The control of burn wound sepsis.

This presentation reviews the course of burn wound sepsis in a group of 621 acute patients treated at the Shriners Burns Institute, Cincinnati Unit, between 1970 and 1976. During this period of time, the overall mortality rate fell from 14% in 1970 to 3 and 5%, respectively, in 1975 and 1976. Staphylococcus aureus was the most commonly recovered organism from the burn wound, colonizing 85% of the burn patients. Beta hemolytic streptococcus represented a potential threat despite the fact that it was recovered from only 5 to 10% of the patients. Pseudomonas aeruginosa showed a decrease in colonization during the period of this study, from 50% of the wounds in 1970 to 21% in 1976. Candida albicans was the fungal organism most commonly recovered from the burn wound and from the blood stream. Fifteen deaths occurred in this group as a result of invasive infection, one from S. aureus, five from P. aeruginosa, two from Klebsiella-Enterobacter, and one from Escherichia coli, as well as six fungal deaths, five from Candida albicans and one from mucormycosis. Therapeutic measures used to control burn wound sepsis consisted of prevention of contamination from exogenous sources, control of burn wound pathogens, early recognition of invasive burn wound sepsis, aggressive management of the burn wound, and optimal nutritional support. During this period the extent of burn associated with a survival of 50% has risen from 50% in 1970 to 80% in 1976. This improvement in survival is directly related to progressive improvement in local and systemic measures available for the control of infection.

Improved survival in severely burned animals using intravenous Corynebacterium parvum vaccine post injury.

This study was designed to determine the potential benefit or toxicity of an immunomodulator, Corynebacterium parvum vaccine, when it is given after severe burn injury. Forty conditioned beagles received a 33% total body surface 3-degree flame burn and were resuscitated with Ringer's lactate solution (3 ml/kg/% burn). Wounds were treated daily for 10 days with silver sulfadiazine cream. Two days and nine days after burn, 21 of the animals received C. parvum vaccine (10 mg/kg IV) in a saline infusion, while 19 control animals were given only saline infusion according to a double-blind protocol. Serial measurements were made of temperature, weight, food intake, hematocrit, hemoglobin, red blood count, white blood count, differential, platelet count, fibrin degradation products, activated partial thromboplastin time, clot retraction, C3, blood cultures, neutrophil function, monocyte function, opsonic index, Na, K, Cl, BUN, glucose creatinine, total protein albumin, albumin/globulin ratio, alkaline phosphatase, SGPT, and SGOT. During 45 days of observation, only 16% of the saline control dogs survived compared to 47% of the treated animals. Total white counts and neutrophil function were the only values which were significantly better in animals receiving C. parvum. However, their correlation with increased survival was marginal This preclinical trial suggests that C. parvum is an effective immunodulator for prevention of fatal infection following burn injury. There were no demonstrable toxic effects of the material in this study.

Tibial compartment syndromes in burn patients. A report of four cases.

Anterior and posterior motor compartment syndrome have been observed in four burn patients. Recognition was difficult because of multiple concurrent problems, including burns and thrombophlebitis of the involved extremities. Early fasciotomy was performed in one case, with good return of function. Muscle necrosis occurred in two patients in whom diagnosis was delayed. Electromyography is of benefit in confirming the diagnosis and providing follow-up management. It is important to maintain a high index of suspicion of this syndrome in patients with overlying burns.

Acute upper airway obstruction in the postburn period.

Upper airway obstruction in the severely burned patient is a well-known problem that is due to mucosal edema secondary to the effects of toxic substances and heat on the laryngeal and tracheal mucosa. Herein, we report a different cause of airway obstruction seen in the late postburn period during the induction of anesthesia for reconstructive procedures. This obstruction is due to the presence of severe burn-scar contractures of the neck that prevent successful endotracheal intubation. We have seen this occur 17 times in 13 patients. All of the patients were successfully treated by an emergency neck release, after which most of the patients could be intubated and the release then skin grafted. Surgeons operating on patients with scar contractures of the neck should be aware of this condition and its appropriate treatment.

Experience with amphotericin-B in the treatment of systmeic candidiasis in burn patients.

Systemic candidiasis has emerged as a major cause of death in burn patients. An increase both in the incidence of systemic candidiasis and its increase as a cause of death has been observed. Treatment with systemic amphotericin-B prior to 1971 at our institution was rarely successful. This was felt to be in part due to lack of sufficiently early recognition of the infection and to delay in the initiation of appropriate systemic therapy. From 1971 to 1975, fifteen patients have been treated with systemic amphotericin-B with one death. There have been no fatalities from candidiasis since 1972. No serious complications attributed to the use of amphotericin-B were observed. Prompt initiation of therapy with intravenous amphotericin-B is advised for burn patients in whom systemic candidiasis is present.

Closing the burn wound.

With recent advances in supportive therapy and surgical care, closure of the burn wound now can be accomplished earlier and more effectively than previously. Only by keeping the patient in a state of positive nitrogen balance, immunologically competent, and in equilibrium with the bacteria colonizing the burn wound can early wound closure be carried out with a minimal number of postburn complications.

Infections following burn injury.

Those factors that have contributed most to the control of burn wound sepsis in the burn patient since 1930 have been the advent of penicillin, the institution of burn center care, the availability of aminoglycosides and antifungal agents, the advent of topical therapy, the aggressive treatment of the burn wound by excisional therapy, a better understanding of respiratory therapy, the support of immune competence, and the recognition of the importance of nutritional support (Fig. 1). At the Shriners Cincinnati Unit, the extent of burn associated with a survival rate of 50 per cent has risen from 70 per cent in 1970 to 80 per cent in 1978. The better chance of survival for burn patients during this period can be directly related to a progressive improvement in the local and systemic measures available for the control of infection.

