[Burns and Diabetes Mellitus: Epidemiology, Clinical Presentation and Prognosis]. / Brûlures Chez Le Diabétique: Étude Épidémiologique, Clinique et Pronostique.

Burns in diabetics are quite frequent and serious in relation to diabetic neuropathy, which is common in this population, delaying healing and predisposing to the risk of infection. The objective of this study was to describe the characteristics of burns in diabetics hospitalized at the CTB of Tunis over 18 months. During the study period, 891 patients were hospitalized, including 43 diabetics (5%). The average age of our patients was 57 years old with a male predominance (65%). Type 2 diabetes was present in 86% of cases and type 1 diabetes in 14% of cases. Degenerative complications were reported in 10 cases (23%), such as diabetic retinopathy (n=6), diabetic nephropathy (n=4) and diabetic neuropathy (n=6). The circumstances of burns were related to a domestic accident in 2/3 of the cases (76.7%). Thermal burns were involved in 83.7% of cases. 86% of the patients had decompensated their diabetes during their hospitalization. Sepsis marked the evolution of the patients in 55.8% of cases. In our study, poor prognostic factors were: a glycosylated haemoglobin > 13%, an extent of burns greater than 20%, and a delay in consultation greater than 6 hours. The mortality rate was 18.6%.

Suicide by Self-Immolation in the Pediatric Population.

Self-immolation is a violent way of committing suicide. Few studies have focused on this phenomenon in children. The aim of this study was to determine the epidemiological profile of children who committed suicide by fire. A retrospective descriptive study was conducted in an intensive burn care department in Tunis, over a period of 10 years (2011-2020). Of a total 3077 patients, 761 were admitted for burns by suicide attempt, among them 62 children and adolescents (8%). The number was on average six per year. The highest annual prevalence was noted in 2011 (27% of cases). The mean age was 16 and a half years old. The majority of cases were adolescents aged 15 or older. There is a male predominance (sex ratio:3). Total burn surface area (TBSA) was on average 44%. The act of self-immolation occurred in public places in 58% of cases. Socio-economic environment was unfavorable in 60% of cases. The suicidal act of self-immolation was due to a family conflict in 34% of cases (n=21). Seven patients (11%) had a history of mental illness. Forty-three patients (70%) required mechanical ventilation. The length of hospital stay was on average 30 days. The mortality rate was 56.5%. In conclusion, self-immolation is frequent in the pediatric population; it induces severe burns associated with a poor prognosis.

L' immolation est un moyen de suicide particulièrement violent. Peu d'études se sont penchées sur ce phénomène chez l'enfant. Cette étude a pour but de déterminer le profil des enfants recourant au feu pour se suicider. Il s'agit d'une étude rétrospective réalisée sur une période de 10 ans (2011-2020) dans la réanimation spécifique du CTB de Tunis. Sur 3 077 patients admis, 761 avaient réalisé une tentative de suicide (TS) parmi lesquels 62 (8%) enfants ou adolescents. Vingt-sept pour cent des cas sont survenus en 2011 (6/an en moyenne). L'âge moyen est de 16 ans 1/2, la majorité des patients étant des adolescents de 15 ans ou plus. On observe un prédominance masculine (3M/1F). La surface atteinte moyenne représente 44% SCT. La TS est réalisée dans un espace public dans 58% des cas. Le contexte socio ­ économique est considéré défavorable dans 60% des cas, avec un contexte de conflit familial à l'origine de 34% (21 fois) des TS. Sept patients (11%) avaient un passé psychiatrique. Quarante - trois patients (70%) ont eu besoin de ventilation mécanique. La durée moyenne de séjour a été de 30 j, la mortalité de 56,5%. En conclusion, les TS par le feu ne sont pas rares chez les enfants. Elles entraînent des brûlures graves, au pronostic péjoratif.

[Acute Pancreatitis Related to Tigecycline in ICU Burn Patients]. / Pancréatitis Aiguë Liée à La Tigécycline Chez Des Patients Brülés En Réanimation.

