Pathological Analysis of Post-Burn Hypertrophic Scars according to Various Scar Ages

PURPOSE: This study investigated the morphological characteristics of hypertrophic scars of various ages. METHODS: This was a retrospective study. Tissue samples from 170 normal skin (control) and 126 scar tissue after undergoing conservative treatment (CT) (n=62) or split thickness skin graft (STSG) (n=64) were obtained. Time from injury (CT) or surgery (STSG) was grouped into periods as follows: first 6 months (period 1), 7~12 months (period 2), 13~24 months (period 3), 25~120 months (period 4), >120 months (period 5). Epidermal thickness (ET), dermal thickness (DT), and dermal collagen fiber thickness and length (CFT, CFL) were measured using an image analyzer. RESULTS: Scar tissue ET was significantly thicker compared to normal skin (P<0.05) and was greatest at period 1. Scar tissue DT was significantly thicker compared to normal skin (P<0.05), which increased until period 3 but then decreased afterwards. Scar tissue CFT was significantly thinner compared to normal skin (P<0.05) except for period 5. Scar tissue CFL was significantly longer compared to normal skin (P<0.05). Significant differences were observed especially in younger scar ET, DT, CFT, and CFL. CONCLUSION: These findings may assist to increase the understanding of the pathohistological changes in burn scar tissues over time and provide guidance in receiving burn treatment.

Interleukin-31, Interleukin-31RA, and OSMR Expression Levels in Post-burn Hypertrophic Scars

BACKGROUND: Although several studies have shown the role of interleukin-31 (IL-31) and its receptors in inducing pruritus in certain skin disorders, knowledge of its role in post-burn hypertrophic scars is insufficient. Therefore, the histopathological expression levels of IL-31, IL-31 receptor alpha (IL-31RA), and oncostatin M receptor (OSMR) in post-burn hypertrophic scar tissues were investigated and compared with normal tissue expression levels. METHODS: Samples of hypertrophic scar tissue were obtained from 20 burn patients through punch biopsy. Normal samples were obtained from areas adjacent to the burn injury site of the same patients. Samples were placed in 10% neutral buffered formalin, embedded in paraplast, and processed into serial 5-μm sections. Immunohistochemistry results were semi-quantitatively evaluated for IL-31, IL-31RA, and OSMR. By hematoxylin and eosin staining, epidermal and dermal thickness were assessed with a microscope and digital camera. Intensities were rated on a scale of 1 to 4. RESULTS: Percentages for IL-31, IL-31RA, and OSMR in the epidermal basal layer cell cytoplasm were significantly greater in the burn scar tissue compared to normal skin, as well as the dermal and epidermal thickness (p < .05). There was a significant difference in IL-31 epidermal basal layer intensity in burn scar tissue compared to normal skin (p < .05). Besides the OSMR basal layer intensity, IL-31 and IL-31RA intensities between the burn scar and normal tissues were not significant. However, correlations were significant, indicating that the greater the infiltration percentage, the higher the intensity (p < .05). CONCLUSIONS: IL-31, IL-31RA, and OSMR expression levels are increased in hypertrophic scars compared with normal tissue.

Serial Changes of Heat Shock Protein 70 and Interleukin-8 in Burn Blister Fluid

BACKGROUND: It has been reported that heat shock protein 70 (HSP70) and interleukin-8 (IL-8) play an important role in cells during the wound healing process. However, there has been no report on the effect of HSP70 and IL-8 on the blisters of burn patients. OBJECTIVE: This study aimed to evaluate the serial quantitative changes of HSP70 and IL-8 in burn blisters. METHODS: Twenty-five burn patients were included, for a total of 36 cases: twenty cases on the first day, six cases on the second, five cases on the third, three cases on the fourth, and two cases on the fifth. A correlation analysis was performed to determine the relationship between the concentration of HSP70 and IL-8 and the length of the treatment period. RESULTS: The HSP70 concentration was the highest on the first day, after which it decreased down to near zero. Most HSP70 was generated during the first 12 hours after the burn accident. There was no correlation between the concentration of HSP70 on the first day and the length of the treatment period. No measurable concentration of IL-8 was detected before 5 hours, but the concentration started to increase after 11 hours. The peak value was measured on the fourth day. CONCLUSION: While HSP70 increased in the first few hours and decreased afterwards, IL-8 was produced after 11 hours and increased afterward in burn blister fluid. These findings provide new evidence on serial changes of inflammatory mediators in burn blister fluid.

