual results are pending for all patients. In the authors' view, this technique provides excellent means of supporting the penis to accomplish superb graft take in this hard-to-manage area.

Housinger T.A., Keller B., Warden G.D. J. Burn Care Rehabil., 14: 525-7, 1993.

EXPERIENCE WITH 'PATIENTS WITH BURNS WHO REFUSE BLOOD TRANSFUSION FOR RELIGIOUS REASONS

Patients who are deemed mentally competent and who refuse blood transfusion should have their wishes respected. The authors describe four such patients with burns who identified themselves as Jehovah's Witnesses, one of whom died. It is recommended that patients should be fully infortned of the immediate and anticipated risks of their decisions. They should be asked daily, in private (i.e. not in the presence of family members or co-religionists), if they wish to change their minds,(out of the four patients described, one in fact did,). Thetechniques used -are reporred for. each of the four'cases. Staged, excision. and skin graft'operations with minimal blOod,loss were performed. Two patients were treated with prythropoietin.,

Kim I)., Slater H., Goldfarb I.W., Hammell'E.J. J.Burn Care Rehabil., 14: 541-3, 1993.

Vibriolysin is a proteolytic enzyme secreted by a marine. organism (Vibrio proteolyticus). This novel proteolytic composition was examined for its suitability for the debridement of burn eschar. M vitro and in vivo data obtained in full-thickness burns in a porcine model showed that this protease 'readily, thoroughly and selectively hydrolyses eschar proteins. Vibriolysin exhibits numerous desirable properties, e.g. selective hydrolysis of dead but not viable tissue, debridement in the absence of bleeding, and compatibility with adjunct topical therapies. It is suitable for formulation in hydrophilic vehicles and exhibits excellent storage capacity in such compositions at ambient temperature.

Durham D.R., Fortney D2., Nanney L.B. J. Burn Care Rehabil., 14: 544-51, 1993.