Clinical experience of acticoat™ treatment in extensive burn wounds.

Acticoat™ (Smith & Nephew, Hull, UK) is a relatively new form of silver antimicrobial barrier dressing produces a moist healing environment along with the sustained release of ionic silver for improved microbial control. The benefits of acticoat™ in the management of extensive burn wounds have been well established. Acticoat™ has been reported to reduce wound infection and promote healing. No evidence has emerged of resistance or cytotoxicity to acticoat™. Given these potential advantages, we have used acticoat™ in a variety of treatment of extensive burn wounds at burn unit, Siriraj Hospital during September 2002-May 2005. We reviewed with attention to wound etiology, % of organism colonization, efficacy and cost effectiveness. Due to its long lasting properties led to less frequent dressing changes and reduce trauma and pain to burn patients. It is particularly benefit to patients who suffered from partial thickness burn wound especially in children and high% of total body surface area (TBSA) patients (>15%). Acticoat™ treatment in extensive burn wounds also confirmed its efficacy, low labor cost set up and cost effectiveness compared to conventional dressing with silver sulfadiazine.

Comparison of efficacy of 1% silver sulfadiazine and Acticoat for treatment of partial-thickness burn wounds.

BACKGROUND: Acticoat (Smith & Nephew, Hull, UK) is a silver-coated dressing reported to reduce infection and exhibit antimicrobial activity in wounds. OBJECTIVE: The purpose of the present study was to compare the efficacy ofacticoat and 1% silver sulfadiazine (1% AgSD) for treatment of partial thickness burn wounds. MATERIAL AND METHOD: The authors reviewed 50 patients who had partial thickness burn wounds less than 25% admitted to Siriraj Burn Unit from May 2002 to September 2005. All patients were divided into 2 groups: the acticoat treated group (25 patients) and the 1% silver sulfadiazine treated group (25 patients). The 2 groups were compared for the etiology of burn wound, demographic data including age, sex, % Total Body Surface Area burn (TBSA%), cultured organisms, wound infection and outcome of Length Of hospital Stay (LOS) and level of pain. RESULTS: The authors found no significant differences in age, TBSA (%) between both groups. 7 patients (28%) developed wound infection. There were no differences in wound infection and LOS between both groups (p > 0.05). All of the patients who developed wound infection responded well to targeted topical and systemic antibiotic treatment. The 1% AgSD treated group (6 of 25, 24%) obtained more split thickness skin graft to close the granulation defects compared to patients who were treated with acticoat (4 of 25, 16%) but no statistical significance, p = 0.32). Average pain scores in the acticoat treated groups were significantly lower than the 1% AgSD treated group (4 +/- 0.6 versus 5 +/- 0.7, respectively). CONCLUSION: The present study confirms the efficacy of acticoat treatment in partial thickness burn wound. The authors conclude that acticoat has an advantage of limiting the frequency of replacement of the dressing and provides a less painful alternative to wound care with 1% AgSD with comparable incidence of burn wound infection. This is due to its long wear time and the ease of application and removal.

Comparison of a immunonutrition formula enriched arginine, glutamine and omega-3 fatty acid, with a currently high-enriched enteral nutrition for trauma patients.

The severe trauma or burn patients required aggressive resuscitation, operation and metabolic support to reduce morbidity and motality. Nutrition is one of the most important treatment for these patients, improving body protein and immune function, reducing rate of infection and shortening hospitalization. METHOD: To evaluate the metabolic and immune effects of dietary arginine, glutamine and omega-3 fatty acids (fish oil) supplementation, we performed a prospective study in patients age 15-60 yrs after severe trauma (Injury Severity Scores (ISS) 15-30) or burn patients (body surface area (BSA) 30-60%) in Siriraj Hospital. They were randomized to receive either Neomune or Traumacal. The nasogastric feeding was started in post-injury day 2 (PID2) with half of concentration at the rate of 30 ml/h. From PID3 to PID10, the normal concentration was administered at the rate of 80-100 ml/h depending on optimal caloric requirement. All patients received 5 per cent dextrose in half or full strength saline solution as clinically indicated. No other oral nutrients apart from study formula were allowed during the study. Blood sample was with-drawn on PID2, PID6 and PID11 for measurements of CBC, coagulogram, albumin, transferrin, CRP, LFT, BUN, Cr, CD3, CD19, CD4, CD8, C3, IgG, IgM, and IgA. Nitrogen balance was calculated from UUN. Unpaired student t-test was applied to compare variables between the two groups. RESULTS: 36 patients were selected (16 trauma and 20 burn), male = 29, mean age = 29.86 yrs. The patients were divided equally into two groups to receive Neomune or Traumacal. The data were compared and showed significance on total protein on PID11 (Neomune = 6.52 +/- 1.29, Traumacal = 5.59 +/- 1.21, p = 0.03) and serum triglycerides on PID11 (Neomune = 128.39 +/- 53.45, Traumacal = 186.25 +/- 84.07, p = 0.02). The ICU stay was observed shorter in Neomune than in Traumacal group (3.41 and 7.83 days) with no statistical significance. The wean-off respirator day was also shorter in Neomune than in Traumacal group (2.71 and 7.39 days). One patient in each group died. CONCLUSIONS: The feeding of Neomune in critically injured patients was well tolerated as Traumacal and significant improvement was observed in serum protein. Shorten ICU stay and wean-off respirator day may benefit from using the immunonutrient formula.

Prophylactic antibiotic in minor traumatic wound: Is it worth.

