Experiencia en reconstrucción del paciente gran quemado agudo con microcirugía

Introducción: Las quemaduras son un trauma frecuente de ocurrencia en todo el mundo, que ha experimentado importantes aumentos de sobrevida. Su manejo requiere la reposición de la barrera cutánea, lo que se logra en la mayoría de los casos con el uso de injertos dermo-epidérmicos. Sin embargo, existen algunas veces lesiones complejas que no logran sanar mediante injertos, arriesgando la funcionalidad o vitalidad del área comprometida, que requerirán reparaciones complejas con el uso de colgajos microqui- rúrgicos (CM). Metodología: Estudio descriptivo retrospectivo en que incluimos todos los pacientes gran quemados agudos admitidos en Hospital de Urgencia de la Asistencia Pública, Servicio de Quemados y Rehabilitación, desde abril de 2019 hasta diciembre de 2020 los que fueron manejados con colgajo micro- quirúrgico. Revisión de ficha clínica para obtención de variables demográficas y del procedimiento con análisis de frecuencia de ocurrencia. Resultados: En nuestro período de estudio hubo 376 ingresos y 21 pacientes recibieron 25 CM. La mayoría hombres (96%), edad promedio 40 años, superficie comprometida promedio 16%, mecanismo más frecuente electricidad (64%) y fuego (32%). La ubicación más frecuente del colgajo fue en extremidades inferiores (64%) y el colgajo más utilizado fue el anterolateral de muslo (80%). Tiempo medio a reconstrucción fueron 40 días, no hubo pérdida total del colgajo. Discusión: se realizó un CM en 5,6% de nuestros ingresos, la mayoría durante el intervalo primario tardío, sin pérdidas totales. Estos resultados representan la consolidación de la técnica que permite su uso en el paciente gran quemado durante su etapa aguda, permitiendo coberturas complejas y manteniendo riesgo quirúrgico y tasa de complicaciones adecuada con enfoque en rehabilitación precoz.

Introduction: Burns are the fourth most common trauma. Microsurgery has evolved as a valuable tool in the acute setting allowing early closure of complex wounds in order to avoid infection, maintain function or even for limb salvage in one stage reconstruction. We present our experience at our burn center in Chile. Method: We performed a retrospective analysis of all major burn patients admitted in the National Burn Center in Chile who received a microsurgical flap in the period between April 2019 to December 2020. Results: A total of 21 patients had 25 free flaps. All patients but one were male (96%), mean age 40 years (range 20-69 years). Total body surface area means 16% (range 1-64%). Most of the injuries were caused by high voltage electricity (64%) and fire (32%). 64% were performed in lower limbs and 36% in upper limbs. In 80% of the cases, anterolateral thing flap was chosen. Mean time to reconstruction was 40 days. We didn't experience a total flap lost in this series. Discussion: In the acute phase microsurgery proved to be safe and feasible albeit a small surgical indication. We performed a flap in 5.6% of our admissions, mostly during late primary interval with no flaps lost. Our results acknowledge the consolidation of the technique for its use in the acutely burned setting, allowing complex coverage while maintaining the surgical risk and an internationally acceptable rate of losses and complications.

Intubación orotraqueal en el trauma por quemaduras en Uruguay: rol de la intubación profiláctica / Orotracheal intubation in burn trauma in Uruguay: the role of prophylactic intubation / Intubação orotraqueal no trauma por queimaduras no Uruguai: papel da intubação profilática

