Large Body Surface Area Burns Research Articles

Mini-Autogenous Skin Grafts with Skin Homografts Versus Autogenous Skin Graft for Covering Post Burn Wounds in Children

Introduction: Burns, as a common type of injury in children,have many developed techniques for management of itswounds, but still have many obstacles which meet plasticsurgeons. One of these is the lack of the donor sites forautogenous skin grafting especially in large body surface areaburns which are unfortunately common in developing countrieswith limited technical and financial resources. Finding asuitable methodology to address this problem was our mainhypothesis in this project. A mixed grafting technique basedon using mini-autogenous skin grafts covered with largehomogenous skin graft had been investigated for this purpose.Patients and Methods: This study is a prospective studyof 20 patients with post burn raw areas who were treated asinpatients at the Burn Unit of Assiut University Hospital,Egypt between September 2017 and September 2019. Patientswere divided into 2 groups. Group: 1 with 10 children treatedby covering the wounds with mini autogenous skin grafts andskin homo grafts and Group: 2 with 10 children treated bythe conventional autogenous skin grafts only.Results: The mean age was 6.8±2.3 years, 15 males and5 females. The mean of the harvested skin in group 1 was1.7±0.67% vs. 3.3±1.06% for group 2 (p < 0.001). Althoughthe mean time of surgery was significantly longer for patientsof group 1, these patients showed significant less bleedingfrom the site of the donor than the 2nd group. There werenon-significant differences between both groups regardingthe take of the graft at the recipient site (p=0.476). Thehyperpigmentation was significantly higher among patientsof group 2 (p=0.024).Conclusion: From this study we advocate the use of miniautogenous skin grafts covered with skin homografts forcovering the extensive post burn raw areas in children. Itprovides the covering for wide raw areas in presence ofshortage of the donor sites. It is a valid reliable procedurewith easier and less expensive aspects suitable for developingand low-income countries where large wound burns are socommon.No specific grants were received by this research fromfunding agencies in the commercial, public, or not-for-profitsector.

First aid is associated with improved outcomes in large body surface area burns

BackgroundAnimal studies indicate treating burn injuries with running water (first aid) for 20 min up to 3 h after burn reduces healing time and scarring. We have previously demonstrated the benefits of first aid in minor burn injuries with respect to a reduction in wound depth, faster healing, and decreased skin grafting utilisation. The purpose of this cohort study was to assess the effect of first aid on clinical outcomes in large body surface area burn injuries (≥20%). MethodsData was prospectively collected for patients with ≥20% TBSA burns from 2004– 2018. Multivariate regression analysis was used to determine the association of adequate first aid with 8 outcomes – mortality, total length of stay, total body surface area (TBSA), percentage/proportion of TBSA that was full thickness [PFTI], TBSA grafted, number of re-grafting sessions, intensive care admission, and intensive care length of stay. Adequate first aid was defined as the application of 20 min of cool, running tap water up to 3 h following the burn injury. Findings390 patients were identified. Adequate first aid was received in 35.6% (139) of patients. There was a trend towards a reduction in mortality (OR 0.37; 95% CI 0.12–1.13; P = 0.08). Patients who received adequate first aid had a statistically significant 9.8% reduction in TBSA (95% CI −13.6% to −6.1%; P < 0.0001) as well as a 12% lower PTFI compared to patients who received inadequate first aid (95% CI −19% to −4%; P < 0.01). Whilst there was no significant effect of adequate first aid on the TBSA grafted (P = 0.37), adequate first aid was associated with a significantly less number of re-grafting sessions (95% CI −-0.29 to −0.08; P < 0.001). InterpretationAdequate first aid with 20 min of running water is associated with improved outcomes in large burn injuries. Significant benefits are seen in a reduction in TBSA, proportion of the burn wound that is full thickness, as well as decreased re-grafting. This has significant patient and health system benefits and adds to the body of evidence supporting 20 min of cooling in burns care.

