An observational cross-sectional study to assess teaching, knowledge and resource availability to provide surgical burn care by surgical trainees in hospitals in KwaZulu- Natal, South Africa.

BACKGROUND: Surgical management of burn injuries is within the scope of practice of general surgeons in most low- and middle-income countries (LMICs), like South Africa. This study aims to assess the teaching, knowledge and resource availability to perform basic surgical procedures for burn injuries amongst surgical trainees in KwaZulu-Natal. METHODS: The study design is an observational descriptive cross-sectional study using quantitative questionnaires, including registrars in the Department of Surgery at the University of KwaZulu-Natal. RESULTS: There was a response rate of 57%. The hospitals have been grouped into regions of coastal, western and northern to reflect the three areas where surgical registrars receive their training. There was a large range of clinical and surgical skill teaching between regions. Equipment and operating time availability is more available in the west and north than in the coastal regions, which is reflected in the reported practical experience. Acute indications for surgery were better understood than those for chronic burns. CONCLUSION: The surgical capacity in general surgery in KwaZulu-Natal to meet the burden of injury for burns is deficient. While some theoretical knowledge exists, the practical component is insufficient, which could be due to a lack of equipment and training. In order to address the burden of burn injury in KwaZulu-Natal, a provincial plan needs to be developed. Access to equipment and theatre should be prioritised and practical skills training should be developed with reinforcement of theoretical knowledge as part of a training strategy for general surgical registrars.

Who tells the story of burns in low-and-middle income countries? - A bibliometric study.

INTRODUCTION: Low- and middle-income countries (LMICs) remain drastically underrepresented in health research, with African countries producing less than 1% of the global output. This work investigates authorship patterns of publications on burns in LMICs. Original research studies addressing burn injuries in LMICs and published between 1st January 2015 and 31st December 2020 were included in the review. Descriptive statistics were performed for country affiliations of authors, World Bank Country Income Groups, WHO group, study-focus and country studied. Of the 458 results, 426 studies met the inclusion criteria. Nearly a quarter of papers on burns in LMICs had both first and senior authors from high-income countries (HICs, n = 95, 24.4%), more than half of the papers had both first and senior authors from upper middle- income countries (upper MICs, n = 222, 57.2%), while less than 1% (n = 3) had first and senior authors exclusively from lower-income countries (LICs). Eleven percent (n = 41/388) of all papers were written without either first nor senior author being from the country studied, and 17 of them (41%) had both first and senior authors from the USA. Twenty-five (6%) of the papers had the first author and not the senior author from the country of focus, while six (2%) had the senior and not the first author from the country of interest. To overcome global health challenges such as burns, locally led research is imperative. The maximum benefit of HIC-LMIC collaborations is achieved when LMICs play an active role in leading the research. When LMICs direct the research being conducted in their country, the harm of inherently inequitable relationships is minimized.

A practical formula for fluid resuscitation in acute paediatric burns in a low resource setting: A pilot study.

BACKGROUND: Appropriate fluid resuscitation of acute burn injury is critical and there are recognized challenges with fluid resuscitation, including those with relevance to low resource settings. We developed a practical protocol that guides burn resuscitation and sought to evaluate the safety of our modified resuscitation formula through a small pilot study that particularly addresses the problems we have experienced in a low resource setting. METHODS: Children with burns more than 15% total body surface area admitted within 24 h of injury to Edendale Hospital between 1 June 2021 and 31 August 2021 were included. The resuscitation formula used was 2 mls of Ringers Lactate per bodyweight in kilograms per% total body surface area (TBSA) given over 24 h and adjusted according to urine output. Data analysed included age, weight, mechanism, TBSA, hours post burn at presentation to hospital, total fluid given in the first 24 h of admission, total urine output in the first 24 h of admission, number of fluid adjustments made during the first 24 h and complications related to fluid resuscitation. RESULTS: Ten children were included. The median age was 3 (IQR 2-5) years old, with a mean weight of 14.9 (SD 5.07) kilograms, a median TBSA of 17.4 (IQR 16-26)%, presenting at a median of 12 (6.5-18) hours post burn injury. Mechanism of burn was scald in all cases, with 9 being hot water and hot food in one. In the first 24 h a mean of 2.05 (SD 0.58) mls/kg of fluid was received with a mean urine output of 1.66 (SD 0.57) mls/kg/hr. CONCLUSION: The results of this pilot study to evaluate the safety of our protocol seem reasonable. It is limited by the lack of larger injuries as well as adult patients and a larger prospective study is pertinent.