Introducción: La Intubación orotraqueal (IOT) profiláctica en pacientes con sospecha de Injuria Inhalatoria (II) es una práctica clínica extendida en nuestro país. La misma puede estar asociada a complicaciones y a un aumento de los costos asistenciales. Objetivo: caracterizar a la población de pacientes que ingresaron con IOT al Centro Nacional de Quemados, determinar la incidencia de Intubación orotraqueal no necesaria (IOTNN) así como las complicaciones vinculadas a la misma. Método: Estudio retrospectivo, observacional, analítico. Se incluyeron todos los pacientes con quemadura térmica ingresados al CENAQUE con vía aérea artificial entre enero de 2015 y julio 2023. Se determinaron características demográficas, circunstancias de la injuria, lugar y técnico que realizo la IOT, porcentaje de superficie corporal total quemada (SCTQ), scores de severidad, días de ARM, estado al alta y diagnóstico de II por fibrobroncoscopía. Se analizaron las complicaciones asociadas a la IOT y ARM. Dichas variables fueron contrastadas entre el grupo extubado exitosamente en las primeras 48 horas (IOTNN) y aquellos extubados luego de las 48 horas (IOTP). Resultados: Se incluyeron 562 pacientes. La incidencia de IOTNN fue 41,7% e II 46,7%. Se observaron diferencias significativas entre IOTNN y IOTP para edad [34 (24-48) versus 45 (30-62); p <0,001, para SCTQ [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], Rev. Baux [48 (33-62) versus 77 (60-99), p <0,001], incidencia de II (32% versus 56,6%, p <0,001). La aspiración de VA (30% versus 20,2% p 0,018), extubación durante el traslado (2% versus 0% p 0,043) e incidencia de NA (Neumonía aspirativa) y NAVP (neumonía asociada a la ventilación mecánica precoz) (56,3% versus 15% p <0,001) fueron mayores en el grupo IOTP. Conclusiones: La IOTNN en los pacientes con quemaduras es frecuente en nuestro medio y se asocia a complicaciones. La misma es realizada por médicos sin formación en el manejo de la vía aérea.

Introduction: Prophylactic Orotracheal Intubation (OTI) in patients with suspected Inhalation Injury (II) is a widespread clinical practice in our country. It can be associated with complications and increased healthcare costs. Objective: To characterize the population of patients admitted with OTI to the National Burn Center, determine the incidence of unnecessary Orotracheal Intubation (UOTI), and the associated complications. Method: Retrospective, observational, analytical study. All patients with thermal burns admitted to the National Burn Center (CENAQUE) with an artificial airway between January 2015 and July 2023 were included. Demographic characteristics, injury circumstances, location, and technician performing the OTI, percentage of total body surface area burned (TBSA), severity scores, days on mechanical ventilation, discharge status, and diagnosis of II by fibrobronchoscopy were determined. Complications associated with OTI and mechanical ventilation were analyzed. These variables were compared between the group extubated successfully within the first 48 hours (UOTI) and those extubated after 48 hours (necessary OTI, NOTI). Results: 562 patients were included. The incidence of UOTI was 41,7% and II 46,7%. Significant differences were observed between UOTI and NOTI in age [34 (24-48) versus 45 (30-62); p <0.001], TBSA [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], Baux score [48 (33-62) versus 77 (60-99), p <0,001], incidence of II (32% versus 56.6%, p <0,001). Aspiration of the airway (30% versus 20,2% p 0,018), extubation during transport (2% versus 0% p 0,043), and incidence of aspiration pneumonia (AP) and early ventilator-associated pneumonia (VAP) (56,3% versus 15% p <0,001) were higher in the NOTI group. Conclusions: UOTI in burn patients is frequent in our setting and is associated with complications. It is performed by physicians without training in airway management.

Introdução: A intubação orotraqueal (IOT) profilática em pacientes com suspeita de lesão por inalação (LI) é uma prática clínica difundida em nosso país. Esta prática pode estar associada a complicações e ao aumento dos custos assistenciais. Objetivo: Caracterizar a população de pacientes que ingressaram com IOT no Centro Nacional de Queimados, determinar a incidência de intubação orotraqueal desnecessária (IOTD) e as complicações associadas. Método: Estudo retrospectivo, observacional, analítico. Foram incluídos todos os pacientes com queimadura térmica admitidos no CENAQUE com via aérea artificial entre janeiro de 2015 e julho de 2023. Foram determinadas características demográficas, circunstâncias da lesão, local e técnico que realizou a IOT, porcentagem da superfície corporal total queimada (SCTQ), escores de gravidade, dias de ventilação mecânica, estado na alta e diagnóstico de LI por fibrobroncoscopia. Complicações associadas à IOT e à ventilação mecânica foram analisadas. Essas variáveis foram comparadas entre o grupo extubado com sucesso nas primeiras 48 horas (IOTD) e aqueles extubados após 48 horas (IOTP). Resultados: Foram incluídos 562 pacientes. A incidência de IOTD foi de 41,7% e LI de 46,7%. Diferenças significativas foram observadas entre IOTD e IOTP em relação à idade [34 (24-48) versus 45 (30-62); p <0,001], SCTQ [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], índice de Baux [48 (33-62) versus 77 (60-99), p <0,001], incidência de LI (32% versus 56,6%, p <0,001). A aspiração de via aérea (30% versus 20,2% p 0,018), extubação durante o transporte (2% versus 0% p 0,043) e incidência de pneumonia aspirativa (PA) e pneumonia associada à ventilação mecânica precoce (NAVM) (56,3% versus 15% p <0,001) foram maiores no grupo IOTP. Conclusões: A IOTD em pacientes com queimaduras é frequente em nosso meio e está associada a complicações. A mesma é realizada por médicos sem formação no manejo da via aérea.

Effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage / 中南大学学报(医学版)

OBJECTIVES@#In recent years, it has been reported that the anti-shock effect of plasma substitutes in adult patients with major burn in shock stage is not good. However, due to the shortage of clinical frozen plasma supply, it is impossible to guarantee that frozen plasma is used as colloidal solution for anti-shock treatment. The purpose of this study is to explore the effect of the infusion ration between frozen plasma and plasma substitutes on the prognosis of adult patients with major burn in shock stage.@*METHODS@#This study enrolled 586 adult patients with major burn by selecting the hospitalization burn patients, who had been hospitalized at the Jiangxi province burn center from September 2014 to April 2019. The patients with the infusion ratio of frozen plasma to plasma substitutes ≥2꞉1 at 48 hours after admission were included in the experimental group, otherwise they were included in the control group. The basic clinical data and clinical prognosis indicator in the 2 groups were compared. Logistic univariate regression analysis was used to screen the influential factors of 30-day mortality in adult patients with major burn, and logistic multivariate regression analysis was used to obtain independent risk and protective factors; Kaplan-Meier method was used to draw the survival curve of the 2 groups, and log-rank test was used to compare the 30-day survival rate of the 2 groups.@*RESULTS@#There were significant differences in the infusion volume of frozen plasma and plasma substitutes between the 2 groups at 48 hours after admission (both @*CONCLUSIONS@#Infusion ration between frozen plasma to plasma substitutes at 48 hours after admission is an independent protective factor for 30-day mortality of adult patients with major burn. In the early stage of adult patients with major burn, frozen plasma should be used as the anti-shock therapy as far as possible (frozen plasma꞉plasma substitute ≥2꞉1) to improve the prognosis and reduce the of 30-day mortality.

Intravenous Colistin Therapy for Multidrug-Resistant Gram-Negative Bacterial Infections in Major Burn Injuries

PURPOSE: The aim of this study was to investigate the characteristics of Acute Kidney Injury Network (AKIN)-defined nephrotoxicity in patients undergoing intravenous colistimethate sodium (CMS) therapy for major burns. METHODS: This retrospective study included burn patients who received more than 48 h of intravenous CMS between September 2009 and December 2015. Data collection was performed using the institution's electronic medical record system. Patients assigned to the developed nephrotoxic group experienced aggravation of current AKIN stage during CMS treatment; those assigned to the non-nephrotoxic group experienced no change in current or exhibited improved AKIN stage during CMS therapy. RESULTS: A total of 306 patients were included in this study. All patients were grouped according to AKIN stage: AKIN 0 (n=152); AKIN 1 (n=6); AKIN 2 (n=9); AKIN 3 (n=139). The baseline creatinine (Cr) level was 0.73 mg/dL. The incidence of nephrotoxicity was 50.3% according to AKIN stage; overall mortality was 45.8%. The non-nephrotoxic group consisted of 127 (74.7%) patients and 43 (25.3%) were in the developed nephrotoxic group. In patients requiring continuous renal replacement therapy (CRRT), baseline Cr level was 0.83 mg/dL, pre-CMS Cr level was 1.17 mg/dL, and post-CMS Cr level was 1.34 mg/dL. CONCLUSION: CMS can be administered without signs of nephrotoxicity for a certain period (approximately 1 week), it can be used relatively safely for 2 weeks. Application of CMS is a reasonable option for treating infections caused by multi-drug resistant gram-negative bacteria in patients with major burns. The caution should be exercised nevertheless.