Drug-induced acute pancreatitis (AP) associated with tigecycline (TGC) is considered a rare complication (incidence between 1‰ and 1%). In this paper, we report five cases of AP occurring after the administration of TGC in septic patients hospitalized in intensive burn care in Tunisia over 9 years. The diagnosis of AP was based on clinical and/or biological signs. Among 303 cases treated with TGC, AP occurred with an incidence of 1.65%. The mean age was 28±6 years. Only one patient had a history of chronic alcoholism. The prescribed dose was 200 mg as a loading dose, followed by 100 mg twice a day. The time to onset of symptoms after initiation of TGC was 5.4 days [2-7]. PA was suspected due to abdominal pain associated with nausea and vomiting (n=2), occlusive syndrome (n=1) and fortuitously increased pancreatic enzymes in 2 patients under mechanical ventilation. The mean lipase level at diagnosis was 447 IU ± 135 IU (4.5 to 10 times the normal). All the aetiologies of AP were ruled out, including gallstones, hypercalcemia, hypertriglyceridemia, trauma and infections. The mean time to symptom resolution after stopping TGC was 4±2 days [5-7] and to the normalization of pancreatic enzymes it was 9 days [2-20 days]. In conclusion, clinical and biological monitoring was necessary in patients treated with TGC in order to avoid severe forms, especially in at-risk patients.

[Procalcitonin: The Ideal Biomarker To Guide Initiation, Change and Withdrawal of Antibiotics in Septic Burn Patients?] / La Procalcitonine: Biomarqueur De Choix Pour Guider L'Initiation, La Modification Et L'Arrêt De L'Antibiothérapie Chez Les Brûlés Sepitques?

The goal of this study was to assess plasma procalcitonin (PCT) concentrations during infectious events of burns in the ICU. We conducted a prospective, observational study in a 20-bed Burn Intensive Care Unit in Tunisia. A total of 120 septic patients admitted to the Burn ICU were included in our study. Sepsis was assumed according to the French Burn Association criteria for the presence of infection. Serum PCT was measured over the entire septic episode every 48 hours until resolution of infection, based on clinical signs and decrease of PCT of about 80% compared to its initial value. Patients were assigned to two groups depending on clinical course and outcome: Group A = patients with favourable evolution; Group B = patients with unfavourable evolution. Monitoring of kinetics of PCT allowed us to judge the effectiveness of the initial antibiotic therapy, with a threshold of 43.5% decrease at day 3 of treatment, with a better sensitivity and specificity of 79.6% and 87.7% respectively. In addition, PCT monitoring allowed a reduction in the duration of antibiotic therapy of 5±2.8 days versus 8 to 10 days before the use of PCT.

Brûlure Et Atteinte Oculaire: Incidence, Facteurs De Risque Et Pronostic.

Ocular lesions in burns are common and diagnosis is often late, leading to functional impairment including loss of vision to these individuals. A retrospective study was conducted to assess ocular lesions in burns during ICU stay (01/01/2013 to 30/09/2020) in a 20-bed burn ICU in Tunis. Twenty-six cases combining burns and ocular lesions were reviewed. The average age was 26, with a sex-ratio 3.3/1. TBSA was 22±13%. Face was affected in 23 patients, and mechanical ventilation was required in 10 cases. Diagnosis of ocular lesion was noted at 4.5 H (1-33 H) after burn injury. Main clinical signs were: eye redness (n=5) and purulent eye discharge (n=5). Lesions were mainly corneal abscess and corneal ulcer. Treatment combined local antibiotics (n=16) associated to systemic antibiotics in 10 cases. Surgery was required in 2 cases. Loss of vision was noted in 2 patients. Risk factors of corneal abscess were: facial burn (p=0,01); burn depth (p=0,02) and mechanical ventilation (p=0,04).

Hypernatremia Risk Factors And Prognostic Impact In Burn Patients: A Case Control Study.

