SEVERE BURNS IN CHILDREN IN ALBANIA: HOW HAS THE EPIDEMIOLOGY OF BURNS IN CHILDREN CHANGED IN THE PAST 25 YEARS?

This study is aimed at describing the patterns and trends of burns among children in the past 25 years in Albania, a transitional post-communist country in the Western Balkans. It included all burned children admitted to the Intensive Care Unit of the University Hospital Center "Mother Teresa" of Tirana in the past 5 years (i.e., 2018-2022). Overall, 275 children treated at the Service of Burns and Plastic Surgery were included in this analysis. Incidence of burns in children has importantly declined during the last 25 years. Of 275 children included in this study, 50.2% were boys and 49.8% were girls. The age range was from 2 months to 16 years. The number of children with burns declined progressively, but the lowest number was seen in 2020, which is explained by the Covid-19 pandemic. On the whole, the most affected age group is that of 1-3 year-olds. Regardless of age, hot liquids (51%) and pure hot water (39%) were the main causative agents of burns among children. There was an important decrease in the number of burns due to flame (from 18.5% to 7%) and chemical burns (from 5.9% to 1%). No electrical burns were found in the records. Most of the burned cases were burns of more than one site on the body, representing 35% of all the cases. Burns among children continue to constitute a significant burden of morbidity among Albanian children, which is a cause of concern. However, compared with 25 years ago, the total number of severely burned children has dropped in Albania.

Cette étude a pour but de décrire l'épidémiologie des brûlures touchant les enfants et son évolution au long des 25 dernières années en Albanie, état ci-devant communiste de l'ouest des Balkans. Nous avons répertorié des 275 enfants admis dans service de réanimation du CHU Mère Theresa de Tirana entre 2018 et 2022 et prise en charge par l'équipe brûlologique de cet hôpital. L'incidence des brûlures infantiles a fortement décru durant les 25 dernières années. Le sex-ratio était quasiment à l'équilibre (50,2% de garçons et 49,8% de filles). Les enfants étaient âgés de 2 mois à 16 ans, le groupe le plus à risque étant les 1-3 ans. Le nombre d'enfants brûlés était en décroissance progressive, avec un thalweg en 2020, expliqué par la pandémie Covid-19. La proportion des brûlures par flamme a chuté de 18,5% à 7%, celle des brûlures chimiques de 5,9% à 1%, notre série ne recensait pas de brûlure électrique. Plusieurs régions du corps étaient atteintes dans 35% des cas. Les brûlures sont un fardeau pathologique pour les enfants albanais, ce qui reste préoccupant bien que le nombre de brûlés ait chuté dans cette population depuis 25 ans.

Sodium Balance Analysis In The Burn Resuscitation Period.

The different formulae for resuscitation therapy after thermal damage recommend 0.5-0.6 mmol sodium for each % TBSA burned, suggesting fluid requirements from 2-4 ml/kg/% burn because of sodium loss in burned and unburned tissues. There is a gap especially in the recommendations regarding dysnatremia in the burn population. Many studies have focused on calculating amount of resuscitation fluids, avoiding the situation of "fluid creep", and not on calculating sodium remaining in the body after resuscitation. The goal of this observational study was to provide data for sodium disturbances in the shock period after burns. Our study underscores the challenge of understanding whether there is a relationship between amount of crystalloid fluids given during resuscitation and meeting sodium needs. We set out to examine sodium balance (sodium deficit, received, excreted, and retained) after burns. The area under the ROC curve was performed by analyzing fluid and sodium load. Moreover, we conducted linear regression to analyze if there was a correlation between sodium retained and sodium excreted. Sodium deficit persisted until the second 24h despite resuscitation. Resuscitation was performed using Parkland formula, but urine output (UO) values were higher than expected. The threshold for fluid administration (ml/kg/%) or fluid load in the first 24h and sodium load (mmol/kg/%) for positive state (sodium received >0.5-0.6 mmol/kg/%) was 3.7 ml/kg/%. With linear regression, it was evident that sodium excreted was responsible for sodium retained, indicating a moderate correlation in the first 24h and a strong correlation in the second 24h. Resuscitation with LR did not correct hypoosmolality hyponatremia, which persisted even after the first 24h, especially in patients with burns >60%. If more than 3.7 ml/kg/% of LR is given, a sodium load higher than the normal level will be introduced, leading to increased urinary output, elevated sodium excretion, and non-correction of plasma sodium at the end of resuscitation. What is important for colleagues in clinical practice is that the focus of burn resuscitation should be expanded with data regarding sodium balance and the impact of dysnatremias in morbidity and mortality.

