An innovative local treatment for staphylococcal scalded skin syndrome.

Staphylococcal scalded skin syndrome (SSSS) is the clinical term used to describe a range of blistering skin disorders induced by the exfoliative toxins of Staphylococcus aureus and prevalently affects neonates, infants and toddlers who lack antibodies to S. aureus toxins. SSSS is a highly contagious disease and is characterised by erythema and fever, followed by the formation of large fragile superficial blisters, which rupture only to leave extensive areas of denuded skin. A diagnosis of SSSS relies on the clinical picture, as well as on histological and microbiological findings. Neonates and young infants are particularly susceptible to a lack of the protective skin barrier, which may cause excessive protein and fluid losses, hypothermia and secondary infection. Due to a complete denudation of skin, the patients also suffer from almost unbearable pain. In our communication, we present an innovative temporary coverage of the denuded skin with Suprathel (PolyMedics Innovations GmbH, Denkendorf, Germany). Suprathel relieves pain, prevents heat loss and secondary infection, accelerates wound healing, does not need to be changed and makes daily care easy for the nurses and is well tolerable for the patient.

Role of neutrophils in the intestinal alterations associated with thermal injury.

We have examined the role of neutrophils in the alterations observed in the intestines of rats subjected to 40 per cent surface area scald injury. Histologically, there was no evidence of neutrophilia in the intestinal tissue, and myeloperoxidase activity in mucosal scrapings was not elevated. The distribution of labelled human neutrophils injected into the burned rats showed no enhancement of uptake in the intestines, although there was increased uptake by the lung. The present data suggest that neutrophil migration may not play a role in the alterations in small intestinal function and morphology seen in burn trauma in the rat, but may be a factor in lung damage associated with thermal injury.

Effect of acute and chronic lipopolysaccharide (LPS) administration on reticuloendothelial system (RES) phagocytic activity in vivo.

The effect of injection or chronic infusion of lipopolysaccharide (LPS) into unanaesthetized rats on the distribution of [99Tcm-]SC has been determined. At a dose of 2.5 mg/kg, LPS injection caused a marked alteration in the distribution of the radiolabelled material, with more uptake being achieved in the lung while less was taken up by the spleen. Kidney and liver uptake were also changed. Chronic infusion of LPS at a similar dose (3 mg/kg in 24 h) caused a marked increase in the uptake of the radioactive material by the lung only. These data are consistent with a working hypothesis that the alterations in RES phagocytic activity of the lung observed in rats subjected to burn trauma could be related in part to LPS, either coming as a bolus, or being continuously presented.

Role of skin in the burn-induced reduction of reticuloendothelial phagocytic activity in rats.

Acute burn trauma has been demonstrated to depress reticuloendothelial system (RES) phagocytic activity, which could partially explain the development of septicaemia in burn patients. In the present study we have attempted to determine the role that skin plays in the depression of the RES. One group of Lewis rats was subjected to a 100 degrees C scald burn for 10 s. Eschar was then removed and implanted onto the backs of a second group of normal controls. A third group of Lewis rats were subjected to sham treatment; the eschar of these animals was removed and implanted onto the back of a fourth group of normal rats. The excision sites of the donor animals were immediately covered with Biobrane. Twenty-four hours later the technetium-99m sulphur colloid [( 99mTS]SC) method described earlier (Trop et al., 1989) was used to determine phagocytosis in these four groups of animals. Acute burn trauma produced a marked reduction in colloid uptake by the spleen and a marked increase in the uptake of colloid material by the lung, although no effect was observed on liver or kidney uptake. Implantation of the burn eschar into normal control rats had no statistically significant effect upon colloid uptake. These data suggest that alterations in phagocytic activity of the spleen and lung occur within minutes after burn injury and may be unrelated to the presence of the burn eschar itself.

Effect of platelet activating factor on reticuloendothelial system function.

