Marija Trop

A retrospective analysis of securing autologous split-thickness skin grafts with negative pressure wound therapy in paediatric burn patients

BACKGROUND AND AIM Deep dermal and full-thickness burn wounds are excised and grafted with split-thickness skin grafts. Especially in less compliant patients such as young children, conventional fixing methods can often be ineffective due to high mobility rates in this age group. The aim of this retrospective single-centre study was to give an overview of our experience in the fixation of autologous split-thickness skin grafts (ASTSGs) on burn wounds by negative pressure wound therapy (NPWT) in paediatric patients. METHODS A retrospective analysis describing 53 paediatric patients with burns or burn-related injuries who were treated as 60 individual cases were conducted. All patients received ASTSGs secured by NPWT. RESULTS Of the individual cases, 60 cases with a mean age of 8±6 years (the youngest was 3 months, the eldest was 24 years old) were treated in a single procedure with ASTSG and NPWT. Total burn surface area (TBSA) was, median (med) 4.5% (3.0-12.0%). The TBSA of deep dermal thickness to full-thickness (IIb-III°) burns was med 4.0% (2.0-6.0%). The TBSA treated with ASTSG and NPWT was med 3.5% (2.0-6.0%). Take rate was, med 96% (90-99%) with a total range of 70-100%. The only significant correlation that could be found was between the grafted TBSA and the take rate. The smaller the grafted TBSA the better the take rate resulted, as expected. In three cases, major complications were noted. CONCLUSION To sum up our experience, the NPWT system has developed itself to be a constant, well-implemented and useful tool in securing ASTSGs to the wound bed. The main advantage of the technique is a much higher mobility of the patient compared to conventional fixation methods. The high compliance rate of an often challenging group of patients such as children recompenses possible higher costs compared to conventional fixation methods.

Use of Suprathel® Dressing in a Young Infant with TEN

Abstract:  Toxic epidermal necrolysis and Stevens‐Johnson syndrome are potentially life‐threatening skin disorders. We report that a 3‐month‐old infant, a patient with toxic epidermal necrolysis, who in addition to a standard resuscitation protocol for burns received treatment with Suprathel® (PolyMedics Innovations GmbH, Filderstadt, Germany) and fatty gauze as topical wound dressings in the form of a whole body cover with complete recovery. This is the first case report of Suprathel® being used successfully in a baby with toxic epidermal necrolysis.

Continuous arteriovenous hemofiltration in critically ill children with acute renal failure

Last year, five critically ill children with acute renal failure were treated by continuous arteriovenous hemofiltration. Mean treatment duration was 326 +/- 89 (SD)h, for a total of 1632 h. Mean ultrafiltration rates of 5.4 +/- 1.7 ml/min X m2 achieved mean serum urea levels of 150 +/- 25 mg/dl and a decline of mean prehemofiltration serum creatinine level of 3.5 +/- 3.6 to 2.9 +/- 2.0 mg/dl posthemofiltration. Continuous arteriovenous hemofiltration allowed adequate parenteral nutrition with a mean caloric intake of 79.6 +/- 9.2 kcal/kg X day. In the four surviving patients, urinary output started between 12 and 42 days after the onset of acute renal failure. Continuous arteriovenous hemofiltration is a very effective extracorporeal therapeutic system to control azotemia, fluid, and electrolyte balance in critically ill children with acute renal failure and hemodynamic instability.

Transdermal uptake and organ distribution of silver from two different wound dressings in rats after a burn trauma

Silver‐containing wound dressings are an integral part of wound therapy in adult and pediatric burn patients. The antimicrobial effect of silver is well known and has been described in numerous studies. Side effects are rarely reported from silver‐containing wound care products, even though systemic absorption of silver has been shown by elevated levels of silver in the blood of patients after silver exposure during wound therapy. This animal study investigated the silver levels of blood and in which organs and tissues silver is detectable after long‐term application of silver‐containing wound dressings after a burn trauma. In male rats, a major full‐thickness scald was created on their backs according to a standardized burn model. Two different silver‐containing wound dressings (nanocrystalline silver [NCS] and silver sulphate foam [SSF]) were applied initially and changed every 7 days. Weekly blood drawings revealed an increase of blood silver in week three with significant higher values in the SSF compared with NCS group (Ag μg/kg 135.8 vs. 61.7; means; p ≤ 0.05). Thereafter, the NCS group showed significantly higher blood silver levels than the SSF group at week five (Ag μg/kg 192.3 vs. 81.3; means; p ≤ 0.01) and six (Ag μg/kg 168.2 vs. 32.9; means; p ≤ 0.01). After 6 weeks, the animals were sacrificed, and the organs and tissues were analyzed for their silver content by inductively coupled plasma mass‐spectrometry. Silver was detectable in all analyzed organs and tissue samples, with higher silver values in parenchymatous organs in the NCS than SSF group (Ag μg/kg; spleen: 3,469 vs. 260; kidney: 3,186 vs. 289; liver: 2,022 vs. 313; means; p ≤ 0.05). Silver was also detectable in brain, testis, lung, heart, and muscle tissue.

