Ischemic intestinal complications in patients with burns.

Enteral bacterial translocation has been implicated as a major cause of morbidity in instances of trauma, but little clinical evidence of the loss of intestinal mucosal integrity has been documented. A retrospective review of the medical and autopsy records of all patients admitted between 1982 and 1988 was performed to describe the incidence of intestinal pathologic findings. Of all deaths, a total of 53 per cent of adults (greater than 18 years old) and 61 per cent of children (zero to 17 years old) were noted to have ischemic intestinal pathologic findings on autopsy, ranging from superficial necrosis to full thickness mucosal necrosis extending into the omentum. More than 80 per cent of these patients were septic at the time of death, with endogenous intestinal flora species most frequently identified as the causative agent. Less than 1 per cent (n = 16) of the patients admitted were clinically identified with intestinal pathologic examination, surgically explored and underwent resection of the intestine. Despite intervention, this group suffered a 69 per cent mortality rate. Although the documentation of bacterial translocation in a human model may be obscured by other potential sources of contamination, for example, burn wound, in combination with the immunosuppression inherent to the thermally injured, may lead to bacterial contamination of the systemic circulation and, therefore, may be a significant contributor to morbidity and mortality after thermal injury.

Improved myocardial oxygen utilization following propranolol infusion in adolescents with postburn hypermetabolism.

The purpose of this study was to determine if propranolol (0.5 mg/kg and 1 mg/kg), administered intravenously (IV) at the height of the postburn hypermetabolic response, would decrease myocardial oxygen requirements, without adversely affecting overall oxygen delivery or total body oxygen consumption. To test this hypothesis, six nonseptic patients age 17 +/- 3 years with burns over 82% +/- 11% total body surface area were given propranolol with continuous hemodynamic monitoring. Propranolol was administered to these patients 20 +/- 15 days postburn. Two clinically derived indices of myocardial oxygen consumption, pressure-work index (PWI) and rate-pressure product (RPP), were used to estimate the energy expenditure of the working heart. Both PWI and RPP were significantly decreased from baseline after 0.5 mg/kg propranolol, 31% for PWI (P less than .001) and 30% for RPP (P less than .01). Similarly, a decrease from baseline was seen after 1.0 mg/kg propranolol, 32% for PWI (P less than .001) and 35% for RPP (P less than .01). Cardiac index (L/min/m2) demonstrated no significant change [7.4 +/- 1.1 (prepropranolol), 6.5 +/- 1.3 (after 0.5 mg/kg propranolol), and 6.8 +/- 1.0 (after 1.0 mg/kg propranolol)] and exceeded the upper limits of normal (hyperdynamic state) throughout the study. Oxygen delivery index (962 +/- 209 mL/min/m2) and oxygen consumption indices [(254 +/- 78 mL/min/m2 by Fick method and 236 +/- 78 mL/min/m2 by inspired and expired gases)] were elevated at baseline and unaffected by propranolol. The decrease in PWI and RPP was achieved mainly by propranolol's effect to lower both heart rate and BP.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased mortality with intravenous supplemental feeding in severely burned patients.

Patients with large cutaneous burns are characterized by an elevated metabolic rate and lose up to 25% of their body weight within 3 weeks. A previous study suggested that intravenous supplementation to attain nutritional requirements was of no benefit in patients with cutaneous burns covering greater than 50% of their total body surface area. In this study 39 patients with burns greater than 50% of their total body surface area were randomly assigned to receive intravenous supplementation of enteral calories (n = 16) or enteral calories alone (n = 23). Intravenous supplementation decreased the amount of enteral calories that patients with burns could tolerate. The mortality rate was significantly higher (p less than 0.05) in the intravenously supplemented group at 63% as compared with 26% in the group receiving enteral calories alone. Both groups showed significant decrease in natural killer cell activity when compared with controls at both 0 to 7 and 7 to 14 days after injury. T cell helper/suppressor ratios were depressed in both groups when compared with controls; however, the intravenously supplemented group was significantly depressed at 7 to 14 days after burn. Both groups demonstrated hepatomegaly, moderate fatty infiltration, and cholestasis. It is suggested that intravenous supplementation should be carefully evaluated and used only in patients with total enteral failure.

A comparison of conservative versus early excision. Therapies in severely burned patients.