Correction of postburn syndactyly: an analysis of children with introduction of the VM-plasty and postoperative pressure inserts.

An analysis of 190 operations for correction of postburn syndactyly in children showed that none of the procedures commonly used was entirely satisfactory because of partial recurrence of the lesion or less than optimal cosmetic results. Complete correction of the dorsal slant was a particular problem. Because of this, a new operation, designated the VM-plasty, was devised specifically for correction of postburn syndactyly, and this procedure was evaluated in 24 deformities. Our experience suggests that incision of the web with simple closure, simple YV-plasties, and simple or complex Z-plasties should not be used for postburn correction of webs 2, 3, and 4. The five-flap technique of Rousso and, occasionally, Z-plasties are suitable for correction of simple webs of the thumb space, and rotational flaps are suitable in some instances for correction of webs 2, 3 and 4. However, the VM-plasty now appears to be preferable in all instances of volar or dorsal webs where there is no limitation of the back of the hand at or distal to the metacarpophalangeal joints with the fist clenched. Contractures limiting the clenched fist usually require a graft to achieve complete anatomic correction. An adjunctive procedure of graded interdigital pressure inserts was evaluated following the correction of 28 webs and appeared to prevent the appearance of hypertrophic scar formation with improved cosmetic appearance and preservation of the dorsal slant.

Surgical correction of postburn flexion contractures of the fingers in children.

One-hundred forty-eight operative procedures for flexion contractures of the finger(s) following burn injury in children have been studied in detail with follow-up from 6 months to 8 years. Intramedullary K-wires, used for 53 procedures where a graft was done, were associated with a significantly worse long-term result, and graft take was not improved by using K-wires. Length of time between burn injury and reconstruction, age at time of operation, the use of full-thickness versus partial-thickness grafts, and the digit involved had an apparent effect on final result. The use of postoperative topical steroids could not be evaluated adequately in this study. The preferred operative techniques for this condition are discussed.

Breast reconstruction in the burned adolescent female (an 11-year, 157 patient experience).

The experience accumulated after reconstruction of 157 burned breast patients has led to the development of surgical principles and techniques tailored to this problem. Most important among these principles is that the surgeon recognize and preserve viable breast bud tissue in the debridement phase of the acute burn. Reconstruction should begin when the burned breast envelope is insufficient and restricts normal growth. Best results are obtained if contracture release is complete, if defects are covered by thick split-thickness skin grafts, and if nipple-areola reconstruction is obtained from a normal opposite breast if present. Postoperative management should continue until wounds are mature and should include techniques to prevent contracture recurrence.

Surgical treatment of elbow contractures in postburn children.

One-hundred and forty-six postburn elbow contractures in children were classified into four categories--simple band, complex band (crosses shoulder and/or wrist joint), diffuse scar, and limited scar--to assess the results of surgical treatment. The best results were seen in children less than 5 years of age and in children with less than 50 percent third-degree total body surface area burns. Types of release included skin grafts, local flaps (with or without graft), and deep releases. Generally, good to excellent results were seen regardless of technique of release, and in no case was the postoperative contracture worse than the preoperative contracture. Full extension was restored in 82 percent of contractures that were less than 50 degrees and in 50 percent of contractures greater than 50 degrees. Major complications were uncommon, with 4 of 171 elbows requiring reoperation because of skin-graft or flap loss. Repeat releases were of minimal functional benefit.

Prospective clinical study of Hydron, a synthetic dressing, in delivery of an antimicrobial drug to second-degree burns.

This clinical trial prospectively evaluates the potential beneficial effects of antimicrobial drug delivery from a synthetic dressing (Hydron-AgSD) formed on second-degree burn wounds. A paste composed of polyethylene glycol-400, poly 2-OH ethylmethacrylate, and silver sulfadiazine (AgSD 1%-3%) matured within one hour to form a solid dressing. In 27 patients, comparable areas of second-degree wounds on the same patient were selected at random for test and control (silver sulfadiazine 1% only) sites. The mean total time of the synthetic dressing application per patient was about nine days, and each dressing remained in place for nearly four days. During this interval the control sites required four dressings changes. In 17 tests for infections, the control areas were contaminated but no bacteria were detected under the synthetic dressing; in three tests, the controls had no bacteria, whereas the synthetic dressing did. Healing of burns was similar under both types of dressing. Benefits of Hydron treatment included increased patient comfort because of the reduced number of dressing changes and, in some cases, greater freedom from contaminating bacteria.

Failure of topical steroids and vitamin E to reduce postoperative scar formation following reconstructive surgery.

One hundred fifty-nine operative procedures for postburn contractures of interdigital webs (96), the axilla (46), or the neck (17) were prospectively randomized to be treated postoperatively for four months with a topical steroid (Aristocort A), topical vitamin E, or the base cream carrier for these drugs. The nature of the medication was blinded both to the patient and to the evaluator. Patients were followed for one year. Observations were made for range of motion, scar thickness, change in graft size, and ultimate cosmetic appearance. No beneficial effect of either vitamin E or topical steroid could be demonstrated. However, adverse reactions occurred in 16.4% of patients receiving active drug, compared to 5.9% treated only with base cream. Interestingly, the grafts initially contracted and subsequently grew to be a size larger (about 20%) than the original graft by one year. It is concluded that neither topical steroid nor topical vitamin E is effective in reducing scar formation after grafting procedures for reconstruction for postburn contractures.