Continuous arteriovenous haemofiltration in children with postoperative cardiac failure.

Six children with refractory heart failure were treated by continuous arteriovenous haemofiltration. The cause of the failure was postoperative fluid overload or low cardiac output with anuria or oliguria. This produced a mean (2 SD) negative fluid balance of 1.4 (0.6) ml/kg/h and reduced mean (2 SD) body weight from 4.7 (2.2) to 4.2 (2.3) kg over a period of 57.5 (31.1) hours. Central venous pressure fell significantly from 13.7 (3.1) to 7.7 (0.7) mm Hg while the mean (2 SD) arterial pressure increased significantly from 44.6 (5.5) to 52.6 (5.1) mm Hg. In three infants urine production resumed when normal blood volume had been achieved. The other three infants needed further haemofiltration because of prolonged renal failure. All but one was weaned from artificial ventilation and catecholamine treatment. No adverse haemodynamic effects were noted. One child need operation for a femoral artery thrombosis after 12 days of continuous arteriovenous haemofiltration.

Innovative scald burn model and long-term dressing protector for studies in rats.

R are frequently used for experimental studies in burns. Scalding is the easiest mechanism for provoking a dermal burn; the ability to vary water temperature, time of exposure, and the burned area make this method effective for reproducing almost any kind of thermal wound. Last but not least, rats are readily available, inexpensive, and easy to manage. In general, a scald injury in rats is inflicted on anesthetized animals by immersion of the area to be burned into a water bath. The area of exposure is determined by the aperture in the template, which can be an elaborately designed apparatus, a metal wire cage, or a simple metal plate with a rectangular aperture through which the body part is immersed in a water bath for a specified amount of time. To establish a standard long-term method for protecting the burn wound dressings from being eaten by the rats and thereby tainting the scientific results, we searched the relevant literature and found that there was nothing available for that purpose. After several tests, the armor described later used together with our scald template was found to be satisfactory for our experiment series. With the use of the armor, the silver detected in the blood should originate only from the wound, with no additional absorption from the gut. In this article, an innovative scald protocol and armor are being presented.With this template firmly pressed on the shaved back, only the area to be burned is in contact with the boiling water. The burn wound is uniform in size and depth and can certainly be reproduced. The template is easy and fast to fabricate at a low cost and at any size. The armor ensures that the dressings stay in place for a minimum of four or even more weeks and prevents the rats from eating the silver-coated wound material.

The safety of nanocrystalline silver dressing on burns: a study of systemic silver absorption.

I write in reply to the article entitled ‘‘The safety of nanocrystalline silver dressing on burns: A study of systemic silver absorption’’ by Vlachou et al. [1]. The authors point out in their introduction that ‘‘. . .Argyria is most often seen after chronic occupational exposure, but has also been reported after the use silver nitrate for burns (6). Trop et al. (9) [2] reported a case in which raised liver enzymes and argyria-like symptoms were observed when 30% burns were treated with Acticoat. However, it is unclear whether the symptoms were indeed a result of the dressing or of the burn itself (10). . .’’ [3]. The study of systemic silver absorption by Vlachou et al. [1] was performed in adult burn patients (mean age of 38.9 years) who suffered small partial-thickness burns (median% TBSA 5%) and small full-thickness burns (median% TBSA 4%) and required skin grafting. In general such burns do not provoke any therapeutic problems. Due to the small area exposed to the silver dressing Acticoat the absorption of silver cannot be expected to be high. By coincidence the study of systemic silver absorption by Vlachou et al. [1] was supported by a research grant from Smith and Nephew, UK, and there is no conflict of interest. By coincidence the author of the reference 10 in Vlachou’s study, Letter to the Editor of J Truama is Parker Alison Smith & Nephew Medical Ltd., UK. By coincidence the Authors Vlachou et al. [1] do not cite Trop [4] Letter to the Editor of J Trauma, a reply to Parker’s Letter where the ‘‘Final Report of Company Smith & Nephew [5] regarding product incident report’’, which was handed in to the Ministry of Social Security and Generations Austria on 5 February 2003. (GZ: 20.562/52-VI/A/2/03), had been cited. The last paragraph of this report regarding the product Acticoat incident reads (quote): ‘‘Conclusion: It would appear that the high blood silver levels, transient argyria and altered liver function tests noted in this patient were a result of the use of Acticoat dressings for 6 days to treat 30% burns’’. In my opinion a reliable company should accept an unexpected and undesirable effect of their product and handle the problem with reasonable care, and top-class researchers should perform their scientific work impartially and independently.