Manu H. Desai

A comparison of conservative versus early excision. Therapies in severely burned patients.

Early excision and grafting of small burn wounds is a generally accepted treatment. Early excision of burn injuries greater than 30% total body surface area (TBSA) in adults, however, has not been universally accepted. In this study, 85 patients whose ages ranged from 17 to 55 years with greater than 30% total body surface area (TBSA) burns were randomly assigned to either early excision or topical antimicrobial therapy and skin grafting after spontaneous eschar separation. Mortality from burns without inhalation injury was significantly decreased by early excision from 45% to 9% in patients who were 17 to 30 years of age (p less than 0.025). No differences in mortality could be demonstrated between therapies in adult patients older than 30 years of age or with a concomitant inhalation injury. Children (n = 259) with similar large burns treated by early excision showed a significant increase in mortality with increasing burn size and with concomitant inhalation injury (p less than 0.05). The mean length of hospital stay of survivors was less than one day per per cent of TBSA burn in both children and adults.

Reduction in Mortality in Pediatric Patients with Inhalation Injury with Aerosolized Heparin/acetylcystine Therapy

Smoke-inhalation injury causes a destruction of the ciliated epithelium that lines the tracheobronchial tree. Casts produced from these cells, polymorphonuclear leukocytes and mucus, can cause upper-airway obstruction, contributing to pulmonary failure. We have reported that a combination of aerosolized heparin and a mucolytic agent, N-acetylcystine [corrected], can ameliorate cast formation and reduce pulmonary failure secondary to smoke inhalation. In this study, 90 consecutive pediatric patients between 1985 and 1995 who had bronchoscopically diagnosed inhalation injury requiring ventilatory support were studied. Forty-three children admitted between 1985 and 1989 acted as controls. Forty-seven children admitted between 1990 and 1994 received 5000 units of heparin and 3 ml of a 20% solution of N-acetylcystine [corrected] aerosolized every 4 hours the first 7 days after the injury. All patients were extubated when they were able to maintain spontaneously a PaO2/FIO2 ratio of more than 400. The number of patients requiring reintubation for successive pulmonary failure was recorded, as was mortality. The results indicate a significant decrease in reintubation rates, in incidence of atelectasis, and in mortality for patients treated with the regimen of heparin and N-acetylcystine [corrected] when compared with controls. Heparin/N-acetylcystine [corrected] nebulization in children with massive burn injury and smoke-inhalation injury results in a significant decrease in incidence of reintubation for progressive pulmonary failure and a reduction in mortality.

Effects of insulin on wound healing.

BACKGROUND Insulin plus glucose, given for 7 days to hypermetabolic burn patients, has been shown to stimulate limb protein anabolism. We hypothesized that insulin plus glucose given to burn patients would also stimulate wound healing. METHODS Six patients with burns >40% total body surface area were randomized to receive insulin or placebo in a crossover study during the healing of their first and second donor sites. Insulin treatment was titrated at 25 to 49 U/h to achieve a plasma insulin level of 400 to 900 microU/mL for 7 days. Patients receiving insulin received dextrose 50 at 20 to 50 mL/h, titrated to maintain euglycemia. Donor-site biopsies were taken at 7 days and evaluated by three observers blinded to the treatment. RESULTS The mean (+/-SD) donor-site healing time was reduced from 6.5 +/- 1.0 days with placebo to 4.7 +/- 1.2 days during insulin infusion (p < 0.05). Laminin showed intense staining along the basal lamina and blood vessels. Collagen type IV staining also increased after insulin therapy compared with placebo. CONCLUSION Data indicate that high doses of insulin and glucose can be safely administered to massively burned patients to improve wound matrix formation.

Dynamics of the protein metabolic response to burn injury.

The protein metabolic response to burn injury was assessed in 17 children aged 7.1 +/- 1.1 years (mean +/- SEM) and a mean burn size of 65 +/- 7% total body surface area (TBSA) during the acute, flow, convalescent, and recovery phases. Stable isotopes of leucine, valine, lysine, and urea were infused in postabsorptive patients in order to measure protein kinetics. The absolute rate of protein breakdown was assessed from the plasma flux of the essential amino acids (EAA), and the rate of urea production (Ra urea) was used as an index of net protein catabolism. Compared to values obtained in recovered patients, the plasma fluxes of all three EAAs were significantly increased (P less than .05), indicating an increased protein breakdown, during the acute, flow, and convalescent phases of injury. Ra urea, however, was only significantly increased during the flow phase (P less than .01), suggesting that protein breakdown was adequately counteracted in the acute and convalescent phases by elevations in protein synthesis but not in the flow phase. The protein kinetic response did not correlate with changes in the metabolic rate since resting energy expenditure (REE) was significantly increased above predicted levels during the acute and flow phases (by 40% and 50%, respectively), and returned to normal in convalescence.(ABSTRACT TRUNCATED AT 250 WORDS)

Early burn wound excision significantly reduces blood loss.

The hypothesis that near-total early excision of large burns in children can be performed safely with a reduction in blood loss was tested. Of 1662 acutely burned patients admitted to this institution between 1982 and 1989, 594 underwent near-total excision of cutaneous flame or scald burn injuries in a single procedure. Operations took less than 3 hours and there were no operative deaths. Blood losses in burns of more than 30% total body surface area (TBSA) were significantly less at 0.40 +/- 0.06 mL/cm2 and 0.49 +/- 0.49 mL/cm2 excised when surgery was performed within the first 24 hours or after the 16th day after burn, respectively, when compared to 0.75 +/- 0.02 mL/cm2 for those excised between 2 and 16 days after burn (p less than 0.05). Blood loss for burns of less than 30% TBSA was of 1.19 +/- 0.13 mL/cm2. Early excision did not increase mortality rate when compared to later excision times. We suggest that near-total excision of large burns within the first 24 hours reduces blood requirements and morbidity without adversely altering hemodynamic stability or increasing mortality risks.