Clinical and Histological Correlation in Post-Burn Hypertrophic Scar for Pain and Itching Sensation

BACKGROUND: Hypertrophic scar following a burn is caused by the excessive deposit of collagen resulting in an exaggerated wound healing response. The burn patient complains of pain and itching over the scar, which can give rise to cosmetic and functional problems. OBJECTIVE: The aim of this study was to investigate the clinical and histological correlation of a hypertrophic burn scar for itching and pain sensations. METHODS: Thirty-eight patients underwent a scar release and skin graft. the modified Vancouver scar scale and the verbal numerical rating scale were recorded. All biopsies were taken from scar tissue (scar) and normal tissue (normal). Histologically, tissues were observed in the epidermis, the monocytes around the vessels, the collagen fiber, elastic fiber, and the mast cells. RESULTS: The mean total score of MVSS was 8.4+/-2.7 (pliability 2.0+/-0.9; thickness 1.8+/-0.9; vascularity 2.0+/- 0.9; and pigmentation 2.1+/-0.9). Pain and itching were 2.4+/-2.0 and 2.9+/-3.0. Epidermis were 7.9+/-2.8 layers (scar) and 4.0+/-0.8 layers (normal). The collagen fibers were thin and dense (scar) and thicker and loose (normal). The elastic fibers were thin and nonexistent (scar) and thin and loose (normal). Mast cells were 11.2+/-5.8/high power field (scar) and 7.4+/-4.1 (normal). CONCLUSION: As the scar tissue thickens, the itching becomes more severe. The stiffness of the scar with the pain appeared to be associated with the condition of the tissue. The correlation between clinical and histological post-burn hypertrophic scars will help further studies on the scar. This helped with the development of the base material for therapeutic strategies.

Bilateral recurrent laryngeal nerve palsy in a patient undergoing consecutive thyroid operations / 대한마취과학회지

No abstract available.

The effect of heated breathing circuit on body temperature and humidity of anesthetic gas in major burns / 대한마취과학회지

BACKGROUND: Cold and dry gas mixtures during general anesthesia cause the impairment of cilliary function and hypothermia. Hypothermia and pulmonary complications are critical for the patients with major burn. We examined the effect of heated breathing circuit (HBC) about temperature and humidity with major burned patients. METHODS: Sixty patients with major burn over total body surface area 25% scheduled for escharectomy and skin graft were enrolled. We randomly assigned patients to receiving HBC (HBC group) or conventional breathing circuit (control group) during general anesthesia. The esophageal temperature of the patients and the temperature and the absolute humidity of the circuit were recorded every 15 min after endotracheal intubation up to 180 min. RESULTS: There was no significant difference of the core temperature between two groups during anesthesia. The relative humidity of HBC group was significantly greater compared to control group (98% vs. 48%, P < 0.01). In both groups, all measured temperatures were significantly lower than that after intubation. CONCLUSIONS: The use of HBC helped maintain airway humidity, however it did not have the effect to minimize a body temperature drop in major burns.

Pericardial tamponade caused by massive fluid resuscitation in a patient with pericardial effusion and end-stage renal disease: A case report / 대한마취과학회지

Pericardial tamponade can lead to significant hemodynamic derangement including cardiac arrest. We experienced a case of pericardial tamponade in a patient with end-stage renal disease. Hemodynamic changes occurred by unexpectedly aggravated pericardial effusion during surgery for iatrogenic hemothorax. We quickly administered a large amount of fluids and blood products for massive bleeding and fluid deficit due to hemothorax. Pericardial effusion was worsened by massive fluid resuscitation, and thereby resulted in pericardial tamponade. Hemodynamic parameters improved just after pericardiocentesis, and the patient was transferred to the intensive care unit.

Hemidiaphragmatic paralysis and hemohydrothorax following right internal jugular vein catheterization / 대한마취과학회지

No abstract available.

The Effect of Weight-Compensated Intravenous Patient-Controlled Analgesia in Burns

PURPOSE: The pain related to burn is moderate to severe and difficult to control regardless of medications. We evaluated the effect of intravenous patient-controlled analgesia (IV PCA) with weight-compensated regimen of fentanyl and ketorolac in burn surgery. METHODS: consecutive 82 patients received IV PCA after burn surgery. They were divided into two groups according to total body surface area% (TBSA%): group I (TBSA> or =25%, n=21) group II (TBSA or =25%) was difficult to control by conventional IV PCA, even through weight-compensated regimen. Pain of burn (TBSA> or =25%) should be controlled by increased dose of analgesics and approaches other than conventional medication.

