Nikki Allorto

Burn resuscitation on the African continent

A survey of members of the International Society of Burn Injuries (ISBI) and the American Burn Association (ABA) indicated that although there was difference in burn resuscitation protocols, they all fulfilled their functions. This study presents the findings of the same survey replicated in Africa, the only continent not included in the original survey. One hundred and eight responses were received. The mean annual number of admissions per unit was ninety-eight. Fluid resuscitation was usually initiated with total body surface area burns of either more than ten or more than fifteen percent. Twenty-six respondents made use of enteral resuscitation. The preferred resuscitation formula was the Parkland formula, and Ringers Lactate was the favoured intravenous fluid. Despite satisfaction with the formula, many respondents believed that patients received volumes that differed from that predicted. Urine output was the principle guide to adequate resuscitation, with only twenty-one using the evolving clinical picture and thirty using invasive monitoring methods. Only fifty-one respondents replied to the question relating to the method of adjusting resuscitation. While colloids are not available in many parts of the African continent on account of cost, one might infer than African burn surgeons make better use of enteral resuscitation.

The Emergency Management of Severe Burns Course in South Africa

The Emergency Management of Severe Burns (EMSB) Course is an important component of the South African Burn Society’s commitment to improving the standard of burn care in South Africa. A one-day course in the ATLS mould, it has proved to be an extremely helpful aid to healthcare practitioners faced with major burns in any setting. This paper outlines the history of the EMSB course since its introduction to South Africa in 2005, under license from the Australia and New Zealand Burn Association (ANZBA).

Vasoconstrictor clysis in burn surgery and its impact on outcomes: Systematic review and meta-analysis

AIM Clysis is the subcutaneous or subdermal injection of a vasopressor containing fluid, with or without local anaesthetic agent, and has been used to limit blood loss in patients undergoing surgical burn management. In this systematic review and meta-analysis we aimed to determine the impact of clysis of a vasoconstrictor on burn patient outcomes. METHODS We conducted a systematic review to identify trials investigating clysis in burn patients undergoing debridement and/or skin grafting. For each eligible trial we aimed to extract the outcomes of perioperative blood loss, blood transfusion, duration of surgery, graft success and healing time, inflammatory response, sepsis, mortality, duration of hospital stay, catecholamine levels and cardiovascular effects in both the short (<72h) and long term (30 days) after surgery. RESULTS From 443 citations, we selected 39 for full-text evaluation, and identified 10 eligible trials. Due to a lack of reporting on outcomes of interest, meta-analysis could only be conducted for the outcome of red blood cell (RBC) units transfused per patient. Patients receiving clysis (n=222) were transfused 1.89 less units (95% CI -2.12 to -1.66) as compared to those not receiving clysis, although this was associated with a high degree of heterogeneity (I(2)=88%). CONCLUSION Few studies have adequately evaluated the impact of clysis in burn surgery on patient important outcomes such mortality, duration of surgery and graft success. These results suggest clysis may reduce the need for blood transfusion but additional high quality research is required.

Burn surgeons in South Africa: A rare species

BACKGROUND The high burden of burn injuries in South Africa (SA) requires surgeons skilled in burn care. However, there are few dedicated burn surgeons and properly equipped units or centres. OBJECTIVES To quantify the involvement of surgeons in burn care in SA hospitals, identify factors that attract surgeons to pursue burn care as a career and deter them from doing so, and understand the challenges of hospitals treating burn patients around the country. METHODS This was a prospective, qualitative study. Questionnaires were handed out at the South African Burn Society Congress in September 2013 and a trade symposium in March 2014. RESULTS One hundred questionnaires were handed out, and there was a 70% response rate. Twenty-six (39%) of the respondents had a specialist surgical qualification. Only half the units had registrars (48%) and interns (51%) on their staff. Only 30% of the respondents were dedicated to burn care alone, the majority being involved on a part-time basis. The most common factor respondents suggested was needed to recruit future burn care providers, cited by 76%, was better facilities and resources. Other factors included training and skills development (59%), subspecialist training (55%), development of a diploma in burn care (52%), development of research (52%) and healthcare worker psychological support (45%). DISCUSSION We have demonstrated that current workforce resources for burn care are inadequate, the major deficit being lack of training and the resource-restricted environment. This survey provides basic information towards workforce planning, which can be used to inform the necessary strategic decisions.