Morbidity and mortality of paediatric burns patients at Maputo Central Hospital, Mozambique

Background: The incidence of paediatric burn injuries is increasing in Africa. Paediatric burn injuries are among the leading causes of preventable morbidity and mortality in sub-Saharan Africa. Research on the morbidity and mortality in this setting is much needed.Methods: We conducted a prospective questionnaire-based analysis of paediatric burn patients presenting to the Maputo Central Hospital during a five-month period. Interviews were conducted with the children's caretakers by 2 paediatric surgery residents and 1 paediatrician at the Eduardo Mondlane Medical School in Maputo, with the aid of nursing staff.Results: Questionnaires were completed for 66 patients. Most burns occurred from scald injuries (n = 46), particularly from cooking (n = 27) and bathwater (n = 19), followed by fire injuries (n = 16). Burns occurred more frequently in the afternoon (n = 26) and morning (n = 23). Many patients reported no adult caretaker present at the time of the burn injury (n = 24). Most burns were grade II (n = 49). Nearly half of the patients received a blood transfusion (n = 30). One-third of the patients underwent operative surgical debridement (n = 21). Skin grafting was performed on a subset of these patients (n = 13). A large number of patients developed a wound infection (n = 39). All deaths occurred in patients who were admitted to the paediatric intensive care unit and had sepsis (n = 9). The mean total body surface area (TBSA) of burn deaths was 37% (range 20% to 50%), and many deaths were secondary to fire burns (6 of 9; 66.7%).Conclusions: Most paediatric burn injuries occur in association with domestic activities, such as cooking and bathing. Adult caretakers are frequently not present at the time of the burn injury. Mortality rates are high, especially for large body surface area burns caused by fire. Educational programmes may help reduce the incidence of burns and the associated morbidity and mortality. The improvement and expansion of emergency and intensive burn care services may help to improve survival.Keywords: burns; morbidity; mortality; paediatrics; paediatric surgery; Mozambique

Early management of paediatric burn injuries

Abstract Burns are a common form of trauma in children, resulting most frequently from scalds but also contact, flame, electrical and chemical sources. Burn patients have a wide spectrum of injury severity and diverse outcome, ranging from superficial burns with no lasting physical signs to deep, large body surface area burns which are profoundly life-changing, affecting all physiological systems. Size, site and depth are important factors affecting treatment and outcome. There are important anatomical, physiological and psychosocial differences between adults and children. Their body proportions are different, they have thinner skin, smaller airways, reduced blood volume and high levels of distress. They are vulnerable to non-accidental injury. Children require formal fluid resuscitation and maintenance fluids for burns more than 10% total body surface area. Complications include infection, toxic shock syndrome, adverse scarring and psychological sequelae. This paper discusses how correct assessment and management in the acute stage can reduce later morbidity and mortality.

Inability to determine tissue health is main indication of allograft use in intermediate extent burns

IntroductionCutaneous allograft is commonly used in the early coverage of excised burns when autograft is unavailable. However, allograft is also applied in intermediate-extent burns (25–50%), during cases in which it is possible to autograft. In this population, there is a paucity of data on the indications for allograft use. This study explores the indications for allograft usage in moderate size burns. MethodsUnder an IRB-approved protocol, patients admitted to our burn unit between March 2003 and December 2010 were identified through a review of the burn registry. Data on allograft use, total burn surface area, operation performed, operative intent, number of operations, intensive care unit length of stay, and overall length of stay were collected and analyzed. Data are presented as means±standard deviations, except where noted. ResultsIn the study period, 146 patients received allograft during their acute hospitalization. Twenty-five percent of allograft recipients sustained intermediate-extent burns. Patients with intermediate-extent burns received allograft later in their hospitalization than those with large-extent (50–75% TBSA) burns (6.8 days vs. 3.4 days, p=0.01). Allografted patients with intermediate-extent burns underwent more operations (10.8 vs. 6.1, p=0.002) and had longer hospitalizations (78.3 days vs. 40.9 days, p<0.001) than non-allografted patients, when controlled for TBSA. Clinical rationale for placement of allograft in this population included autograft failure, uncertain depth of excision, lack of autograft donor site, and wound complexity. When uncertain depth of excision was the indication, allograft was universally applied onto the face. In half of allografted intermediate-extent burn patients the inability to identify a viable recipient bed was the ultimate reason for allograft use. ConclusionsUnlike large body surface area burns, allograft skin use in intermediate-extent injury occurs later in the hospitalization and is driven by the inability to determine wound bed suitability for autograft application. Allograft application can be utilized to test recipient site viability in cases of autograft failure or uncertain depth of excision.