Amputations secondary to burn injuries in a resource-limited setting.

INTRODUCTION: Amputations are a devastating consequence of severe burns. Amputations in a resource-limited setting are challenging as rehabilitation services available to these patients are inconsistent and often fragmented. Epileptic patients are a particularly vulnerable group when it comes to burn-injuries and often sustain deeper burns. The aim of this study is to analyse amputations secondary to burn injuries. We seek to identify vulnerable groups as a means for advocacy efforts to reduce the devastation of an amputation secondary to a burn injury. This paper highlights the burden of these injuries on the healthcare system and emphasizes the need for additional trained therapists for the rehabilitation of these patients. METHODS: A retrospective database review was conducted. All burns admissions who underwent an amputation between 1 February 2016 and 31 January 2019 were considered. RESULTS: A total of 1575 patients were admitted during the study period. Fifty-four percent of the admissions were paediatric patients. The amputation rate in the paediatric population was 1.5% (13/850) while in the adult population it was 4.8% (35/724) . Most paediatric amputations were as a result of electrical injuries. Flame burns were most likely to result in amputations in the adult group and convulsions were the leading circumstance leading to the injury. There was no significant difference in sepsis or length of stay between the groups. There were no mortalities in the paediatric group but there was an 11% mortality rate in the adult group. CONCLUSION: The incidence of amputations in burns is low, however, it remains a devastating morbidity. Epileptics are a vulnerable group and these patients account for the most amputations among adult burns patients. Education interventions are needed regarding their diagnosis, administration of their medication and the importance of compliance. Advocacy efforts to ensure constant supply of anti-epileptic drugs at the clinics and other district level health facilities is also essential. Electrical injuries in children are not as common as hot water scalds, however, they are more likely to result in amputation. Communities need to be informed of the risk associated with illegal electrical connections and initiatives need to drive the safe provision of affordable electricity to these under-privileged, vulnerable communities.

Barriers to adequate analgesia in paediatric burns patients.

BACKGROUND: All children with burn injuries experience pain at some time during their management and recovery. Burn pain is challenging to manage, owing to a combination of factors. The process of achieving adequate analgesia involves the correct scripting of medication based on the doctor's knowledge, the correct fulfilling of that script, and patient compliance. OBJECTIVES: To assess two components of this process, correct scripting of medication based on the doctor's knowledge and the correct filling of that script, to highlight potential barriers to adequate analgesia for burn-injured patients being followed up at an outpatient department. Patient compliance was out of the scope of this study. METHODS: The study was conducted in the Pietermaritzburg Burn Service (PBS) in Pietermaritzburg, South Africa, and was undertaken in two parts. The first part was conducted through an anonymous, voluntary questionnaire completed by doctors working in hospitals referring to the PBS. The aim of the questionnaire was to identify deficits in knowledge of doctors regarding background analgesia for burn-injured children. The second part was conducted through an audit of the outpatient folders of children attending the PBS outpatient clinic to identify discrepancies between analgesia prescribed and analgesia supplied to the patient. RESULTS: Thirty-six doctors completed the questionnaire. While nearly all the doctors prescribed background analgesia, just over half (58%) prescribed paracetamol, and of those, only half prescribed the correct dose. Half of the doctors prescribed tilidine, and only half of them knew the correct dose. Forty-seven percent of the doctors prescribed both paracetamol and tilidine for background analgesia. The outpatient folders of 59 children attending the outpatient clinic were audited. Fifty-three patients were prescribed paracetamol. There was a statistically significant difference between the paracetamol volume prescribed and the volume supplied (p<0.0001). Twenty-four patients were prescribed ibuprofen. There was a statistically significant difference between the ibuprofen volume prescribed and the volume supplied (p<0.0001). CONCLUSIONS: Burn-injured children commonly receive inadequate analgesia in our setting. The reasons for this are multifactorial. The correct dose and the correct drugs for burn-related background pain are deficits in the knowledge of doctors who deal with this common problem. Furthermore, even if the correct drug and dose are prescribed, the correct volume of medication is often not issued by the pharmacy. This study highlights barriers to achieving adequate analgesia in children with burns being managed as outpatients. Potential strategies to overcome barriers include improving education with regard to pain management and burns at an undergraduate and postgraduate level, and improved supply chain management.

qSOFA as a predictor of ICU outcomes in a resource-limited setting in KwaZulu-Natal Province, South Africa.

