Atilla Coruh

Propofol–ketamine vs propofol–fentanyl combinations for deep sedation and analgesia in pediatric patients undergoing burn dressing changes

Background:  The aim of this study was to compare propofol–ketamine (PK) and propofol–fentanyl (PF) combinations for deep sedation and analgesia in pediatric burn wound dressing changes.

Stromal vascular fraction improves deep partial thickness burn wound healing.

OBJECTIVE The practice of early burn wound excision and wound closure by immediate autologous skin or skin substitutes is the preferred treatment in extensive deep partial and full-thickness burns. To date there is no proven definite medical treatment to decrease burn wound size and accelerate burn wound healing in modern clinical practice. Stromal vascular fraction is an autologous mixture that has multiple proven beneficial effects on different kinds of wounds. In our study, we investigated the effects of stromal vascular fraction on deep partial-thickness burn wound healing. METHODS In this study, 20 Wistar albino rats were used. Inguinal adipose tissue of the rats was surgically removed and stromal vascular fraction was isolated. Thereafter, deep second-degree burns were performed on the back of the rats by hot water. The rats were divided into two groups in a randomized fashion. The therapy group received stromal vascular fraction, whereas the control group received only physiologic serum by intradermal injection. Assessment of the burn wound healing between the groups was carried out by histopathologic and immuno-histochemical data. RESULTS Stromal vascular fraction increased vascular endothelial growth factor, proliferating cell nuclear antigen index, and reduced inflammation of the burn wound. Furthermore, vascularization and fibroblastic activity were achieved earlier and observed to be at higher levels in the stromal vascular fraction group. CONCLUSIONS Stromal vascular fraction improves burn wound healing by increasing cell proliferation and vascularization, reducing inflammation, and increasing fibroblastic activity.

Risk factors for nosocomial infection and mortality in burn patients: 10 years of experience at a university hospital.

To evaluate the risk factors for nosocomial infection (NI) and mortality in a university hospital, 10-year data of burn patients were assessed retrospectively. The study was conducted at Erciyes University’s Burn Center during 2000 and 2009. The records of 1190 patients were obtained. Overall, 131 (11%) patients had 206 NIs with an incidence density of 14.7 infections/1000 patient days. Burn wound infection (n = 109, 53%) was the most common NI. High (%TBSA burned) and late excision were found to be the most significant risk factors for the development of NI. Pseudomonas aeruginosa was the most frequent causative microorganism. However, the prevalence of multidrug-resistant Acinetobacter baumannii has increased in recent years with a prevalence of 47% in 2009. The carbapenem resistance of P. aeruginosa has decreased in recent years, whereas that of A. baumannii increased and it had a prevalence of 94% in the last year. Conversely, the most important risk factors for mortality were advanced age, high %TBSA and having an underlying disease. Prevention of NI is an important issue in burn units to reduce mortality rates. Early excision and wound closure are important therapeutic approaches for the prevention of burn wound infection.

Retrospective Analysis of Two Hundred Thirty-Five Pediatric Mandibular Fracture Cases

Maxillofacial fractures are encountered less commonly during childhood period due to anatomic, social, cultural, and environmental factors. Although the incidence of all maxillofacial fractures is 1% to 15% among pediatric and adolescent patients, this rate drops to less than 1% in children below 5 years age. Two hundred thirty-five cases (≤16 age) with mandibular fracture were evaluated retrospectively. Patients records were examined in terms of age, gender, cause of fracture, fracture localization, number of fractures, fracture pattern, accompanying injuries, applied treatment methods, and complications. Mean age of cases was 9.2 years and 165 cases were male, 70 were female. Traffic accidents as the most common etiologic cause in all ages. Falls is the second most common cause which particularly affects children above age of 2 years. All cases had 333 fractures and the most common fracture localization was parasymphysis region (34%). The other most common fracture localizations were as follows: condyle (19%), corpus (13%), dentoalveolar region (12%), angulus (11%), symphysis region (9%), and ramus (2%). There was only a single fracture line in 145 cases, 40 cases had unilateral multiple and 50 cases had bilateral fracture lines. We applied symptomatic (conservative) treatment in 20 (8%) of our cases; fracture fixation with interdental wires or closed reduction methods were employed in 122 patients. Internal fixation with open reduction (OR) was performed on 51 (22%) patients. Both closed and OR techniques were carried out in 30 (13%) patients. Pediatric mandibular fractures, which are seen less frequently compared with those of adults, require a specific and different treatment. Although mostly less invasive methods are preferred, we believe that ORs should be considered when required.

