Melva Kravitz

Use of indirect calorimetry in the nutritional management of burned patients.

The use of indirect calorimetry in assessing and monitoring nutritional support in burn patients is reported. Twenty-nine patients with a mean burn size of 35% TBSA were monitored with 228 measurements of resting energy expenditure (REE), calculations of respiratory quotient (RQ), and substrate metabolism. Daily weights, nitrogen balance determinations, and routine laboratory tests were also obtained. Oxygen consumption (VO2) was 186 +/- 39 ml/min/M2, corresponding to REE of 2,506 +/- 543 kcal/day. REE varied during the course of wound healing, demonstrating a biphasic course. Metabolic rate was also significantly increased with the performance of routine procedures such as dressings and surgery. Measurements of REE were a mean 76% of predictions based on the Curreri formula, and 1.47 times basal energy expenditure (BEE) calculated by the Harris-Benedict equation. Neither formula provided for the great variations observed in daily, and individual, measurements of REE. During the study, patients consumed 2,900 +/- 811 kcal/day, which exceeded REE by 1.14. This was associated with mean weight loss of 3.2% (range, -16 to 9%). RQ was less than 0.85 in 9% of determinations, but exceeded 1.0 24% of the time. Protein accounted for 17 +/- 3% of total metabolism, corresponding to a calorie:nitrogen ratio of 128:1. Practically, however, provision of this much protein proved difficult. Routine use of indirect calorimetry permits tailoring of nutritional support for burn patients, and is valuable in the early detection of significant under- or overnutrition.

Sleep disorders in children after burn injury

Eighty-two children and adolescents between the ages of 30 months and 20 years (mean, 11.8 years) who were admitted to one of two pediatric burn units with a mean initial burn injury of 43.8% total body surface area and a mean age at time of injury of 4.2 years were studied 1 year or more after burn injury (mean, 7.3 years). Subjects were found to have profound at-home sleep disorders, which were manifested as nightmares in 30 subjects (37%), bed-wetting in 20 (24%), and sleep-walking in 6 (18%). Dream content related to normal childhood topics in 45 patients (55%), burn injury in 6 (7%), and burn treatment in 5 (6%). No relationship exists between age at time of burn, length of time after burn injury, cause of burn injury, family history of nightmares, or patient history of bed-wetting and the incidence of nightmares. Daytime naps were reported in 50 subjects (63%), although 46 (mean age, 11.7 years) were well beyond the normal age for napping.

A Two-stage Technique for Excision and Grafting of Burn Wounds

While the technique of early excision and grafting has many advantages in the treatment of thermal injuries, it is not without significant complications. Hemorrhage accompanying burn wound excision can be deceptively great, as can the metabolic stress of large surgical procedures performed in the postburn period. In an effort to minimize these complications, we have developed a two-stage technique for excision and grafting of burn wounds. This technique employs layered excision of eschar, followed by an overnight stabilization period for restoration of normal body temperature and blood volume. Continuous soaking of excised areas promotes hemostasis, and insures a viable base for autografting performed on the following day. During 1978-1979, 117 burn patients underwent 137 two-stage excision and grafting procedures. Mean graft size was 1,988 cm2. Eighty-two per cent of the patients had all necessary grafting performed in a single two-stage operation, including grafts as large as 5,700 cm2. No graft loss occurred as a result of graft hematoma formation. Mean blood loss calculated for each two-stage operation was 2,627 cc, one third of which resulted from the harvesting of autografts. Temperature decrease during surgery was also great, with significant hypothermia occurring in 51% of procedures exceeding 2 hours in length. We conclude that performing excision and grafting in two stages limits hemorrhage and heat loss from each individual surgery, thereby permitting the performance of larger procedures. Nonetheless, continued awareness of the magnitude of these complications remains an essential of successful excisional therapy.

