'Getting Under our Skin': Introducing Banked Allograft Skin to Burn Surgery in South Africa

Deceased donor skin possesses many of the properties of the ideal biological dressing; and a well-stocked skin bank has become a critically important asset for the modern burn surgeon. Without it; managing patients with extensive burns and wounds becomes far more challenging; and outcomes are significantly worse. With the recent establishment of such a bank in South Africa; the challenge facing the medical fraternity is to facilitate tissue donation so that allograft skin supply can match the enormous demand

A Review of the Peri-Operative Management of Paediatric Burns: Identifying Adverse Events

Background. Burn injuries are common in poverty-stricken countries. The majority of patients with large and complex burns are referred to burn centres. Of the children who qualify for admission; according to burn admission criteria; about half require some kind of surgical procedure to obtain skin cover. These range from massive full-thickness fire burns to skin grafts for small; residual unhealed wounds. Burn anaesthetic procedures are of the most difficult to perform and are known for high complication rates. Reasons include peri-operative sepsis; bleeding; issues around thermoregulation; the hypermetabolic state; nutritional and electrolyte issues; inhalation injuries and the amount of movement during procedures to wash patients; change drapes and access different anatomical sites. The appropriate execution of surgery is therefore of the utmost importance for both minor and major procedures.Objective. To review the peri-operative management and standard of surgical care of burnt children.Methods. This was a retrospective review and analysis of standard peri-operative care of burnt children at Red Cross War Memorial Children's Hospital; Cape Town; South Africa. A total of 558 children were operated on and supervised by the first author. Factors that could adversely affect surgical and anaesthetic outcomes were identified.Results. There were 257 males and 301 females in this study; with an average age of 50.1 months and average weight of 19.5 kg. The total body surface area involved was 1 - 80%; with an average of 23.5%. Inhalational injury was present in 11.3%; pneumonia in 13.1%; wound sepsis in 20.8%; and septicaemia in 9.7%; and organ dysfunction in more than one organ was seen in 6.1%. The average theatre temperature during surgery was 30.0oC. Core temperatures recorded at the start; halfway through and at completion of surgery were 36.9oC; 36.8oC and 36.5oC; respectively. The average preoperative and postoperative haemoglobin levels were 11.28 g/dL and 9.64 g/dL; respectively. Blood loss was reduced by the use of clysis from 1.5 mL/kg/% burn to 1.4 mL/kg/% burn. Adverse intraoperative events were seen in 17.6% of children.Conclusion. Burn surgery is a high-risk procedure and comorbidities are common. Anaesthesia and surgery must be well planned and executed with special reference to temperature control; rapid blood loss; preceding respiratory illnesses and measures to reduce blood loss

The Hospital Costs Associated with Acute Paediatric Burn Injuries

Background. Ongoing rationing of healthcare threatens services that are well established; and cripples others that desperately require investment. Burn; for one; remains a neglected epidemic in South Africa (SA); despite the magnitude of the problem.Objective. To identify the prominent components contributing to the cost of hospital admission with paediatric burn injury. Determining the true costs of specialist services is important; so that resources can be allocated appropriately to achieve the greatest possible impact.Methods. A retrospective study was undertaken over 1 year to determine patient demographics and injury details of 987 patients admitted with burn injuries to Red Cross War Memorial Children's Hospital; Cape Town; SA. The in-hospital financial records of 80 randomly selected patients were examined. This was followed by a prospective study to determine the financial implications of four cost drivers; i.e. bed cost per day; costs of medications received; costs of dressings for wound care; and costs of surgical intervention. A random selection of 37 dressing changes (in 31 paediatric patients) and 19 surgical interventions was observed; during which all costs were recorded.Results. As expected; severe flame burns are responsible for more prolonged hospital stays and usually require surgical intervention. Scald burns comprise the greatest proportion of burn injuries; and therefore account for a considerable part of the hospital's expenditure towards burn care.Conclusion. While community programmes aiming to prevent burn injuries are important; this study motivates for the implementation of accessible ambulatory services in low-income areas. This strategy would enable the burn unit to reduce its costs by limiting unnecessary admissions; and prioritising its resources for those with more severe burn injuries

Nephron-sparing surgery for bilateral wilms' tumours: a single-centre experience with 23 cases

Introduction: The challenge of management with bilateral Wilms' tumours is the eradication of the neoplasm; while at the same time preserving renal function. Surgical management with a variety of nephron-sparing techniques; combined with chemotherapy and occasionally supplemented by transplantation has evolved over the last 30 years to achieve remarkable success. We document the experience of a single centre in a developing country. Material and Methods: Twenty-three bilateral Wilms' tumours were seen in our service between 1981 and 2007. Treatment was; in most cases; according to National Wilms' Tumour Study Group protocols; with initial bilateral biopsy; neoadjuvant chemotherapy; and tumourectomy. Technique of nephrectomy included full mobilization of the tumour-involved kidney; topical cooling with slush ice; vascular exclusion; tumour resection and reconstruction of the remnant kidney. Results: Twelve patients are alive and free of disease one to 15 years after treatment; all with well-preserved renal function (lowest glomerular filtration rate was 65 ml/min per (1.73 m 2 ). None of the survivors have hypertension. Eleven have died (two of unrelated disease) including six of the seven with spread outside the kidney. All three with unfavourable histology are alive. Four of the five metachronous presentations are alive; as are eight of 12 patients with synchronous bilateral tumours who presented since 2000. Conclusions: Appropriate chemotherapy and nephron-sparing surgery can achieve good results with preservation of adequate renal function in nearly all cases. Unfavourable histology did not have a reduced survival in our series. Metastatic spread outside the kidney had a poor prognosis

Cirugia pediatrica ambulatoria: el desarrollo de un centro de Hospital de Dia / Ambulatory Pediatric Surgery: the development of a Day Care surgical center

La cirugia ambulatoria se ha transformado en un importante componente dentro de la pra ctica quirurgica. En 1987 se crea una unidad de Hospital de Dia en el Hospital de Niños de la Cruz Roja en Sudafrica. Evaluamos la experiencia acumulada en un periodo de 8 años (1987-1994) y la relacionamos con la cantidad total de intervenciones quirurgicas, la preparacion preoperatoria, utilizacion diaria de las instalaciones y cuidados postoperatorios junto con las complicaciones. En ese periodo se operaron 20.545 pacientes con una edad promedio de 3 anos. Participaron 9 sub-especialidades. El asesoramiento y la preparacion prequirurgica redujeron el porcentaje de suspension el dia de la cirugia a menos del 6 por ciento con un uso efectivo de las horas programadas de quirofano del 90 por ciento. Los escasos recursos humanos de enfermeria fueron tambien optimizados (relacion Paciente/Enfermera=11/1). El seguimiento postoperatorio de todos los procedimientos inguino-escrotales arrojo un porcentaje de complicaciones menor al 4 por ciento. La mayor parte de los procedimientos se efectuaron en menos de 30 minutos y solo el 0,8 por ciento excedio 1 hora de tiempo quirurgico. El promedio de tiempo de internacion fue de 6 horas. No se presentaron mayores complicaciones y la aceptacion por parte de los padres y los pacientes fue excelente. Solo 16 niños requirieron hospitalizacion prolongada durante la noche. Presentamos recomendaciones para establecer y mejorar los servicios del Hospital de Dia. Se puede concluir que las comunidades y las autoridades de los paises en vias de desarrollo pueden establecer un servicio de Hospital de Dia efectivo practico y eficiente, con bajos costos, expendiendo las instalaciones para la practica de cirugia ambulatoria