Thomas C. Rutan

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.

Effect of propranolol administration on hemodynamic and metabolic responses of burned pediatric patients.

Hypermetabolism, increased heart rate, and lipolysis are responses to high catecholamine levels associated with burn injury. This study tests the hypothesis that adrcncrgic beta blockade in burns could reduce myocardial work, lipolysis, and negative nitrogen balance without adversely affecting cardiac or metabolic function. Eighteen patients with burns of 70 ± 3% total burn surface area (TBSA) (Mean ± SEM), were studied after a 5-day infusion of 2 nig/Kg of intravenous (I.V.) propranolol infusion every 24 hours without their cardiac output or resting energy expenditure being adversely reduced. Heart rate, left ventricular work, and rate pressure product were significantly reduced by 20, 22, and 36%, respectively (P < 0.05). Plasma glucose, free fatty acids, triglycerides, and insulin levels remained unchanged. The rate of urea production, however, was significantly increased by 54 ± 12% in fasted patients, and to a much lesser 12 ± 2% in fed patients. The marked decrease in myocardial work afforded by propranolol administration may be of clinical benefit in the treatment of large burns. Variations in drug dosage and feeding regimens will, however, need to be perfected to limit catabolic effects.

Long-term reduction in bone mass after severe burn injury in children.

OBJECTIVE Because burn victims are at risk of having bone loss, a cross-sectional study was undertaken to determine whether severe burn injury had acute and long-term effects on bone mass or on the incidence of fractures in children. METHODS Dual-energy x-ray absorptiometry of the lumbar portion of the spine was performed on 68 children: 16 moderately burned (15% to 36% of total body surface area) and 52 age-matched severely burned (> or = 40% of total body surface area). Twenty-two severely burned children were hospitalized and studied within 8 weeks of their burn, and 30 others were studied approximately 5 years after discharge. In the severely burned group, both hospitalized and discharged, serum and urine were analyzed for calcium, phosphorus, intact parathyroid hormone, osteocalcin, and type I collagen telopeptide. RESULTS Sixty percent of severely burned patients had age-related z scores for bone density less than -1, and 27% of severely burned patients had age-related z scores for bone density less than -2 (p < 0.005, for each). In the moderately burned group, 31% of patients had z scores less than -1 (p < 0.005 vs normal distribution), but only 6% had z scores less than -2 (p value not significant). There was evidence of increased incidence of fractures after discharge in the severely burned patients. Biochemical studies were compatible with a reduction in bone formation and an increase in resorption initially, and with a long-term persistence of low formation. CONCLUSION We conclude that acute burn injury leads to profound and long-term bone loss, which may adversely affect peak bone mass accumulation.

Determinants of mortality in pediatric patients with greater than 70% full-thickness total body surface area thermal injury treated by early total excision and grafting

Recent advancements in burn care have improved the survival rates of victims with severe burn injuries. The total mortality rate in a series of 1,057 pediatric patients admitted to Shriners Burns Institute Galveston Unit between 1982 and 1986 was 2.7%. The burn size resulting in a 50% death rate was 95% of the total body surface area (TBSA). In this study 19 survivors and 13 nonsurvivors with greater than 70% full-thickness TBSA burn injuries were compared. All survivors were adequately resuscitated upon arrival 11% sustained an inhalation injury. Forty-six per cent of the nonsurvivors sustained an inhalation injury; 31% were not initially adequately resuscitated. The presence of preadmission shock and inhalation injury were early determinants of mortality with secondary renal, pulmonary, or cardiovascular collapse being the later predictors of mortality in these massively burned pediatric patients.

