Erol Kesiktas

A retrospective analysis of 1083 Turkish patients with serious burns

A total of 1083 burn cases hospitalised at a burn center between August 1988 and the end of 1997 were studied retrospectively to determine the factors and demographic features associated with burn injury in Turkey. The means for patient age and percent total body surface area (TBSA) burned were 18.1 years and 31.2%, respectively (medians were 14.0 years and 25.0%, respectively). Burn injuries were more common in winter and spring, and most occurred in the home. The majority of patients were city dwellers, and had been referred from public hospitals. There was a predominance of male patients (71.9%) in the study population, but the proportions of children and adults were equal. Almost half of the males and the majority of the females were children/students. The vast majority of female adults were housewives, and most of the men were employed outside the home. More than half of the patients suffered second-degree burns, and the others all had deeper burn injuries. The most frequent cause of burn in the study population was flame. Children mainly suffered from scalding, and adults from flame and electrical burns. There were no differences between the sexes regarding depth of burn; whereas percentage total burned surface area was higher in females. Children had a lower mean TBSA and lower rate of third-degree burns. Mortality rate of the study population was 33.5%. The study results identified various risk factors and the groups at high risk for serious burns and indicated some ways that prevention programmes can be improved.

A retrospective analysis of 1083 Turkish patients with serious burns. Part 2: burn care, survival and mortality.

Epidemiological investigations of burn patient series help practitioners to identify factors that affect patient survival. Our aim was to contribute to the body of knowledge in this area by determining how survival related to certain variables in burn cases. The records of 1083 burn patients who were hospitalised between August 1988 and the end of 1997 were retrospectively reviewed. Of this total, 363 (33.5%) died of burn complications, namely, multi-organ injury due to sepsis (47.1% of deaths), renal failure (44.6%), respiratory injury (5.8%) and gastrointestinal bleeding (2.5%). Mortality was higher in children/students, females, retired persons. Extent and depth of burn were important predictors of patient survival. Flame not only was the commonest burn cause but also carried the highest mortality risk. Most of the 1083 patients were referred to our hospital within 3 days of the injury. Deaths commonly occurred within 7 days. The mortality rate for patients who received medical therapy only was higher than that in the group that underwent both medical and surgical treatment (48.4 versus 10.0%, respectively). The study results highlighted various factors that are related to patient survival. These should be considered in the provision of optimal burn care. Training and experience are important elements in burn care and educational meetings should be held regularly for the staff of the burn unit.

Neutrophil gelatinase associated lipocalin as an indicator of acute kidney injury and inflammation in burned children

INTRODUCTION Neutrophil gelatinase associated lipocalin (NGAL) is a novel predictor of acute kidney injury (AKI), which increases with inflammation. We aimed to assess whether serum NGAL (SNGAL) and urine NGAL (UNGAL) can predict AKI in burned children. METHODS Patients were referred within the 12 h of burn to our center. Serum samples for SNGAL, C-reactive protein (CRP), procalcitonin (PCT) and urine for UNGAL, microalbumine (Umalb), creatinine (Ucr) were obtained at both admission and the 5th day after burn. Blood urea nitrogen (BUN) and serum creatinine (Scr) were examined daily. RESULTS Twenty-two subjects were enrolled and six (27.2%) of them developed AKI within the 48 h of injury. Burn size and abbreviated burn severity index (ABSI) were significantly increased in patients with AKI. CRP, PCT, SNGAL and UNGAL levels at admission and day 5 were significantly higher in patients with AKI than in those without AKI and controls. Scr was not significant between AKI and non-AKI groups at hospital days 1 and 5. A SNGAL level of 315 ng/ml and a UNGAL level of 100 ng/ml were determined as predictive cut-off values of AKI at admission (sensitivity and specificity: 71.4%, 83.3% and 93.3%, 93.7%, respectively). SNGAL and UNGAL were positively correlated with CRP, PCT, ABSI and Umalb/Ucr. CONCLUSION SNGAL and UNGAL are good early predictors of AKI in children with severe burn. NGAL might reflect the severity of burn insult and also could be used as an indicator of inflammation in burn children.

