The past 25 years of pediatric burn treatment in Graz and important lessons been learned. An overview.

INTRODUCTION: The aim of this study was to characterize the epidemiology of pediatric and adolescent burns admitted to the Children's Burns Unit at the Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Austria, between January 1st 1988 and December 31st 2012. METHODS: This is a retrospective review over the past 25-years and describes admission rate by gender and age groups, causes of burns, anatomical sites of burns, extent and depth of injury, length of hospital stay, child abuse and in-hospital mortality. RESULTS: In the studied 25 year-period, 1586 pediatric burn patients were admitted. 1451 patients were "acute" admissions, 64 "secondary" admissions and 71 patients did not fulfill the inclusion criteria. Of the 1451 patients, 930 (64%) were male and 521 (36%) female. The majority of patients - 880 or 60.6% - were children from 1 to 5 years of age. Domestic burns occurring at home resulted in 1164 (80.2%) of injuries and scalds were the most common type of thermal trauma with 945 (65.1%) patients. According to the extent of injury 1106 (76.2%) patients suffered burns of <10% with an median length of hospital stay of 3 days. 14 children (0.98%) - 8 girls and 6 boys - were confirmed victims of abuse and 4 patients (0.3%) died. CONCLUSION: The study provides a good opportunity to review changes in burn care over a long time period, at a single center, including children and adolescents, with stable surgical and rehabilitation staff. The data is also important for the design of prevention programs and establishment of burn care capacities, since the analysis showed no change in the incidence of burn related admissions over the time period studied.

Phototoxic plant burns: report of a case and review of topical wound treatment in children.

Acute photodermatitis provoked by skin contact with giant hogweed (Heracleum mantegazzianum) and exposure to ultraviolet radiation is a rare cause of phytophotodermatitis in children. We report the case of a 10-year-old girl with extensive photodermatitis after contact with giant hogweed and prolonged exposure to sunlight. The lesions involved 10% of the body surface area, mainly the lower extremities. After initial application of topical steroids to the skin erythema, the topical approach was changed due to extensive bullae. Debridement and temporary wound closure with an adequate dressing was undertaken. This is the first case report of application of Suprathel (PolyMedics Innovations, Denkendorf, Germany) on a phytophototoxic burn-like wound with a favorable outcome.

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.

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.

Management of burn wounds.

Small and moderate scalds in toddlers are still the most frequent thermal injuries the pediatric surgeons have to face today. Over the last years, surgical treatment of these patients has changed in many aspects. Due to new dressing materials and new surgical treatment strategies that are particularly suitable for children, today, far better functional and aesthetic long-term results are possible. While small and moderate thermal injuries can be treated in most European pediatric surgical departments, the severely burned child must be transferred to a specialized, ideally pediatric, burn center, where a well-trained multidisciplinary team under the leadership of a (ideally pediatric) burn surgeon cares for these highly demanding patients. In future, tissue engineered full thickness skin analogues will most likely play an important role, in pediatric burn as well as postburn reconstructive surgery.

Use of Suprathel dressing in a young infant with TEN.

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.

Two decades' experience of renal replacement therapy in paediatric patients with acute renal failure.

During the past 20 years, childhood renal replacement therapy (RRT) and the treatment of underlying diseases experienced extensive advances. We reviewed the data of our critically ill patients with acute renal failure (ARF) and RRT, comparing two decades from 1985 to 1994 and from 1995 to 2004. There were 87 patients with a mortality rate of 45% in the first decade, decreasing to 28 patients with a mortality rate of 39% in the second decade. The mortality rate decreased from 51% to 20% in patients older than one year, while the mortality rate in patients younger than one year increased from 38% to 88%. Yet, the absolute number of these non-survivors younger than one year decreased from 16 to seven patients. The decrease of RRT was mainly caused by a decrease of ARF secondary to heart surgery, oncologic disorders and sepsis. Whereas the majority of patients (75%) were treated with continuous haemofiltration in the first decade, 75% of patients were treated with continuous haemodiafiltration in the second decade. In conclusion, advances in the diagnosis and treatment of underlying disorders have reduced the need for RRT in critically ill paediatric patients during the past 20 years. In addition, there was a tendency for a decrease in the overall mortality, which might be caused by changing treatment policies and advances in RRT technology. Nevertheless, the high mortality rate in small infants is challenging.

Silver-coated dressing acticoat caused raised liver enzymes and argyria-like symptoms in burn patient.

BACKGROUND: Treatment of acute burn wounds with silver sulfadiazine (SSD) has raised concern about potential silver toxicity. Numerous adverse reactions and side effects have been reported and an increasing resistance to SSD, especially in Pseudomonas strains, have motivated researchers to search for an alternative wound dressing. METHODS: Recently, a silver-coated wound dressing Acticoat (Smith & Nephew, Inc.) has become available for use in burn patients. It is a three-ply dressing, consisting of an inner rayon/polyester absorptive core between two layers of silver-coated, high-density polyethylene mesh. In a moist environment, the nanocrystals of silver are released and improve the microbial control in the wound. RESULTS: After 1 week of local treatment with Acticoat in a young, previously healthy 17-year-old boy with 30% mixed depth burns, hepatotoxicity and argyria-like symptoms, a grayish discoloration of the patient's face, appeared. The silver levels in plasma (107 microg/kg) and urine (28 microg/kg) were clearly elevated, as well as the liver enzymes. As soon as the local application of Acticoat was aborted, the clinical symptoms and liver enzymes returned to the normal values. CONCLUSIONS: This is the first report on silver toxicity in a patient with 30% burns who received Acticoat for local treatment. Due to substantial experiences with adverse SSD reactions and side effects, it is appropriate to keep the possibility of a toxic silver effect in burn patients treated with Acticoat silver-coated wound dressing in mind. The silver levels in plasma and/or urine should be monitored.