Background: Sepsis is a major cause of morbidity and mortality, especially in critical care patients. Developing tools to identify patients who are at risk of poor outcomes and prolonged length of stay in intensive care units (ICUs) is critical, particularly in resource-limited settings. Objectives: To determine whether the quick sequential organ failure assessment (qSOFA) score based on bedside assessment alone was a promising tool for risk prediction in low-resource settings. Methods: A retrospective cohort of adult patients admitted to the intensive care unit (ICU) at Edendale Hospital in Pietermaritzburg, South Africa (SA), was recruited into the study between 2014 and 2018. The association of qSOFA with in-ICU mortality was measured using multivariable logistic regression. Discrimination was assessed using the area under the receiver operating characteristic curve and the additive contribution to a baseline model using likelihood ratio testing. Results: The qSOFA scores of 0, 1 and 2 were not associated with increased odds of in-ICU mortality (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 0.86 - 1.79; p=0.26) in patients with infection, while the qSOFA of 3 was associated with in-ICU mortality in infected patients (aOR 2.82; 95% CI 1.91 - 4.16; p<0.001). On the other hand, the qSOFA scores of 2 (aOR 3.25; 95% CI 1.91 - 5.53; p<0.001) and 3 (aOR 6.26, 95% CI 0.38 - 11.62, p<0.001) were associated with increased odds of in-ICU mortality in patients without infection. Discrimination for mortality was fair to poor and adding qSOFA to a baseline model yielded a statistical improvement in both cases (p<0.001). Conclusion: qSOFA was associated with, but weakly discriminant, for in-ICU mortality for patients with and without infection in a resource-limited, public hospital in SA. These findings add to the growing body of evidence that support the use of qSOFA to deliver low-cost, high-value critical care in resource-limited settings. Contributions of the study: This study expanded the data supporting the use of qSOFA in resource-limited settings beyond the emergency department or ward to include patients admitted to the ICU. Additionally, this study demonstrated stronger predictive abilities in a population of patients admitted with trauma without suspected or confirmed infection, thus providing an additional use of qSOFA as a risk-prediction tool for a broader population.

A comparison of analgesia requirements in children with burns: Do delayed referrals require higher procedural analgesia doses?

Background: Our clinical impression is that delayed referrals require more analgesia than children referred to our service acutely. Previous work demonstrated poor uptake of analgesia protocols at district hospitals with probable inadequate background and procedural analgesia, which may account for this. The purpose of this study was to compare analgesia requirements for dressing changes of paediatric patients referred to us acutely versus those children with delayed referral (i.e. more than 21 days post injury). Our hypothesis is that paediatric patients with delayed referral require higher doses of ketamine when taking length of stay and total body surface area (TBSA) of the burn into account. Methods: Data for children under 12 years, admitted to the Pietermaritzburg Burn Service (PBS) from the 1 July 2017 until 30 June 2018 was reviewed. Total ketamine dose during admission, weight, days admitted and TBSA were analysed. The total ketamine use in milligram per kilogram per days admitted per TBSA (mg/kg/days admitted/TBSA) was calculated. Statistical analysis was performed to compare the total ketamine dose between the acute and delayed referral groups. Results: One-hundred-and-ninety-seven patients were included. Patients were divided into two groups, the acute group including those referred to the PBS early (prior to 21 days post-burn) and the delayed referral group (those referred 21 days or more post burn). The acute group consisted of 167 patients and the chronic group 30 patients. There is a statistically significant difference between the total ketamine dose (mg/kg/days admitted/TBSA) for the acute referral and delayed referral groups (p = 0.01). The median total ketamine dose (mg/kg/days admitted/TBSA) of the acute referral group was 0.27 (Range: 0-7.05) and the median total Ketamine dose (mg/kg/days admitted/TBSA) for the delayed referral group was 0.41 (range: 0.1-3.89). Conclusion: Patients with delayed referrals require more ketamine to achieve adequate procedural analgesia than patients referred acutely. Inadequate analgesia in the acute phase of the burn may influence this, underpinning the importance of adequate analgesia right from the time of the injury.

