Joseph M. Still

The use of a collagen sponge/living cell composite material to treat donor sites in burn patients

The objective of this study was to examine the safety and efficacy of bilayered cellular matrix, (OrCel) Ortec International, Inc., New York, NY in facilitating timely wound closure of split-thickness donor sites in severely burned patients. We utilized a matched pairs design; each patient had two designated donor sites of equivalent surface area and depth. Sites were randomized to receive a single treatment of either OrCel or the standard dressing Biobrane-L (Bertek Pharmaceuticals) Sugarland, TX. The results demonstrate that OrCel was more effective in facilitating timely wound closure of split-thickness skin donor sites than Biobrane-L. The healing time for OrCel sites was significantly shorter than for sites treated with Biobrane-L. This acceleration of wound healing was clinically important in enabling earlier recropping. OrCel sites also exhibited reduced scarring. Therefore, treatment of donor site wounds with OrCel is well tolerated, promotes more rapid healing, and results in reduced scarring when compared with conventional therapy with Biobrane-L.

Use of dermal regeneration template in contracture release procedures: a multicenter evaluation.

Integra dermal regeneration template (Integra Life Sciences, Plainsboro, N.J.) is an effective treatment for full-thickness burns. It can also be useful in contracture release procedures; however, the clinical utility of a dermal regeneration template in contracture release procedures has not been adequately characterized. In this multicenter investigation, the outcomes of release procedures incorporating a dermal regeneration template for 89 consecutive patients, who underwent a total of 127 contracture releases, were retrospectively evaluated. The procedures involved the application of Integra, which includes a temporary silicone epidermal substitute and an artificial dermal layer. After formation of a neodermis, the silicone layer is removed and replaced with an epidermal autograft. Data on patient and contracture site history, treatment methods, physician assessments of range of motion or function, patient satisfaction, recurrence, and adverse events were collected with a standardized questionnaire. Release procedures for the study patients involved the neck, axilla, trunk, elbow, knee, hand, and other anatomical sites. The mean postoperative follow-up period was 11.4 months. At 76 percent of the release sites, range of motion or function was rated as good (significant improvement in range of motion or function) or excellent (maximal range of motion or function possible) by physicians. Responding patients expressed satisfaction with the overall results of treatment at 82 percent of the sites. No recurrence of contracture at 75 percent of the sites was observed during follow-up monitoring. Patient age and prior surgical treatment at the site did not significantly affect the results of treatment. However, outcomes were superior at mature sites, i.e., those for which more than 12 months had elapsed since the original injury. Postoperative complications rarely necessitated regrafting. These results indicate that a dermal regeneration template provides a useful alternative technique for contracture release procedures. The study data indicate that this approach leads to favorable functional outcomes and a high rate of patient satisfaction. This modality also seems to be versatile, because a range of anatomical sites are amenable to treatment with a dermal regeneration template, regardless of prior surgical treatment, and both pediatric and adult patients respond well to this form of therapy. Furthermore, Integra confers functional and cosmetic benefits similar to those of full-thickness grafts but without comparable potential for donor-site morbidity.

A multicenter clinical trial of a biosynthetic skin replacement, dermagraft-TC, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds

This multicenter study compared the use of a biosynthetic human skin substitute with frozen human cadaver allograft for the temporary closure of excised burn wounds. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) consists of a synthetic material onto which human neonatal fibroblasts are cultured. Burn wounds in 66 patients with a mean age of 36 years and a mean burn size of 44% total body surface area (28% total body surface area full-thickness) were surgically excised. Two comparable sites, each approximately 1% total body surface area in size, were randomized to receive either DG-TC or allograft. Both sites were then treated in the same manner. When clinically indicated (> 5 days after application) both skin replacements were removed, and the wound beds were evaluated and prepared for grafting. DG-TC was equivalent or superior to allograft with regard to autograft take at postautograft day 14. DG-TC was also easier to remove, had no epidermal slough, and resulted in less bleeding than did allograft while maintaining an adequate wound bed. Overall satisfaction was better with DG-TC.

Diagnosis of burn depth using laser-induced indocyanine green fluorescence: a preliminary clinical trial

Clinical assessment of burn depth is frequently inaccurate. In order to effectively plan the treatment of burn wounds, an accurate diagnosis of burn depth is desirable. A new method for evaluating the depth of burns by imaging the blood flow through the burned tissue using fluorescence from intravenously injected indocyanine green (ICG) dye illuminated with a 785-nm, near-infrared diode laser array was evaluated. Nine patients and 15 individual burn sites were studied. Five sites were classified by the ICG study as superficial second degree, four were deep-dermal second degree, and six were third degree. Etiology of the injuries included flame, contact burns, and scalds. The date postburn of the study ranged from 1 to 11 days. In all cases, the relative fluorescence levels (e.g. superficial second-degree burns yielded relatively bright fluorescence, third-degree burns appeared much darker than surrounding normal skin) were found to correlate well with actual burn depth as determined by histologic examination of biopsies and intraoperative clinical assessment.

Evaluation of the circulation of reconstructive flaps using laser-induced fluorescence of indocyanine green.