Early excision and grafting of small burn wounds is a generally accepted treatment. Early excision of burn injuries greater than 30% total body surface area (TBSA) in adults, however, has not been universally accepted. In this study, 85 patients whose ages ranged from 17 to 55 years with greater than 30% total body surface area (TBSA) burns were randomly assigned to either early excision or topical antimicrobial therapy and skin grafting after spontaneous eschar separation. Mortality from burns without inhalation injury was significantly decreased by early excision from 45% to 9% in patients who were 17 to 30 years of age (p less than 0.025). No differences in mortality could be demonstrated between therapies in adult patients older than 30 years of age or with a concomitant inhalation injury. Children (n = 259) with similar large burns treated by early excision showed a significant increase in mortality with increasing burn size and with concomitant inhalation injury (p less than 0.05). The mean length of hospital stay of survivors was less than one day per per cent of TBSA burn in both children and adults.

Longitudinal assessment of breast development in adolescent female patients with burns involving the nipple-areolar complex.

Long-term follow-up of breast development in adolescent female patients with burns of the anterior chest wall is poorly documented. Between 1971 and 1976, 28 female patients with photographic documentation of burns to the anterior chest wall involving the nipple-areolar complex were reviewed. All patients were followed at least until their early teens. The mean age at the time of thermal injury was 5.9 +/- 2.5 years, with a mean follow-up time of 8.9 +/- 2.6 years. Thirteen patients (46 percent) were admitted to the Shriners Burns Institute in Galveston for acute care of their burns. Fifteen patients (54 percent) were referred for long-term follow-up or specific reconstructive procedures following care of the acute burns. In spite of significant thermal injury to the anterior chest wall with involvement of the nipple-areolar complex, no patient failed to develop breasts. Twenty patients (71 percent) required releases of the anterior chest wall to assist breast development. All anterior chest wall releases were accomplished with the use of skin grafts or local skin flaps.

Comparison of complications during rehabilitation between conservative and early surgical management in thermal burns involving the feet of children and adolescents.

To evaluate the long-term sequelae of early surgical management compared with conservative therapy, a retrospective review from January 1976 to December 1984 was undertaken. Through inspection of burn diagrams, 395 patients were identified with burns involving the foot. From 1976 through 1980, 109 patients were managed in a conservative fashion with topical antimicrobial therapy and delayed debridement and grafting; 36 of these patients with severe burns were managed with skeletal suspension. Between 1981 and 1984, 136 patients were treated with earlier surgical debridement and grafting; during this period, skeletal suspension was rarely used. No statistical difference was found in mortality, amputations, incidence of open wounds, development of contractures, or number of patients requiring reconstructive procedures between conservative and early excision therapy except in those children treated with skeletal suspension. Thus in burns involving the feet in children, early excision and grafting does not alter the resultant morbidity compared with conservative burn management.

Candida infection in massively burned patients.

Immunosuppressed burned patients receiving antibiotics for suppression of bacterial infection are ideal hosts for opportunistic fungi. Massive excision of burns with autograft and homograft coverage has radically changed the course of disease. Three hundred ninety-three patients were admitted to the Shriners Burns Institute, of whom 125 patients had fungus cultured during their hospitalization and 42 patients subsequently developed involvement of three or more organs. Twenty-one of the 42 patients developed Candida septicemia requiring amphotericin B or flucytosine therapy. The mean third-degree burn in patients with Candida septicemia was 65% total body surface area compared to three-organ involvement/no clinical sepsis at 38% mean third-degree burn. Patients developing candidemia did so during the first week postburn and 7 days after excision therapy. It is hypothesized that massive burns with immunosuppression are further suppressed by repeated surgical intervention, anesthesia, and perioperative use of broad-spectrum antibiotics, further predisposing these patients to early development of Candida septicemia. With early recognition of burn wound invasion by routine biopsies, wound swabs, and early amphotericin therapy, the mortality has been reduced to 14% compared to 60-90% reported in other series.

Extravascular lung water changes following smoke inhalation and massive burn injury.

During a 3-year period (1984 through 1987), 40 patients with smoke inhalation, cutaneous burns, or a combination of both injuries were studied. Injuries were assigned to the three categories on the basis of bronchoscopic findings and clinical history. Eleven patients had simultaneously sustained a common smoke-inhalation injury without burns while trapped in a burning ship; twelve patients had massive cutaneous burns over 50% of the total body surface area (TBSA); and seventeen patients had cutaneous burns over more than 30% of the TBSA and inhalation injury. Colloid oncotic pressure was maintained with salt-poor albumin infusion. Central venous pressure, arterial saturation, inspired oxygen, arterial pressure, and urine output were continuously monitored. Extravascular lung water (EVLW) and cardiac output were measured by the double indicator (thermal dye dilution) technique. EVLW remained normal throughout the study period in the group of patients with burns alone. In the first 24 hours after injury, EVLW increased in both groups with smoke injury and remained elevated for more than 48 hours after injury in patients with smoke injury only. The group with both smoke-inhalation and burn injuries showed an early increase in EVLW, which returned to normal by 28 hours after injury and which remained normal until 5 days after injury. The EVLW level then increased again until the end of the study period. In this study, lung edema formation is attributed to the toxic effect of smoke inhalation.