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

Metabolic Rate Alterations in Early Excision and Grafting versus Conservative Treatment

This study was done to determine whether early massive excision and grafting would decrease the hypermetabolic response that characterizes burn injury. Thirteen consecutively admitted adult males with burns over more than 45% of the total body surface area (TBSA) were randomly assigned to one of two treatment groups. One group was treated by excising the burn within 72 hours of injury and grafting with autograft overlaid with cadaveric allograft or cadaveric allograft alone depending on available donor sites and size of recipient areas. The second group was treated conservatively with daily hydrotherapy and twice daily applications of topical antimicrobial agents until granulating beds could receive autografts. Resting energy expenditure (REE) was calculated from measurement of vO2 and vCO2 at the patients bedside. The responses of the two groups were comparable: the REE was approximately 20-30% above the predicted basal metabolic rate (BMR). Excisional therapy did not markedly decrease the hypermetabolic response to burn injury.

Management of the Pediatric Patient With Burns

Two million people in the United States receive medical treatment each year for burn injuries. One hundred thousand of these patients are hospitalized, and 7800 die as a direct result of their injuries. Of the patients that are hospitalized 30% to 40% are under 15 years of age. Sixty-seven percent are male. The average age of children with burns is 32 months. Flame burns account for approximately 13% of accidents, scalds account for 85%, and electrical and chemical burns account for approximately 2%. The majority of scald injuries are small. Sixteen percent of burn injuries are not accidental, and approximately half of these are a result of documentable, inflicted abuse.

Risk of aluminum accumulation in patients with burns and ways to reduce it.

Severely burned patients experience a bone lesion consisting of markedly reduced bone formation and evidence of decreased resportion. The cause of the lesion may be multifactorial, but aluminum loading, which also occurs in patients with burns, has been documented to produce this type of injury in both humans and animals. To assess the risk of aluminum loading with patients with burns, we analyzed fluids, creams, and medication used in the management of acute burn injury for aluminum content. These substances were classified according to route of administration: cutaneous, enteral, or parenteral, to assess the risk of aluminum loading. Cutaneous exposure to aluminum is greatest from baths, which may provide up to 8 mg aluminum. However, the dynamics of aluminum entry into the blood via a damaged skin barrier are unclear. Enteral exposure to aluminum is no greater than daily dietary exposure. Parenteral sources of aluminum, especially 25% human serum albumin and calcium gluconate, provide the most significant risk of loading because of direct introduction of aluminum into the circulation. Substitution with a different brand of albumin and calcium chloride can reduce the parenteral aluminum load by as much as 95% and minimize any role aluminum may play in the pathogenesis of this bone lesion.

Evaluation of a caloric requirement formula in burned children treated with early excision

This study was undertaken to evaluate the effectiveness of a standard caloric requirement formula, as determined by retrospective analysis of weight gain of patients treated by serial debridement, for patients treated by early excision. The caloric intakes of 61 patients with more than 40% third-degree burn, 27 treated with serial debridement of the burn wound and 34 treated with early massive excision, were reviewed and compared to their calculated requirements. Nutritional support in both groups was similar. Of the 48 survivors there was no difference in their age, % TBSA burn, and per cent meeting caloric requirement. The early excision survivors had a greater percentage third-degree burn and weight change but a decreased length of stay. It was concluded that even though the formula, previously developed at our institution, may lead to a slight overestimation in determination of the caloric needs of early excision patients, it is an acceptable means of determining their requirements.

Fungal sepsis: an increasing problem in major thermal injuries.

In major thermal burns there has been an alarming emergence of fungal sepsis as defined by involvement of three or more organs and/or repeated positive blood cultures. During an 18-month period, we treated 72 patients (aged 18 +/- 2 years; TBSA burn, 57 +/- 3%; percent of third-degree burn, 45 +/- 3) with fungal sepsis. In all patients with documented three-organ involvement, treatment was with intravenous amphotericin (0.5 mg/kg body weight/day), immediate wound debridement, and early wound closure. The mortality was 32% (23 patients); 49 (68%) survived infection. Sixty-two variables were reviewed retrospectively using multiple regression analysis to ascertain specific factors associated with fungal sepsis and their relationship to survival. In burn patients, fungal sepsis is a strong determinant of survival, and its occurrence overshadows traditional factors presently utilized to predict clinical outcome.