Prise en charge des brûlés par télé-expertise.

At the end of 2013, we proposed the possibility of obtaining specialized burn advice 24/7 via pictures transmitted through a dedicated email address, to healthcare professionals. This simple tool is now a success, and we received one request for advice per day in 2015, resulting in an exchange of numerous emails. This simple process offers a number of benefits: it allows burn centres to regulate patient flows all year long, gives healthcare professionals access to a burn care specialist when and as quickly as they need, ensures each patient receives dedicated care, and allows national authorities to provide the best public health service and gain financial profits. However, a tool that uses email is much too simple and insufficiently secure, therefore it can only represent the first step towards a much more "professional" solution.

Estimation of blood loss during adult burn surgery.

INTRODUCTION: Large burns excision and graft can produce major blood loss. The main objective of this study is to evaluate the blood loss in relation with the excision size in square centimeters (cm2) in adults. PATIENTS AND METHODS: We conducted a monocentric, observational, prospective and open study in a burn intensive care unit. Patients aged-over 18 with burn wounds excision and autografting covering at least 5% of total body surface area (TBS) were enrolled. Blood loss was evaluated with Mercuriali formula. RESULTS: 139 procedures were evaluated: median graft size was 1637cm2, median blood loss was 0.8ml/cm2 excised and grafted skin and median total blood loss was 1444ml. 84 procedures (i.e. 60.4%) required transfusion. 66 procedures concerned upper limbs, 75 lower limbs, 17 head and 72 trunk. 126 procedures used tangential excision, 10 used fascia excision and 3 used the two techniques. Patients with comorbidities (ASA score 3 or 4) had more bleeding (p=0.001). CONCLUSION: The results that were obtained, i.e. approximately 0.8ml/cm2 of excised and grafted skin, are similar to those of other published studies, which concerned specific populations such as pediatrics. Determining blood loss in one centre can help physicians to calculate the excisable area without any transfusion. However, blood loss can vary widely between patients and one must consider individual clinical situation to provide safe surgery.

Utilisation d'une solution polyamphotère lors de lésions et brûlures chimiques oculaires cutanées et buccales. effet sur la douleur de la diphotérine®.

Polyamphoteric washing solutions (PWS) have been used for several years, mainly in industries, for cases of chemical ocular or cutaneous splashes by acid or alkali. We collected 37 cases reporting the use of PWS for ocular and cutaneous chemical splashes from several centres. Among the 37 cases, 55.26% resulted from occupational exposure. Among ocular exposures, initial clinical symptoms included pain (20 cases), blepharospasm (4 cases), hyperaemia (15 cases), palpebral oedema (2 cases) and blurred vision (7 cases). Among cutaneous exposures, 2 injuries were classified as deep, and 11 as superficial. Mean (SD) pain (VAS) before PWS was 6,29 +/- 2,74; mean (SD) pain after PWS was 1,47 +/- 1,73. Early application of PWS to the eye or skin reduces the intensity of pain that is associated with chemical damage. Early application of amphoteric solution appears to reduce the incidence of sequelae, provided its pre-hospital and hospital use is early. However, further studies are needed.

[Not Available]. / Bactériophages et phagothérapie: utilisation de virus naturels pour traiter les infections bactériennes.

The use of bacteriophages, natural predators of bacteria, is an effective technique in the fight against bacterial infections. Long since forgotten in the western world, it is still practised in parts of Eastern Europe as the primary weapon of choice against bacterial infections in public health policy. The global emergence of multidrug-resistant bacteria, or « superbugs ¼, and the associated risk of returning to the pre-antibiotic era have brought the benefits of phagotherapy back to the fore. The purpose of this paper is to highlight the biology and place of bacteriophages in their natural context and explain why and how phagotherapy can be an effective solution to treat bacterial infections.

[Not Available]. / Épidémiologie descriptive de la brûlure dans un territoire de santé exemple du « territoire nord franche-comté ¼ durant l'année 2014.

This is an epidemiologic study of the need for Health Services for burns in the northern part of Franche Comté (north-east of France) along year 2014 (114 patients). Mean age was 26 years (8 month-81 years), one third of burns occurred in children below 15. Most burns take part in summer, around mealtime, in "school-free" days, at home and are scalds. Their surface is low (4,81%) and they are usually partial thickness ones. Patients are consulted in Emergency Department in 88,59% of the cases, and hospitalised thereafter in a Burns Unit (in Lyon more than Nancy or Metz) in 12,28%.

35ème congrès SFB, table ronde «nutrition¼: transcription des communications.

Chaque année, le congrès de la SFB est l'occasion d'une mise au point sur un thème (« table ronde ¼.) Celui choisi en 2015 était la nutrition. Huit orateurs se sont succédés, faisant le point sur les données actuelles de la science, les pratiques dans les centres, et les recommandations actuelles, datant de 2013. Cet article se propose de diffuser les interventions.

[Burn: An inflammatory process]. / La brûlure : une pathologie inflammatoire.