Application of split-thickness dermal grafts in deep partial- and full-thickness burns: a new source of auto-skin grafting.

Early tangential excision of nonviable burn tissue, followed by immediate skin grafting with autograft or allograft, has resulted in the improvement of burn patient survival. The aim of this study was to add split-thickness dermal grafts (STDGs) as a new source of auto-skin grafting tool to our reconstructive armamentarium in deep partial- and full-thickness burns and soft tissue defects. The authors successfully applied STDGs along with split-thickness skin grafts as a new source of auto-skin grafting in 11 deep partial- and full-thickness burns over a period of 1 year without any significant donor site morbidity. Dermal graft take was complete in all but one patient. There was no donor site healing problem, and donor site epithelization was completed generally 1 week later than split-thickness skin graft by semi-open technique. Autologous split-thickness skin grafting still remains the standard therapy for burn wound closure but may be in limited availability in severe burns. The authors conclude that STDGs may be a new source of auto-skin grafting tool in extensive deep partial- and full-thickness burns.

Ketamine-propofol vs ketamine-dexmedetomidine combinations in pediatric patients undergoing burn dressing changes.

The aim of this study was to compare ketamine-propofol (KP) and ketamine-dexmedetomidine (KD) combinations for deep sedation and analgesia during pediatric burn wound dressing changes. After obtaining approval from the University Ethics Committee, burn wound care or wound dressing changes were performed on 60 American Society of Anesthesiologists physical status I and II inpatients aged between 8 and 60 months with second-degree burns ranging from 5 to 25% TBSA. After recording the demographic data, the heart rate, systolic arterial pressure, diastolic arterial pressure, peripheral oxygen saturation, respiratory rate, and Ramsey sedation scores were recorded for all patients before and during the procedure. Group KP (n = 30) received 1 mg kg−1 ketamine + 1 mg kg−1 propofol and group KD (n = 30) received 1 mg kg−1 ketamine + 0.5 µg kg−1 dexmedetomidine for induction. Additional propofol (1 mg kg−1) for group KP and additional dexmedetomidine (0.5 µg kg−1) for group KD were administered when required. No statistically significant differences in sedation scores and peripheral oxygen saturation and diastolic arterial pressure (P > .05) were found between the two groups. However, systolic blood pressure values in group KD showed a significant increase after induction (P < .05). The recovery time was longer in group KD than in group KP (P < .05). The respiratory rate was higher in group KD than in group KP beginning from the fifth minute of the procedure. A significant amount of respiratory depression and hypoxia was observed in group KP but not in KD (P < .05). Both the KP and KD combinations were effective for sedation and analgesia during dressing changes in the pediatric burn patients. The KD combination can be considered as an excellent alternative for pediatric wound dressing changes which does not result in respiratory depression.

Repair of traumatic orbital wall defects using conchal cartilage

Background: The authors’ aim was to investigate the efficiency of conchal cartilage grafts in defective orbital wall fractures, which are encountered isolated or in combination with other orbitozygomatic fractures. The authors assessed, for this purpose, the follow-up results of patients treated by using conchal cartilage grafts. Methods: Ten patients who had defective orbital wall fractures and were treated by using conchal cartilage graft among those treated for facial fractures in the authors’ clinic were included in the study. The wall defects in the patients were detected either with preoperative radiologic images or with orbital exploration performed to look for a possible defect accompanying the fracture with orbital extension during the operation. In all patients (four isolated and six combined orbital fractures), who had defects varying from 100 to 400 mm2, conchal cartilage grafts were adapted to the defect. In the postoperative follow-up, Hertel exophthalmometry was also performed together with clinical examination so that enophthalmos that might develop as a complication could be assessed. Results: In the postoperative period, cartilage graft was palpated slightly in two patients at the edge of the infraorbital rim. Limitation in eye movement, diplopia, and enophthalmos did not occur in our patients, except for one who reported to us 1 year after the primary trauma. No complication in the donor area was observed. Conclusions: Conchal cartilage could be considered one of the autogenous materials among those materials suitable for the repair of defective orbital wall fractures that are not oversized. It has the advantages of being adequate for reconstruction of the fracture, easy to obtain, easily adaptable to the orbital walls, and having minimum morbidity at the donor site.