Fluid resuscitation in thermally injured children

The fluid resuscitation requirements and mortality from thermal injury were reviewed in 177 children admitted to the Intermountain Burn Center over a 7 year period. Mean burn size was 27 percent of the total body surface area, whereas the mean full-thickness burn size was 13 percent of total body surface area. Twelve percent of children had associated inhalation injuries. The mean amount of fluid received during burn shock resuscitation was 5.8 +/- 0.25 ml/kg per percentage of total body surface area burned and the mean amount of sodium, 1.06 +/- 0.04 mEq/kg per percentage of total body surface area burned. There was no morbidity due to fluid overload. The presence of inhalation injury did not increase fluid or sodium requirements, but did increase mortality (29 percent versus 7 percent, p less than 0.05). The resuscitative mortality rate for all pediatric patients was 7 percent, the in-hospital mortality rate was 15 percent, and the 50 percent mortality burn correlate for these patients was 64 percent of the total body surface area. Data on children with burns were compared with an unselected, concurrent group of adult burn patients using an analysis of covariance. Fluid and sodium requirements were significantly higher for children, but there was no difference in the length of resuscitation or mortality rate. We conclude that children require much more fluid for resuscitation from burn shock than adults with similar burns. Appropriately aggressive fluid therapy for acute thermal injury in children is essential to achieve an acceptable survival rate in these patients.

Plasma Exchange Therapy in Patients Failing to Resuscitate from Burn Shock

Irreversible burn shock results from failure of fluid resuscitation and is almost invariably fatal. Because of the implied role of circulating serum factors in the generation of burn shock, the use of plasma exchange was evaluated retrospectively in patients with major thermal injuries who had failed to respond to conventional therapy. Twenty-two patients with a mean burn size of 47.9% total body surface area and a mean age of 22.7 years underwent plasma exchange for ongoing burn shock after standard fluid resuscitation failed. A therapeutic response was documented in 95.4% of the patients, characterized by a sharp decrease in fluid requirements from a mean of 260% above the predicted hourly volume to within calculated requirements by 2.3 hours following plasma exchange. Markedly improved urine output and resolution of lactic acidosis were also demonstrated. No major complications occurred. We conclude that plasma exchange facilitates resuscitation from burn shock in a select group of patients who do not respond to conventional volume therapy.

Management of tar and asphalt injuries

Tar and asphalt burns are unique injuries because the chemical is difficult to remove without inflicting further tissue injury. Since 1978, 42 patients have been treated for hot tar or asphalt injuries, 30 of whom required hospitalization. Inpatients were all male with a mean age of 27.2 years and a mean burn size of 9.3 percent total body surface area (mean full-thickness injury 5.3 percent total body surface area). Burns of critical areas were present in 63.3 percent of the inpatients. A petroleum-based, surface-active solvent was used to remove the tar or asphalt. This solvent proved nonirritating and removed tar much faster than other agents. Early excisional therapy was performed in 63.4 percent of the patients, 80 percent of whom returned to work within 6 weeks of injury. Principles of management include rapid cooling of tar or asphalt to solidify the inciting agent and dissipate heat; removal with a new, non-toxic solvent; early excision and grafting of appropriate injuries; and an aggressive, early back-to-work philosophy.

Early surgical decompression in the management of electrical injuries

Abstract Eighty patients with electrical injuries admitted to the University of Utah Intermountain Burn Center in the last 5.5 years were reviewed. Early surgical decompression with fasciotomy and sequential wound debridement appear to result in a low amputation rate and conservation of limb length. The technetium-99m pyrophosphate scan is the most helpful adjunctive method to locate hidden areas of muscle damage.

Excisional therapy of facial burns.

Sixty-eight patients underwent excisional therapy for deep thermal and full-thickness burns of the neck and face. The mean time of skin grafting of face and neck burns was 19.8 days postburn. Technically, excisional procedures of the face are extremely difficult, with massive blood loss and difficulty in removing nonviable tissue in contoured areas. The mean area grafted per patient was 528.7 Sq cm, or 3.6% of the total body surface area (TBSA). Blood loss was 700 cc per percent of TBSA excised. The skin grafting procedure was performed using closed-mesh skin grafting (CMSG). The placement of closed-mesh cuts in the direction of natural skin lines of the face and neck produced a final graft result that had the appearance of normal skin rather than the usual waxy appearance of sheet graft. Excisional therapy with application of CMSG resulted in improved final cosmetic appearance, with a marked decrease in hypertrophic scarring and contracture formation when used in association with pressure devices.

Thermal injury in an adrenalectomized patient

The occurrence of thermal injury in an adrenalectomized patient on long-term steroid replacement therapy illustrated the role of adrenal hormones in the systemic responses to thermal injury. This unusual patient demonstrated an inadequate response to fluid resuscitation and excessive third-space fluid losses, defective thermogenesis, profound nutritional abnormalities, impaired wound healing, and compromised immunologic function. Nutritional support required correction of calorie-nitrogen proportions from 180:1 to 90:1, following which the patient was in positive nitrogen balance.