Thermal injury induce a two-phase inflammatory response: first, a pro-inflammatory status, resulting in a systemic inflammatory response syndrome, then an anti-inflammatory phase characterized by a profound defect in cellular-mediated immunity. This inflammatory reaction proceeds from complex phenomenons in whom many cellular elements are involved (macrophage is the central one) and very complex molecular products interact (especially cytokines). These phenomenons promote significant physiopathologic consequences, especially on cardiovascular homeostasis and endothelial permeability, that lower the prognosis. The inflammatory reaction can be modified, enhanced or maintained by adverse events (i.e. infection) resulting in degradation of clinical situation. Despite a better comprehension of the phenomenons underlying this inflammatory process, diagnosis or therapeutic applications are at that time disappointing.

Syringotropic cutaneous T-cell lymphoma: an immunophenotypic and genotypic study of five cases.

There is uncertainty about the exact nosological relationship between mycosis fungoides, follicular mucinosis, syringolymphoid hyperplasia with alopecia (SLHA) and syringotropic cutaneous T-cell lymphoma (CTCL). We report the clinical, histological, immunophenotypic and genotypic characteristics of a series of five patients (three men and two women) with syringotropic CTCL. We also review the 15 cases of SLHA previously reported in the literature. We conclude that syringotropic CTCL is a distinct clinicopathological variant of mycosis fungoides which may present on its own with characteristic punctate erythema or more commonly in association with folliculotropic lesions. Syringotropic CTCL is characterized histologically by infiltration of sweat glands by atypical lymphocytes in association with syringolymphoid hyperplasia. Cases of SLHA represent a syringotropic form of CTCL in association with follicular involvement, and such cases need to be investigated using T-cell receptor gene analysis of both skin and blood. Only limited conclusions on prognosis can be derived from our preliminary data. However, a review of the literature suggests that the prognosis does not differ significantly from other types of mycosis fungoides of equivalent stage.

Response of livedoid vasculitis to intravenous immunoglobulin.

Livedoid vasculitis is a chronic condition characterized by recurrent painful ulceration of the lower limbs, which heals to leave atrophie blanche surrounded by hyperpigmentation and telangiectasia. We report two patients with livedoid vasculitis who, after failure of conventional therapies, responded to intravenous immunoglobulin (IVIg). There was healing of areas of active ulceration and improvement of erythema, swelling and pain. IVIg has been used successfully to treat a variety of vasculitic disorders and appears to be well tolerated. We suggest that this treatment is offered to patients who have livedoid vasculitis that is unresponsive to other therapies.

[Percutaneous tracheostomy]. / Trachéotomie percutanée.

OBJECTIVES: The aim of this study was to evaluate the different techniques of percutaneous tracheostomies, their advantages, drawbacks, complications and to compare them to standard surgical tracheostomies. This study will consider only elective (non emergency) bedside procedures in intensive care units. DATA SOURCES: Extraction from Medline database of english and french articles on percutaneous tracheostomies and searching along with major review articles. STUDY SELECTION: The collected articles were selected according to their qualities regarding to their evidence level. In addition to several important or historic references, the literature of the five past years was studied. DATA EXTRACTION: The articles were reviewed according to their contribution for techniques, perioperative and postoperative complications, recent advances, advantages and drawbacks of all procedures. Publications addressing recent comparisons between surgical and percutaneous tracheostomies were specially studied. DATA SYNTHESIS: Four techniques of bedside percutaneous tracheostomies are available and marketed, in France: Ciaglia's dilation technique (with multiple or unique dilator), Griggs's technique (using a special designed forceps), and Fantoni's technique (Trans Laryngeal Tracheostomy). The most spred but also first described technique is the Ciaglia's (1985). The most recent articles comparing surgical and percutaneous tracheostomies techniques are not able to demonstrate a superiority of one of them in terms of feasibility or safety. In other words, there should be a slight advantage for the percutaneous tracheostomy regarding to the late post-operative complications, as there should be a slight advantage for the surgical techniques regarding to the perioperative complications. The literature analysis point out firstly the learning curve for percutaneous dilational tracheostomy, with a significant decrease of complication incidence with the operator's experience and secondly the continuous endoscopic guidance seems to increase the safety of the percutaneous procedure. CONCLUSION: Since there has been a great deal of percutaneous tracheostomy in the intensive care units, the incidence of tracheostomy have increased in those services. There is a trend to replace the surgical procedure by the percutaneous one. However, according to the potentially jeopardizing complications, percutaneous tracheostomy should be done by an experienced operator with the help of a continuous endoscopic guidance.

Clinical pharmacokinetics of ciprofloxacin in patients with major burns.

