|Annals of Burns and Fire Disasters - vol. IX ~
n. 2 - June 1996
A FORMULA TO CALCULATE BLOOD CROSS-MATCH REQUIREMENTS FOR EARLY BURN SURGERY IN CHILDREN
Burn surgery in children is inevitably accompanied by massive blood loss, the exact quantity of which it would be very useful to be able to predict accurately. In order to rationalize blood ordering procedures and to prevent unnecessary wastage a formula has been elaborated which predicts the blood volume expected to be lost during paediatric surgery by relating blood loss to the total body surface involved (i.e. bum plus donor area) and the circulating blood volume. This formula is as follows: EBL = (A + B)/32 x blood volume (ml), where EBL = expected blood loss, A = % recipient burn area for grafting, and B _= % donor site area. The predicted blood loss was compared with actual blood loss in 111 consecutive paediatric patients, and a significant correlation was found between the two values. The formula therefore provides an accurate prediction of how much blood is necessary to be cross-matched prior to early surgical management.
Brown R.A., Grobbelaar A.O., Barker S.,
AN ALTERNATIVE METHOD OF SKIN GRAFTING: THE SCALP MICRODERMIS GRAFT
Microskin grafting has been used successfully to treat major burns when donor skin areas are inadequate. This technique is not however in general use because of difficulties related to mincing and floating procedures. Floating produces more microskin patches with the dermal side upwards than with the epidermal side upwards. Another problem is that many microskin patches are lost in the container during flotation. A solution to this problem is the preparation of the microskin from the second layer scalp skin. This provides a graft of hair follicule cells which can be sown on the wound either side upwards. Grafting was performed on well-prepared granulation beds or on the bed after fascial excision of the burn. The cover dressings used were Allograft and Biobrane. The best combination was grafting on the bed following fascial excision with an allograft cover. This technique offers an alternative method of skin grafting in patients with limited skin donor areas, provided the scalp itself is not burned.
PELVIC ABSCESS INDUCED BY A METHICILLIN. RESISTANT STAPHYLOCOCCUS AUREUS FROM HAEMATOGENOUS SPREAD VIA THE CVP LINE IN A BURN PATIENT
This article describes a rather unusual case in which a methicillinresistant Staphylococcus aureus (MRSA), normally considered to be only a local wound problem, was involved in deep tissue infection. A 38-yearold woman making a good recovery from a partial-thickness bum covering 42% TBSA on the trunk and extremities developed fever and hip pain when she was about to be discharged from hospital, some eight weeks post-burn. Magnetic resonance imaging indicated an intermuscular pelvic abscess. Open drainage was performed and pus culture showed an MRSA with the same sensitivity profile as a previous CVP catheter tip culture that had been found one month post-bum during routine tests. The infection was treated with vancomycin 500 ing every 6 h for 3 weeks. The most likely route for the formation of the pelvic abscess was haematogenous dissemination. This case should remind us that MRSA infection is not only a local problem, particularly in the immunocompromised condition caused by bum injury.
Lin T-W., Liu C.-H
EXTENSIVE THROMBOSIS OF THE CAVAL VENOUS SYSTEM AFTER CENTRAL VENOUS CATHETERS IN SEVERELY BURNED PATIENTS
Central venous catheters (CVC) are the most frequently used invasive devices in critical care medicine. They are routinely used for a number of purposes, but they may on occasion cause complications, e.g. haemotoma, immediate and delayed pneumothorax, and septic vegetations at the catheter tip, together with, but less often, cardiac tamponade, pericardial effusion, right atrial thrombus or thrombosis of the superior vena cava (SVC) causing an SVC syndrome. Two such cases of SVC syndrome are described in this article. The clinical course, diagnostic problems and treatment options are described. It is concluded that CVC thrombosis should be included early in the differential diagnosis of trunk and extremity oedema in patients with indwelling CVC and that thrombolytic therapy is safe and effectivr in severely burned patients.
Germann G., Kania N.M.
ACCELERATED HEALING AND REDUCED NEED FOR GRAFTING IN PEDIATRIC PATIENTS WITH BURNS TREATED WITH ARGININE-GLYCINE-ASPARTIC ACID PEPTIDE MATRIX
It is well established that rapid wound closure correlates with reduced mortality rate in patients with major burns. Expeditious closure also helps to reduce complications such as wound sepsis, bacteraemia and pulmonary problems. In paediatric patients these considerations are of great importance. The process of dermal healing can be promoted by an arginineglycine-aspartic acid (RGD) peptide matrix which provides a molecular scaffold facilitating cell ingrowth and the establishment of normal tissue architecture. This prospective study in 57 paediatric patients with partial-thickness scald burns investigates the effectiveness and safety of treatment with RG1) peptide matrix, with silver sulphadiazine used as control treatment. Either one or the other treatment was applied to matched burn sites daily for up to 21 days. With RGI) peptide matrix under synthetic occlusive dressing, the incidence of healing was nearly three times higher than with control treatment, average healing time was 2.5 days shorter, extent bum closure at all treated sites 37% greater, and the number of grafting procedures four times lower. All differences were statistically significant. RGI) peptide matrix, which was well tolerated, thus promoted and accelerated healing and contributed to reducing morbidity and treatment costs in partial-thickness bums in paediatric patients.
