Central line-related sepsis in acute burn patients.

A retrospective review of all 443 burn patients admitted during a 13-month period from October 1, 1992 to October 31, 1993, was completed. Of these, 8 were transferred and eliminated from the study. Twenty-two patients who were felt to be terminal on admission and did not have blood cultures were included in the demographic data but were excluded from subsequent statistical analysis. One hundred ten patients had central venous lines (CVLs). Three patients with CVLs were transferred, thus leaving 107 patients with CVLs for statistical analysis. Additionally, 17 of the aforementioned terminal patients who had CVLs and 1 patient with a CVL who had documented sepsis before CVL insertion were excluded, leaving 89 patients with CVLs used in statistical analysis. Mean burn surface for those with central lines was 35.8 per cent, and for those without, 10.9 per cent. Sixty-four patients (59.8%) with a central line had inhalation injuries, as did 18 patients (5.5%) without. The number of lines per patient varied from 1 to 7. Sixty-one patients had one line, 46 had more than one. The total number of central line days for the entire group was 1749. The mean number of central line days per patient was 16.3. The mean number of line days per catheter was 8.48. The mortality rate for the 107 patients with a central line was 34 (32.7%). Mortality for all patients was 41 (9.4%). The incidence of sepsis increased with increasing number of central line days and increasing number of central line changes, but the effect of these two factors on the incidence of sepsis could not be studied separately, as they are highly correlated with each other. The most commonly recovered organisms were various types of Staphylococcus. Polymicrobial infections were common. There were 51 subclavian, 17 internal jugular, and 135 femoral catheters inserted. By logistic regression analysis, there was no statistically significant difference in the incidence of sepsis between upper- and lower-body CVL sites. Twenty-four patients (22.4%) with a CVL and one or more positive blood cultures were felt to have demonstrated sepsis. Some had more than one septic episode while lines were in place, reported as separate patients but not as separate septic episodes.

Primary excision of the burn wound.

Early excision of burn eschar and wound closure significantly improves survival following major burn injury. Immediate primary excision performed by burn-experienced surgeons in dedicated burn care facilities can reduce further morbidity and mortality, length of hospital stay and medical costs. Burn care at the millennium is evolving rapidly into a subcategory of trauma surgery, with burn patients increasingly being viewed as victims of major trauma who benefit most from immediate and definitive surgical correction of their injuries.

An approach to the management of toxic epidermal necrolysis in a burn centre.

Toxic epidermal necrolysis syndrome, a life-threatening skin disorder, requires specialized nursing care to optimize survival. The similarity of the condition to partial skin thickness burns suggests that management on a burn unit is an effective means of therapy. A review of eight patients treated at our Burn Center emphasizes the need for aggressive team management of the condition.

Experience with polymicrobial sepsis in a regional burn unit.

A 2-year review of 795 patients admitted to a regional burn unit was carried out to determine the incidence of polymicrobial sepsis. Of 38 bacteraemic patients, 21 (55 per cent) had polymicrobial sepsis in 1990. Of 38 cases in 1991, 12 patients (31.6 per cent) had polymicrobic infections. Of 36 deaths in 1990, 13 were attributed to sepsis, 12 of 29 (31.6 per cent) in 1991. Of the patients who died in 1990, eight (21 per cent) were polymicrobic septic deaths and six (15.8 per cent) in 1991. The problem has been reported in immunocompromised patients, especially those with terminal malignancies, but has rarely been noted in burn patients. Recognition of the seriousness of the problem and the aggressive antibiotic therapy appropriate to the organisms in question is advised.

Trichosporon beigelii septicaemia in a burn patient.

A patient with Trichosporon beigelii sepsis secondary to a 31 per cent burn is reported. Good results were obtained by treatment with amphotericin B. No other reports of septicaemia due this organism in burn patients have been found by us, although the organism has been reported as a cause of sepsis in cancer patients.

Management of candida septicaemia in a regional burn unit.