The acute surgical management of injury to the helix and antihelix in patients with large body surface area burns

Deformity or loss of the ear may be caused by superficial dermal burns or deep burns. The depth of ear burns is progressive because the ear protrudes from head and is easily affected by external pressure. Therefore, burn wounds of the ear should be debrided as early as possible, before irreversible changes of the cartilage, and covered with healthy tissue. We describe a surgical procedure for treatment of the extensively burned ear. With this technique, the helix is covered by a postauricular advancement flap, and the antihelix is covered by a skin graft. Because the procedure is straightforward and can be completed within a short time, it can be performed at the same time as other life-saving measures. The use of a skin flap permits adequate debridement in terms of both depth and width, minimising the risk of infection. The helix can be reconstructed to provide a natural appearance, and late ulcer formation due to external irritation is prevented. We have treated 15 ears on 11 patients with this procedure and have consistently obtained a satisfactory outcome.

Status cosmeticus resulting in graft breakdown in large body surface area burns

Status cosmeticus resulting in graft breakdown in large body surface area burns

064 Proliferation and Growth Factor Exression of Human Keratinocytes on Microcarrier Beads

Human keratinocytes have been extensively used for the treatment of large body surface area burn injuries. We have studied the potential for treating non‐thermal, chronic wounds with keratinocytes grown on microcarrier beads placed into porous retrievable bags. The current studies were undertaken to examine the growth characteristics of these cells on Cytoline‐1™ microcarrier beads, and how this growth correlated with the expression of growth factors.Human keratinocytes were expanded in Keratinocyte Basal Medium‐2 with standard supplements (Clonetics, Inc.). The cells were trypsinized and added to Cytoline‐1™(Pharmacia Biotech) beads at 13.3 × 106 cells per mL pre‐equilibrated beads. The beads were seeded into roller bottles and cultured in a humidified 37° C incubator for up to two weeks. Cell numbers were monitored by direct cell counting on the beads following hematoxylin staining; and by protein and DNA content. Aliquots of media were also assayed for levels of PDGF and VEGF by immunoassay (QuantikineR, R&amp;D Systems).Keratinocytes showed a lag in growth with a sustained decrement in cells per bead from 456 to 346 cells/bead by day 7. This was followed by a robust growth response to 551 cells/bead by day 11. These values correlated with total cellular protein (994, 738, and 1164 ug); and DNA content. The secretion of PDGF and VEGF by human keratinocyte under these conditions, did not directly correlate to the cell number but rather indirectly to the increase in cell number after the 7 days of stagnant growth. These results suggest that the vulnerary effect observed with human keratincytes on microcarrier beads is dependent on acculturation of the cells to the microbead environment, after which they begin to express elevated levels of growth factors important for healing.

Finger ischemia secondary to the synergistic agonist effect of norepinephrine and ergonovine and in a burn patient

Ergonovine (Ergometrine) is an effective uterotonic agent used in the management of post-partum bleeding. It has been found to induce ischemia of the coronary artery as well [1,2]. Norepinephrine is used to treat hypotensive septic shock in large body surface area burns. Combined use of these drugs in the management of burn septicemic shock and post-partum bleeding can produce a synergistic agonist effect that could result to compromised peripheral circulation and subsequent finger ischemia.

Trends in burn admissions in Scotland during 1970–1992

This retrospective study involved analysis of the data of the inpatients discharged with a diagnosis of burns, from various hospitals in Scotland, during the period 1970–1992. There were 51350 such inpatients all over Scotland, with an average annual rate of 2233 cases. Overall burn incidence in actual numbers was 43.7 per cent in < 15 year olds, 41.2 per cent in 15–64 year olds and 15.1 per cent in ≥ 65 year olds. Burn rates per 100 000 population were highest in < 15 year olds and lowest in 16–64 year olds. The pattern of burn admissions has changed. Since 1987 the highest numbers of burn inpatients were the 16–64 year olds, followed by children, then the elderly. There has been a gradual but sustained fall in burns admissions in all age categories. The downward trend was statistically significant ( t = 8.48, 21 d.f., P < 0.001). Though the population of the elderly (≥ 65 year olds) increased by about 13 per cent, the burn admissions and all deaths due to burns did not reveal an upward trend. The population of the old (81 + year olds) increased by 60 per cent during the same period. The incidence of burns was above average when > 80 year olds were considered separately, approaching the levels found in children. However the rate and incidence of burns in the 65–80 year olds resembled that of the younger age group (16–64 year olds). The total number of deaths due to burns and/or smoke inhalation has declined in all age groups and the decline has been statistically significant (chi-squared = 19.62, 1 d.f., P < 0.001). Maximum number of deaths occurred in ≥ 65 year olds (44 per cent), followed closely by 16–64 year olds (43.5 per cent), and 12.5 per cent of deaths in adolescents and children. The decline was due to improved management of burns and a decrease in the number of patients having large body surface area burns.