Regulation of Lipolysis in Severely Burned Children

In this study, the rates of lipid mobilization and of lipolysis have been quantified in severely burned children. In all 12 patients studied, the basal rates were determined. In seven patients, the lipolytic responsiveness to an infusion of epinephrine (0.015 μg/kg/min) was tested, and in the other five patients, the response to beta-adrenergic blockade (propranolol, 1 mg/kg) was tested. The rate of appearance (Ra) of free fatty acids (FFA) was quantified by means of the infusion of 1-13C-palmitate to determine the rate of lipid mobilization, and Ra glycerol was determined using d5-glycerol to assess the rate of lipolysis more directly. In five patients, body composition was determined after recovery by means of H218O dilution. The basal rate of lipolysis was higher than normal in the burned children. In four of the seven patients infused with epinephrine, there was a pronounced increase in Ra glycerol. In all patients given beta-blockade, Ra glycerol decreased greatly. Changes in Ra FFA corresponded with the changes in Ra glycerol in each case. Total body fat was very low (approximately 2% body weight), reflecting the surgical removal of fat in the process of burn wound excision. From these data it is concluded that lipolytic responsiveness to catecholamines in severely burned children is variable, but not absent, despite chronically elevated levels of catecholamines. The total extent of lipolysis may be limited by the available fat mass in children treated with fascial excision. In such patients, the limitation in the ability to mobilize an adequate amount of FFA to fully meet energy requirements provides an important rationale for the clinical practice of providing nutritional support in hourly boluses, as opposed to infrequent meals, since any period of even a few hours in which nutrients are not being absorbed will result in an energy substrate deficiency and consequent increase in amino acid oxidation.

Lack of long-term durability of cultured keratinocyte burn-wound coverage: a case report.

Cultured epithelial autografts have been advocated for permanent closure of skin surfaces after massive thermal injuries. A 10-year-old boy sustained a nearly 100% total body surface area burn (98% full-thickness) in an explosion accident. Cultured epithelial autograft was used to cover 70% of the total body surface area on postburn day 26. In spite of early success of coverage, 60% of cultured epithelial autograft areas blistered and sloughed over the ensuing weeks. Electron microscopic examination of a biopsy specimen of the healed cultured epithelial autograft (80 days after placement) revealed a lack of dermal attachments of the anchoring fibrils. Additionally, blister fluid that was taken from the bullae of the cultured epithelial autograft revealed levels of 18 ng/ml thromboxane and 24 ng/ml prostaglandin E2. These levels are significantly higher than those seen in acute burn blister fluid and indicate an ongoing inflammatory process. Cultured keratinocytes, although they provide early wound closure, may not provide adequate long-term coverage for patients with massive burns.

The Quality of Life after Major Thermal Injury in Children: An Analysis of 12 Survivors with 80% Total Body, 70% Third-degree Burns

Twenty-one children admitted between December 1981 and May 1985, with greater than 80% total body surface area burn (TBSAB), underwent total excision and grafting of all of their wounds within 72 hours of injury. Twelve survivors (with an average TBSAB of 89%, 82% third degree) were studied in detai

Conservative treatment of scald burns is superior to early excision

Early excision of deep burns has been advocated; however, it is difficult to clinically determine the depth of scald burns during the early postburn period. This prospective, randomized study was designed to determine whether early excision was superior to conservative treatment of scald injuries. Patients with scald injuries (which were not caused by grease) of clinically indeterminant depth were randomized to early (n = 12) or late (n = 12) excision; all patients with obvious superficial and full-thickness injuries were excluded. In the early excision group, all deep wounds were tangentially excised and grafted within 72 hours of admission, whereas in the late treatment group wounds were excised and grafted after 2 weeks had passed since injury. Area excised, postburn day of excision, percent graft take, operating-room time, blood replacement, incidence of infection, and length of hospital stay were compared. No patient experienced a significant wound infection or systemic sepsis. A significantly smaller area of excision was necessary for those patients who were treated with delayed surgery, and concomitant decreases in operating-room time and blood loss were observed. Notably, only one half of the patients who were randomized to the delayed excision group ultimately required surgical intervention to achieve wound closure. Graft take was comparable for both groups, as was length of hospital stay. Early clinical evaluation of scald injuries appears to be equivocal, and later evaluations reveal a less severe injury. Financial gains can be made when surgical excision of scald injuries is delayed until 2 weeks after injury because of a related reduction in hospital expenditures.

Long-term psychosocial adjustment following burn injury

Young adult survivors of severe childhood burn injuries were assessed for indicators of psychopathology and for factors that might enhance psychosocial adjustment. The results describe this group of burn victims as young people of average intelligence, still in school or otherwise employed and within normal limits on the measures of psychological adjustment. Some individuals, however, did evidence significant indicators of psychological disturbance. The only factors identified as significantly differentiating the most obviously disturbed subjects from the better-adjusted or well-adjusted victims were the perceptions held by those subjects that their families are less cohesive and less independent. These results emphasize the need to promote the familial support system and to encourage the values of autonomy and self-sufficiency. The results also affirm that severely injured burn victims can be expected to develop acceptably happy lives.