The effect of platelet activating factor (PAF) injections on the uptake of 99mTc-SC (99mTc-SC (99mTc-sulphur colloid) was determined in vivo. PAF (2 micrograms) injected intravenously into unanaesthetized, unrestrained rats was associated with the development of lesions in the small intestine and alteration of 99mTc-SC uptake in vivo. 99mTc-SC uptake into the lung was increased while spleen uptake was decreased. Pretreatment of the animals with a PAF antagonist, SRI-64-441, prevented the intestinal lesions and alterations of 99mTc-SC uptake. Macrophages, isolated from lung lavage of the PAF-treated rats, demonstrated a decreased generation of hydrogen peroxide in vitro. The present results suggest that, in addition to its other effects on the immune system, PAF can also alter the in vivo phagocytic activity of the reticuloendothelial system in the rat.

Effect of haemolysis on reticuloendothelial system (RES) phagocytic activity in rats.

The role of haemolysis of blood in the alterations in the uptake of [99mTc]SC ([99mTc]-sulphur colloid) in vivo in the rat has been examined. When the haemolysed blood (produced by first freezing the blood in liquid nitrogen) was infused into synergenic Lewis rats via the tail vein, there was a significant reduction in the uptake of the [99mTc]SC by the spleen, but lung, liver and kidney uptake remained constant. These results suggest that haemolysis of the blood may play a role in the alterations in RES phagocytic activity observed in the spleen following thermal injury.

Effect of heta-starch colloidal solutions on reticuloendothelial phagocytic system (RES) function in burned and infected rats.

The biodistribution of the plasma expander colloidal solution, heta-starch (HES), has been examined in rats, subjected to thermal injury or sepsis. The ability of these solutions to alter RES phagocytic function of [99mTc]-sulphur colloid ([99mTc]SC) uptake in vivo has been examined. The biodistribution of radiolabelled HES has been determined in normal rats. The HES colloidal solution has no deleterious effect upon RES function in vivo in the thermally injured animals or the septic animals as compared to sham controls. In addition, the HES colloidal solution seemed to be distributed primarily within the liver, spleen and kidney, with a small amount residing in the lung. Thermal injury did not increase the uptake of this material by the lung. These results suggest that the use of HES in thermally injured and septic individuals has no deleterious effects on RES function, nor does it accumulate in the lungs, and hence, should be advocated for use in these situations.

Effect of chronic interleukin-2 treatment on RES phagocytic activity in the rat.

The effect of chronic interleukin-2 (IL-2) injection upon reticuloendothelial system (RES) function in the rat has been determined. Seven-day treatments with two doses of human recombinant IL-2 resulted in a dramatic reduction in the phagocytic uptake of the liver and spleen, while increasing the weight of both organs. There were dramatic histological changes in the intestine, liver and spleen as well. These results suggest that the chronic use of IL-2 can result in hepatic dysfunction, which is associated with altered RES phagocytic function.

Platelet-activating factor induces intestinal necrosis, but not septic shock, in germ-free and specific-pathogen-free rodents.

Platelet-activating factor (PAF) was injected into conventional mice, endotoxin-resistant mice (C3H/HEJ), conventional rats, germ-free rats and specific-pathogen-free (SPF) mice. The PAF resulted in significant necrosis and damage to the small intestines of all the animals tested. In general, the frequency and severity of the lesions were similar in all groups. All the conventional rats and mice, as well as the endotoxin-resistant HEJ mice, were dead 18 h after the injection of the PAF, while all the germ-free rats and the SPF mice survived. These data demonstrate that development of massive intestinal lesions, in the absence of aerobic bacteria, is not sufficient to cause the death of the host from septic shock and endotoxaemia.

Controlled mechanical hypoventilation in a paediatric burn patient as treatment of acute respiratory distress syndrome.

The paediatric patient we are describing suffered a scald injury covering 83 per cent of the total body surface area (TBSA). This injury was complicated by Klebsiella pneumoniae septicaemia resulting in multiorgan failure (MOF). Acute respiratory distress syndrome (ARDS), gastrointestinal insufficiency, hepathopathy and wound conversion to full thickness posed the main problems. The boy was ventilated with pressure-controlled mechanical ventilation. The concept of permissive hypercapnia (PHC) resulted in a complete resolution of ARDS within 4 weeks. From our experience, further lung injury among infants and children suffering from severe ARDS can be avoided by using controlled mechanical hypoventilation. It is a simple and safe technique that allows adequate oxygenation.

Effect of acute burn trauma on reticuloendothelial system phagocytic activity in rats. II: Comparison of uptake of radiolabelled colloid and bacteria.

