Conrado C. Bondoc

Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury.

A bilayer artificial skin composed of a temporary Silastic epidermis and a porous collagcn-chondroitin 6-sulfate fibrillar dermis, which is not removed, has been used to physiologically close up to 60% of the body surface following prompt excision of burn wounds in ten patients whose total burn size covered 50–95% body surface area (BSA). Following grafting, the dermal portion is populated with fibroblasts and vessels from the wound bed. The anatomic structure of the artificial dermis resembles normal dermis and serves as a template for the synthesis of new connective tissue and the formation of a “neodermis,” while it is slowly biodegraded. This artificial skin has physiologically closed excised burn wounds for periods of time up to 46 days before the Silastic epidermis was removed. At the time of election when donor sites are ready for reharvesting, the Silastic epidermis is removed from the vascularized artificial dermis and replaced with 0.004 auto-epidermal graft in sheet or meshed form. Clinical and histologic experience in a relatively short follow-up period (2–16 months) indicates that “neodermis” retains some of the anatomic characteristics and behavior of normal dermis, thus promising improvement in the functional and cosmetic results, as well as providing physiologic function as a skin substitute. The artificial skin is easily sterilized and stored at room temperature, capable of large scale production, and immediately available for grafting, indicating its potential for easy and relatively economic use in the burn patient

Significant reductions in mortality for children with burn injuries through the use of prompt eschar excision.

During the past 19 years, mortality due to burn injuries has markedly declined for children at the Boston Unit of the Shriners Burns Institute (SBI), dropping from an average of 9% of SBI admissions during 1968–1970 to an average of 1% during 1981–1986. Detailed statistical analysis using logistic regression was necessary for determining whether this decline in mortality was explained by changes in patient characteristics, such as age or burn size, which are known to strongly influence the outcome of burn injuries. This dramatic decline in mortality during the past 19 years was not the result of change in the age of the patients or their burn sizes; rather, it may be attributed to improvements in burn care. Results of this statistical analysis indicated that, for burn injury patients whose ages ranged from 11 days to 19 years, age had no demonstrable effect on survival from a burn injury. Children survived burn injuries at least as well if not better than the young adult (20–29 years of age). Also, infants (less than 1 year old) survived as well as other children (2–19 years old). Dramatic improvement in survival occurred in patients with burns covering more than 50% of the body surface area. Since 1979, mortality has been essentially eliminated for patients with burn sizes less than 70% of the total body surface area (of 296 patients with burns covering 15–69% of the total body surface area, only two patients died). During the period 1979–1986, 29 of 37 patients (78%) survived an 80% or greater total body surface area thermal injury.

Primary Excision and Prompt Grafting as Routine Therapy for the Treatment of Thermal Burns in Children

There is much evidence that the most important factor in the successful treatment of skin destruction after thermal injury is to remove dead tissue and promptly close the wound. While the exact methods employed to achieve this goal may vary, in the cases reported here three basic methods were used: (1) simple excision of burn eschar with immediate closure with autograft for small and medium-sized burns; (2) excision and immediate wound closure with autograft supplemented by allograft, with replacement of allograft by autograft before extensive allograft rejection, for large burns; and (3) immunosuppression and temporary skin transplantation for massive third degree burns. All have markedly decreased hospital stay and complications, and in large and massive burns mortality was substantially reduced.

The acutely burned hand : management and outcome based on a ten-year experience with 1047 acute hand burns

Optimal hand function has a very positive impact on the quality of survival after burn injury. Over a 10-year period, 659 patients with 1047 acutely burned hands were managed at the Sumner Redstone Burn Center of the Massachusetts General Hospital. Our approach to acutely burned hands emphasizes ranging and splinting throughout hospitalization, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. This approach is associated with normal function in 97% of those with superficial injuries and 81% of those with deep dermal and full-thickness injuries requiring surgery. Although only 9% of those with injuries involving the extensor mechanism, joint capsule, or bone had normal functional outcomes, 90% were able to independently perform activities of daily living.

The Contribution of a Bacterially Isolated Environment to the Prevention of Infection in Seriously Burned Patients

