Ezio Nicola Gangemi

Epidemiology and Risk Factors for Pathologic Scarring After Burn Wounds

OBJECTIVE To describe the clinical characteristics of postburn scars and determine the independent risk factors specific to these patients. While burns may generate widespread and disfiguring scars and have a dramatic influence on patient quality of life, the prevalence of postburn pathologic scarring is not well documented, and the impact of certain risk factors is poorly understood. METHODS A retrospective analysis was conducted of the clinical records of 703 patients (2440 anatomic burn sites) treated at the Turin Burn Outpatient Clinic between January 1994 and May 15, 2006. Prevalence and evolution time of postburn pathologic scarring were analyzed with univariate and multivariate risk factor analysis by sex, age, burn surface and full-thickness area, cause of the burn, wound healing time, type of burn treatment, number of surgical procedures, type of surgery, type of skin graft, and excision and graft timing. RESULTS Pathologic scarring was diagnosed in 540 patients (77%): 310 had hypertrophic scars (44%); 34, contractures (5%); and 196, hypertrophic-contracted scars (28%). The hypertrophic induction was assessed at a median of 23 days after reepithelialization and lasted 15 months (median). A nomogram, based on the multivariate regression model, showed that female sex, young age, burn sites on the neck and/or upper limbs, multiple surgical procedures, and meshed skin grafts were independent risk factors for postburn pathologic scarring (Dxy 0.30). CONCLUSION The identification of the principal risk factors for postburn pathologic scarring not only would be a valuable aid in early risk stratification but also might help in assessing outcomes adjusted for patient risk.

Acute complex traumas of the lower limbs : a modern reconstructive approach with negative pressure therapy

Acute traumas of the lower limbs cause complex functional damage for the association of skin loss with exposed tendons, bones, and/or vessels, requiring a multidisciplinary approach. Once bone fixation and vascular repair have been carried out, the surgical treatment for skin damage is usually based on early coverage with conventional or microsurgical flaps. Negative pressure therapy can play a primary role in the management of the elderly or intensive care patients, where wounds are secondary to life‐threatening problems. A total of 35 patients with 37 acute traumatic wounds of the lower limbs were treated with vacuum‐assisted closure (VAC®) therapy for an average of 22 days (range 3–46 days). The sponge was applied the day after bone fixation, vascular repair, and surgical debridement of nonviable tissues, so as to obtain a better control of bleeding. After VAC® treatment, all patients quickly developed healthy granulation tissue and a significant reduction in both extent and depth of wounds. Split‐thickness skin grafts were used to cover granulation tissue in most of the cases (66%—24 cases), and then local flaps (13%—five cases) or direct sutures (8%—three cases). The wounds healed spontaneously without surgical management in four patients. One patient died during the treatment period for concomitant diseases. No relevant complications directly related to VAC® therapy were observed other than one case of severe pain in an amputated stump. The average follow‐up duration was 265 days (range 33–874 days). No further tegumentary reconstruction was required. VAC® therapy may represent a valid alternative to immediate reconstruction in selected cases of acute complex traumas of the lower limb and allows for a stable functional result, using a minimally invasive approach.

Low triiodothyronine serum levels as a predictor of poor prognosis in burn patients.

OBJECTIVE Euthyroid sick syndrome is a common finding in critically ill patients with nonthyroidal illness, characterized by low serum levels of free triiodothyronine (fT3) with a peculiar increase in reverse T3 (rT3) and normal-to-low free thyroxine (fT4) as well as thyroid-stimulating hormone (TSH) levels. This condition has been proposed as a prognostic factor of worse outcome in critically ill patients, while no conclusive data are available in burns. METHODS Since thyroid function testing is contained in our baseline laboratory tests at admission, we retrospectively evaluated fT3, fT4 and TSH in 295 consecutive burn patients admitted to the Burn Center of Turin from January 2002 to December 2006, comparing hormone levels in survivors and non-survivors. RESULTS fT3 and TSH levels were significantly lower (p<or=0.0002) in non-survivors compared to survivors, while no significant difference between the two populations was found in fT4 concentrations. Excluding from the study 20 patients who received dopamine administration for more than 21h, serum fT3 levels fell further still (p=0.0003). In addition, fT3 concentrations showed a significant correlation with burn severity expressed by the Roi score (Spearmans correlation coefficient -0.37 with p<0.00001). CONCLUSION Low fT3 levels are associated with poor outcome in burn patients. Hence, fT3 measurement could be proposed as a strong and cost-effective tool of poor prognosis.