The uptake of radiolabelled colloid or bacteria was compared in normal rats and animals subjected to acute burn trauma. The uptake of colloid by the liver was unaffected by burn trauma, but uptake of the labelled bacteria was reduced. Spleen uptake of both colloid and bacteria was reduced by burn trauma while lung uptake was increased. These data are consistent with the hypothesis that acute burn trauma alters reticuloendothelial system phagocytic activity in the rat towards both inert particles and live bacteria.

Procel burn cover used as a total body dressing in burns.

A 26-month-old boy sustained a scald injury covering 83 per cent of his total body surface area (TBSA). He also developed sepsis and multiorgan failure (MOF). Locally he was treated with Procel burn cover and silver sulphadiazine cream (SSD) for 23 days. By using Procel, the dressing-change time was shortened significantly. Procel burn cover controlled core and skin temperature more effectively compared to conventional dressing, and the staff acceptance increased because of its easy and fast use. Based on our observation, this material can be used successfully as a total body dressing with children with extensive partial thickness burns or temporarily in full thickness burns until wound excision can be performed.

Continuous arteriovenous renal replacement therapy.

As urea and creatinine clearances achieved by continuous arteriovenous hemofiltration tend to be low, efforts were made to increase urea and creatinine elimination by modifying the original continuous arteriovenous hemofiltration system. We investigated the urea and creatinine clearances of different continuous renal replacement therapy systems. Urea clearance achieved by spontaneous arteriovenous hemofiltration was 9.1 ml/min, suction-supported arteriovenous hemofiltration 15.3 ml/min, arteriovenous hemodiafiltration 15.4 to 19.3 ml/min, arteriovenous hemodialysis 18.9 to 22.1 ml/min. Creatinine clearances ranged between 11.1 (spontaneous arteriovenous hemofiltration) and 25.1 ml/min (arteriovenous hemodialysis). Continuous arteriovenous hemodialysis seems at present to be the ideal renal replacement therapy system to compensate azotemia in hypercatabolic patients. Its urea and creatinine clearances are high, its clinical tolerance good and it is simple and safe.

Arteriovenous hemofiltration in children with multiple organ system failure.

In the last year nine critically ill children with multiple organ system failure (MOSF) were treated by continuous arteriovenous hemofiltration (CAVH). The mean number of organ systems involved was five per patient (range 4 to 7). Mean duration of hemofiltration was 136 hours (range 10 to 432 h.). Mean ultrafiltration rates of 6.4 +/- 3.0 ml/m2 b.s./min achieved mean serum creatinine levels of 2.39 +/- 1.49 mg/dl. Hypervolemia and pulmonary edema were corrected rapidly by CAVH. Total parenteral nutrition with a mean caloric intake of 62 +/- 15 kcal/kg b.w./day was provided throughout the hemofiltration period. In addition high ultrafiltration rates allowed delivery of large amounts of i.v. medications. CAVH is an ideal extracorporeal renal replacement system to control azotemia, fluid, electrolyte, and acid-base status in critically ill children. It carries the potential to improve survival rate in children with MOSF.

Arterial blood pressure immediately after thermal injury: the role of anesthesia.

Mean arterial blood pressure was measured in anesthetized rats. The duration that the rats were under anesthesia with ether or methohexital was brief, and the animals were allowed to awaken early after injury. Three hemodynamic measurements were compared: (1) lowest mean arterial blood pressure, (2) duration at lowest mean arterial blood pressure, and (3) time to recover initial mean arterial blood pressure. In these studies the anesthetic agents reduced mean arterial blood pressure by 36%, recovering to normal pressures within 24 to 39 minutes. During the hemodynamic observation period, no significant additional hemodynamic effects as a result of the thermal injury were seen. Administration of resuscitation fluid did not significantly affect hemodynamics during the observation period in this study. These studies demonstrate that anesthesia dominates the short-term cardiovascular effects of thermal injury, and therefore caution is required in the interpretation of acute cardiovascular effects immediately after thermal injuries with patients under general anesthesia.

Effect of irreversible dermal necrosis on phagocytic activity of reticuloendothelial system.