A surgical conundrum: Tessier number 4 cleft.

Objective Among the rarest of the craniofacial clefts is the Tessier no. 4 cleft; and hence little has been published about its management and treatment. Complete forms of the cleft yield poor surgical results because of the shortened oculoalar and oculo-oral distance and inadequate soft and bony tissue. Multiple sequential corrective operations are required. A primary early concern is the protection of the eye, particularly in severe forms in which corneal exposure occurs. This article presents two cases of Tessier no. 4 clefts, one unilateral and the other bilateral, and discusses the problems encountered during their surgical and postoperative managements.

Fractures of the mandible: a 20-year retrospective analysis of 753 patients.

BACKGROUND The craniofacial region is one of the most frequently injured parts of the body, and mandibular fracture is one of the commonest facial skeletal injuries. The most frequent causes of mandibular fractures are the traumas related to traffic accidents, falls, interpersonal violence, and sports activities, etc. METHODS Seven hundred fifty-three cases (615 male, 138 female; megan age 36.2 years) (age >16) with mandibular fracture were evaluated retrospectively. Patient records were examined in terms of age, sex, etiology, seasonal variation, fracture localization, accompanying traumas, treatment modality, and postoperative complications. RESULTS Traffic accidents were the most common etiologic cause in all age groups and both sexes. All cases had a total of 1090 fractures, and the most common fracture localization was the parasymphysis (28.6%), followed by the condyle, corpus, angulus, symphysis, dentoalveolar process, ramus, and coronoid process, respectively. In 25 (3.3%) patients with fissure-like, non-displaced fracture, only symptomatic treatment was applied. Closed reduction with elastic bandage, arch bar, quick-fix screws or Ivy Loop was the only method performed in 280 (37.2%) patients. Osteosynthesis by open reduction and internal fixation (miniplates, screws or transosseous wiring) was performed in 403 (53.5%) patients; closed reduction techniques were also performed in 134 of these patients. CONCLUSION In the recent years, double-road constructions, increased traffic audits and regulation of the traffic rules decreased the incidence of mandibular fractures.

An Undescribed Scalding, “Çökelek” Burns in Turkish Children: Is Acidic Effect the Reason of High Mortality and Double-Hit Injury?

This retrospective review was aimed to evaluate for the first time the risk factors in addition to the demographic and epidemiological features of immersion scalds by hot çökelek in 23 preschool-aged Turkish children younger than 7 years of age, who were admitted to the burn unit of Erciyes University Medical Faculty between January 1996 and August 2006. This retrospective study consisted of 23 hospitalized scalded children by hot çökelek. Hot çökelek burns were studied in terms of age, sex, length of hospital stay, seasonal variation, regions of involvement, the time between burn and admission to our burn unit, extent of burn injury, mortality, morbidity, and treatment modalities. The study consisted of 17 male (74%) and 6 female (26%) pediatric burns with a male-to-female ratio of 2.83:1, which was more frequent in boys. The mean age distribution, extent of burn injury, length of hospital stay, and mean transport time were 3.47 ± 1.41 (range, 2–6 years), 36.60 ± 16.60% (range, 12–79%), 26.00 ± 10.88 (range, 13–38 days), and 8.69 ± 3.73 (range, 2–15 hours), respectively. The overall mortality rate of the study population was 47.8% (11 of 23 children died). All patients suffered deep partial and full thickness burn injuries and received surgical treatment. Hot çökelek burns with acidic component should be considered important because of its high morbidity and mortality. We emphasize the admittance criteria of patients into burn units need to be reviewed in countries where çökelek is being widely consumed.