Modified first world mortality scores can be used in a regional South African burn service with resource limitations

INTRODUCTION Survival following a major burn is highly dependent on the availability of scare and expensive resources such as critical care services, modern dressings and access to operating theatres. Scoring systems, which predict mortality have been developed and can be used to identify patients in whom the outlay of these resources is futile. The aim of this study was to analyse the mortality at a regional South African burn service and to see if these scoring models developed in a resource rich environment were applicable to our setting. METHODS Consecutive admissions to the Edendale burn service, South Africa were collected from patient records over a 2-year period from July 2013 to June 2015. Demographic, burn details and final outcome (lived or died) were captured for statistical analysis. Each patient was scored using the Modified Baux, Coste et al., Belgian Outcome of Burn Injury (BOBI) and Abbreviated Burn Severity Index (ABSI) scores. Validation of models and inferential statistics were done to determine new breakpoints more applicable to our sample. RESULTS A total of 748 patients were included in the sample, with a mortality rate of 7.1%. The mean Modified Baux score was 27 (range 1-134), with the new breakpoint of 40 predicting 74% of the mortalities compared to the 42% predicted by the old breakpoint of 75. The mean ABSI score was 4 (range 2-15), with a lower break point of 6 predicting 75% of deaths compared to 42% with the old breakpoint of 8. The mean Coste score for the sample was 12 (range 0-100). With a suggested break point of 85 (predicting 50% mortality), only 6% of mortalities were predicted. The new break point of 17 predicted 91% of deaths. The original break point for the BOBI score was 6 (range 0-7). This included 42% of deaths. With a new breakpoint of 1, 74% of deaths were predicted. DISCUSSION Our data has shown that in our environment a significant number of fatalities occur in patients with potentially salvageable burns, and the breakpoints for the mortality prediction scores such as, the Modified Baux score, Coste et al. score, BOBI and ABSI scores are much lower than high-income countries. However these mortality predictive scores can be used in a resource scarce South African setting to triage patients into risk categories by lowering the breakpoints. This may facilitate early and more aggressive management of high-risk burn patients, improving survival rates, as well as efficient and judicious use of critical care and other resources.

Analysis of referrals and triage patterns in a South African metropolitan adult intensive care service

BACKGROUND Intensive care unit (ICU) beds are scarce resources in low- and middle-income countries. Currently there is little literature that quantifies the extent of the demand placed on these resources or examines their allocation. OBJECTIVES To analyse the number and nature of referrals to ICUs in the Pietermaritzburg metropolitan area, South Africa, over a 1-year period, to observe the triage process involved in selecting patients for admission. METHODS A retrospective review of the patients referred to ICUs at Greys and Edendale hospitals, Pietermaritzburg, was performed over a year. The spectrum of patients was evaluated with respect to various demographics, and the current triage process was observed. RESULTS The Pietermaritzburg Metropolitan Critical Care service (PMCCS) received 2,081 patient referrals, 53.4% (1,111/2,081) of males and 46.6% (970/2,081) of females, with a mean patient age of 32 years. The majority of referrals were of surgical patients (39.3%, 818/2 081), followed by medical (18.9%, 393/2,081), trauma (18.6%, 387/2,081) and obstetrics and gynaecology (11.7%, 244/2,081). The chief indications for referral were the need for cardiovascular and respiratory support. Of these referrals, 72.0% (1,499/2,081) were accepted and planned for admission and 28.0% (582/2,081) were refused ICU care. Of the patients accepted, 60.7% (910/1,499) experienced delays prior to admission and 37.4% (561/1 499) were never physically admitted to the units. CONCLUSIONS The PMCCS receives a far greater number of patient referrals than it is able to accommodate, necessitating triage. Patient demographics reflect a young patient population referred with chiefly surgical pathology needing physiological support.