Analgesia protocols for burns dressings: Challenges with implementation.

BACKGROUND: The aim of this study is to compare doctors' knowledge regarding analgesia in paediatric burns patients in a setting where analgesia protocols are provided but not reinforced to a setting where the same protocols are used but with constant re-enforcement from burns surgeons. METHODS: We reviewed questionnaires completed anonymously by doctors managing burns children in the Pietermaritzburg (PMB) Hospital Complex and the referral hospitals. RESULTS: The questionnaire was completed by 43 doctors with 53% of the participants working in the referral hospitals. Procedural sedation was given by 98% of doctors. All PMB doctors giving procedural sedation used ketamine compared to 39% in the referral hospitals, which was statistically significant (×2 = 18.237; p < 0.001). Eighty percent of PMB doctors were aware of the correct doses of ketamine and compared to 8% of referral doctors. This was statistically significant (×2 = 21.778; p < 0.001). When assessing the adequacy of analgesia, all of the doctors from PMB used a scoring system or clinical impression. In the referral doctor group, 54% used a scoring system, 38% used the child screaming as an indicator of inadequate analgesia. CONCLUSION: We have identified a discrepancy in knowledge between staff in an academic burn centre and those in peripheral referral hospitals. This discrepancy translates into differences in quality of burn analgesia which patients receive. Ongoing efforts must be directed towards changing the culture of district institution and strengthening attempts to standardize care across the region.

Modified first world mortality scores can be used in a regional South African burn service with resource limitations.

INTRODUCTION: Survival following a major burn is highly dependent on the availability of scare and expensive resources such as critical care services, modern dressings and access to operating theatres. Scoring systems, which predict mortality have been developed and can be used to identify patients in whom the outlay of these resources is futile. The aim of this study was to analyse the mortality at a regional South African burn service and to see if these scoring models developed in a resource rich environment were applicable to our setting. METHODS: Consecutive admissions to the Edendale burn service, South Africa were collected from patient records over a 2-year period from July 2013 to June 2015. Demographic, burn details and final outcome (lived or died) were captured for statistical analysis. Each patient was scored using the Modified Baux, Coste et al., Belgian Outcome of Burn Injury (BOBI) and Abbreviated Burn Severity Index (ABSI) scores. Validation of models and inferential statistics were done to determine new breakpoints more applicable to our sample. RESULTS: A total of 748 patients were included in the sample, with a mortality rate of 7.1%. The mean Modified Baux score was 27 (range 1-134), with the new breakpoint of 40 predicting 74% of the mortalities compared to the 42% predicted by the old breakpoint of 75. The mean ABSI score was 4 (range 2-15), with a lower break point of 6 predicting 75% of deaths compared to 42% with the old breakpoint of 8. The mean Coste score for the sample was 12 (range 0-100). With a suggested break point of 85 (predicting 50% mortality), only 6% of mortalities were predicted. The new break point of 17 predicted 91% of deaths. The original break point for the BOBI score was 6 (range 0-7). This included 42% of deaths. With a new breakpoint of 1, 74% of deaths were predicted. DISCUSSION: Our data has shown that in our environment a significant number of fatalities occur in patients with potentially salvageable burns, and the breakpoints for the mortality prediction scores such as, the Modified Baux score, Coste et al. score, BOBI and ABSI scores are much lower than high-income countries. However these mortality predictive scores can be used in a resource scarce South African setting to triage patients into risk categories by lowering the breakpoints. This may facilitate early and more aggressive management of high-risk burn patients, improving survival rates, as well as efficient and judicious use of critical care and other resources.

Liberal transfusion strategies still the trend in burn surgery.