Failure of TPN supplementation to improve liver function, immunity, and mortality in thermally injured patients.

Hypermetabolism with negative nitrogen balance and immune deficiencies characterize the systemic response to major thermal injury. Patients with burns greater than 50% of the total body surface area (TBSA) initially have poor gastrointestinal function, making it difficult to deliver sufficient enteral calories to meet nutritional requirements. Controversy has developed over whether to supplement oral alimentation with total parenteral nutrition (TPN) early in their treatment. This study randomly assigned 28 patients with burns greater than 50% TBSA to receive TPN supplementation or no TPN supplementation in the first 10 days postburn. Patients receiving TPN supplementation had significantly lower T-cell helper-to-suppressor cell ratios than the unsupplemented group. However, there was no difference in mortality between the groups (eight in each). All patients who died developed hepatomegaly associated with fatty infiltration cholestasis and antemortem liver function abnormalities, indicating that this syndrome is the result of burn injury itself, not TPN.

Determinants of mortality in pediatric patients with greater than 70% full-thickness total body surface area thermal injury treated by early total excision and grafting.

Recent advancements in burn care have improved the survival rates of victims with severe burn injuries. The total mortality rate in a series of 1,057 pediatric patients admitted to Shriners Burns Institute Galveston Unit between 1982 and 1986 was 2.7%. The burn size resulting in a 50% death rate was 95% of the total body surface area (TBSA). In this study 19 survivors and 13 nonsurvivors with greater than 70% full-thickness TBSA burn injuries were compared. All survivors were adequately resuscitated upon arrival 11% sustained an inhalation injury. Forty-six per cent of the nonsurvivors sustained an inhalation injury; 31% were not initially adequately resuscitated. The presence of preadmission shock and inhalation injury were early determinants of mortality with secondary renal, pulmonary, or cardiovascular collapse being the later predictors of mortality in these massively burned pediatric patients.

Effect of early excision on patients with major thermal injury.

A randomized study was carried out to determine the effect on mortality of early massive excision of large burns. Fifty consecutive adult patients admitted to our hospital burn unit between December 1983 and January 1986 with 2 degrees and 3 degrees burns totaling at least 30% total body surface area (TBSA) were randomized on admission to one of two groups. The patients received either conservative therapy or early massive excision of all full-thickness burns. The two groups were similar in average size of burn but differed in their average age. In the patients with burns greater than 50% TBSA and no inhalation injury, mortality was decreased with early excision, which can be explained entirely by age differences alone. There was not a significant difference in length of stay, blood requirements, or in mortality in other groups of patients.

Skeletal suspension in the management of severe burns in children. A sixteen-year experience.

From 1966 to 1983, skeletal suspension was used at the Shriners Burns Institute, Galveston, Texas, for the treatment of 626 burned pediatric patients who had 1128 affected extremities. Skeletal suspension was used for 863 acutely burned extremities (76.5 per cent) to facilitate skin-grafting and in 265 extremities (23.5 per cent) for functional positioning in the surgical correction of burn-acquired deformities. In a retrospective examination of these patients, there were fifty complications (4.4 per cent) related to the skeletal suspension, of which forty-five (4.0 per cent) were infections. All infections resolved with removal of the pins or the administration of antibiotics, or both. With this established low rate of complications, skeletal suspension continues to be a useful adjunct in the care of the severely burned pediatric patient.

The optimal time for excision of scald burns in toddlers.

During the past decade, morbidity and mortality have been shown to be decreased by early excision and grafting in treatment of moderate and large burns. Because of the lack of data on the efficacy of such treatment in scald burns, a retrospective study was done of children under age 4 who were admitted to a burn unit within three days of scald injury. Four groups were examined according to day of first surgical procedure: (1) sooner than five days; (2) 6-10 days; (3) 11-20 days; and (4) later than 20 days. The four groups (similar in age, weight, and percent of TBSA burn) were also analyzed for differences in percent of excised area, blood loss, and length of hospital stay. The amount of excised area in group 1 was significantly larger than in groups 2 and 3, and group 1 also had a significantly greater blood loss. Only in group 4 was the length of stay significantly increased. If excision could be delayed until after day 5, the area excised and the blood loss might be decreased without prolonging hospital stay.