Les différentes formules de remplissage initial après brûlure recommandent l'apport de 0,5 à 0,6 mmol de Na pour chaque pour cent de surface brûlé avec un volume de 2 à 4 mL/kg/% (en attirant l'attention sur le risque de sur-remplissage), en raison des pertes sodées tant en zone brûlée qu'en zone saine. Les dysnatrémies, fréquentes chez les brûlés, peuvent s'expliquer par le peu de cas fait au contenu sodique total après le remplissage initial. Le but de cette étude observationnelle était de recueillir des données concernant les déséquilibres sodés pendant la période du choc initial. Elle souligne la nécessité de comprendre s'il existe une relation ente le volume perfusé et les apports sodés nécessaires. Nous avons calculé le bilan sodé (Na perdu, apporté, excrété, retenu) après une brûlure. L'aire sous la courbe ROC a été réalisée en analysant les apports liquidien et sodé. De plus, nous avons effectué une régression linéaire à la recherche d'une corrélation entre Na excrété et Na retenu. Le déficit en sodium persiste à h48, malgré le remplissage, utilisant la formule de Parkland, constatant que les diurèses étaient supérieures à celles attendues. Le seuil de volume perfusé dans les 24 premières heures permettant l'apport de 0,5 à 0,6 mmol/kg/% de Na était de 3,7 mL/kg/%. En régression linéaire, la corrélation entre Na retenu et Na secrété est modérée pendant les premières 24 h, forte le jour suivant. Le remplissage au Ringer-lactate ne corrigeait ni l'hypoosmolalité ni l'hyponatrémie, qui persistaient après h24, en particulier chez les brûlés >60 %. Au delà de 3,7 mL/kg de RL pendant les 24 premières heures, une surcharge sodée est réalisée, entraînant une augmentation de diurèse et natriurèse, la natrémie n'étant pas corrigée en fin de remplissage. Il faut retenir pour la pratique clinique que l'attention doit être portée sur l'équilibre sodé. L'impact des dysnatrémies sur morbidité et mortalité devrait être étudié.

Measurements Of Injury-Related Outcomes: Statistical And Analytical Data From Albania.

Numerous burn mortality indicators and prognostic scores are necessary to classify with priorities severely burned patients in order to predict outcome. The purpose of this paper is to evaluate mortality predictors on admission, in order to determine Lethal Area 50 and to validate burn prognostic scores. The study is retrospective, clinical and analytical. The data utilized were accessed by investigating the medical charts of 5033 patients hospitalized with severe burns within the Intensive Care Unit of the Service of Burns in Tirana, Albania over the period 1992-2019. Descriptive and inferential statistics were performed using PSS 23 software. Statistical significance is defined as p<0.05. The incidence rate of hospitalization of patients with severe burns initially increased from 4.1 to 7.9 persons per 100,000 population/year in the period 1992 to 1999, followed by a decrease from 7.9 to 4.8 in 2019. Mortality was 12.2% and the average burn crude death rate was 0.7 patients per 100,000 population/year. Lethal Area 50 for the second decade (2010-2019) was 82.2%. All tested burn prognostic scores had good predictive values. In addition to the commonly used outcome predictors such as age, burn size and inhalation burn, we concluded that additional determinants like depth of burn and etiology of burns determined an unfavorable outcome. Fatality risk was 4 times higher in patients with full-thickness burns, 2.6 times higher in patients with flame burns, and 4 times higher in patients with inhalation injury.

De nombreux scores de gravité se proposent d'évaluer le devenir des patients brûlés. Cette étude rétrospective, clinique et analytique, a pour but d'évaluer et valider ces différents scores ainsi que de déterminer la « surface létale 50- SL50 ¼. Elle a utilisé les dossiers de 5 033 patients hospitalisés dans le secteur de réanimation du CTB de Tirana entre 1992 et 2019. L'incidence annuelle a augmenté de 4,1 à 7,9/100 000/an entre 1992 et 1999 puis est redescendue pour atteindre 4,8 en 2019. Avec une mortalité hospitalière de 12,2%, la mortalité par brûlure à l'échelle de la population albanaise était de 0,7/100 000/an, la SL50, évaluée entre 2010 et 2019, étant à 82,2% SCT. Si tous les scores existant avaient un bon rendement prédictif, nous proposons d'adjoindre à l'âge, la surface brûlée et l'inhalation de fumées, la profondeur et l'étiologie de la brûlure comme facteurs de mauvais pronostic. Le décès était 4 fois plus fréquent chez des patients ayant une brûlure profonde (même risque en cas d'inhalation de fumée) et 2,6 fois plus fréquent après brûlure par flamme.

Statistical and clinical analysis of alterations in glucose values after burns.