Clinical and Histological Analysis after Laser Treatment in Hypertrophic Scar

PURPOSE: A hypertrophic scar following a burn injury is caused by the excessive deposit of collagen resulting in an exaggerated wound healing response. The aim of this study was to investigate the clinical and histological analysis after laser treatment in hypertrophic scar. METHODS: Three patients underwent a hypertrophic scar contrcture release and skin graft. The Modified Vancouver Scar Scale (MVSS) is commonly used to evaluate scars. It was composed of pliability, height, vascularity and pigmentation. Thickness was measured by an ultrasound. Pain and itching over the scar were recorded by using the Verbal Numerical Rating Scale (VNRS). All biopsies were taken from scar tissue and normal tissue for grafting area in the operation room. Epidermis and monocytes around vessels, collagen fiber, elastic fiber and mast cell of scaring dermis part observed histologically. RESULTS: On the basis of microscopic findings in patient 3, there are two patterns. The upper part of dermis shows thickened, glassy, eosinophilic collagen bundles which is similar to that of keloid formation. The lower part of dermis shows hypercellular collagen fibers, which is similar to that of regular hypertrophic scar pattern. Probably this patient may have a tendency of keloid formation or secondary change of Laser therapy. Clinical correlation is suggested. CONCLUSION: The laser has the improvement of hypertrophic scaring but can make histological changes due to many procedures. We should be aware of the side effects of the laser.

Macintosh laryngoscope vs. Pentax-AWS video laryngoscope: comparison of efficacy and cardiovascular responses to tracheal intubation in major burn patients / 대한마취과학회지

BACKGROUND: Patients with major burns accompanied with airway edema need more attention for airway management. Although the Pentax-AWS has an advantage in managing endotracheal intubation more easily, its usefulness cannot be assured if it does not maintain hemodynamic stability in burn patients. The aim of this study was to compare cardiovascular responses and general efficacy of the Pentax-AWS and Macintosh laryngoscopes in burn patients. METHODS: American Society of Anesthesiologists physical status 2 or 3 adult patients with major burn injury were randomly assigned to group P (AWS, n = 50) or group M (Macintosh, n = 50). Fifty-nine patients assigned to the Macintosh group and no patient to AWS group were excluded because of failure to first intubation. Hemodynamic data at baseline, just before and after intubation as well as 3, 5 and 10 minutes after intubation and grade of sore throat were recorded in two groups. Intubation time, success rate of intubation, number of intubation attempts and the percentage of glottic opening (POGO) scores were also observed and analyzed in all patients. RESULTS: A statistically significant increase in heart rate just after laryngoscopy was seen in group M. The success rate of the first attempt in group P (100%) was greater than with the group M (46%). POGO scores were higher in group P (97 +/- 4%) than in group M (48 +/- 29%) CONCLUSIONS: The use of Pentax-AWS offers a reduced degree of heart rate elevation compared with the Macintosh laryngoscope and better intubation environments in major burn patients.

The BIS and hemodynamic changes in major burn patients according to a slow infusion of propofol for induction / 대한마취과학회지

BACKGROUND: Many pathophysiologic alterations in patients with major burns can cause changes in the response of propofol. The aim of this study is to determine the appropriate induction dose of propofol using a slow infusion rate for major burn patients to obtain desirable sedation and hypnotic conditions with minimal hemodynamic changes. METHODS: 45 adults with major burns and who were electively scheduled for escharectomy less than a week after injury were recruited. For induction with propofol, the patients were randomly allocated to one of two groups (group 1: 1.5 mg/kg, n = 20 and group 2: 2.0 mg/kg, n = 25). The infusion rate was 20 mg/kg/hr. The systolic and diastolic blood pressure (SBP, DBP), the heart rate, the bispectral index and the modified observers' assessment of the alertness/sedation scale (OAA/S) were measured before the induction and after the propofol infusion, as well as immediately, 3 and 5 minutes after intubation. RESULTS: The SBP and DBP were significantly decreased after the propofol infusion in both group, but there were no significant differences between the two groups. The BIS values after the propofol infusion and intubation were 44.2 +/- 16.1 and 43.5 +/- 13.8 in group 1, and 45.6 +/- 10.3 and 46.5 +/- 11.4 in group 2, respectively, and there were no differences between the 2 groups. CONCLUSIONS: When propofol is administrated to major burn patients, an induction dose of 1.5 mg/kg is appropriate and a slow infusion rate of 20 mg/kg/hr is safe for maintaining the desired hypnotic conditions and this dose and rate cause no significant hemodynamic problems.