Plasma Lactate Clearance as Early Predictors of Morbidity in Major Burn Patients

The Effects of Early Tracheostomy in Flame Burned Patients with Inhalation Injury

PURPOSE: We designed our study to find optimal timing for tracheostomy, and to determine the effects of early tracheostomy on clinical courses in flame burned patients with inhalation injury. METHODS: A retrospective chart review was completed for adult patients admitted to Hangang Sacred Heart Hospital Burn Center, Hallym University Medical Center, Seoul, Korea, between March 1, 2004 and February 28, 2009, who were diagnosed with flame burn with inhalation injury and who underwent tracheostomy during their hospitalization. One hundred eighteen patients were enrolled in this study. Patients were assigned to one of three groups based on the timing of tracheostomy: postburn days (PBD) 0 to 7 [Early tracheostomy (ET) group], 8 to 12 [Intermediate tracheostomy (IT) group], and greater than 13 [Late tracheostomy (LT) group]. We compared incidence of pneumonia, duration on mechanical ventilation, length of stay in intensive care unit (ICU LOS), and survival between groups. To assess the effect of tracheostomy on pulmonary function, we analyzed changes of PaO2/Fio2 (P/F) ratio. RESULTS: There were 46 patients in the ET group, 47 in the IT group and 25 in the LT group. Tracheostomy day (PBD) was 5.2+/-1.7 in ET group, 10.0+/-1.5 in IT group, and 14.8+/-1.9 in LT group (P<0.01). Statistics did not show the correlation between the timing of the tracheostomy and the incidence of pneumonia. Also mortality rate in each group showed no significant differences. There were significant differences between groups for duration on mechanical ventilation and ICU LOS (P<0.01). P/F ratio correlated with time flow showed no significant differences (P=0.10). Also there were no differences between groups in changes of P/F ratio (P=0.08). CONCLUSION: In flame burned patients with inhalation injury who require prolonged mechanical ventilation, performing tracheostomy within PBD 7 may shorten the duration on mechanical ventilation and length of stay in intensive care unit.

A case of neonatal major burn by electrical heating pad / 대한주산의학회잡지

Burn in neonates have been reported following the use of pulse oximeters, phototherapy blanket, infrared heating lamp, laryngoscope, and warming bottle. This case reports a newborn who had major burn injuries of 45% total body surface area (TBSA) including 3rd degree burns of 20% TBSA on her back, buttocks, both thighs and heels by exposure to an electrical heating pad for 3 hours. She developed significant systemic response, showing disseminated intravascular coagulation, electrical imbalance, jaundice, hypoalbuminemia, acute renal failure, and persistent pulmonary hypertension of the newborn. The potential hazard of the electric heating pad is reported in order to alert clinicians to this specific risk, to stimulate concern about other similar problems with materials in contact with skin, and to prevent burn of newborns in the neonate unit.

The Effect of Early Escharectomy on Pro- and Antiinflammatory Cytokines in Major Burn Patients / 대한마취과학회지

BACKGROUND: Early escharectomy has been shown to improve survival rates and treatment outcomes in major burn patients. However, its mechanism, especially in human immune systems, has not been fully elucidated. This observational study, focusing on cytokines, was conducted to assess changes in the levels of tumor necrosis factor alpha (TNF alpha) and interleukin-10 (IL-10) in major burn patients that underwent early tissue excision. METHODS: Seventeen ASA physical status II or III adults major burn patients, admitted to general surgery for burn wound care, were initially recruited. When early escharectomy was scheduled, a series of blood samples was obtained four times at 72 and 24 hours preop and at 24 and 72 hours postop. Changing levels of TNF alpha and IL-10 were measured by quantitative sandwich immnuoassay. RESULTS: Subjects suffered from 70% TBSA burns. Both cytokines demonstrated a significant tendency to increase in the blood during the study period. Although they temporarily decreased 24 hours after surgery, this effect did not last. CONCLUSIONS: Burn injury certainly increases cytokine response. Early escharectomy appears to decrease the pro and anti-inflammatory cytokines only temporarily. It did not seem to have any long term effect in the human immune system in major burn patients, probably due to the complex nature of the injury.