The purpose of this study was to evaluate independent factors (mainly critical hyperglycaemic values on admission) with an impact on outcome in burn patients (sepsis and mortality) and analyse prevalence of critical hyperglycaemia on admission and during burn disease in adult and elderly patients with severe burns. This was an observational retrospective cohort study involving burn patients (≥ 20 years old) hospitalized in the ICU of the Burn Facility in Albania during 2010-2014. Patients were categorized as having euglycaemia, moderate or critical hyperglycaemia. Regression analysis, hyperglycaemia prediction test and risk measurement were performed for the population. Statistical significance for SIH was only found for glucose values on admission, presence of diabetes and BMI. Using 180 mg/dl as cut off for critical hyperglycaemia, we found that this test had a sensitivity of 66.67% (95% CI: 44.68% to 84.33%), specificity of 88.20% (95% CI: 84.16% to 91.51%), PPV of 29.63% (95% CI: 17.99% to 43.61%) and NPV of 97.26% (95% CI: 94.67% to 98.81%). Statistical significance was found for patients with critical hyperglycaemia on admission regarding relative and absolute risk measures for sepsis and mortality. Glucose values on admission, as one of the derangement features of burn shock, are prognostic factors in critical hyperglycaemia during disease, and have a close relationship with other outcomes (sepsis and mortality).

L'objet de cette étude est l'analyse des facteurs indépendants (essentiellement l'hyperglycémie à l'admission) ayant un impact sur le devenir des patients (sepsis et mortalité) ainsi que l'étude de la prévalence de l'hyperglycémie à l'entrée comme en cours d'hospitalisation chez des patients adultes (avec un sous-groupe de patients âgés) sévèrement brûlés. Il s'agit d'une étude rétrospective concernant des patients de plus de 20 ans hospitalisés dans lez service de réanimation pour brûlés albanais entre 2010 et 2014. Trois catégories de patients ont été définies: glycémie normale, modérément élevée, fortement élevée. Une analyse par régression a été effectuée pour évaluer la corrélation entre le devenir du patient et ses glycémies. Une corrélation avec l'hyperglycémie de stress a été trouvée en cas de glycémie élevée à l'admission, en cas de diabète et avec l'IMC. Un seuil de 180 mg/dL pour la définition d'une glycémie fortement élevée permet d'obtenir une sensibilité de 66,67% (IC95 44,68-84,33%), une spécificité de 88,2% (IC95 84,16-91,51%), une valeur prédictive positive de 29,63% (IC95 17,99-43,61) et une valeur prédictive négative de 97,26% (IC95 94,67-98,81%). Il existe une association statistiquement significative entre l'hyperglycémie à l'entrée et la morbi-mortalité. Une hyperglycémie initiale est un facteur pronostic défavorable, en termes de complications infectieuses et de moralité, chez les patients gravement brûlés.

Net fluid accumulation and outcome. A randomized clinical trial.

Outcome measures are the first step in determining the consequences of health care. These include mortality, morbidity, and quality of life. As major burns are life-threatening conditions, the main priority in discussing outcome measures is mortality as a problem-specific measure. A number of studies have shown that mortality is predominantly determined by many variables obtained as "admission" predictors" as also by numerous variables obtained during the hospital course. Net fluid accumulation (NFA) is one of the many important factors that correlate with clinical outcome. The purpose of this paper is thus to evaluate NFA during resuscitation with Ringer's lactate (RL) and its relationship with mortality. We hypothesized that rigorous monitoring of fluid replacement therapy might result in lower fluid retention, which could be effective in the prognosis of severely burned patients. In this prospective randomized study, the patients were divided into two groups of 55 cases each. In RL group 1, the patients were resuscitated using the Parkland formula in adults and the Galveston Shriner formula in children, without modifications, while in RL group 2 the formula was utilized as a starting-point only and the amount of fluid was modified in each case on the basis of the clinical situation and urine output. It was found that there was a statistically significant difference in NFA between the two groups (p = 0.001), as also a statistically significant difference between the amount of fluids given and the complications (p = 0.08). The majority of patients who died (70%) presented higher NFA values in the period of resuscitation. There was a statistically significant difference between mortality and total body surface area burned (p = 0.036), comorbidities (p = 0.015), cause of burn (p = 0.004), inhalation injury (p = 0.027). The degree of NFA correlated, with a linear positive relationship, with morbidity (Kendall's tau_br = 0.143, p = 0.019) and, with a negative relationship, with mortality (Kendall's tau_br = 0.234, p = 0.001). Mortality as the primary endpoint was 16% in group 1 and 9% in group 2. Giving the smallest amount of fluids necessary for adequate resuscitation can be effective in creating a successful and specific therapy for all burn patients. With regard to morbidity and mortality, predictor factors, as also the method of resuscitation, have an influence in maintaining constant NFA values.

