Irving Feller

Use of amnion for the treatment of Stevens-Johnson syndrome

Stevens-Johnson syndrome (toxic epidermal necrolysis) has similar pathophysiologic characteristics to extensive partial-thickness burns. Successful treatment of a 6-year-old with this syndrome denuding 95% of her body surface, with 6.5 square feet of amnion is reported.

A Prospective Controlled Trial of Biobrane Versus Scarlet Red on Skin Graft Donor Areas

A prospective trial of Biobrane versus scarlet red as a skin graft donor site dressing was done in 21 burn patients with mean total body surface area burns of 31.9%. Corresponding body areas were randomly selected on each patient to receive one of the dressings. Daily evaluations were made of subjective expression of pain, exudate formation and infection, and time of separation of the dressing from the wound. Biobrane was found to be superior in reducing donor site pain. However, with Biobrane there was a higher incidence of infection (57% v 9.5%) and a significant delay in separation from the wound. Scarlet red was found to be more cost-effective. Occlusive dressings have previously been shown to have a high incidence of complications (30%). In extensive burns, isolating the donor site from the wound is difficult and may lead to increased complications. Scarlet red appears to be superior to Biobrane for skin graft donor sites in this patient population.

Monilial Sepsis in the Surgical Patient

Candida infections commonly occur following the introduction of broad spectrum antibiotics, especially in those patients with a severe debilitating condition necessitating the use of indwelling intravenous and urinary catheters. The patient’s clinical response tends to mimic that seen in gram-negative sepsis, except that the developmental course of the septic state is much more insidious.

Rapid quantification of bacterial and fungal growth in burn wounds: biopsy homogenate Gram stain versus microbial culture results

A prospective analysis of 370 burn wound biopsies was done to correlate Gram-stain results from biopsy homogenates with quantitative culture results. The number of bacteria seen in a total of 10 oil immersion microscope fields of Gram-stained homogenates was correlated with significant microbial growth (1 x 10(5) organisms/gram of tissue) of the same biopsy homogenate plated on trypticase soy agar. Of the biopsies examined, Gram-negative rods were present in 36.8 per cent, Gram-positive cocci in 49.7 per cent and yeast in 15.9 per cent. Mixtures of organisms were present in 24.3 per cent. When Gram stains showed one or more organisms per oil immersion microscope field, the correlation with significant microbial growth was 94.5 per cent or more. When five or more organisms were seen per field, the correlation with significant growth became 97 per cent or greater. When no organism was seen on Gram stain, the cultures grew significant numbers of organisms 19.1 per cent of the time or less. This false-negative rate was considered to be high. It is believed, however, that this method of early detection of significant burn wound microbial growth may prove to be valuable in the management of severely burned patients.

Gastrointestinal haemorrhage in burn patients.

Gastrointestinal haemorrhage after burn injury remains a potentially lethal problem. A retrospective review of 3852 burn patients over 15 years revealed an incidence of gastrointestinal haemorrhage of 2.2 per cent and a mortality of 0.16 per cent. This low incidence of haemorrhage and mortality can be directly related to an aggressive prophylactic treatment with antacid and titration of the gastric pH to 5.5 or above. With this aggressive management programme, few operative procedures were required. A review of autopsy data showed that the site of haemorrhage was distributed throughout the gastrointestinal tract with the predominant site being the stomach.

The National Burn Information Exchange: The Use of a National Burn Registry to Evaluate and Address the Burn Problem

The NBIE, a voluntary registry of specialized burn-care facilities that was founded in 1964, currently has 50 active participants representing 35 per cent of the nations hospital beds for burned patients. Participating physicians submit information on the initial hospitalization of emergent and acute burn patients and, separately, on the reconstruction process for these patients. As of January 1986, a total of 94,594 patients data are on file from 130 hospitals; 13,671 of these are reconstructive and 80,923 emergent and acute admissions. Information concerning new patients is submitted at a rate of about 6000 patients annually. The data are analyzed using INQUIRE, an original data retrieval system. Data on treatment methods and outcome have been used to establish baseline standards for the burned patients care and survival. In addition, these data have been used to document institutional differences in mortality rates and indicate methods used by the more successful hospitals. The data also are being used to describe the long process of recovery from severe burns and to monitor changes in outcomes of burn accidents continually. The result of these analyses has been documentation of an overall improvement in survival and decline in hospitalization times at all levels of burn severity. Data also can be used with institution-specific data to look at organizational variables affecting survival. Use of this epidemiologic data allows prevention projects to be targeted at the groups at greatest risk. A newer application looks at the equity of the HCFA prospective payment system based on the DRGs assigned to burn severity. The NBIE is an example of how a voluntary, national registry, properly computerized and effectively managed, can contribute to resolving the problem it was established to study. The NBIE has been useful in increasing the understanding of health professionals and government decision makers of a complicated disease process. It has had a direct effect on the quality of patient care and on the process of controlling the incidence of burn injuries.

A severity grading chart for the burned patient

A graphical method for the quick computation of admission severity for the burned patient is described. The method is easily used by non-technical personnel and requires only the patients age, an estimate of the percentage body surface area burned, and knowledge of the presence or absence of a perineal burn. The severity estimate is obtained by simply applying a straight-edge to the provided chart and reading the severity score from the scale crossed by the straight-edge. The severity score used is an estimate of the patients mortality risk and is based on an extensively validated multiple logistic model which was developed using the combined experience of 11,200 patients at 12 major United States burn units. This severity score can be used with other severity and treatment factors to determine the level of care needed, and as an aid in triage decisions.

Prevention of postoperative infections.

If the incidence of nosocomial infection in surgical patients is to be reduced, the present approach to prevention and control must be re-evaluated and technological data from other sciences brought to bear. A checklist system for closer control is presented.

Diagnosis and Treatment of Postoperative Bacterial Sepsis

Early diagnosis and treatment of bacterial sepsis is essential if septicemia is to be successfully overcome. Too often, treatment is delayed for want of overt signs of sepsis, while more subtle early changes have gone unrecognized. A pragmatic approach to diagnosis and treatment of bacterial sepsis following operative procedures is described. The emphasis is on infection by gram-negative organisms.