Donor site repair

Delayed healing of skin donor sites may be costly and life threatening, especially in patients with large body-surface area burns. A donor site dressing should maximize the ability of the wound to heal without increasing the risk of local infection, systemic infection, or both. Specifically, the possibility of a secondary infection may either slow the healing process or ultimately convert the donor site to a full-thickness wound. A number of materials, ranging from gauze to biological agents, have been investigated for use as donor site dressings. The use of hydrocolloids for donor sites has been studied extensively, and, compared with conventional dressings, improved healing rates are reported. Our recent study using a hydrocolloid dressing confirmed earlier research showing fewer infections and more rapid donor site healing.

Microbiology and Healing of the Occluded Skin-Graft Donor Site

Delayed healing of skin-graft donor sites may be costly and life-threatening, especially in patients with large body surface area burns. A donor site dressing should maximize the ability of the wound to heal without increasing the risk of local infection, systemic infection, or both. Specifically, the possibility of a secondary infection may either slow the healing process or ultimately convert the donor site into a full-thickness skin loss. A number of materials ranging from gauze to biologicals have been investigated for use as donor site dressings. The use of hydrocolloids for donor sites has been widely studied and has shown improved healing rates over the rates reported for conventional dressings. Our recent study using hydrocolloids confirmed earlier research that showed fewer infections and more rapid donor site healing.

Changes in diaphragm polyinositol phosphates caused by a large body surface area burn

Respiratory problems are common among burn patients, and an understanding of the changes that occur in the phosphatidyl inositol signal transducing system (s.t.s.) in diaphragm muscle may identify pharmacological agents that would be useful in the treatment of these patients. This report examines changes that occur in polyinositol phosphates of diaphragm muscle due to the systemic effects of large (> 30 per cent) body surface area (per cent BSA) burns. Burn injury was applied to specific per cent BSA of the dorsal and ventral skin surfaces of mice. At postburn day 21, polyinositol phosphate levels were measured in the diaphragm by the incorporation of myo-[2 −3h]inositol with separation of the phosphates by anion-exchange chromatography. All data were analysed using analysis of variance and curve fitting. In the diaphragm, levels of [ 3H]inositol, inositol-1,4,5 trisphosphate (IP 3), inositol-1,4 bisphosphate (I1,4P 2) and inositol-1 phosphate (I1P) increased with increasing burn size. Furthermore, a variety of independent relationships existed between the various phosphates in each burn group (i.e. control, 20 per cent and 50 per cent BSA burn). These data indicate that the systemic effects of burn trauma result in changes in the polyinositol phosphate part of the phosphatidyl inositol signal transducing system of diaphragm muscle.

Stress Ulcer Syndrome

Stress ulcer syndrome refers to gastroduodenal erosions or ulcers that develop acutely in relation to major physi ological stress, usually manifested clinically as upper gastrointestinal (UGI) bleeding. These lesions occur most often in the gastric fundus. Endoscopy has shown gastroduodenal mucosal lesions in 75 to 100% of inten sive care unit (ICU) patients within 72 hours of admis sion. Patients at high risk for stress ulcer include those with large body surface area burns, intracranial lesions associated with coma, fulminant hepatic failure, sepsis, and trauma and abdominal, cardiovascular, and thoracic surgery patients. Also considered high risk are ICU pa tients with superimposed complications such as shock, mechanical ventilation for more than 3 days, coagulopa thy, jaundice, and sepsis. Approximately 15% of ICU pa tients will experience UGI bleeding from stress ulcer. Patients bleeding from stress ulcer have an overall mor tality rate approaching 65% compared with 9 to 22% mortality in patients without stress ulcer. When strati fied according to occult blood loss versus clinically significant bleeding, mortality can be as high as 90% in patients overtly bleeding; 30% of deaths are directly related to bleeding. Both antacids and H2 receptor an tagonists are effective in prophylaxis for stress ulcer bleeding.