: A new system of patient protection from bacterial crossinfection called the Bacteria Controlled Nursing Unit (BCNU) is described, based on strict environmental control of a 6 x 10 foot area surrounding the patients bed rather than the entire patient room or isolation ward, plus the ability to deliver all medical care without entering the protective environment and maintaining all monitoring, life support, and i.v. equipment outside the controlled environment. The clinical effectiveness of this system in the treatment of burn patients has been studied and compared with the effectiveness of single room isolation on a burn isolation ward and conventional isolation techniques on an open burn ward. The studies show that the BCNU is significantly more effective in preventing bacterial cross-contamination than conventional precautions (3.8% vs. 13.1%, P < 0.001; and 8% vs. 22.8%, P < 0.001) over a two and four week period. The studies also indicate that there was a significant increase in the probability of infection occurring following cross-contamination than occurring after auto-contamination (65% vs. 39%, P < 0.005), emphasizing the importance of preventing cross-contamination in reducing the overall infection rate in seriously burned patients. Clinical evaluation of the unit proved it to be compatible with intensive nursing and medical care without increasing the nurse to patient ratio. The unit provided sufficient control of bacterial cross-infection to allow reduction in mortality and improvement in the effectiveness of burn care through routine prompt excision of burn eschar and immediate wound closure to be carried out in severe and massively burned patients without a limiting threat of bacterial burn wound sepsis.

Clinical trials of amniotic membranes in burn wound care.

Four test conditions of increasing complexity were used to evaluate the clinical efficacy of amniotic membranes as biologic dressings on donor sites and burn wounds in children. These were the clean-skin donor-site wound, the uncontaminated shallow partial-thickness burn wound, the bed of freshly excised full-thickness wounds, and the granulating surface of colonized burn wounds. The rate of epithelialization under amniotic membranes was the same as that under 5% scarlet red ointment or 0.5% silver nitrate solution dressings. Preservation of a healthy excised wound bed and maintenance of a low bacterial count in contaminated wounds paralleled the experience with human allograft dressings despite technical difficulties and the absence of vascularization of amniotic membrane and its fragile structure. Tentative conclusions are drawn as to the mechanisms by which biologic dressings exert their beneficial effects.

Increased survival after massive thermal injuries in adults: preliminary report using artificial skin

Survival of major burn injuries has improved markedly from an expected survival of 10% to 20% in both children and adults to an expected survival of 60% in children with burns greater than 70% BSA. Increased survival for adults after similar burn injuries has been less dramatic than in children because of the profound influences of advancing age and the coexistent processes of aging upon survival after a major injury. Consecutive admissions of patients with massive burn injuries (greater than or equal to 70% BSA) to the Massachusetts General Hospital Adult Burn Unit from 1974 to 1986 were analyzed statistically using univariate and multiple logistic regression analysis to identify factors associated with survival and to identify patient characteristics associated with increases in expected survival. Survival of adults with massive burn injuries has improved markedly, from 24% of adults admitted to the Adult Burn Center in 1974-75 to 48% of adults admitted in 1984-86. An increased likelihood of survival was shown to be associated with the use of artificial skin. Improved survival rates in these massive burn injuries were attributed to multiple factors including wound management of prompt eschar excision and immediate wound closure.

Long-term functional results of selective treatment of hand burns

Four hundred seventy-eight patients with hand burns (786 hands) were treated at the burn service of the Massachusetts General Hospital. Long-term evaluation showed that early incision and immediate autografting of deep second degree, mixed second and third degree, and third degree full-thickness hand burns resulted in 93 percent, 95 percent, and 93 percent, respectively, excellent to good functional results. There was no significant differences in results in patients with superficial second degree burns treated nonsurgically with silver nitrate dressings and early physical therapy compared with results in patients with deep second degree, mixed second and third degree, and third degree hand burns treated with early excision and grafting. No patient with fourth degree burns had excellent to good results. Permanent damage was related to extent of original injury to the extensor tendons and joint capsules. On the basis of this broad experience, it is believed that all burned hands judged unlikely to heal within 3 weeks will benefit from early excision and grafting by experienced surgical personnel.

Patterns of high tension electrical injury in children and adolescents and their management

High tension electrical burn injury occurred in twenty-nine patients over a period of seven years, causing two deaths, and demonstrating two reasonably distinct patterns. Major surface thermal burns from involvement in an electric arc, augmented by flame burns of ignited clothing, occurred in eleven patients. By contrast, eighteen children demonstrated wounds of entrance and exit of current and varying effects of deep thermal injury along the path of the maximally conductive blood vessels and nerves of extremities. An aggressive surgical approach was taken in patients with both types of injury, with the objective of prompt identification and excision of devitalized tissues and closure of thw wound. In the deep condictuve type of injury, frozen section and subsequent histologic study served as a guide to adequacy of excision and preservation of viable tissue. Even so, amputation of fifteen extremities and four other major excisions were required in twelve patients.

Early Excision and Prompt Wound Closure Supplemented with Immunosuppression

A rational approach to the problem of extensive skin destruction secondary to burns appears to be early excision of devitalized tissue and immediate closure of the wound. This concept, coupled with strict protection of the patient against cross-infection, and nutritional support, may be employed successfully as routine burn care for small as well as moderate burns that require hospitalization. A key addition to treatment of massive deep burns is the use of immunosuppression.