Hypernatremia is associated with poor outcomes in critically ill patients. Hypernatremia risk factors in burned patients are not well studied. We aimed to identify hypernatremia risk factors and to evaluate outcomes in burned patients admitted to our burns intensive care unit. A case control study was conducted in adult burned patients hospitalized between January 1st 2017 and December 31st 2019. Cases who developed hypernatremia (>145 meq/L) during hospitalization were matched 1:1 with controls based on age and total burn surface area. There were 57 cases and 57 controls with a mean age of 41 ± 18 years. The majority of patients had major burns (n=99, 86.8%). The time onset of hypernatremia was seven days post burn. Compared to controls, the case group mostly consisted of transferred patients with longer time from injury to intensive care unit admission. Inhalation injury, mechanical ventilation, intravenous fosfomycin and colistin were associated with hypernatremia. Admission to the intensive care unit after six hours post-burn was the independent risk factor (OR=4.5). Hypernatremia was associated with longer length of stay and with higher mortality. We conclude that delayed management, inhalation injury, mechanical ventilation, fosfomycin and colistin administration are the main hypernatremia risk factors in burned patients.

L'hypernatrémie est un paramètre pronostic défavorable chez les patients de réanimation. Ses facteurs de risque n'ont pas été bien étudiés chez les brûlés. Nos objectifs étaient d'identifier les facteurs de risque d'hypernatrémie et d'évaluer son impact sur le pronostic des brûlés hospitalisés dans notre unité de réanimation. Une étude cas-témoins a été menée chez des brûlés hospitalisés entre le 1er janvier 2017 et le 31 décembre 2019. Les cas (hypernatrémie >145 meq/L pendant l'hospitalisation) ont été appariés 1/1 avec des témoins, en tenant compte de l'âge et de la surface brûlée. Nous avons colligé 57 cas et 57 témoins âgés de 41±18 ans. La plupart des patients (n=99 soit 86,8%) souffraient de brûlures étendues. L'hypernatrémie s'est installée après sept jours des brûlures. Les cas avaient plus souvent été transférés d'une autre institution et étaient pris en charge dans le service après un délai plus long. Les lésions d'inhalation, la ventilation mécanique, la fosfomycin et la colimycine étaient les facteurs de risque d'hypernatrémie. L'admission en réanimation au-delà de six heures en était le facteur de risque indépendant (OR=4,5). L'hypernatrémie était associée à une durée de séjour plus longue et à une mortalité plus élevée. Nous concluons que la prise en charge tardive, les lésions d'inhalation, la ventilation mécanique, la fosfomycine et la colimycine sont les facteurs de risque d'hypernatrémie chez les brûlés.

Bactériémies Nosocomiales: Épidémiologie Clinique Et Bactériologique Chez Les Brûlés.

Nosocomial bacteremia (NB) is one of the most severe infections in burns in intensive care units. Their prognosis is worsened with the emergence and spread of multidrug resistant bacteria (MDR). Our retrospective study aimed to investigate clinical and bacteriological characteristics of NB occurring in patients hospitalized in the Trauma and Burn Center's Burn Unit (TBC-BU) in Tunisia, during a 3-year period (2016-2018). We found 261 NB in 216 patients, for a prevalence of 25.7% and an incidence density of 13.4‰ days of in-patient stay. The vast majority (88.9%) of NB occurred during the first 2 weeks of hospitalization. The catheterrelated bacteremia rate was 11.1%. P. æruginosa (20.2%) and A. baumannii (16.8%) were the 2 species most frequently isolated when S. aureus represented only 7.5% of isolates. Resistance rates were high, with 71% of P. æruginosa resistant to ceftazidime, 64% of S. aureus being MRSA, 69,5% of resistance to 3rd generation cephalosporins among Enterobacteriaceae, and colimycin remaining the only regularly active antibiotic (98%) on A. baumannii. The MDR rate was 44%, represented mainly by A. baumannii, ESBL-E and P. æruginosa. The mortality rate due to NB was 25%, with a significantly higher rate of MDR in fatal NB compared to that in NB with favorable outcome (p = 0,000019).

Brûlures Chimiques: Étude Rétrospective Sur Un An Dans Le Centre De Traumatologie Et Des Brûlés De Ben Arous À Tunis. À Propos De 123 Cas.