A new method for evaluating the circulation in surgical flaps using laser-induced fluorescence of indocyanine green (ICG) images is reported. In clinical trials the authors found that ICG imaging demonstrated good circulation accurately in 16 of 21 flaps with no clinical manifestations of compromised circulation. In 3 patients in whom partial discoloration and cyanosis of the flaps were visible, the dye study indicated poor circulation in the identical areas. In 2 other patients in whom flaps appeared clinically satisfactory, the flaps were shown by ICG imaging to have greatly compromised circulation. In a patient in whom the flap was left in place, slough of almost the entire flap resulted. Another flap with questionable circulation was returned to its original location, where it healed. Thus, while it is a still a new approach and under continual evaluation, the use of ICG fluorescence shows promise as a valuable adjunct to current methods of flap evaluation.

Self-inflicted burns

Over a 3-year period 17 people were admitted for intentionally self-inflicted burns. The mean total body surface area burn was 29.5%, and 59% of the patients sustained an inhalation injury. Two patients died from their injuries (one male and one female). The method most often used (59%) was a flammable liquid ignited by a flame. Of those patients, 50% used gasoline. Fifty-nine percent of the patients were current substance abusers, with alcohol (80%) being the favored drug. Aside from substance abuse, psychiatric abnormalities were present in 53% of the patients. Schizophrenia/schizoaffective disorders was the primary psychiatric diagnosis (44%), with most patients having undergone previous psychiatric treatment. All had diagnosed disorders (using the Diagnostic and Statistical Manual III--Revised) including substance abuse and/or other psychiatric disorders. Actual stated suicidal intent was present in 41% of the cases, and another 41% were irrational attempts to escape from or control emotional pain.

A comparison of the effect of early insertion of standard latex and silver-impregnated latex foley catheters on urinary tract infections in burn patients.

A retrospective study was designed to compare the incidence of urinary tract infections during two different time periods in burn patients treated with two different types of Foley catheters. In time period 1, latex catheters present on admission were not changed. In time period 2, catheters were replaced on admission with silver alloy-impregnated catheters. In time period 1, the rate of symptomatic urinary tract infections was 7.2 per 1,000 catheter-days. In time period 2, the rate was 4.4 per 1,000 catheter-days. Results, compared using Fishers exact test, revealed a statistically significant P value of .029. The use of silver-impregnated catheters significantly lowered the rate of urinary tract infection at our burn center.

Experience with necrotizing fasciitis at a burn care center.

Necrotizing fasciitis is a soft tissue infection that causes necrosis of subcutaneous tissue and fascia but usually spares skin and muscle. Management of this condition consists of early diagnosis, broad-spectrum antibiotic coverage, aggressive surgical debridement, wound closure, and intensive supportive care. Mortality estimates reported in the literature have ranged from 20 to 75%. We report the cases of 12 patients treated at the Joseph M. Still Burn Center in Augusta, GA. Because aggressive surgical debridement combined with medical support is required for successful treatment, we recommend that treatment be administered at a burn care center. We performed a retrospective chart review of all patients admitted to our center with a diagnosis of necrotizing fascitis between May 1, 1995, and June 1, 2000. Patients were managed collaboratively by burn surgeons and critical care intensivists in consultation with other appropriate specialists. The mean time from initial diagnosis until transfer to the burn center was 14 days (range, 0–60 d). Complications included pneumonia, heart failure, metabolic abnormalities, anemia, and sepsis. Four (33%) of the 12 patients died, with the primary cause of death being multiorgan failure. Although our sample size is too small to reach statistical significance, the data suggest that early referral to a burn or wound care center improves patient outcome.

Experience with burns of the eyes and lids in a regional burn unit

During a 3-year period 1527 patients with burns were admitted to a regional burn unit in Augusta, Georgia. Two hundred thirty patients (15.06%) were referred for consultation by an ophthalmologist. Thirty-two patients had preexisting ophthalmic problems that were believed to warrant consultation. One hundred eighty-nine patients were seen because of facial burns. Of these, 143, or 9.36%, had burn injuries of the eyes or lids that required care. Lid involvement was encountered in 122 (7.98%) cases. In 78 cases lid involvement was bilateral (in the remainder, unilateral). In 61 cases thermal or chemical burns to the conjunctiva or lens were present. Skin grafts to the lids were required for acute care in 11 instances. Tarsorrhaphies were done in 11 instances. In one case the lids were essentially destroyed, and extensive reconstruction with flaps was needed. Late reconstruction with grafting of the lids was done in five cases. In three eyes (two patients) enucleation was eventually required. Ten patients without burns who had toxic epidermal necrolysis were also treated on the unit. Consultation with an ophthalmologist is believed to be important in patients with significant ocular or periocular injury. The importance of maintaining moisture to the globe is stressed.

An approach to the management of toxic epidermal necrolysis in a burn centre

Toxic epidermal necrolysis syndrome, a life-threatening skin disorder, requires specialized nursing care to optimize survival. The similarity of the condition to partial skin thickness burns suggests that management on a burn unit is an effective means of therapy. A review of eight patients treated at our Burn Center emphasizes the need for aggressive team management of the condition.