Cardiovascular crisis after small dose local infiltration of epinephrine in patient with asymptomatic subarachnoid hemorrhage: A case report / 대한마취과학회지

The infiltration of dilute epinephrine solution has been used for many years to provide hemostasis. However, epinephrine has adverse cardiovascular effects, such as arrhythmia, pulmonary edema, and even cardiac arrest. We have experienced epinephrine-induced cardiovascular crisis, with severe hypertension, tachycardia, and cardiac arrest after subcutaneous infiltration of a 2% lidocaine and 1 : 200,000 epinephrine solution in a patient with an asymptomatic subarachnoid hemorrhage. We provided successfully advanced cardiac life support in the operating room and cardioverted the patient back into a sinus rhythm with no untoward effects. The patient recovered without any apparent sequelae after intensive care.

Hypothermia During Total Hip Arthroplasty with Combined Spinal-epidural Anesthesia

In operations of the lower extremities in elderly patients, regional anesthesia is preferred over general anesthesia because regional anesthesia is associated with less deep vein thromboses, pulmonary emboli, bleeding, transfusion volume, and can better control post-operative pain. During surgery, a drop in core temperature frequently occurs. In elderly patients, temperature control and compensatory abilities are physiologically impaired. During induction of regional anesthesia, such as spinal anesthesia, elderly patients often do not complain of coldness, despite the decrease in the core temperature. Also, problems associated with hypothermia can easily be overlooked because anesthesiologists are less concerned about measuring the body temperature of patients than they are during induction of general anesthesia. Because perioperative hypothermia can cause various complications, such as infection, bleeding, cardiac injury, and shivering, closer attention is necessary. We report a case of hypothermia that developed during total hip arthroplasty under combined spinal-epidural anesthesia.

The Hemodynamic Effect of the Local Epinephrine Injection to a Burn Scar

BACKGROUND: As a method for reducing bleeding, epinephrine local infiltration is used in hypertrophic scar release. However, this can induce unexpected increased absorption and increase the cardiovascular risk. Therefore we evaluated the hemodynamic effects of epinephrine local infiltration. METHODS: Sixty patients underwent hypertropic scar release under general anesthesia. Thirty patients who do not have a history of hypertension were classified as group 1, and thirty patients who had a history of hypertension were classified as group 2. The heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were observed before injection of epinephrine and every minute up to six minutes after injection of epinephrine. RESULTS: Even though the HR significantly increased at 1 and 2 minutes in each group, the difference between the two groups was not significant. The SBP, DBP and MAP were significantly increased in group 2 compared to group 1. The SBP of group 2 significantly increased at every minute up to six minutes and group 1 had a significant increased for 2 minutes. The DBP of group 2 significantly increased for 3 minutes and group 1 significantly increased for 2 minutes. The MAP of group 2 significantly increased for 2 minutes and group 1 significantly increased for 2 minutes (P < 0.05). CONCLUSIONS: Local infiltration of epinephrine in hypertrophic scar temporarily increases the heart rate and blood pressure. Therefore, the patient with hypertension can have an increased the cardiovascular risk and this should be carefully considered.

Hemoptysis and obstruction of the endotracheal tube by blood clot in a pediatric patient: A case report / 대한마취과학회지

Hemoptysis leading to airway obstruction by blood clot is a serious and potentially lethal condition in pediatric patients because of the unpredictable course and technical difficulty of managing small airways. An 11-month-old male patient with a contact burn on his left foot was intubated uneventfully during induction for general anesthesia. After 15 minutes, we noted blood in his endotracheal tube along with high airway pressure and desaturation. Immediate suction was performed, and the oxygen saturation recovered, but the airway pressure and small exhaled tidal volume were unchanged. We had difficulty differentiating endotracheal tube obstruction from bronchial spasm at that time. We successfully managed the endotracheal obstruction by extubation with removal of the blood clot and reintubation after the diagnosis was made using fiberoptic bronchoscopy. We review the etiology and management of airway obstruction and hemoptysis in the operating room.

The changes of heart rate, blood pressure and cardiac index in burn surgery under propofol-remifentanil anesthesia and desflurane anesthesia

BACKGROUND: Major burns can alter the hemodynamic effect caused by anesthesia. Total intravenous anesthesia induces little hemodynamic change and desflurane has a rapid induction advantage among the different kinds of inhalation anesthesia. The study compared propofol and remifentanil anesthesia with desflurane anesthesia during induction and maintenance anesthesia. METHODS: Forty patients, who were scheduled for burn surgery, were randomly assigned to either Group 1 (n = 20) or Group 2 (n = 20). Group 1 was induced and maintained with an infusion of propofol and remifentanil. After inducing anesthesia with propofol and rocuromium, group 2 was maintained with desflurane. The heart rate and mean arterial pressure, and cardiac index were measured in the operation room, after induction (AI), after intubation (AT) and at 5, 10, 15 and 20 minutes after intubation. RESULTS: There was a significantly lower heart rate in group 1 than in group 2. The heart rate of group 2 showed a significant increase at AI, AT, 5, 10, 15 and 20 minutes after intubation. There was no significant difference in the mean arterial blood pressure and cardiac index between the two groups. CONCLUSIONS: During burn surgery, total intravenous anesthesia was effective in attenuating the hemodynamic effects.

