Five Years Experience With Meek Grafting in the Management of Extensive Burns in an Adult Burn Center.

BACKGROUND: In extensive burn injuries with lack of donor sites for skin grafting, the Meek technique of skin expansion can be an efficient and effective method in covering extensive wounds. The aim of this retrospective study was to present our experience with the Meek technique of grafting. METHODS: We performed a retrospective analysis of patients from our burn center who underwent Meek grafting between 2012 and 2016. Demographics, burn details, clinical course, operative management, and outcomes were collected and analyzed from patient records and operative notes. Outcome measures, including graft take rate, complications and need for further surgery, were recorded. RESULTS: Twelve patients had Meek grafting. The average age was 38 years (range: 15-66). The average percent total body surface area burned was 54.3% (range: 31%-77%). Eighty-three percent of grafted areas healed well, and no regrafting was necessary. In the remaining 17%, infection and hematoma were the leading cause of graft failure. CONCLUSIONS: Meek grafting constitutes a rapid and efficient surgical approach for the skin coverage of extensive full-thickness burn injuries with limited autograft donor sites.

HISTORIQUE: En cas de brûlures étendues et en l'absence de siège de donneur pour procéder aux greffes cutanées, la technique Meek d'expansion cutanée peut être une méthode efficace et efficiente pour recouvrir des plaies étendues. Cette étude rétrospective vise à présenter l'expérience des auteurs relativement à la technique de greffe Meek. MÉTHODOLOGIE: Les auteurs ont procédé à l'analyse rétrospective de patients du centre pour grands brûlés qui ont subi la technique de greffe Meek entre 2012 et 2016. Ils ont recueilli les données démographiques, les détails des brûlures, l'évolution clinique, la prise en charge opératoire et les résultats cliniques et ont analysé le dossier du patient et les notes de l'opération. Ils ont colligé les mesures des résultats cliniques, y compris le taux de prise de la greffe, les complications et la nécessité d'une nouvelle opération. RÉSULTATS: Douze patients d'un âge moyen de 38 ans (plage de 15 à 66 ans) ont subi la technique de greffe Meek. Le pourcentage moyen de la surface corporelle totale brûlée était de 54,3 % (plage de 31 % à 77 %). Ainsi, 83 % des zones greffées ont bien guéri et n'ont nécessité aucune nouvelle greffe. Dans les 17 % de zones restantes, l'infection et l'hématome étaient les principales causes d'échec de la greffe. CONCLUSIONS: La technique de greffe Meek est une approche opératoire rapide et efficace pour couvrir de peau des brûlures pleine épaisseur étendues lorsque les sièges d'autogreffe sont limités.

Electrical injury - a dual center analysis of patient characteristics, therapeutic specifics and outcome predictors.

BACKGROUND: Electrical injuries represent life-threatening emergencies. Evidence on differences between high (HVI) and low voltage injuries (LVI) regarding characteristics at presentation, rhabdomyolysis markers, surgical and intensive burn care and outcomes is scarce. METHODS: Consecutive patients admitted to two burn centers for electrical injuries over an 18-year period (1998-2015) were evaluated. Analysis included comparisons of HVI vs. LVI regarding demographic data, diagnostic and treatment specific variables, particularly serum creatinine kinase (CK) and myoglobin levels over the course of 4 post injury days (PID), and outcomes. RESULTS: Of 4075 patients, 162 patients (3.9%) with electrical injury were analyzed. A total of 82 patients (50.6%) were observed with HVI. These patients were younger, had considerably higher morbidity and mortality, and required more extensive burn surgery and more complex burn intensive care than patients with LVI. Admission CK and myoglobin levels correlated significantly with HVI, burn size, ventilator days, surgical interventions, amputation, flap surgery, renal replacement therapy, sepsis, and mortality. The highest serum levels were observed at PID 1 (myoglobin) and PID 2 (CK). In 23 patients (14.2%), cardiac arrhythmias were observed; only 4 of these arrhythmias occurred after hospital admission. The independent predictors of mortality were ventilator days (OR 1.27, 95% CI 1.06-1.51, p = 0.009), number of surgical interventions (OR 0.47, 95% CI 0.27-0.834, p = 0.010) and limb amputations (OR 14.26, 95% CI 1.26-162.1, p = 0.032). CONCLUSIONS: Patients with electrical injuries, HVI in particular, are at high risk for severe complications. Due to the need for highly specialized surgery and intensive care, treatment should be reserved to burn units. Serum myoglobin and CK levels reflect the severity of injury and may predict a more complex clinical course. Routine cardiac monitoring > 24 h post injury does not seem to be necessary.

Continuous hemoadsorption with a cytokine adsorber during sepsis - a review of the literature.

Sepsis is a well-recognized healthcare issue worldwide, ultimately resulting in significant mortality, morbidity and resource utilization during and after critical illness. In its most severe form, sepsis causes multi-organ dysfunction that produces a state of critical illness characterized by severe immune dysfunction and catabolism. Sepsis induces the activation of complement factor via 3 pathways and the release of inflammatory cytokines such as tumor necrosis factor alpha (TNF-α) and interleukin-1beta (IL-1ß), resulting in a systemic inflammatory response. The inflammatory cytokines and nitric oxide release induced by sepsis decrease systemic vascular resistance, resulting in profound hypotension. The combination of hypotension and microvascular occlusion results in tissue ischemia and ultimately leads to multiple organ failure. Several clinical and experimental studies have reported that treatment using adsorption of cytokines is beneficial during endotoxemia and sepsis. This review article analyzes the efficacy of CytoSorb® adsorber in reducing the inflammatory response during sepsis. The CytoSorb® adsorber is known to have excellent adsorption rates for inflammatory cytokines such as IL-1ß, IL-6, IL-8, IL-10, and TNF-α. Studies have demonstrated that treatment with cytokine adsorbing columns has beneficial effects on the survival rate and inflammatory responses in animal septic models. Additionally, several cases have been reported in which treatment with cytokine adsorbing columns is very effective in hemodynamic stabilization and in preventing organ failure in critically ill patients. Although further investigations and clinical trials are needed, treatment with cytokine adsorbing columns may play an important role in the treatment of sepsis in the near future.