OBJECTIVE: Blood is a limited resource in middle-income countries such as South Africa. Transfusion is associated with complications and expense. We aimed to understand our transfusion practices in burn surgery as well as ascertain the opinion of a broader group of surgeons and anaesthetists regarding transfusion triggers in order to understand the rationale and bias that drives current transfusion practice in our setting. METHOD: Firstly, we investigated the current blood practices at our regional burn service through an audit of perioperative notes for all patients receiving packed cell transfusions in a 24-month period. Secondly, we formulated a questionnaire asking for opinion on acceptable preoperative and postoperative haemoglobin targets for a list of elective, emergency and burn operations that was distributed at a number of meetings. RESULTS: Seventy-two patients received a total of 103 perioperative transfusions. The median preoperative haemoglobin was 9.8 g/dL in both children and adults and the median postoperative haemoglobin was 10.1 and 9.1 g/dL in children and adults respectively. The cohort was divided into two groups: the first surgery and the subsequent surgeries. In the adult group the mean time to first surgery post burn was 11.5 days with a median volume of 0.73 mls/kg/% operated surface area (range 0.16-1.54) of packed cells transfused per operation. In the paediatric group the mean time to first surgery post burn was 9 days (range 2-54) with a median volume of 1.1 mls/kg/% operated surface area (range 0.56-2.14) of packed cells transfused per operation. One hundred and fifty questionnaires were handed out and 103 (69%) were completed. The average proposed preoperative and postoperative haemoglobin was 9.3 g/dL and 8.4g/dL respectively. The majority of respondents (60% in elective surgery, 43% in emergency surgery and 60% in burn surgery) would like preoperative haemoglobin to be 10 g/dL and above. CONCLUSION: Research suggests that a restrictive blood transfusion approach is being increasingly implemented as best practice. However, our surgical community does not seem to accept a restrictive strategy as part of blood management principles. A shift in this practice could result in clinical benefit by reducing complications and increasing cost saving in our resource constrained setting. We plan to protocolise earlier surgery and blood conservation strategies intraoperatively in addition to a restrictive strategy in our burn service.

'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

Vasoconstrictor clysis in burn surgery and its impact on outcomes: systematic review and meta-analysis.

AIM: Clysis is the subcutaneous or subdermal injection of a vasopressor containing fluid, with or without local anaesthetic agent, and has been used to limit blood loss in patients undergoing surgical burn management. In this systematic review and meta-analysis we aimed to determine the impact of clysis of a vasoconstrictor on burn patient outcomes. METHODS: We conducted a systematic review to identify trials investigating clysis in burn patients undergoing debridement and/or skin grafting. For each eligible trial we aimed to extract the outcomes of perioperative blood loss, blood transfusion, duration of surgery, graft success and healing time, inflammatory response, sepsis, mortality, duration of hospital stay, catecholamine levels and cardiovascular effects in both the short (<72h) and long term (30 days) after surgery. RESULTS: From 443 citations, we selected 39 for full-text evaluation, and identified 10 eligible trials. Due to a lack of reporting on outcomes of interest, meta-analysis could only be conducted for the outcome of red blood cell (RBC) units transfused per patient. Patients receiving clysis (n=222) were transfused 1.89 less units (95% CI -2.12 to -1.66) as compared to those not receiving clysis, although this was associated with a high degree of heterogeneity (I(2)=88%). CONCLUSION: Few studies have adequately evaluated the impact of clysis in burn surgery on patient important outcomes such mortality, duration of surgery and graft success. These results suggest clysis may reduce the need for blood transfusion but additional high quality research is required.

A closer look at burn injuries and epilepsy in a developing world burn service.

BACKGROUND: Burn injuries in South Africa result in significant morbidity and mortality, and specific vulnerable groups of patients are at increased risk of sustaining a burn injury. Epileptic patients are one such vulnerable group. The spectrum of burn injuries sustained by epileptic patients in a South African township and the pattern of injury, mechanism and outcome were reviewed in this study. METHOD: A retrospective review of all epileptic patients admitted to the burn service of Edendale Hospital was undertaken for the period July 2011 to June 2013. RESULTS: One hundred and ninety-seven adult patients were admitted with burns over this period. There were 39 epileptic patients in this cohort, of whom 26 were female. The average age of the patients was 36 years (a range of 21-40 years). The majority of patients sustained a small total body surface area burn. The most common mechanism of burn was from a fire or flames, followed by hot water scalding. Coal or wood fires were the predominant energy source used for heating and cooking at home. CONCLUSION: Epileptics comprise a significant proportion of patients who sustain a burn injury. Typically, they sustain burns during a seizure. These are mostly caused by open flames in the South African environment, and are deep. They tend to be confined to the upper torso, upper limbs and hands. Injury prevention programmes should target epileptics as a vulnerable group.

Burn resuscitation on the African continent.