OBJECTIVE: To better master the use of ciprofloxacin (CPF) in burn patients, a clinical study, including pharmacokinetics in serum and urine, was undertaken in a pathophysiologically homogeneous population of major-burn subjects. METHODS: Twelve major-burn patients who were infected with Pseudomonas aeruginosa, enterobacteria and gram-positive cocci, received CPF (600 mg t.i.d.). The mean body surface area affected by third-degree burns was 31.8 +/- 14.5%. Two series of blood samples were drawn after the first and seventh doses; urine was collected during the first infusion. Levels of CPF in serum and urine were measured by means of high-performance liquid chromatography. A non-compartmental method was used for kinetic and graphic analysis of concentration-time pairs. RESULTS: No adverse effects were noted. Trough concentrations measured on day 3 (mean +/- SD) were above the minimum inhibitory concentration (MIC) for the organism responsible for infection; i.e., 2.0 +/- 1.2 microg. ml(-1), and maximum concentrations were high 9. 9 +/- 3.4 microg. ml(-1). An area under the concentration-time curve (AUC)/MIC ratio above 125 SIT(-1) (where SIT is the serum inhibitory titer), which has been strongly correlated with clinical response and time to bacterial eradication, was achieved in 11 patients with a MIC of 0.5 microg. ml(-1). There was a statistically significant difference between C(min) and AUC determined on day 1 and day 3. In contrast to healthy volunteers, CPF clearance rates were notably decreased. CONCLUSION: The pharmacokinetics of CPF was altered in major-burn patients. The recommended dosage regimen for administration of CPF, i.e. 600 mg t.i.d. shows no adverse effects and a good microbiological efficacy.

[Surgery for epidermolysis bullosa in children: value of the association of inhalation anesthesia and locoregional anesthesia]. / Chirurgie de l'épidermolyse bulleuse grave chez l'enfant: intérêt de l'association anesthésie générale par inhalation-anesthésie locorégionale.

Due to the cutaneous and mucosal fragility associated with epidermolysis bullosa, this disease is a source of various practical problems for the anaesthesiologist concerning the surgical posture, the monitoring of vital functions, the airways control and the vascular access, as all these procedures may worsen, sometimes dramatically, the lesions in these young patients, still in a precarious health state. Basing on published studies and their own experience, the authors have used in these patients a combined locoregional and general anaesthesia. The latter was obtained with isoflurane, administered in the non intubated and spontaneously breathing patient through a closed surgical isolation container (Vi-Drape), including the patient's head and ventilated with a ventilator generating a PEEP for long procedures. The results obtained during 9 procedures in 3 children are reported and discussed. For several shorter procedures (for example wound dressing), intramuscular ketamine was used.

Oxygen uptake and mixed venous oxygen saturation during aortic surgery and the first three postoperative hours.

This study was designed to determine the significance of changes in mixed venous oxygen saturation (SVO2) associated with aortic surgery. In 12 patients undergoing aortic aneurysm repair, SVO2 was monitored using a fiberoptic pulmonary arterial catheter, and oxygen uptake (VO2) was measured at 2-min intervals by a mass-spectrometer system. Excluding the phase of aortic clamping, VO2, hemoglobin, and arterial oxygen saturation were moderately stable during anesthesia, and changes in SVO2 were correlated with changes in cardiac output (CO). SVO2 remained stable during infrarenal aortic clamping, but increased during supraceliac aortic clamping. During the first three postoperative hours, changes in SVO2 were opposite to changes in VO2 and CO. They were especially marked in the patients whose preoperative left ventricular ejection fraction was less than 50%. We conclude that SVO2 changes are an indicator of same-direction changes in CO during general anesthesia except during periods of aortic clamping. The interpretation of SVO2 changes is more complex during aortic clamping and during the immediate postoperative period, two critical periods during which simultaneous changes in VO2 and CO occur.

[Aneurysm of iliac arteries. Is it anatomo-clinical entity? Report of 18 cases]. / L'anévrisme des artères iliaques. Une entité anatomo-clinique? A propos de 18 cas.

338 patients with aorto iliac aneurysms were operated in the Department of vascular surgery (Hosp. E.-Herriot-University A.-Carrel Lyon). Retrospective evaluation found 20 solitary iliac artery aneurysms (AAIS) in 18 patients (2 bilateral AAIS). 77% of aneurysms were on the common iliac artery, 17% on the internal iliac artery, and one case of mycotic aneurysm on the external iliac artery. 8 patients (44.4%) were asymptomatic, 5 (27.8%) had non specific complaints. Rupture or acute ischemia occurred in 5 cases (27.8%). The incidence of non atherosclerotic cause (dysplasia 33.3%, infection 16.7%) in this series shows a real difference with AAA (atherosclerotic dominant etiologic factor). The value of C.T. scanning and sonographic evaluation and their extensive use in vascular and non vascular diagnostic problems are an obvious explanation for increasing AAIS reports. The risk of rupture is probably higher than in AAA because of the incidence of arterial dysplasias (1/3 in this study) and mycotic origin. This occurrence suggests an aggressive surgical management. Aneurysmorrhaphy with graft interposition by intraperitoneal approach is the routine technique for most of surgeons. An alternative procedure (retroperitoneal approach) was performed on ten of our patients (55.5%). No perioperative mortality and low morbidity rate (one case of phlebitis) in our cases support this surgical management. The survival rate based on actuarial method is estimated 64% at five years (all grafts patent).