Posterior interosseous forearm flap in reconstruction of first web space.

Use of a fascial flap is often required for reconstruction of a skin defect on the dorsum of the hand. For this purpose, a distally based dorsal forearm fasciosubcutaneous flap based on the perforators of the posterior interosseous artery was developed. The distally based dorsal forearm fasciosubcutaneous flap and especially the posterior interosseous artery flap are a convenient and reliable alternative for reconstructing skin defects of the hand after the release of post-burn adduction contracture of web space I involving vital structure exposure. Although the posterior interosseous artery flap is suitable for covering dorsal skin defects of the hand and avoids interference with the forearm's two main arteries, the dissection of the vascular pedicle is frequently quite complex and tedious.

Head and neck burns: acute and late reconstruction.data of burn injury management in 2007.

Modern burn care is based on operative wound management. The evidence is clear that prompt excision and closure can be lifesaving for patients even with large burns. Facial burns that are full-thickness need grafting. Deep dermal facial burns need surgery in the third week post-burn. Deep burns to the eyelids should be excised and grafted early in order to prevent cicatricial ectropion and corneal exposure. Following healing from burns, the reconstruction of severe deformities and scars of the face, head, and neck confronts the surgeon with some of the most challenging problems in reconstructive surgery. Our purpose is to provide some retrospective data on acute and late reconstruction of head and neck burns in 2007. Eighty-one patients are considered who were operated on in the Burns and Plastic Surgery Service of the University Hospital Centre in Tirana, Albania, suffering from burns and also from burn deformities in the head and neck regions. A description is given of the different types of operative techniques used for head and neck reconstruction as also of developmental aspects of burned face deformities (physical and psychological) and of their correction. In all, 246 patients with burns and burn deformities were subjected to surgery in 2007. Of these we have extracted 81 cases in which the pathology concerned the head and the neck, including 13 cases of full-thickness facial burns needing excising and grafting. The other 68 cases were burn deformities. This last group of patients included 19 with facial deformities, 14 with perioral deformities, 12 with burn alopecia, ten with upper and lower eyelid deformities, nine with ear deformities, and four with cervical deformities. The operative techniques used were skin grafts (split-thickness or full-thickness), composite grafts, pedicle flaps, and tissue replacement. In burn alopecia cases, we used tissue expansion for the correction. Head and neck burns constitute some of the most challenging problems in acute wound care and in the subsequent rehabilitation and reconstruction.With knowledge of the reconstruction techniques available, plus an accurate diagnosis of tissue deficiency and secondary distortion, a carefully performed surgical plan is the first step for achieving improvements in a burn-deformed face.

Electrical burns.

A brief description is given of a case involving a man suffering from deep injuries due to the passage of electric current in both arms. Through this description we wish to demonstrate our strategy for the selection of the most appropriate surgical techniques, illustrating this with relevant photos. The formation of thrombi in the brachial arteries obliged us to proceed to bilateral amputation at the level of the forearms. Even though this patient now has no hands, he made a full recovery and leads a normal life.

Spread of Burn and Non-burn Pathologies, Anaesthetic Support and some Management Data.

In this article we present the surgical activity of the Burns Service in the University Hospital Centre in Tirana. Not only burn patients but also patients with trauma and soft tissue losses are hospitalized in a burns centre, as well as patients needing plastic surgery coming from similar specialities. In 2006, 1127 patients were subjected to surgery in our service. The techniques of anaesthesia used are general anaesthesia (endotracheal tube, laryngeal mask airway, intravenous) and regional anaesthesia. An anaesthesiologist acting in the role of physician manager can add significant value to the overall operating room process by improving efficiency in resource utilization and simultaneously quality of care. We have found that giving priority to burns, including burns sequelae and other hospitalized burn patients, if possible in day surgery, can optimize the bed occupancy rate.

Planning and technical details when treating a post-burn hand contracture.

Hand contractures are still a problem in everyday plastic surgery practice. We decided to review the hand contractures we had treated over a 5-yr period (2000-2004) and to present some guidelines for their prevention. In the 5-yr period we operated on 206 patients with hand contractures. The number of patients demonstrates that not infrequently our plastic surgeons still have to treat this condition. The age group most liable to this form of burns sequelae is that of children up to five years old, because of the deeper burns they suffer in the hands. The surgical approach to post-burn contractures of the hand is discussed from three aspects: the skin aspect, the osteotendinous aspect, and the wound closure procedure. The discussion puts special stress on the risk of impairing blood supply to the distal phalanges, which is related not only to the involvement of the arteries in the scar tissue but also to spasms or accidental damage in the digital arteries. Special attention must be paid when the fifth finger is interested.