Mega dose corticosteroid treatment for traumatic superior orbital fissure and orbital apex syndromes.

The superior orbital fissure syndrome and orbital apex syndrome are rare complications of craniomaxillofacial traumas. The neurologic symptoms are generally due to reversible neuropathy caused by edema, contusion, and compression of the nerves. Much has been written but no firm conclusions have been reached on the best mode of treatment. Whereas some authors advocate emergency optic nerve decompression, others recommend mega dose corticosteroids alone. We have treated 11 patients with traumatic superior orbital fissure or orbital apex syndromes with mega dose corticosteroids in the last 10 years. No complications attributable to the very high dose of corticosteroids were observed. The long-term follow-up of the patients showed complete recovery. These satisfactory results have led to our recommendation of the mega dose corticosteroid treatment in the management of these patients.

Comparison of effects of ketamine, ketamine-dexmedetomidine and ketamine-midazolam on dressing changes of burn patients

Objective: The aim of this randomized, controlled study was to compare the sedoanalgesic effects of ketamine-dexmedetomidine and ketamine-midazolam on dressing changes of burn patients. Materials and Methods: Following Ethics Committee approval and informed patient consent, 90 ASA physical statuses I and II adult burn patients were included in the study. Patients were randomly divided into three groups. Ten minutes before dressing change, the dexmedetomidine group (group KD) (n = 30) received a continuous infusion of dexmedetomidine at a rate of 1 μg kg-1, the midazolam group (group KM) (n = 30) received a continuous infusion of midazolam at a rate of 0.05 mg kg-1 and the saline group (group KS) (n = 30) received a continuous infusion of saline intravenously. One minute before dressing change, each patient was administered 1 mg kg-1 ketamine intravenously. Hemodynamic variables, pain and sedation scores, the number of patients requiring additional ketamine, time to dressing change and recovery time were recorded. Results: Systolic blood pressure (SBP) values were significantly lower at, before and after ketamine administration; and 5, 10 and 15 minutes after the procedure in group KD in comparison with the other groups (P <0.05). There was no significant difference in pain scores among the groups during the study period. Sedation scores were significantly higher in group KD than in groups KM and KS at the end of the first hour (P <0.05). Time to dressing change and recovery time were similar in all the groups Conclusion: In burn patients undergoing dressing changes, although both combinations ketamine-dexmedetomidine and ketamine-midazolam offered an effective sedoanalgesia without causing any significant side effect, the former resulted in higher sedation and lower hemodynamic discrepancy.

Evaluation of vascularized graft reconstruction of the mandible with Tc-99m MDP bone scintigraphy

AimThe aim of this study was to evaluate the value of bone scintigraphy for the assessment of graft viability following vascularized bone grafts in patients with mandibular reconstruction.MethodsWe investigated 16 patients with vascularized grafts from the fibula (13 patients) and iliac crest (3 patients) in the last 8 years. For the follow up of all these patients, Tc-99m MDP bone scintigraphy was performed between 2-10 days postoperatively. SPECT study was included in 5 patients. For the evaluation of the grafts, a six-grade scoring system was used. The grading system was based on a comparison of tracer uptake between graft and the cranium. The uptake was defined as increasing from grade 6 to grade 1.ResultsThirteen of the 16 grafts had an uncomplicated clinical course. Complications in the graft occurred in three patients. In the analysis of planar scintigrams, patients with uncomplicated healing showed increased uptake in 12 of the 13 grafts (grade 1-3) and 1 showed the same level tracer uptake compared to cranium (grade 4). In the failed 3 grafts, decreased uptake was observed (grade 5 and 6). In 5 patients, SPECT was performed in addition to planar imaging. In these patients, 4 of the 5 grafts had an uncomplicated clinical course and 1 had a complicated one. In the analysis of SPECT images, while all the grafts with an uncomplicated clinical course exhibited increased uptake (grade 1-3), the failed graft showed decreased uptake (grade 6).ConclusionThree-phase bone scintigraphy performed within 10 days after the mandibular reconstruction is a useful tool to monitor the viability and early complications of vascularized mandibular bone grafts. SPECT is also recommended. It may contribute to interpretation of the bone scans and to precise assessment of graft viability.

