Necesidad de reconocer a la "Medicina del Quemado" como una nueva e independiente especialidad / The need to consider the "Burned Patient Medicine" as a new and independent medical specialty

La frecuente observación, aún en nuestros días, de pacientes con graves quemaduras atendidos en lugares no apropiados, que no cuentan con los recursos humanos y físicos necesarios para afrontar el tratamiento que tal patología requiere, ha motivado la presentación de este artículo. En el texto de esta nota se hace referencia a una frase de Dupuytren (prestigioso cirujano francés) del año 1839 que decía que “el tratamiento de las quemaduras ha sido objeto en todos los tiempos de las tentativas más bizarras (extravagantes) del empirismo” resultando incomprensible que 175 años después siga teniendo vigencia. Se deja constancia de que los cirujanos plásticos han sido los que desde comienzos del Siglo XX se han ocupado del tratamiento local y han aportado el recurso del autoinjerto de piel para la reposición cutánea, pero para atender a los pacientes graves, la necesidad del tratamiento integral demostró que esta situación excede los alcances de la Cirugía Plástica y, por lo tanto, han debido convocar a médicos clínicos (actualmente a terapistas intensivos) para que tomen a su cargo la corrección de las alteraciones generales (pulmonares, renales, inmunológicas e infecciones) y las desviaciones metabólicas que ocasionan las quemaduras graves. También, se recomienda actualmente en diversas publicaciones, la asistencia integral por un “grupo interdisciplinario” pero no se aclara quién debe coordinarlo y qué conocimientos debe tener el coordinador. Su presencia es indispensable para lograr la armónica acción del conjunto. Como medio para corregir estas deficiencias, se recuerda que: a) se ha solicitado al Ministerio de Salud de la Nación el reconocimiento de la “Medicina del Quemado” como Especialidad Básica; b) que desde el año 2006 se dicta una Diplomatura sobre “Fisiopatología, Clínica y Tratamiento Integral de las Quemaduras”...

The frequent observation, even in our days, of severely burned patients admitted in inappropriate places which lack the necessary human and physical resources to face the treatment of this pathology motivated the present article. Dupuytren, the renowned French surgeon, affirmed in 1839 that “the treatment of burns has always been subject to the most extravagant attempts of empiricism”. It is difficult to understand how this assertion maintains its validity 175 years later. In this work we refer to the fact that since the beginning of the 19th Century plastic surgeons have dealt with local treatment and implemented the procedure of the skin graft; however, in the case of severely burned patients requiring an integral treatment, plastic surgery proved to be insufficient. Clinicians (as well as intensive care professionals) were required to deal with the general disorders (lung, kidney and immunological disorders and infections) and the metabolic alterations produced by severe burns. In different works integral assistance by an “interdisciplinary group” is also recommended, but who should hire its services or the kind of knowledge required to do it is not clearly specified. The presence of a coordinator is vital to ensure a harmonious action of the group. As a means to correct these deficiencies, it is important to remember that: a) it has been requested to the Ministerio de Salud de la Nación the recognition of the “Burned Patient Medicine” as a basic specialty; b) a two-year Diploma in “Physiopathology, Clinic and Integral Treatment of Burns” is delivered since 1996; c) the creation of a four-year residency for the recent graduates is suggested; d) postgraduate courses are offered to those who will integrate the interdisciplinary groups of attendance of the burned patient, in order to obtain what the Ministerio de Salud de la Nación considers “additional capacities”...

Systemic perioperative antibiotic prophylaxis may improve skin autograft survival in patients with acute burns.

Skin autograft is the most important definitive treatment for acute-deep burns. Wound infection is the most important cause of autograft loss. Prior clinical studies have not shown any significant difference in the autograft survival rate and the use of perioperative systemic antibiotics. Their study assesses the potential benefit of systemic antibiotics in this setting, especially when topical antibiotics or artificial skin products are not readily available. The authors designed a prospective, randomized study in a cohort of patients with acute burns to assess the hypothesis that the use of systemic antibiotic prophylaxis affects the rate of skin autograft survival. Enrolled patients could have more than one autograft procedure done. These patients were randomized for each surgical procedure. The outcome measurement was autograft survival rate between the two groups. From October 2001 to October 2006, 77 patients were enrolled with a mean age of 41.7 years (SD +/- 19.4) and a mean skin total burn body surface area of 21.8 (SD +/- 23). The experimental group had 44 autograft procedures with systemic antibiotics (AP) and the control group had 46 procedures without antibiotics (NP). The rate of autograft survival for the AP group was 97% and for the NP group was 87% (P < .01) There was a partial autograft loss in 10 procedures (23%) in the AP group and 23 procedures (50%) in the NP group (P < .01). Patients with acute deep burns treated with autografts may benefit from systemic perioperative antibiotics prophylaxis, as antibiotics seem to be associated with increase autograft survival rate. The risk of colonization in other parts of the body with multidrug resistant bacteria warrants further study.