Chemical burns are rare but have specific diagnosis and treatment characteristics. We present a retrospective study among the 123 patients treated in the Tunis Burns Unit during the year 2018. They were young (36.4 years), active men (69%). Most (51%) burns were work-related. Only fiftyseven patients had their burn immediately washed, and time to the first specialized examination was 3.7 days. Burned surface was low, frequently involving the hands. The majority of patients (121/123) did not need surgery and the treatment length was 20 days, resulting in aesthetic or functional disability in 46.3% of the cases. It seems that information and prevention measures are lacking, despite the fact they are the best means to reduce the incidence of chemical burns, which have high individual and collective costs. If a chemical burn occurs, it should be copiously washed, and the victim should be urgently examined by a burn specialist.

Brûlures Et Épilepsie : À Propos D'Une Série Tunisienne.

Patients with epilepsy are a high-risk population for severe burns. A retrospective study was conducted to assess burns during epileptic seizure in epileptic patients. The study was conducted in a 20- bed burn ICU in Tunis over the period 01/01/2011 to 30/06/2019. Fifty cases combining burns and epilepsy were reviewed. Twenty patients (11 women and 9 men, sex-ratio 0.6) suffering a burn following an epileptic seizure were included. The average age was 46. Epileptic disease was uncontrolled in 75% of our patients and 35% were not receiving any antiepileptic treatment. Burns were related to domestic accident in 95% of cases, 2/3 of which were related to a fall on a brazier. Lesions were deep in 70% of cases, requiring excision of necrotic tissue. Only two patients benefited from a dermal-epidermal graft. Amputation was necessary in 5 patients. Mortality was 25%, related to refractory septic shock.

Sténose trachéale chez les brûlés : incidence et facteurs de risque.

Tracheal stenosis remains frequent, especially in intensive care patients requiring prolonged intubation or tracheotomy. There is little data in the literature regarding this complication in burn patients. The aim of our study was to determine incidence, characteristics and risk factors of tracheal stenosis in burn patients. A retrospective study was conducted in a 20-bed burn ICU in Tunis over 7 years. It included all patients who presented tracheal stenosis confirmed by endoscopic and/or radiological exploration. Tracheal stenosis was confirmed in 15 patients with an overall incidence of 0.8% and an incidence of 3.5% in intubated patients. The mean age was 24 years, with TBSA of 28±15%. The burn was thermal in all patients. Facial burn was noted in all patients. Inhalation syndrome was observed in 12 patients. Duration of intubation was 16±12 days. Dyspnea, stridor and dysphonia were the most common symptoms. The onset of clinical signs was 30 days on average after extubation. All patients underwent bronchoscopy and/or cervico-thoracic scan for diagnosis. The average distance between the stenosis and vocal cords was 27 mm and the average degree of stenosis was 68%. The average length was 20 mm. Therapeutic management was based on: dilation in 3 cases, Montgomery tracheal T-tube insertion in 2 cases, and endoscopic laser therapy in 3 cases. Tracheal resection-anastomosis was performed in 5 patients. The evolution was favorable in 8 patients. Restenosis was observed in 2 patients. Five patients died. Inhalation injury, facial burn and prolonged intubation were recognized as risk factors that increase the likelihood of this complication.

Pharmacokinetics and pharmacodynamics of Linezolid in burn patients.

Burns induce complex physiological changes such as modification of distribution volume, increased clearance of elements and decrease of protein binding. The pharmacokinetics of many antibiotics may then be modified, which requires dose adjustment. We attempted to evaluate the pharmacokinetics of linezolid in burn patients at a standard dose of 600 mg intravenously thrice a day. A prospective study was conducted in a 20-bed adult burn ICU at a university-affiliated teaching hospital in Tunis. Thirteen adult burned patients with documented and/or suspected multi drug resistant (MDR) gram-positive bacterium-related infections were enrolled in the study. Our study suggests that linezolid dosing at 600mg thrice a day leads to adequate pharmacodynamic/pharmacokinetic exposure to linezolid with a Cmin > 2mg/l in 84.6% of cases, T > MIC in about 87.5% and AUC/MIC > 100 in 61.5% of cases. However, a high variability in linezolid serum concentrations with a substantial percentage of sub-therapeutic levels was observed in a few patients, 15% of cases. Therefore, therapeutic drug monitoring of linezolid might be helpful for adequate dosing of linezolid in burned patients, to avoid the risk of treatment failure or of dose-dependent toxicity.