A survey of members of the International Society of Burn Injuries (ISBI) and the American Burn Association (ABA) indicated that although there was difference in burn resuscitation protocols, they all fulfilled their functions. This study presents the findings of the same survey replicated in Africa, the only continent not included in the original survey. One hundred and eight responses were received. The mean annual number of admissions per unit was ninety-eight. Fluid resuscitation was usually initiated with total body surface area burns of either more than ten or more than fifteen percent. Twenty-six respondents made use of enteral resuscitation. The preferred resuscitation formula was the Parkland formula, and Ringer's Lactate was the favoured intravenous fluid. Despite satisfaction with the formula, many respondents believed that patients received volumes that differed from that predicted. Urine output was the principle guide to adequate resuscitation, with only twenty-one using the evolving clinical picture and thirty using invasive monitoring methods. Only fifty-one respondents replied to the question relating to the method of adjusting resuscitation. While colloids are not available in many parts of the African continent on account of cost, one might infer than African burn surgeons make better use of enteral resuscitation.

Development, implementation, and evaluation of a hybrid electronic medical record system specifically designed for a developing world surgical service.

BACKGROUND: The Pietermaritzburg Metropolitan Trauma Service previously successfully constructed and implemented an electronic surgical registry (ESR). This study reports on our attempts to expand and develop this concept into a multi-functional hybrid electronic medical record (HEMR) system for use in a tertiary level surgical service. This HEMR system was designed to incorporate the function and benefits of an ESR, an electronic medical record (EMR) system, and a clinical decision support system (CDSS). METHODS: Formal ethical approval to maintain the HEMR system was obtained. Appropriate software was sourced to develop the project. The data model was designed as a relational database. Following the design and construction process, the HEMR file was launched on a secure server. This provided the benefits of access security and automated backups. A systematic training program was implemented for client training. The exercise of data capture was integrated into the process of clinical workflow, taking place at multiple points in time. Data were captured at the times of admission, operative intervention, endoscopic intervention, adverse events (morbidity), and the end of patient care (discharge, transfer, or death). RESULTS: A quarterly audit was performed 3 months after implementation of the HEMR system. The data were extracted and audited to assess their quality. A total of 1,114 patient entries were captured in the system. Compliance rates were in the order of 87-100 %, and client satisfaction rates were high. CONCLUSIONS: It is possible to construct and implement a unique, simple, cost-effective HEMR system in a developing world surgical service. This information system is unique in that it combines the discrete functions of an EMR system with an ESR and a CDSS. We identified a number of potential limitations and developed interventions to ameliorate them. This HEMR system provides the necessary platform for ongoing quality improvement programs and clinical research.

Isn't it time for a cadaver skin bank in South Africa?

Improvements in comprehensive burn care, as practiced in dedicated burns units, have reduced mortality and morbidity rates significantly. Strategies deemed most important include the application of fluid resuscitation and nutrition protocols, intensive care and antimicrobial dressings, as well as early excision and grafting. Autografting is limited, however, by availability in very extensive burns, despite the use of expanded (meshed) skin. Alternatives have therefore been required, and deceased donor allograft is considered the gold standard. Fresh allograft use is limited by supply, and legislative and cultural restrictions have significantly influenced availability, despite evidence of its efficacy. This necessitates the establishment of a deceased donor skin bank in South Africa, with a mandate to procure and store allograft for distribution to burns units when required.

L'amélioration des soins aux brûlés, tels qu'ils sont pratiqués dans les unités réservées aux brûlés, a réduit significativement la mortalité et la morbidité. Stratégies jugées les plus importantes comprennent l'application des protocoles sur les fluides de réanimation et de la nutrition, les soins intensifs et les pansements antimicrobiens, ainsi que l'excision précoce et le greffage. L'autogreffe est cependant limitée par la disponibilité chez les grandes brûlures, malgré l'utilisation de la peau étendue (maillée). Des alternatives ont donc été nécessaires, et allogreffe d'un donneur décédé est considérée comme l'étalon-or. Utilisation d'allogreffe fraîche est limitée par l'offre, et les restrictions législatives et culturelles ont influencé de façon significative la disponibilité, en dépit des preuves de son efficacité. Cela nécessite la mise en place d'une banque de peau d'un donneur décédé en Afrique du Sud, qui a pour mandat de se procurer et stocker allogreffe pour la distribution aux unités des brûlures en cas de besoin.