Citrate Anticoagulation for Continuous Renal Replacement Therapy in Critically Ill Patients: Success and Limits

Citrate anticoagulation has risen in interest so it is now a real alternative to heparin in the ICUs practice. Citrate provides a regional anticoagulation virtually restricted to extracorporeal circuit, where it acts by chelating ionized calcium. This issue is particularly true in patients ongoing CRRT, when the “continuous” systemic anticoagulation treatment is per se a relevant risk of bleeding. When compared with heparin most of studies with citrate reported a longer circuit survival, a lower rate of bleeding complications, and transfused packed red cell requirements. As anticoagulant for CRRT, the infusion of citrate is prolonged and it could potentially have some adverse effects. When citrate is metabolized to bicarbonate, metabolic alkalosis may occur, or for impaired metabolism citrate accumulation leads to acidosis. However, large studies with dedicated machines have indeed demonstrated that citrate anticoagulation is well tolerated, safe, and an easy to handle even in septic shock critically ill patients.

Predicting severity of pathological scarring due to burn injuries: a clinical decision making tool using Bayesian networks

It is important for clinicians to understand which are the clinical signs, the patient characteristics and the procedures that are related with the occurrence of hypertrophic burn scars in order to carry out a possible prognostic assessment. Providing clinicians with an easy‐to‐ use tool for predicting the risk of pathological scars. A total of 703 patients with 2440 anatomical burn sites who were admitted to the Department of Plastic and Reconstructive Surgery, Burn Center of the Traumatological Hospital in Torino between January 1994 and May 2006 were included in the analysis. A Bayesian network (BN) model was implemented. The probability of developing a hypertrophic scar was evaluated on a number of scenarios. The error rate of the BN model was assessed internally and it was equal to 24·83%. While classical statistical method as logistic models can infer only which variables are related to the final outcome, the BN approach displays a set of relationships between the final outcome (scar type) and the explanatory covariates (patients age and gender, burn surface area, full‐thickness burn surface area, burn anatomical area and wound‐healing time; burn treatment options such as advanced dressings, type of surgical approach, number of surgical procedures, type of skin graft, excision and coverage timing). A web‐based interface to handle the BN model was developed on the website www.pubchild.org (burns header). Clinicians who registered at the website could submit their data in order to get from the BN model the predicted probability of observing a pathological scar type.

Long-term follow-up of negative pressure wound therapy with instillation: a limb salvage procedure?

Negative pressure wound therapy (NPWT) is a treatment to reduce oedema, stimulate granulation tissue formation, remove wound exudate and diminish wound area, thus preparing it for secondary healing, skin grafting or coverage with flaps. The association of instillation to NPWT (NPWTi) is a new method for treating severe wounds, in particular, limb lesions at high risk for amputation. This therapy helps to deliver instillation fluid automatically into the contaminated wound, before application of negative pressure. These steps, repeated cyclically, help to remove infectious material, leading to a better moist environment, a necessary condition for wound healing. We report our experience of treating three patients with complex wounds and associated noble structure exposition conservatively with NPWTi and flap coverage. In a long‐term follow‐up (5 years), we were able to achieve a stable surgery reconstruction on preserved limbs, without evidence of chronic infection and other sequelae or complications. Despite the fact that our experience is limited , as it is based on only a few cases, it suggests how NPWTi could be considered useful in a conservative approach to the treatment of acute complex wounds of the lower extremities. In these patients with high risk of amputation, a long‐term follow‐up becomes fundamental in order to evaluate wound bed status after NPTWi.

Burns and Acute Kidney Failure

Renal alterations such as proteinuria, hematuria, and electrolyte disturbances are common in patients with severe burns. Two distinct pictures with an early and a late form of acute kidney failure (ARF) have been described: The early form occurs in the immediate postburns period and can in most cases be effectively prevented by early aggressive fluid resuscitation. The late form develops after 2–3 weeks from initial injury and is usually due to sepsis and multiorgan dysfunction syndrome. In the last 20 years, onset and outcome of acute kidney failure in these patients has been improved by early aggressive burn wound excision, new powerful antibiotics, and early enteral nutrition for maintaining gastrointestinal trophism. In patients with established ARF, early intensive extracorporeal treatment is effective in reaching a mean survival rate of 20–50% of treated patients.