Fungal sepsis: an increasing problem in major thermal injuries.

In major thermal burns there has been an alarming emergence of fungal sepsis as defined by involvement of three or more organs and/or repeated positive blood cultures. During an 18-month period, we treated 72 patients (aged 18 +/- 2 years; TBSA burn, 57 +/- 3%; percent of third-degree burn, 45 +/- 3) with fungal sepsis. In all patients with documented three-organ involvement, treatment was with intravenous amphotericin (0.5 mg/kg body weight/day), immediate wound debridement, and early wound closure. The mortality was 32% (23 patients); 49 (68%) survived infection. Sixty-two variables were reviewed retrospectively using multiple regression analysis to ascertain specific factors associated with fungal sepsis and their relationship to survival. In burn patients, fungal sepsis is a strong determinant of survival, and its occurrence overshadows traditional factors presently utilized to predict clinical outcome.

Gasoline explosions, gasoline sniffing: an epidemic in young adolescents.

One hundred twenty-two patients between the ages of 10 and 15 were admitted to the Shriners Burns Institute between July 1981 and November 1984. Seventy-five of the 122 patients sustained burns as a direct result of liquid gasoline explosions. Thirty patients had thrown gasoline on a fire and 17 others admitted to having ignited gasoline with a match. During admission interviews, none of the patients admitted to gasoline sniffing; however, 19 patients were subsequently found to have been sniffing gasoline at the time of the accident. All of the patients with gasoline burns sustained much larger burns, had longer hospitalizations, and required more surgery than did patients burned by other means. Similarly, the 19 patients who had been sniffing gasoline had larger burns, had longer hospital stays, and required more surgery than did those injured by gasoline in other accidents. The most common cause of thermal injury in the ten-to-15 year age group is a gasoline-related accident. The histories of a large number of these adolescents may be compatible with explosions related to gasoline sniffing. Educational efforts relating to the explosive nature of the substance and the dangers of gasoline sniffing are warranted.

Metabolic rate alterations in early excision and grafting versus conservative treatment.

This study was done to determine whether early massive excision and grafting would decrease the hypermetabolic response that characterizes burn injury. Thirteen consecutively admitted adult males with burns over more than 45% of the total body surface area (TBSA) were randomly assigned to one of two treatment groups. One group was treated by excising the burn within 72 hours of injury and grafting with autograft overlaid with cadaveric allograft or cadaveric allograft alone depending on available donor sites and size of recipient areas. The second group was treated conservatively with daily hydrotherapy and twice daily applications of topical antimicrobial agents until granulating beds could receive autografts. Resting energy expenditure (REE) was calculated from measurement of vO2 and vCO2 at the patient's bedside. The responses of the two groups were comparable: the REE was approximately 20-30% above the predicted basal metabolic rate (BMR). Excisional therapy did not markedly decrease the hypermetabolic response to burn injury.

Effect on mortality of inhalation injury.

A retrospective analysis of 1,018 consecutive admissions with cutaneous burn injury over 32 months was carried out. Mortality probabilities as related to age, per cent TBSA burn, and presence of inhalation injury are presented. Incidence of and mortality from inhalation injury both rose with increasing burn area. The incidence of inhalation injury also rose with advancing age; mortality was lowest in the 5- to 14-year old age group and highest in those more than 59 years of age.

Surgical adjuvant treatment of locally advanced breast cancer.

The reported incidence of local recurrence after mastectomy for locally advanced breast cancer (TNM Stage III and IV) is between 30% and 50%. The purpose of this study was to evaluate the effect of radiation therapy (XRT) followed by total mastectomy on the incidence of local recurrence in patients with locally advanced breast cancer. Fifty-three patients who presented with locally advanced breast cancer, without distant metastases, were treated with XRT (4500-5000 R) to the breast, chest wall, and regional lymph nodes. Five weeks after completion of XRT, total mastectomy was performed. There were no operative deaths. The complications that occurred in 22 patients after surgery were flap necrosis, wound infection, and seroma. Patients have been followed from 3 to 134 months. Twenty-five patients are alive (3-134 months), 12 free of disease; 28 patients have died with distant metastases (6-67 months). Isolated local recurrence occurred in only two patients. Four patients had local and distant recurrence (total local recurrence is 6/53). The remaining patients all developed distant metastases. We have devised a treatment strategy which significantly decreases the incidence of local recurrence in patients with locally advanced breast cancer. However, the rapid appearance of distant metastases emphasizes the need for systemically active therapy in patients with locally advanced breast cancer.