Secondary abdominal compartment syndrome in patients with toxic epidermal necrolysis.

INTRODUCTION: Secondary abdominal compartment syndrome (ACS) is a severe complication in patients admitted to burn intensive care units (BICUs). Unlike patients with thermal burns, patients with toxic epidermal necrolysis (TEN) present with a different pathophysiology and usually require less fluid. PATIENTS AND METHODS: We reviewed our registry of adult patients presenting with TEN in our 8-bed BICU over the course of 11 years and identified and analyzed patients treated for ACS and decompressive laparotomy (DL). RESULTS: From a total of 29 patients with bioptic confirmed TEN, 5 underwent DL due to ACS with a mean age of 57 years, mean percentage of total body surface area (TBSA) affected of 54±25%, complete epidermolysis of 28±24% TBSA, a mean severity of illness score (SCORTEN) of 3.8±0.8, and a mean intra-abdominal pressure before DL of 33±7 mmHg. Mortality was 100% in patients with ACS versus 33% without ACS. CONCLUSION: An ACS that requires DL worsens the already critical condition of a TEN patient considerably. TEN-related impaired intestinal functionality and increasing intestinal edema due to systemic capillary leakage warrant early initiation of intra-abdominal pressure monitoring to identify patients at high risk of ACS.

Severe cutaneous adverse reactions: emergency approach to non-burn epidermolytic syndromes.

INTRODUCTION: Although severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome and toxic epidermal necrolysis, are rare, they are associated with considerable morbidity and mortality. METHODS: The current knowledge regarding background, differential diagnoses, critical care and implications for inter-hospital emergency medical service (EMS) transport of these patients is discussed. CONCLUSION: SCAR patients will substantially benefit from early interdisciplinary care and thorough consideration of complications during EMS transport and intensive care treatment.

Toxic epidermal necrolysis in pregnancy: case report and review of the literature.

The authors report the case of a 29-year-old pregnant woman (2g1p) in the 16th week of gestation presenting with extensive toxic epidermal necrolysis (TEN). The cutaneous symptoms began at hands, feet, and in the mouth and developed during the course of 10 days to cover 75% of her TBSA, whereas total epidermolysis was present on more than 40% of her TBSA. Because of progressive swelling and bleeding of the oral mucosa, tracheal intubation was necessary to secure the airway of the patient. Critical care management required sedation, tracheotomy and artificial ventilation (14 days), prolonged fluid resuscitation, daily wound care, topical antiseptic and systemic antibiotic medication, hemostatic therapy and blood transfusion, hypercaloric nutrition, and frequent obstetric ultrasound evaluations. Reepithelialization began simultaneously with progressive epidermolysis and was completed after 35 days of conservative treatment. Because the patient experienced a swollen vulva and a stenotic birth channel, typical sequelae of TEN, a primary cesarean section was required after 40 weeks of gestation. The male infant showed neither signs of skin detachment nor sequelae caused by the prolonged therapy for the mother. A multidisciplinary approach and appropriate medical infrastructure are required to solve the challenge of TEN in pregnancy. In addition, the particular role of gestation in the pathophysiology of TEN needs to be explored further.

Fulminant, undetected Candida sepsis after an apparently survivable burn injury.

We report a 20-year-old male who suffered smoke inhalation injury and burns covering 26% of his TBSA, including his face, dorsal chest, and both the arms. The Abbreviated Burn Severity Index was 5 (likelihood of survival 95%). He underwent burn surgery, requiring massive transfusion. Postoperatively, he appeared increasingly hyperthermic, showed respiratory exhaustion, and was neutropenic (lowest white blood cell count was 0.8 Gpt with a normal granulocyte count). He developed acute respiratory distress syndrome, renal failure, and severe inflammatory response syndrome. Aggressive ventilation patterns, intermittent prone positioning, and high-dose catecholamine therapy were performed. Hydrocortisone therapy and antibiotic prophylaxis did not improve his clinical status. He died after 12 days of septic multiple organ failure. Legal medicine autopsy identified aggressive Candida famata mycosis. The organism mainly affected the alimentary canal, and there were multiple pyemic abscesses in tissues of the heart, liver, spleen, kidneys, lungs, and meninges. Histology confirmed gastric ulcers as the source of the Candida infection. Despite the autopsy findings, all intravital specimens collected (blood, urine, and tracheal mucus) and all clinical Candida antigen tests were unsuspicious. Postoperative neutropenia may be a warning sign of severe infection even in survivable burns. Suppression of immune response and possible previous gastric Candida colonization may contribute to hazardous outcomes. However, delayed and unreliable methods to detect fungal infections remain a major problem in burn care. Occult aggressive fungal sepsis resulting in early multiple organ failure should be kept in mind.