Placement of implants in the mandible reconstructed with free vascularized fibula flap: comparison of 2 cases.

The reconstruction of mandibular continuity defects after tumor resection with free vascularized bone flaps is considered to be a treatment option. Although the fibula flap presents many advantages, it does not offer sufficient bone height to restore the alveolar arch when reconstruction involves a dentate mandible. In this report, 2 patients who were referred to our clinic with reconstructed mandibles with diagnosis of amelablastoma are presented and compared. The mandibles of these patients were reconstructed with free vascularized fibula flaps. Whereas one of the reconstructed mandibles was vertically distracted before implant placement, distraction procedure was not carried out for the other patient. Increasing height of the fibula flap by distraction osteogenesis before implant placement in dentate mandible is desirable from a functional and esthetic point of view.

Upper extremity salvage with a flow-through free flap.

In complex extremity injuries, which include composite tissue lost with devascularization caused by segmental vascular damage, simultaneous coverage of the defects with revascularizations should be required. One-stage reconstruction of both soft tissue coverage and vascular damage can be performed by a flow-through-type free flap. In this series, 5 patients between 13 and 36 years of age with wide composite tissue defects in the cubital region and segmental defects in brachial arteries were operated at our clinic between 1996 and 2003. With the aim of reconstructing the wide tissue defects in the cubital region as well as that of the brachial artery, a radial arterial flow-through flap was applied. The radial artery of the flow-through flap was anastomosed to the proximal ends of the brachial and ulnar arteries in an end-to-end fashion. In 4 of the patients, the radial arterial flow-through flap was prepared from the distal aspect of the wounded forearm and in 1 patient from the contralateral forearm. In the postoperative period, no complications related to the anastomosis were encountered in the flap with all anastomoses found to be patent, and distal circulation was restored. The radial arterial flow-through flap is very useful in the clinical field of major trauma of the cubital region with brachial artery damage with numerous advantages that include the opportunity to work in one single surgical area, shorter dissection times resulting from simple and fixed anatomy, perfect color and tissue adaptation, and the suitability of the vessel caliber and length.

Upper extremity salvage procedure with flow-through free flap transfer taken from the amputated part

An alternative free flap technique in a patient presenting with an incomplete amputation in the right cubital region, resulting from a gunshot wound, is introduced. The defect area was repaired using a flow‐through fasciocutaneous free flap, which, when following a cubical or popliteal region amputation, is a suitable option for revascularisation and salvage of the extremity.

Comparison of autologous and heterologous bone graft stability effects for filling maxillary bone gap after Le Fort I osteotomy.

BACKGROUND The amount of postoperative maxillary relapse of two different bone graft materials after Le Fort I osteotomy were compared in this study. OBJECTIVES The aim of this study is to compare postoperative maxillary relapse rates using heterologous and autologous graft materials after Le Fort I osteotomy. MATERIAL AND METHODS A total of 80 patients who had developmental malocclusion were analyzed retrospectively in this study. Twenty nine (36.2%) and 51 (63.8%) patients underwent Le Fort I osteotomy, and Le Fort I and bilateral sagittal split ramus osteotomy (two-jaw surgery), respectively. Forty two (52.5%) maxillary bone gaps were filled with heterologous bone grafts (group A) and 38 (47.5%) were filled with autologous bone grafts (group B) after Le Fort I osteotomy. The cephalometric graphics and measurements were taken before (T1), 1 week after (T2), and 1 year after (T3) the surgery. The results were documented and determined by the Dolphin imaging 10.5 (Dolphin Imaging, Chatsworth, Calif.) computer program for skeletal relapse. Whether or not the relationship between group As and Bs maxillary relapse rates was evaluated in the postoperative period. RESULTS It was observed that both graft materials have positive effects on maxillary relapse rate in the postoperative period. When the groups are compared to each other, the relapse rates were similar between group A (8.3%) and group B (10.8%) (p>0.05). CONCLUSIONS Heterologous bone graft material (Osteoplant®-Flex) is thought to be a good alternative to autologous grafts in decreasing the relapse rates and reducing the morbidity of the donor area of the patients who underwent Le Fort I osteotomy.