Sepsis due to candida infection is a major cause of mortality and morbidity on our unit. Over a period of 3 years and 4 months, 29 cases of candida septicaemia, diagnosed by blood cultures, were encountered at the burn unit at Augusta Regional Medical Center. Factors known to predispose to fungal sepsis were present in all cases. All patients had large burns (14-98 per cent total body surface (TBSA) with a mean of 48.3 per cent). All but one patient had at least one central venous line. Respiratory problems requiring ventilator support were present in 24 patients. Sixteen patients had Candida albicans sepsis, two in association with another fungal sepsis. Candida parapsilosis was encountered in nine patients, one in combination with another species. Four patients had Candida tropicalis. Amphotericin B was prescribed therapeutically in 25 patients, in seven together with fluconazole. Two patients received fluconazole only and two received no antifungal therapy. There were eight deaths all attributed to sepsis and all of whom had multiple organ failure. Five of those who died had completed a course of amphotericin B therapy, two were receiving treatment at the time of death, and one patient died before culture data became available. Early and aggressive therapy is advised and amphotericin B appears to be the drug of choice.

Use of cultured epidermal autografts in the treatment of large burns.

Mortality in patients with large areas of full skin thickness burns is, in part, due to complications developing during the period of prolonged delay required to obtain enough wound healing to permit skin grafting from limited donor sites. Cultured epithelial autograft (CEA) has become available as an alternative measure to the use of expanded skin autografts and regrafting. Small biopsies are taken and transported to the laboratories of BioSurface Technology where keratinocytes are grown to cover large areas during a 3-week period. The cultured keratinocytes are then available on petroleum jelly gauze which is applied to the patient. The gauze is used as a temporary dressing. To date, 37 patients have been biopsied. Grafts have been applied in 15. Graft 'take' averaged 71.5 per cent at our institution. Two of the patients grafted with CEA died of sepsis. One patient had a 100 per cent loss of the CEA grafts. In 12 patients, the use of CEA probably contributed significantly to wound coverage and survival. Such grafts are more susceptible to mechanical loss than routine autograft, although long-term coverage after several years is considered to be satisfactory. The cost of the process is high.

Massive haemorrhage due to rectosigmoid ulcers in a patient with extensive burns.

A 36-year-old white-skinned male was admitted with 45.5 per cent burns, mostly of full skin thickness. Severe rectal bleeding from rectal ulcerations developed on postburn day 12. Various conservative attempts at management failed, and after multiple transfusions, abdominoperineal resection was carried out with eventual complete recovery. Complications during his acute phase included Pseud. aeruginosa sepsis and Clostridium difficile diarrhoea. Extensive skin grafts were required. The cause of the rectal ulcerations is unclear.

The use of erythropoietin in two burned patients who are Jehovah's Witnesses.

Recombinant-human erythropoietin was given to two burn patients who are Jehovah's Witnesses and hence refused transfusion. Anaemia developing postburn was corrected in both patients. Serum erythropoietin levels were found to be elevated prior to initiation of therapy in both patients.

Caecal perforation due to colonic ulcer in a burn patient.

Non-specific ulcers of the colon are occasionally reported as a cause of perforation of the colon. No previous cases have been reported in burn patients as a cause of perforation, although cases of haemorrhage have been cited. A 42-year-old black-skinned female with a 26 per cent TBSA burn developed a caecal perforation from this cause. Treatment with caecostomy patient recovered successfully.

Burn due to a sawdust explosion.

Burns due to explosions of various types of inflammable dust have been reported, including coal dust, flour and grain dust. A 33-year-old worker was burned over 33 per cent of his body surface area in a sawdust explosion. Recovery was uneventful. This is the first reported case due to this mechanism as far as we have been able to ascertain.

Invasive burn wound infection due to Curvularia species.

A 3-year-old white-skinned female sustained a 44 per cent deep partial and full skin thickness burn due to petrol. She developed an invasive wound infection due to a fungus later identified as Curvularia species, an organism, usually a saprophyte, not previously reported as a cause of invasive burn wound infection. Treatment with surgical excision and Amphotericin B resulted in cure.

Burns of the skull with underlying intracranial meningioma.

A 68-year-old white-skinned male fell head first into a fireplace while having a seizure. Extensive burns of the skull were sustained requiring removal of the necrotic bone. The patient had an underlying meningioma. Healing of the skull was obtained using a latissimus dorsi flap. After the scalp was completely healed, the meningioma was successfully resected with significant improvement in the patient's mental function.

Purulent pericarditis in an adult burn patient treated with survival.

A 41-year-old white-skinned male admitted with 40 per cent total body surface area partial and full skin thickness burns developed septic pericarditis. He had a severe inhalation injury and subsequent pneumothorax. Multiple fibreoptic bronchoscopies were required. The septic pericarditis required pericardectomy which was carried out in two stages. The extensive burns required multiple operations. The patient eventually made a complete recovery.

Diagnosis of burn depth using laser-induced indocyanine green fluorescence: a preliminary clinical trial.

