Alan David Rogers

The Introduction of a Protocol for the Use of Biobrane for Facial Burns in Children

Biobrane has become an indispensible dressing with three established indications in acute burns care at our institution: (1) as the definitive dressing of superficial partial thickness facial burns, (2) after tangential excision of deep burns when autograft or cadaver skin is unavailable, and (3) for graft reduction. This paper details our initial experience of Biobrane for the management of superficial partial thickness facial burns in children and the protocol that was compiled for its optimal use. A retrospective analysis of theatre records, case notes and photographs was performed to evaluate our experience with Biobrane over a one-year period. Endpoints included length of stay, analgesic requirements, time to application of Biobrane, healing times, and aesthetic results. Historical controls were used to compare the results with our previous standard of care. 87 patients with superficial partial thickness burns of the face had Biobrane applied during this period. By adhering to the protocol we were able to demonstrate significant reductions in hospital stay, healing time, analgesic requirements, nursing care, with excellent cosmetic results. The protocol is widely accepted by all involved in the optimal management of these patients, including parents, anaesthetists, and nursing staff.

Ventilator associated pneumonia in major paediatric burns

More than three-quarters of deaths related to major burns are a consequence of infection, which is frequently ventilator associated pneumonia (VAP). A retrospective study was performed, over a five-year period, of ventilated children with major burns. 92 patients were included in the study; their mean age was 3.5 years and their mean total body surface area burn was 30%. 62% of the patients sustained flame burns, and 31% scalds. The mean ICU stay was 10.6 days (range 2-61 days) and the mean ventilation time was 8.4 days (range 2-45 days). There were 59 documented episodes of pneumonia in 52 patients with a rate of 30 infections per 1000 ventilator days. Length of ventilation and the presence of inhalational injury correlate with the incidence of VAP. 17.4% of the patients died (n=16); half of these deaths may be attributed directly to pneumonia. Streptococcus pneumonia, Pseudomonas aeruginosa, Acinetobacter baumanii and Staphylococcus aureus were the most prominent aetiological organisms. Broncho-alveolar lavage was found to be more specific and sensitive at identifying the organism than other methods. This study highlights the importance of implementing strictly enforced strategies for the prevention, detection and management of pneumonia in the presence of major burns.

Burn resuscitation on the African continent

A survey of members of the International Society of Burn Injuries (ISBI) and the American Burn Association (ABA) indicated that although there was difference in burn resuscitation protocols, they all fulfilled their functions. This study presents the findings of the same survey replicated in Africa, the only continent not included in the original survey. One hundred and eight responses were received. The mean annual number of admissions per unit was ninety-eight. Fluid resuscitation was usually initiated with total body surface area burns of either more than ten or more than fifteen percent. Twenty-six respondents made use of enteral resuscitation. The preferred resuscitation formula was the Parkland formula, and Ringers Lactate was the favoured intravenous fluid. Despite satisfaction with the formula, many respondents believed that patients received volumes that differed from that predicted. Urine output was the principle guide to adequate resuscitation, with only twenty-one using the evolving clinical picture and thirty using invasive monitoring methods. Only fifty-one respondents replied to the question relating to the method of adjusting resuscitation. While colloids are not available in many parts of the African continent on account of cost, one might infer than African burn surgeons make better use of enteral resuscitation.

Resuscitation in major burns: the problem of fluid creep

To the Editor: We have noticed an alarming tendency for burn patients to be over-resuscitated, and we believe that protocols should be reviewed in light of our own and international experience. We recently managed an 8-year-old boy with 52% fullthickness burns, who developed abdominal and limb compartment syndromes during the period of resuscitation. The fluid volumes infused above those calculated were 1.6 and 4.7 litres on days 1 and 2 respectively to maintain haemodynamic stability and urine output above 2 ml/kg/h. Within 48 hours of the injury, he developed poor peripheral perfusion and a distended abdomen; the intravesical pressure was 32 mmHg and the abdominal perfusion pressure 23 mmHg. Abdominal decompression and three limb fasciotomies were performed, but small-bowel and lower limb muscle necrosis had developed. The patient deteriorated rapidly despite inotropic support and died. Fluid calculations were based on the Parkland formula at 4 ml/kg/% burn, and a major goal of resuscitation was to maintain urine output above 2 ml/kg/h. 1 The Advanced Paediatric Life Support (APLS) course manual 2 states that the Parkland formula is ‘only a guide; subsequent therapy will be guided by urine output, which should be kept at 2 ml/kg/ hour or more’. Such formulae and guidelines do not negate the value of regular re-assessment of the patient’s clinical condition. Over-reliance on the Parkland formula, and attempts at maintaining fluid output above 2 ml/kg/h as prescribed by APLS, 2 may lead to over-hydration; if severe, this may manifest as compartment syndromes in unburnt limbs and in the abdomen, with potentially lethal consequences. 3-5