Les brûlés présentent une augmentation du volume de distribution et une modification de la clairance de toutes les classes des antibiotiques. De ce fait, il est recommandé d'augmenter la dose de chaque antibiotique chez le brûlé. Le linézolide est recommandé à la dose de 600mg/12h chez les malades en réanimation. Ce travail est entrepris afin d'évaluer la pharmacocinétique du linézolide à la dose de 600mg/8h chez les brûlés. Une étude prospective a été menée dans le service de réanimation des brûlés de Tunis. Ont été inclu, les patients ayant une SCB ≥ 20% ayant une infection suspectée et/ou documentée à cocci à Gram positif multi-résistants. Notre étude suggère que l'administration de linézolide chez le brûlé à la dose de 600mg/8 h permet d'atteindre une meilleure pharmacocinétique, avec Cmin > 2mg/l dans 84,6% des cas, T > MIC dans 87,5% et un ratio AUC/MIC > 100 dans 61,5% des cas. Néanmoins, une variabilité des concentrations sériques de linézolide, avec des taux sub- thérapeutiques ont été notés chez 15% des patients. Le monitorage des taux sériques peut être utile lors de l'utilisation du linézolide chez les brûlés, afin d'éviter l'échec thérapeutique ou la toxicité, dose-dépendante..

The prevalence of healthcare-associated infection in medical intensive care units in Tunisia. Results of the multi-centre nosorea1 study.

OBJECTIVES: To determine the prevalence of Healthcare-Associated Infection (HAI) in medical Intensive Care Unit (ICU), risk factors for these infections and identify the predominant infecting organisms. METHODS: A 1-day point-prevalence study within all medical ICUs in Tunisia, all patients occupying an ICU bed over a 48-hour period were included. Rates of HAI, resistance patterns of microbiological isolates and potential risk factors for HAI were recorded. RESULTS: One hundred and three patients were collected from 15 Tunisian medical ICUs. HAI prevalence was 25.2% CI 95% [15-35].The most frequent HAIs were hospital acquired pneumonia in 19 cases (59%) and catheter related infection in 5 cases (15%). Independent factors associated with HAI occurrence were SAPSII score ≥ 33 with OR 1.047; CI 95% [1.015-1.077], p=0.003 and recent hospitalization with OR 4.14 CI 95% [1.235-13.889], p=0.021. Non-fermenting pathogens were the most frequent microorganisms reported in ICUs ecology, prior colonization and HAIs of the screened patients. CONCLUSION: HAIs are frequent in medical ICUs in Tunisia, which emphasize the importance of specific measures for surveillance and infection control in critically ill patients. Implementing a national monitoring system of HAI should be a major priority of public health in Tunisia.

Lactate: prognostic biomarker in severely burned patients.

Plasma lactate (PL) has been used as a marker of cellular hypoxia and shock. The correlation between PL and clinical outcome has been well accepted in hemorrhagic and septic shock. In contrast to the existing evidence, there are no or almost no data dealing with lactate and burn-related outcome. We attempted to assess whether early plasma lactate (PL) is a useful parameter to predict outcome in burned patients. A prospective study was conducted in a 20-bed adult burn ICU at a university-affiliated teaching hospital in Tunis. Patients admitted within the first 24h post burn with greater than 10% total body surface area (TBSA) burned were enrolled in the study. There were 60 males and 20 females. Mean age was 40.7 ± 19.5 years old, and average TBSA was 32 ± 21%. At admission, 86.7% patients had an initial lactate value of more than 2 mmol/L. In our study, an initial lactate value of 4 mmol/L provided the best sensitivity and specificity: 88% and 79% respectively for predicting sepsis, with an area under the ROC curve of 0,82. Furthermore, plasma lactate cut-off value for mortality prediction was 4.46 mmol/l with a good sensitivity (86%) and specificity (92%). Mortality rate was 36.25%. Plasma lactate appears to be a powerful predictor biomarker of sepsis and mortality in burn patients.