Clinical assessment of burn depth is frequently inaccurate. In order to effectively plan the treatment of burn wounds, an accurate diagnosis of burn depth is desirable. A new method for evaluating the depth of burns by imaging the blood flow through the burned tissue using fluorescence from intravenously injected indocyanine green (ICG) dye illuminated with a 785-nm, near-infrared diode laser array was evaluated. Nine patients and 15 individual burn sites were studied. Five sites were classified by the ICG study as superficial second degree, four were deep-dermal second degree, and six were third degree. Etiology of the injuries included flame, contact burns, and scalds. The date postburn of the study ranged from 1 to 11 days. In all cases, the relative fluorescence levels (e.g. superficial second-degree burns yielded relatively bright fluorescence, third-degree burns appeared much darker than surrounding normal skin) were found to correlate well with actual burn depth as determined by histologic examination of biopsies and intraoperative clinical assessment.

A comparison of susceptibility to five antifungal agents of yeast cultures from burn patients.

Patients with significant degrees of immunocompromise, such as cancer, AIDS and large burns, who have received significant amounts of antibiotics, may develop infections with yeast organisms. Over a 3-year period, all patients with positive fungal blood cultures and most wounds of patients with large burns considered to be a risk of yeast infection were selected and tested for their susceptibility to five antifungal agents, amphotericin B, ketoconazole, miconazole, diflucan, and 5-fluorocytosine. In all, 244 specimens of yeast were tested: 142 Candida albicans, 52 Candida parapsilosis, 26 Candida tropicalis and 13 Trichosporon beigelii. A limited number of other isolates of Candida (12) were also encountered. All Candida organism were sensitive to amphotericin B. There was wide variation in regard to the susceptibility to the other four agents, with C. albicans and C. tropicalis being largely resistant to miconazole and ketoconazole. T. beigelii was recovered in 13 patients. One-half of these organisms was resistant to amphotericin B. Awareness of variations in species and susceptibility are helpful in the selection of appropriate therapeutic antifungal agents.

Osteomyelitis of the spine in a burn patient due to Candida albicans.

A 38-year-old white-skinned male was burned in an ultralight plane crash and sustained a 59 per cent body surface area burn, mostly full thickness skin loss. A fracture of the first lumbar vertebra was noted at admission which was treated without surgery. Candida septicaemia was diagnosed and treated during the acute phase of injury. Extensive grafting was required. Following discharge, the patient began experiencing low-grade back pain which was aggravated on postburn day 277 by a fall down a flight of stairs. Spinal radiographs obtained following this fall revealed osteomyelitis at the level of the eighth and ninth vertebrae with an intervertebral abscess. Following evacuation of the disc space during surgery, the organism was identified as Candida albicans. Treatment with amphotericin B and later fluconazole was initiated. Recovery was uneventful. The infection, probably of a haematogenous origin, is the first such case reported in the literature to our knowledge.

Reconstruction of disruption of the abdominal wall in burn patients.

Two patients with extensive destruction of the full thickness of the abdominal wall and associated intra-abdominal injuries were encountered. One case resulted from burns to a patient pinned under an automobile in contact with the muffler; the other was injured as a result of penetration of the abdominal wall by a railroad coupling and was also burned in an associated welding accident at the same time. Extensive staged debridement and repair of intra-abdominal injuries in several procedures were required in case 1. Closure was eventually achieved with serial applications of mesh and split-thickness autografting. In case 2, an initial attempt at flap closure failed. Coverage initially was obtained with silicone mesh followed by split-thickness grafting. We report successful management of two of these difficult reconstructive challenges.

Enterococcal infections as a cause of mortality and morbidity in patients with burns.

Enterococcal sepsis is a significant cause of death on our burn unit. In a 3-year period, enterococci were responsible for 11% to 13% of all infections. Bacteremias with enterococci ranged from 4.2% to 2.1% per year. Sixty-four percent of enterococcal bacteremias were polymicrobial. Septic deaths associated with enterococcal sepsis ranged from 20% to 10.3%. Antibiotic resistance to enterococci appears to be increasing.

Candida parapsilosis sepsis in patients with burns: report of six cases.

Six patients with burns who had Candida Parapsilosis septicemia were encountered during a 3-year period at a regional burn unit. Four patients treated with Amphotericin B survived; two untreated patients did not. Candida Parapsilosis seems to be increasing in frequency at our unit. The organism is somewhat more resistant to antifungal agents than are other Candida species.