The Emergency Management of Severe Burns Course in South Africa

The Emergency Management of Severe Burns (EMSB) Course is an important component of the South African Burn Society’s commitment to improving the standard of burn care in South Africa. A one-day course in the ATLS mould, it has proved to be an extremely helpful aid to healthcare practitioners faced with major burns in any setting. This paper outlines the history of the EMSB course since its introduction to South Africa in 2005, under license from the Australia and New Zealand Burn Association (ANZBA).

The use of Biobrane® for wound coverage in Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis

INTRODUCTION Published experience describing the use of Biobrane® for wound management in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS-TEN) is limited to case reports and case series involving ten or fewer patients. We have used Biobrane® in the care of SJS-TEN since 2000, and the purpose of this study was to review our experience with the application of Biobrane® for wound coverage in SJS-TEN. METHODS A retrospective review of all cases of SJS-TEN admitted to an adult regional ABA-verified burn center between January 1, 2000 and June 1, 2015 was conducted. Biobrane® application was performed at burn center admission. Values are presented as the median (IQR), or mean±SD where appropriate. RESULTS We identified 42 eligible subjects with SJS-TEN. Biobrane® was applied in 24 subjects. Biobrane®-treated subjects had an age of 51.4±21.7years, with a %TBSA epidermal detachment of 39.5 (30-46), 63% were female and the admission SCORTEN was 3 (2-4, range 1-5). Biobrane® was applied at burn center (BC) admission in 18/24 subjects (82%), and between post admission days 1-4 in four subjects. Biobrane® was applied to 35 (22-40) % of the TBSA (range 7-90) involving all anatomic areas including the head and neck. There were no complications, infections, premature removals, or Biobrane®-associated sepsis in 24/25 applications (96%). In one subject a sheet of the TBSS was removed due to sub-Biobrane® fluid collection, but with negative microbiological cultures. Time to healing was 13 (12-16) days, and burn center length of stay was 34 (15.3-62.3) days. Subjects treated with dressings only (n=18) had a significantly smaller %TBSA epidermal detachment [10 (5-22), p<0.001], and were predominantly diagnosed with SJS (50%) or SJS-TEN overlap (33%). Time to healing among dressing-only subjects was not significantly different [12 (10-14.5) days] than among the Biobrane®-treated subjects, (p=0.127). CONCLUSION Biobrane® was applied to SJS-TEN subjects with more extensive epidermal detachment, had no significant complications, and generally facilitated epidermal healing in under 2 weeks from application.

Fatal non-occlusive mesenteric ischemia and the use of propranolol in paediatric burns

Abdominal complications without abdominal injury are infrequently seen in children with major burns. They are divided into those that occur early during the emergency phase of treatment and those that occur late in the course of treatment. One of the most serious late onset complications is non-occlusive mesenteric ischaemia associated with the use of vasoactive drugs. We report on 2 children who late in the course of their burn injury developed ischaemic necrosis of their entire intestine. Both were on propranolol, the administration of which was continued with even during the periods of septic shock which preceded their demise. We are of the opinion that endogenous catecholamine release during hypotensive and septic episodes in conjunction with β-adrenergic blockage from propranolol could lead to severe splanchnic vasoconstriction from unopposed α-adrenergic activity and hence critical circulation impairment to the bowel in the 2 children.

Ten principles for preventing biofilm-related infections in surgical practice.

There is a growing body of literature regarding the impact of biofilm on device-associated infections (DAI). It has been estimated that DAIs will cost the USA alone more than US

Reducing the surgical complications of smoking by cotinine testing

1 billion. Much of the literature is in the context of the use of orthopaedic, cardiovascular, and plastic surgical prostheses, especially joint and breast implants, but biofilm has been implicated in all surgical fields where foreign materials are placed.

Noninvasive Ventilation in Patients with Major Burn Injuries

We read with interest the edition of SAMJ (November 2013) dedicated to smoking, arguably the most significant modifiable cause of death and disease. One of the areas not addressed relates to the impact of smoking in the context of surgery. It is well recognised that smoking increases the risk of overall complications, arrhythmias, thrombotic episodes, pneumonia, infection, wound healing complications and prolonged hospital stays, as well as the need for further surgery. As surgeons we are frequently held responsible for these complications, and yet the decision to undertake the procedure at all should often be scrutinised, especially in the elective setting, rather than just the technical execution thereof.