Le lactate plasmatique (LP) est utilisé comme marqueur de choc et d'hypoxie cellulaire. La corrélation entre LP et pronostic est validée dans les chocs hémorragique et septique. Il n'y a que peu voire pas de données concernant PL et pronostic chez les brûlés. Nous avons étudié si la mesure précoce de PL avait une valeur pronostique chez les brûlés. Une étude prospective a ainsi été menée dans l'unité de réanimation pour adultes brûlés (20 lits) du CHU de Tunis. Les patients (60 hommes et 20 femmes) admis dans les 24 h d'une brûlure touchant plus de 10% de SCT ont été inclus. L'âge était de 40,5 +/- 19,5 ans, la surface brûlée de 32 +/- 21%. La grande majorité (86,7%) des patients avaient LP > 2 mmol/L à l'admission. Une valeur > 4 mmol/L étaient la plus prédictive de complication septique, avec une sensibilité de 88%, une spécificité de 9% et une aire sous la courbe ROC de 0,82. La mortalité était de 36,25% et un seuil de LP à 4,46 mmol/L prédisait le décès avec une sensibilité de 86% et une spécificité de 92%. LP semble donc être un marqueur prédictif fiable de sepsis et de mortalité chez les brûlés.

La nécrolyse épidermique toxique.

Toxic epidermal necrolysis (TEN) or Lyell's syndrome is a potentially life-threatening dermatological disorder, with clinical and histological features characterized by the destruction and detachment of the skin epithelium and mucous membranes. Intensive symptomatic management is crucial: analgesia, daily dressing changes, prevention of infections and symptomatic intensive care measures (hydration, nutrition and oxygen therapy). The aim of our study is to determine epidemiological, clinical and therapeutic characteristics of patients admitted to the intensive burn care unit of Tunis over 9 years, from July 2001 to July 2009.

Procalcitonin: a diagnostic and prognostic biomarker of sepsis in burned patients.

The goal of this study was to analyse plasma procalcitonin (PCT) concentrations during infectious events of burns in ICU. We conducted a prospective, observational study in a 20-bed Burn Intensive Care Unit in Tunisia. A total of 121 patients admitted to the Burn ICU were included in our study. Serum PCT was measured over the entire course of stay in patients with predictive signs of sepsis according to the Americain Burn Association Criteria for the presence of infection. Patients were assigned to two groups depending on the clinical course and outcome: Group A = non septic patients; Group B = septic patients. A PCT cutoff value of 0,69 ng/ml for sepsis prediction was associated with the optimal combination of sensitivity (89%), specificity (85%), positive predictive value (82%) and negative predictive value (88%). Serum procalcitonin levels can be used as an early indicator of septic complication in patients with severe burn injuries as well as in monitoring the response to antimicrobial therapy.

Le but de cette étude était d'analyser la concentration de procalcitonine plasmatique (PCT) mesurée au cours des cas d'infection chez les patients brûlés en soins intensifs. Nous avons mené une étude observationnelle prospective dans une unité de soins intensifs de 20 lits en Tunisie. Un total de 121 patients admis ont été inclus dans notre étude. La PCT a été mesurée pendant toute la durée du séjour chez les patients avec des signes prédictifs de septicémie selon les critères de l'American Burn Association pour la présence de l'infection. Les patients ont été répartis en deux groupes en fonction de l'évolution clinique et les résultats: Groupe A = pas de patients septiques; Groupe B = patients septiques. Une valeur PCT de 0,69 ng/ml est associée à la combinaison optimale de sensibilité (89%), spécificité (85%), valeur prédictive positive (82%) et valeur prédictive négative (88%). Les niveaux de procalcitonine sérique peuvent être utilisés comme un indicateur précoce de complication septique chez les patients atteints de brûlures graves, ainsi que dans le contrôle de la réponse à la thérapie antimicrobienne.