Effect of 6% Hydroxyethyl Starch Solution on Coagulation Function in Patients with Major Burns / 대한구급학회지

BACKGROUND: Patients with major burns require replacement of intravascular volume. Hydroxyethyl starch (HES) solutions are widely used to replace intravascular volume. Dilution with crystalloids or colloids and corresponding platelet dysfunction are known causes of perioperative bleeding tendencies. The aim of the current study was to evaluate the effect of crystalloid and colloid solutions on platelet function in patients with major burns. METHODS: Forty patients scheduled for burn surgery were divided into 4 groups. The infusion was started with a Hartman solution infusion (group 1) from 7 A.M. until surgery. HES (6%, Voluven(R)) was infused in the following concentrations: 7 ml/kg (group 2), 10 ml/kg (group 3), and 15 ml/kg (group 4). The bleeding time (BT), prothrombin time (PT), prothrombin time international ratio (PT INR), activated partial thromboplastin time (aPTT), hemoglobin (Hb), platelet function analyzer-100 closing time (PFA CT), and platelet count (Plt) were measured. RESULTS: Hartmann solution and HES had no significant effect on the BT, PT, PT INR, a PTT, Hb, and Plt. The post-operative PFA CT was significantly higher in group 4 than in group 3. In group 4, the PFA CT was significantly higher post-operatively compared to pre-operatively. CONCLUSIONS: The use of high dose HES may increase the risk of bleeding tendencies in burn patients.

Effect of Inhaled Sevoflurane and Intravenous Propofol with Remifentanil on the Core Body Temperature in Burn Patients

BACKGROUND: The ability of the body to maintain its temperature is evidently decreased in patients with thermal injury. The aim of this study is was to evaluate the effect of inhaled sevoflurane and intravenous propofol with remifentanil on core body temperature in burn patients. METHODS: Sixty patients scheduled for burn surgery were divided into 4 groups. Within the major burn patients, intravenous propofol and remifentanil group (group I) followed by a continuous infusion of propofol and remifentanil. In inhaled sevoflurane group (group II), propofol 2mg/kg was given intravenously over 10 seconds as a single bolus and was maintained with nitrous oxide and oxygen and 2-2.5% sevoflurane. In minor burn patients, the intravenous propofol and remifentanil group (group III) and inhaled sevoflurane group (group IV) were treated in the same manner. After induction of anesthesia, esophageal stethoscope was placed to monitor the core temperature every five minutes in all patients. RESULTS: During operation, the core temperature of major burn patients was about 0.7-1.0 degreesC greater than that of minor burn patients. Until 95 minutes after induction of anesthesia, this difference showed statistical significant. However, there was no statistical significance after 100 minutes (P < 0.05). There were no statistically significant differences between group I and group II and group III and group IV for burn patients as well. CONCLUSIONS: Compared to minor burn patients, the core temperature of major burn patients was greater, and anesthetics type and administration route during operation had no effect on the core temperature in these patients.

Nonlinear Mixed Effect Modeling of Propofol Population Pharmacokinetics in Patients with Major Burn

BACKGROUND: Major burns can alter the pharmacokinetics of the commonly used drugs during the perioperative period. This study was carried out to define the population pharmacokinetics of propofol in the burned patients during the subacute hyperdynamic phase of the injury. METHODS: Twenty adults, aged 43.7 +/-2.3 years, with total body surface area burn of 44.0 +/-22.2%, were examined at 14.1 +/-2 days after the injury (mean +/-SD). Age and sex gender matched unburned patients served as controls. Propofol 2 mg/kg was given intravenously over 10 seconds as a single bolus in both groups. Blood samples (n = 20) were collected at predetermined intervals. Nonlinear mixed effect modeling was used for the pharmacokinetic analyses of the propofol concentrations, which were determined by HPLC. The cardiac index was measured by esophageal echocardiography. RESULTS: The burns patients had a significantly higher cardiac index (CI). Propofol population pharmacokinetics has shown that clearance (Cl) and total volume of distribution (Vd) of propofol were higher in the burned patients. The significant model influencing covariates are the history of burn injury, extent of the injury and body weight. CONCLUSIONS: There is a large increase in Vd and Cl in the burns patients compared to with the controls. Therefore, the initial bolus dose and short duration infusion may have to be increased in the burns patients, provided the pharmacodynamic sensitivity is unaltered.