Hansbrough J.F., Hemdon D.N., Heimbach
D.M., Solem L.D.,
IMMUNOGLOSULIN M SYNTHESIS AFTER BURN INJURY: THE EFFECTS OF CHRONIC ETHANOL ON POSTINJURY SYNTHESIS
A frequent problem complicating burn injury is acute or chronic ethanol (ethyl alcohol) ingestion, which has a number of deleterious effects on the organism. Its effect on class-specific immunoglobulin (1g) synthesis after burn injury was investigated in C57BL/6 mice (weight 2530 gm). The animals were divided into four groups: bum, ethanol-sham, ethanol-bum and control. Five days after injury or the last ethanol ingestion (2 gm/kg daily in 20% solution in distilled water), cell suspensions from spleen and mesenteric lymph nodes were prepared. The number of class-specific Ig-bearing cells was counted by flow cytometry. Both burn and ethanol alone impaired IgM synthesis; splenic IgM was most affected by bum, and mesenteric lymph node IgM by ethanol. IgM synthesis in the group receiving ethanol pre-bum was significantly impaired in both lymphocyte populations. As IgM is the most important Ig in resistance to bacterial infection, the consistent suppression of IgM synthesis in both these tisues may contribute to the increased incidence and severity of acute infection.
Tabata T., Meyer A.A.
A SIMPLE HUMAN DERMAL MODEL FOR ASSESSMENT OF IN VITRO ATTACHMENT EFFICIENCY OF STORED CULTURED EPITHELIAL AUTOGRAFTS
Four storage protocols were investigated to study the effect of shortterm storage on the viability and in vitro attachment efficiency of cultured epithelial autograft sheets. The protocols were as follows: overnight at 37 'C in keratinocyte culture medium; overnight at 4 'C in phosphate-buffered saline solution; overnight at -80 'C in cryopreservation medium (containing 10% dimethyl sulphoxide); and one week at -80 'C in cryopreservation medium. The 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay was used to assess viability before and after storage. All the storage conditions considered significantly reduced viability compared with fresh sheets. No significant decrease was observed when the sheets stored under the various protocols were compared with each other. The best viability obtained was 60% of that of fresh sheets. The in vitro viability of stored sheets was also compared with that of fresh sheets by culturing them on de-epidermized acellular allodermis and by assessing the composites formed by light microscopy and the MTT assay. It was found that the viability of cultured epithelial autograft sheets was significantly reduced but that up to 60% of viability could be preserved in some cases; however, the subsequent in vitro attachment and proliferation of preserved sheets on allogenic de-epidermized dermis was poor when compared with that of fresh cultured epithelial autograft sheets.
Ghosh M.M., Boyce S.G., Freedlander E.,
SELF-INFLICTED PATIENT BURNS: SUICIDE VERSUS MUTILATION
Suicide by burning is a well-described phenomenon but little information is available regarding persons who deliberately bum themselves without suicidal intentions. This paper, which considers 31 patients admitted with self-inflicted burns, describes differences between selfmutilation and attempted suicide. Of the 31 patients, 16 did not have suicidal intentions (mean burn extent, 1.6% TBSA; range, 0.3-9.0%); the 15 attempted suicide patients presented a greater mean TBSA bum extent (35.4%; range, 11.5-90.0%). The attempted suicide patients mainly used flammable liquids (12 out of 15), while the self-mutilation patients tended to use techniques they could control (scalding, chemicals, contact injuries). Most patients in both groups had a history of psychiatric disorders. Burn care professionals should bear in mind this syndrome of self-mutilation by burning, especially when patients present puzzling injuries. In such cases psychiatric treatment will also be necessary.
Tuohig G.M., Saffle JK, Sullivan J.J.,
Morris S. Lehto S.
PULMONARY FAILURE IN GERIATRIC PATIENTS WITH BURNS: THE NEED FOR A DIAGNOSIS-RELATED GROUP MODIFIER
Inhalation injury and pulmonary failure are major contributors to morbidity and mortality rates, particularly in elderly burn patients. In view of the fact that the contribution of respiratory dysfunction to the cost of bum care has not been reported, this retrospective study was conducted to review all geriatric burn admissions to a burns centre in Minnesota (USA) from 1984 to 1992 in order to determine the impact of inhalation injury and pulmonary failure on mortality rates, length of stay, and reimbursement of hospital charges. It was found that charges for patients without pulmonary failure (defined as seven or more days of ventilatory support from the day of the bum) were two to three times greater than reimbursement, while charges for patients with pulmonary failure were four to fourteen times greater than reimbursement. It is concluded that, with the present diagnosis-related-group (DRG) based payment system, reimbursement is inadequate for elderly patients with bums. It is therefore proposed that the DRG definition of extensive bum should be changed to reflect the severity of bum injuries in the elderly and that such patients who require ventilation support for seven or more days post-burn should be reimbursed under a separate DRG category or that a modifier should be attached to current DRG categories.
Clayton M.C., Solem L.D., Ahrenholz D.H.
ESTIMATING ENERGY NEEDS OF PEDIATRIC PATIENTS WITH BURNS
As many formulae used to assess the energy needs of burned paediatric patients have been found to overestimate required energy consumption, a study was conducted to investigate the accuracy of four such formulae (Boston, Galveston, University of California San Diego [UCSD] original, and UCSD modified). The medical records of 12 paediatric patients who maintained body weight were reviewed retrospec-tively. Analysis of variance was employed to compare their individual energy intakes with their estimated energy needs on the basis of each of the formulae. It was found that all four formulae overestimated the energy intakes that maintained body weight (p <0.05). The estimate that used the Galveston formula was closest to actual energy consumption.
Holland K.A., Gillespie R.W., Lewis M.N.,