P. William Curreri

Infections in burn patients

Systemic sepsis resulting from invasive infection remains the leading cause of death among patients hospitalized with major thermal injury. Prevention of infection and death in burn patients requires a thorough knowledge of the multiple predisposing factors involved and expert application of appropriate diagnostic, supportive, and therapeutic modalities. The improved survival in this population is a result of all these factors, not any one. It is this principle and the adherence to a treatment program that encompasses all the modalities which are so essential in the care of burn patients if continuing progress is to be made in this field. This article describes the current management of infection and infection control in burn patients. The burn wound and pulmonary system remain the major foci for infection in this population. Less common types of infection include suppurative thrombophlebitis, suppurative chondritis, bacterial endocarditis, urinary tract sepsis, sinusitis, intra-abdominal sepsis, and infections of the eyes. Prophylaxis protocols involve proper control of the environment and an anticipation of bacterial colonization. A number of specific monitoring and treatment guidelines have evolved that have proved effective over the years in minimizing morbidity and mortality.

Hypothermia prevents increased capillary permeability following ischemia-reperfusion injury☆

UNLABELLED Severely injured trauma victims are frequently hypothermic. It is unclear, however, whether hypothermia itself is a detrimental or protective physiologic response to injury. One of the major consequences of fluid resuscitation following ischemic injury is edema formation, characterized by ischemia-reperfusion injury models. The purpose of this study was to examine the effect of regional hypothermia on a feline intestinal model of ischemia-reperfusion injury. An autoperfused segment of cat ileum was isolated and arterial, venous, and lymphatic vessels were cannulated. Lymph flow (Q1), lymph (C1), and plasma (Cp) protein concentrations and segmental blood flow (Qb) were measured. Permeability changes were characterized by the minimal C1/Cp ratio obtained by elevating venous outflow pressure. Animals were divided into the following groups: Group I: 1 hr of intestinal ischemia (30 mm Hg) with autoreperfusion; Group II: 1 hr of intestinal hypothermia (28 degrees C) with subsequent rewarming; Group III: 1 hr of combined ischemia and hypothermia. Group III animals were either kept hypothermic (IIIA) or rewarmed (IIIB) during autoreperfusion. Minimal C1/Cp ratios (mean +/- SEM) were as follows: CONTROL 0.15 +/- 0.02; Group I*: 0.32 +/- 0.03; Group II: 0.15 +/- 0.01; Group IIIA: 0.18 +/- 0.02; Group IIIB*: 0.42 +/- 0.02; (* = P less than 0.01 vs control). Reperfusion flow rates were no different between Group IIIA and Group IIIB animals. Ischemia-reperfusion, but not hypothermia alone, caused a marked increase in intestinal capillary permeability. Permeability increased after combined ischemia and hypothermia only if reperfusion was accompanied by rewarming. Hypothermic reperfusion protected against the increased permeability following ischemia.

Penetrating neck trauma: diagnostic studies in the asymptomatic patient.

The selective management of penetrating neck trauma implies an attempt to individualize care and minimize unnecessary surgical exploration. In asymptomatic patients, diagnostic studies are performed in an attempt to exclude clinically unrecognized injuries. This review of 100 consecutive cases of penetrating neck trauma assesses the role of ancillary diagnostic studies in 53 patients selectively managed. The diagnostic yield from a combination of angiography, fluoro-esophagography, and aerodigestive tract endoscopy was 22.6% (12 of 53). However, only five patients (9.4%) actually benefitted from ancillary diagnostic studies, in that angiography documented clinically unrecognized injury. In an effort to avoid the indiscriminate use of ancillary diagnostic studies, a selective management plan based on anatomic zones of injury is provided.

Systemic antibiotic treatment in burned patients.

Systemic antibiotics are a valuable therapeutic modality in the burned patient when properly used. Injudicious use, however, may not only fail to be beneficial to the patient but also may produce harmful effects--either through direct toxicity or by contributing to the emergence of resistant strains of micro-organisms. General guidelines and principles for systemic antibiotic use include the following: The burned patient, despite all efforts, will be exposed to microorganisms. No single agent or combination of agents can destroy all the organisms to which the burned patient is exposed. Treatment involves first identifying the organism responsible for clinical sepsis, then choosing appropriate agents. Combinations of antibiotics are not always synergistic or even additive in effect. Multiagent therapy may have the untoward effect of predisposing to superinfection by yeast, fungi, or resistant organisms. Antibiotics should be used for a long enough period to produce an effect, but not long enough to allow for emergence of opportunistic or resistant organisms. Dosages must be adjusted based on serum concentrations when serum assays are available. In general prophylactic systemic antibiotics are indicated in only a few clinical situations including the immediate preoperative and postoperative periods associated with excision and autografting, and possibly in the early phases of burns in children. The penetration of systemic antibiotics into burn eschar remains an area not fully studied; hence, they cannot be the only therapeutic modality used to treat burn wound infection. Systemic dosages of antibiotics in burns will require alteration depending on the clinical status of the patient. The choice of agent requires a thorough knowledge of side effects, toxicity, and potential benefit. Above all, active surveillance and monitoring of the burned patient and the environment in which he or she is being treated is mandatory for effective treatment. The increasing number of new antimicrobial agents has presented a new dilemma to the practicing clinician because many of these agents have not been evaluated thoroughly in the burned population. With further studies, the armamentarium of the burn treatment team will inevitably increase. It is in this manner only that so many of the unanswered questions will be solved, and that infection will start to decline as the major cause of death in the burned population.

Effects of fibrinogen degradation fragments D and E on cell-mediated immunity

Serum taken from severely traumatized victims suppresses in vitro the response of normal lymphocytes to the mitogenic stimulant phytohemagglutinin (PHA). In the postburn period, fibrin degradation products (fragments D and E) are elevated in a high percentage. Controversy exists as to whether these fragments contribute to what is clinically evident as cell-mediated immune (CMI) suppression. Purified fragments D and E were isolated over an ion exchange cellulose column after activating, with streptokinase, a solution containing fibrinogen and plasminogen. Lymphocytes from six volunteers were cultured with PHA and serial dilutions of fragments D and E; each was analyzed for ability to incorporate radiolabeled thymidine. Fragment E possessed in vitro CMI suppression at pharmacologic doses. Fragment D demonstrated immune suppressive capabilities at doses approximating those estimated to occur in the acute postburn phases of injury.

Academic advancement: Report of a survey by the committee on issues, association for academic surgery

THIS REPORT IS THE SUMMARY of a survey on academic advancement conducted by the Committee on Issues of the Association for Academic Surgery during the Spring of 1973. Questionnaires were mailed to 100 chairmen of departments of surgery, and for comparison to 100 chairmen each of departments/divisions of orthopedics and urology. Strict confidentiality of the survey was maintained and 170 responses were received and tabulated. The profile of the chairmen who responded to the questionnaire is summarized in Table 1. Forty-eight percent of the respondents were general surgeons and the remainder were almost equally divided among the urologists and orthopedists. Eighty-one percent of the general surgical chairmen answered the questionnaire compared to 45% of the subspecialists. The chairmen averaged 50 yr of age and held their positions a mean of 8.5 yr. Eightynine percent considered themselves fulltime at their university. Ninety-two (54%) of the medical schools were statesupported, roughly paralleling the general