'Getting under our skin': Introducing banked allograft skin to burn surgery in South Africa

Deceased donor skin possesses many of the properties of the ideal biological dressing, and a well-stocked skin bank has become a critically important asset for the modern burn surgeon. Without it, managing patients with extensive burns and wounds becomes far more challenging, and outcomes are significantly worse. With the recent establishment of such a bank in South Africa, the challenge facing the medical fraternity is to facilitate tissue donation so that allograft skin supply can match the enormous demand.

Merits and challenges in the development of a dedicated burn service at a regional hospital in South Africa

INTRODUCTION The Edendale Hospital Burn Service was initiated in 2011 to improve the quality of burn care at a regional hospital. This audit reviews the merits and challenges in developing such a service and identifies areas on which to focus quality improvement initiatives. METHODOLOGY The burn admission records were retrospectively interrogated for the years 2012-2013. RESULTS This audit covers an 18-month period in which 490 patients were admitted. Admitted days per percentage burn were 2.6 days per percentage total body surface area burnt. The mortality rate was 13%. Fourteen percent of patients met the criteria for referral to the provincial burn centre but for a variety of logistical reasons only 3% were transferred. CONCLUSION We have redesigned the process of care without alteration of resources. Outcomes of burns less than 30% total body surface area are not acceptable which we believe reflects the lack of infrastructure and systems development. This audit has revealed a number of areas, which are suitable for dedicated quality improvement initiatives.

Ethics of Burn Wound Care in a Low-Middle Income Country

This review focuses on burn care in low- and middle-income countries (LMICs). It attempts to put the burden of disease in perspective by showing that burn care is under-resourced across the spectrum of LMICs and by interrogating the ethical dilemmas and challenges that staff face in caring for burn patients in this environment, with a focus on South Africa. More specifically, it will attempt to address the following issues: the threshold for utilizing the intensive care unit (ICU), how to balance treatment against cost, the percentage burn considered survivable and how it should be determined, the use of skin from both cadavers and living related donors, and the appropriate ethical guidelines for LMICs.

Predicting postoperative haemoglobin changes after burn surgery

BACKGROUND Burn surgery is associated with significant blood loss and fluid shifts that cause rapid haemoglobin (Hb) changes during and after surgery. Understanding the relationship between intraoperative and postoperative (day 1) Hb changes may assist in avoiding postoperative anaemia and unnecessary peri-operative blood transfusion. OBJECTIVE To describe the Hb changes into the first day after burn surgery and to identify factors predictive of Hb changes that would guide blood transfusion decisions. METHODS This was a single-institution, retrospective cohort study that included 158 patients who had undergone burn surgery. Hb was measured at the start and end of surgery, and on the first day (16 - 32 hours) after surgery, and the results were analysed. Peri-operative factors (Hb at the end of surgery, total body surface area operated on (TBSA-op), fluid administration and intraoperative blood administration) were evaluated to determine their association with Hb changes on the first day after surgery. RESULTS The mean (standard deviation) preoperative Hb was 10.6 (2.29) g/dL, the mean postoperative Hb was 9.4 (2.01) g/dL, and the mean Hb on the first day after surgery was 9.2 (2.19) g/dL. Median total burn surface area was 7% (interquartile range 9%, min. 1%, max. 45%), with a mean body surface area operated on (debridement area plus donor area) of 9.7%. Of the 158 patients, 26 (16%) had an Hb <7 g/dL (transfusion trigger) on the first day after surgery. For patients with a high (≥9 g/dL), intermediate (≥7 - <9 g/dL), or low (<7 g/dL) Hb measurement at the end of burn surgery, those with an Hb below the transfusion trigger on the first day after burn surgery were 0%, 27%, and 75%, respectively. End-of-surgery Hb and TBSA-op strongly predicted the first day Hb level. In the intermediate group, 55% of patients with a TBSA-op ≥11% had an Hb below the transfusion trigger on the first day after surgery. CONCLUSION Hb at the end of burn surgery was the best predictor of Hb on the first day after surgery. Patients with an Hb <7 g/dL remained as such on the first postoperative day. Half of the patients with an end-of-surgery Hb ≥7 - <9 g/dL and who had ≥11% TBSA-op had an Hb <7 g/dL on the first postoperative day.