A model of full-thickness dermal necrosis was produced in rats by the application of liquid nitrogen to a 20% total body surface area of the dorsal skin surface. In this model there was an alteration of reticuloendothelial system phagocytic activity of the lung and spleen as measured by the uptake of technetium 99m-labeled sulfur colloid in vivo. The present results suggest that marked alterations in reticuloendothelial system phagocytic activity can be produced by full-thickness dermal necrosis in the absence of heat.

Core body temperature responses immediately after cutaneous thermal injury in rats.

Internal temperatures were continuously measured in rats that received 20% or 40% body surface area cutaneous scald injuries in 25 degrees C and 38.5 degrees C environments. In animals that received thermal injuries in the 25 degrees C environment, intraperitoneal, intraesophageal, and intrarectal temperatures rapidly rose to 40 degrees C within 5 minutes but returned to normal values within 15 minutes after injury. When 20% body surface area injuries were induced in a 25 degrees C environment, all of the animals survived. In the 25 degrees C environment, neither acute core body temperature elevations nor use of fluid resuscitation predicted survival. In contrast, in a 38.5 degrees C environment core body temperatures rapidly exceeded 41 degrees C with the 20% injury, and all of the animals died within minutes in spite of fluid resuscitation. These studies suggest that the ambient environmental temperature may significantly influence a thermally injured animal's ability to rapidly eliminate absorbed heat of injury and result in an elevated core body temperature, which may contribute to the immediate lethality of the injury.

Effect of acute burn trauma on phagocytic activity of the reticuloendothelial system in rats.

The effect of acute burn trauma on phagocytic activity of the reticuloendothelial system measured in vivo with technetium 99m sulfur colloid was examined in rats subjected to acute burn trauma. After the scald injuries (10-second, full-thickness burns) were induced, a reduction in phagocytic activity by the spleen took place with an accompanying increase in the uptake of colloid material by the lungs. Uptake of colloid material by the liver was essentially unchanged. These uptake changes, observed within hours after the inducement of acute burn trauma and apparently continuing for 7 days after burn injury, may explain, in part, the development of septicemia in patients with burns because altered phagocytic activity of the reticuloendothelial system can result in subsequent overabundance of microorganisms and bacteria in the blood.

[Tasks and organization of a pediatric intensive care unit]. / Aufgaben und Organisation einer pädiatrischen Intensivstation (PIPS).

Paediatric intensive care medicine mainly involves infants during the neonatal period and, in particular, premature babies. 70% of the children on assisted ventilation at the paediatric hospital of Graz University in 1985 and 1986 were neonates. Older children needing mechanical ventilation comprised only 1.6% of the total number of patients at our paediatric hospital. Paediatric intensive care units are therefore almost exclusively neonatal care units. Otherwise when serving the needs of children beyond the neonatal period these units are mostly required by paediatric subspecialities (i.e. cardiology, burns unit etc.). In view of the small number of patients in this group a high-standard paediatric intensive care unit should be multidisciplinary and preferentially attached to a university hospital rather than a regional hospital so as to maximise experience in the management of these children and ensure optimal care.

[Congenital malaria due to Plasmodium falciparum and Plasmodium malariae]. / Konnatale Malaria durch Plasmodium falciparum und Plasmodium malariae.

Increasing tourism and growing numbers of immigrants from malaria-endemic countries are leading to a higher importation rate of rare tropical disorders in European countries. We describe, to the best of our knowledge, the first case of connatal malaria in Austria. The patient is the first child of a 24 year old mother who was born in Ghana and immigrated to Austria one and a half years before delivery. She did not stay in an endemic region during this period and did not show fever or any other signs of malaria. The boy was healthy for the first six weeks of his life. In the 8th week of life he was admitted to our hospital due to persistent fever of unknown origin. On physical examination he showed only mild splenomegaly. Routine laboratory testing revealed mild hemolytic anemia with a hemoglobin value of 8.3 g/l. In the blood smear Plasmodium falciparum and Plasmodium malariae were detected. Oral therapy with quinine hydrochloride was successful and blood smears became negative for Plasmodia within 6 days. This case shows that congenital malaria can occur in children of clinically healthy women who were born in malaria-endemic areas even one and a half year after they have immigrated to non-endemic regions.