Antibiotics in minor traumatic wounds may not be useful if the wounds are not severely contaminated and received appropriate management since the chance of infection is usually low. Our objective is to determine the value of antibiotics in minor traumatic wounds. A randomized control trial was done in 166 patients (123 males, 43 females), aged between 6 and 60 years, with minor traumatic wounds. Most wounds were located on head and extremity regions. Cultures were done before suturing in all wounds. The wounds were cleaned and sutured as usual, then divided into two groups, group B treated with antibiotics for at least 3 days, group A no antibiotics was used. Antibiotics were given in 83 wounds. One hundred wounds were completely followed up, 50 with oral antibiotic treatment (penicillin v, cloxacillin or erythromycin). Infection rates of those with and without antibiotic treatment were compared using Chi-square test. Initial cultures showed 91 positive wound cultures (54.6%). Staphylococcus coagulase negative was the major organism (69.2%) found. Four wounds were infected though oral antibiotics were given (group B), where as in the non-antibiotic group(group A) 2 wounds were infected. Comparison with Chi-square test showed no statistical significant difference (p>0.05). We conclude that usage of antibiotics in minor traumatic wound does not reduce wound infection rate. Prophylactic antibiotic in minor traumatic wound should be limited because the incidence of infection is too low to justify the expense and risk of antibiotic administration. Wound debridement and cleansing are more advantageous than antibiotic alone.

Amino acid pattern in polytrauma patients: Non-sepsis patients.

Some studies of the protein metabolism in severely injured patients with sepsis are reported. Knowledge of changes in blood amino acid levels will improve patient management. A prospective study was performed in severely injured patients (ISS 20-40) admitted to ICU as trauma cases, at Siriraj Hospital between January 1993 and December 1994. Ten patients were involved : five non-sepsis patients and five sepsis patients. Blood samples were drawn for determining amino acids levels on the first day of injury, then 7 and day 14. Blood samples were also obtained from three normal non-trauma volunteers as the control group. After injury, amino acids levels increased, in most of the patients, especially serine and lysine which significantly increased, both in non-sepsis groups. Only the especially serine and lysine which significantly decreased in the non-sepsis group at day 14. The branched chain amino acids (valine, leucine, isoleucine) increases more than the aromatic amino acids (phenylalanine, tyrosine, tryptophan). Glutamic acid, for the functional maintenance of mucosal cells of the intestine, and arginine, the immune supporter, were found to have increased in the sepsis group.

Measurement of Intra-abdomonal Pressutre (IAP) inn trauma patients.

To study the measurement of intra-abdominal pressure by urinary catheter, we use Y glass tube connected with Foley catheter. The bladder and catheter was filled with 70 ml. NSS. The height of NSS from pubic symphysis was interpreted as intra-abdominal pressure (IAP). We measured IAP of 20 trauma patients with normal abdominal condition. The average IAP was 3.9 cm H2O. The clinical consequences of elevated IAP will be in the future study.

The factors influenced on the length of hospital stay in burn patients.

The aim of this study was to analyse association between the factors ; (the extent of burn, patient’s age, type of micro-organism, severity of infection and patient’s past medical illness) and the length of hospital stay among 147 survived burn patients who were admitted to the Burn Unit, Siriraj Hospital during January 1, 1994 to August 31, 1997. By using analysis of variance (ANOVA) for bivariate analysis. It was found that statistical significant determinants for variance in the length of hospital stay were extent of burn (F=43.130, df=1,145, p-value<0.0001), type of micro-organism (F=40.792, df=1,145, p-value<0.0001). severity of infection (F=24,409, df=1,145, p-value<0.0001), and type of burn (F=12.815, df=1,145, p-value<0.0001). When we entered these 4 influential independent variables in a final multiple classification analysis, the total explained variance in the length of hospital stay was 44.4% whereas the explained variance were 12.25%, 10.24%, 3.61% and 3.61% for extent of burn, type of micro-organism, severity of infection and type of burn, respectively.

Peripherally inserted centeal catheter line for central access, experience in Siriraj Hospital.

Introduction : Central access is important for parenteral nutrition, chemotherapy, some kinds of drugs. Selection of catheter and method of access are also important to ensure that Patients are safe from complications. PICC line (Peripherally Inserted Central Catheter) is made from polyurethane, and is designed for percutaneous insertion through superior vena cava. Methods : We have studied and used the PICC line with patients who need parenteral nutrition or long-term intravenous fluid application in Siriraj Hospital since November 1995. Results : A total of 35 patients received a PICC line, 23 males and 12 females. The average age was 53.6 years. Indication for central access was parenteral nutrition (28 patients) and for longterm IV fluid (7 patients). We used the pericubital fossa vein in 32 patients and the femoral vein in three patients. The methods of insertion were percutaneous puncture in 24 patients, direct puncture in one patient, and venesection with 10 patients. The PICC line can be use for a maximum of 40 days, but 18.5 days on average. At the time of this report, three patients were continuing the use of PICC lines. We found only one accidenetal arterial puncture at the cubital fossa, and no other serious complication. Reasons for removal were cure in 13 patients, clotting in three patients, phleditis in 10 patients, accidental removal in two patients and death from other problems in four patients, but no cases of infection at the tip of the catheter. With regard to nursing care, a PICC line should be filled with fluid at all times, and care should be taken not to draw the blood back and that there is no unnecarrary flexing of the elbow. Conclusion : From this preliminary study, we have shown that a PICC line, made from polyurethane, can be used with patients who need parenteral nutrition, intravenous drugs, or long-term IV fluid for at least 17 days without any problems. The method of insertion for a PICC line is more superior than the conventional method in the view of low risk of anatomical complication.

Burn and cardiac infection: A case report.

A 12-year old child was flame burned 64% of body surface area. During the treatment at Bun Unit, Siriraj Hospital, there were some complications, hyponatremia, water intoxication and pneumothorax. He died on day 16th after admission. From the autopsy, we found pyopericardium (500 ml). Retrospective study was done, cardiac shadow in his chest 7-day seemed to be enlarged. Review of previous studies was performed.