Laparotomy for blunt abdominal trauma in a civilian trauma service.

This report looks at the group of patients who required a laparotomy for blunt torso trauma at a busy metropolitan trauma service in South Africa. Methods. A prospective trauma registry is maintained by the surgical services of the Pietermaritzburg metropolitan complex. This registry is interrogated retrospectively. All patients who required admission for blunt torso trauma over the period September 2006 - September 2007 were included for review. Proformas documenting mechanism of injury, age, vital signs, blood gas, delay in presentation, length of hospital stay, intensive care unit stay and operative details were completed. Results. A total of 926 patients were treated for blunt trauma by the Pietermaritzburg metropolitan services during the period under consideration. A cohort of 65 (8%) required a laparotomy for blunt trauma during this period. There were 17 females in this group. The mechanisms of injury were motor vehicle accident (MVA) (27), pedestrian vehicle accident (PVA) (21), assault (5), fall from a height (3), bicycle accident (6), quad bike accident (1) and tractor-related accident (2). The following isolated injuries were discovered at laparotomy: liver (9), spleen (5), diaphragm (1), duodenum (2), small bowel (8), mesentery (8) bladder (10), gallbladder (1), stomach (2), colon/rectum (2) and retrohepatic vena cava (1). The following combined injuries were discovered: liver and diaphragm (2), spleen and pancreas (1), spleen and liver (2), spleen, aorta and diaphragm (1), spleen and bladder (1) and small bowel and bladder (2). Eighteen patients in the series (26%) required relaparotomy. In 10 patients temporary abdominal containment was needed. The mortality rate was 26% (18 patients). There were 6 deaths from massive bleeding, all within 6 hours of operation, and 3 deaths from renal failure; the remaining 9 patients died of multiple organ failure. There were 8 negative laparotomies (7%). In the negative laparotomy group false-positive computed tomography (CT) scan findings were a problem in 3 cases, in 1 case hypotension and a fractured pelvis on admission prompted laparotomy, and in the other cases clinical findings prompted laparotomy. All patients who underwent negative laparotomy survived. There were 10 pelvic fractures, 5 lower limb fractures, 2 spinal injuries, 4 femur fractures and 2 upper limb fractures. CT scans were done in 25 patients. In 20 patients the systolic blood pressure on presentation was <90 mmHg and in 41 the pulse rate was >110 beats/min. In 16 patients there was a base excess of <-4 on presentation. Conclusion. Laparotomy is needed in less than 10% of patients who sustain blunt abdominal trauma. Solid visceral injury requiring laparotomy presents with haemodynamic instability. Hollow visceral injury has a more insidious presentation and is associated with a delay in diagnosis. CT scan is the most widely used investigation in blunt abdominal trauma. It is both sensitive and specific for solid visceral injury, but its accuracy for the diagnosis of hollow visceral injury is less well defined. Clinical suspicion must be high, and hollow visceral injury needs to be actively excluded.

A cost model case comparison of current versus modern management of burns at a regional hospital in South Africa.

INTRODUCTION: Institutional data shows a high burden of burn injury, which is managed by a conservative delayed approach. This is daily dressing until spontaneous eschar separation occurs followed by delayed skin grafting. Early excision and grafting is considered active management and is shown to be more cost effective in first world situations. We developed a costing model for both approaches to analyse financial costs in a developing country burns unit. METHODS: Utilising previous audit data of burn care at our institution, a costing model was developed. Individual cost drivers such as dressing, analgesia, theatre costs, and hospital stay were identified. Cost for each driver was multiplied by number of patients and or number of days in hospital. Total cost was a summation of these individual drivers. The costs derived from this model were compared to the cost of care of a single patient in which the burn wound was actively managed. RESULTS: The total cost of care for patients admitted with a burn injury was 29,549,750 ZAR. The estimated total cost of the single patient with a 20% body surface area deep dermal thickness burn treated conservatively at our institution was estimated at 154,000 ZAR, compared with a single patient with equivalent injury treated with an active approach costing 103,000 ZAR. The potential cost saving was ten million rand. CONCLUSION: This simple cost model suggests considerable savings could be made with active burn wound management implementation. Accurate costing of a larger cohort should define these savings more accurately.