Septicaemia in scald and flame burns: appraisal of significant differences.

One hundred and sixty burn patients suffering from septicaemia, hospitalized in the Al-Babtain Centre burns unit, Kuwait, between June 1992 and May 2001, were studied. Thirty-two patients (20%) had scalds and 128 (80%) flame burns, thus representing a ratio of 1:4 among septicaemic patients. There were 20 males (62.5%) in the scald group, compared to 73 (57%) with flame burns. Flame burns were significantly higher (p < 0.01) among non-Kuwaiti patients. The mean ages of the scald and flame burn patients were respectively 6.2 and 31.5 yr. The mean total body surface area burn in scalds was 20% and in flame burns 49%, which was significantly higher (p < 0.001). The 34 septicaemic episodes in 32 scald patients and 212 such episodes in 128 flame burn patients showed a significantly higher incidence in the latter group. The majority of septicaemic episodes, in scalds (82.4%) and flame burns (57.6%), were due to gram-positive organisms, mainly methicillin-resistant Staphylococcus aureus and methicillin-resistant Staphylococcus epidermidis. A significantly increased number of episodes were due to S. aureus (p < 0.001) and Enterococcus (p < 0.05) in scald patients. More surgical operations were performed in flame burn patients and survival increased significantly with an increasing number of grafting sessions (p < 0.001). The mean hospital stay in flame burn patients (56 days) was significantly higher than in scald patients (23 days) (p < 0.001). It is significant to record that all the 38 deaths (29.7%) were in flame burn septicaemic patients (p < 0.001). The scald and flame burn patients were quite distinct in their demographic and clinical characteristics. The flame burn patients were more vulnerable to septicaemia, with a high risk of mortality.

Treatment dilemma: conservative versus surgery in cutis aplasia congenita.

Cutis aplasia congenita (CAC), a congenital absence of skin and its appendages, may extend into underlying muscles and bones. The scalp is the commonest site and it may be associated with acrania. CAC presents either as a thin transparent membrane, a black eschar, an ulcer or a healed scar. The dilemma of either immediate surgical management or conservative treatment is much more pronounced in the presence of acrania. Two patients with scalp lesions measuring 12 x 8 cm and 14 x 12 cm respectively and one patient with 4 cm wide circumferential trunk cutis aplasia treated conservatively are presented. The conservative treatment is simple, easy to carry out, and effective even for large defects; therefore, it is recommended in cutis aplasia congenita till complete healing. Surgical interventions such as tissue expansion and resurfacing, contracture release, etc. are for the correction of subsequent deformity at a later date.

Epidemiological and genetic study of 121 cases of oral clefts in Kuwait.

AIM: The aim of the study was to ascertain some epidemiological factors such as sex and consanguinity that may be associated with cleft lip with or without cleft palate (CL +/- CP) in Kuwait as well as to conduct genetic segregation analysis of these families. SETTING AND SAMPLE POPULATION: A total of 113 families ascertained through 121 CL +/- CP and CP surgical probands in Kuwait. The frequencies of cleft types and the epidemiological variables were calculated using SPSS version 5.0 software. Chi-square for goodness-of-fit test was used to test the significance of the associated epidemiological variables to facial clefts. Genetic segregation analysis was performed on 76 families with extended pedigrees and included only those with non-syndromic CL +/- CP (NS CL +/- CP). Major locus segregation analysis was used to fit models to the observed family patterns under Class A regressive models as implemented by REGD routine in S.A.G.E. release 4.0. A test for heterogeneity was also conducted to complete data set in addition to two subsets: Arabs and nomads. RESULTS: Of the 121 patients, 34(28.1%) had CP, 30(24.8%) had CL and 57 (47.1%) had CL + CP. The male to female ratio was 0.89 for CP, 1.14 for CL, 1.35 for CL + CP and 1.2 for all the clefts. The percentage of consanguineous families among those with a positive family history (60%) was not significantly different from that of the general population (54.3%), whereas for all the families with clefts the percent consanguineous was significantly lower (38%). No evidence of heterogeneity in the results between the Arab and nomad subsets was observed. The results for the major locus segregation analysis were inconclusive. CONCLUSION: No definite association was observed between consanguinity and the occurrence of facial clefts in Kuwait. General transmission models in the full data set showed no evidence of heterogeneity in the results between the Arab and nomad subsets.

Minor [correction of Mi1nor] burns and pneumatocoeles: a case report.

Minor burns in children need to be cautiously managed as they may manifest with life threatening complications especially in the presence of staphylococcal infection. A one and a half year old child with minor burns (12% TBSA), who developed large pneumatocoeles and peumomediastinum following Staphylococcus aureus pneumonia causing severe respiratory distress and needing ventilatory support is presented. Most of the pneumatocoeles were spontaneously absorbed over a period of 10 days while surgical interference was being contemplated. A conservative approach to pneumatocoeles as in non-burn patients may help prevent unnecessary surgery. An extensive English literature search (since 1966) did not reveal any report of pneumatocoeles in association with burns and therefore we believe this to be the first report of its kind.

Acute thrombocytopenic crisis following burns complicated by staphylococcal septicaemia.

The pathophysiological changes in a burn patient can at times manifest as severe complications, the management of which can be extremely challenging to the burn surgeon. A case report of an adult male with burns (18% total body surface area) who developed an acute unexpected thrombocytopenia crisis (2x10(9) l(-1)) on day 3 followed by disseminated intravascular coagulation is presented. The various etiological factors and possible mechanisms leading to thrombocytopenia in burns are discussed. Minor burns may present acute major complications in the presence of other thrombocytopenic factors like trauma and sepsis and thrombocytopenia by it self can be a good indicator of sub-clinical infection.

Staphylococcal septicaemia in burns.

This study analyses staphylococcal septicaemia in a series of 1516 burn patients who were admitted to the burn unit of the Al-Babtain Centre for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait over a period of 6.5 years (1 June 1992-31 December 1998). One hundred and nine patients (7.2%) developed clinically and microbiologically proven septicaemia, of which 80 (73.4%) showed one or the other type of Staphylococcus in their blood. Fifty (62.5%) of them were males and 30 (37.5%) females, with a mean age of 26 years and the mean total body surface area of burns (TBSA) of 45% (range 1-93%). Preschool age children comprised 27.5% of the patients. Flame was the dominant (80%) cause of burn. Of the 80 patients who had 91 episodes of septicaemia, 52 (65%) had MRSA, 8 (10%) MSSA, 11 (13.8%) MRSE and 5 (6.2%) MSSE and 4 (5%) others had mixed organisms. Only the patients with MRSA had multiple episodes. Eight patients (10%) showed septicaemic episodes within only 48 h of admission; however, the majority of the patients (77.5%) had a septicaemic attack within 2 weeks postburn. Of the 52 MRSA septicaemic cases, 39 (75%) survived and 13 (25%) died. Four patients with septicaemia due to mixed infections died. A total of 19 patients were intubated, 14 due to inhalation injury and 5 because of septicaemia; all in the former group died. Glycopeptide therapy (vancomycin/teicoplanin) was instituted immediately following the detection of staphylococci in the blood. No significant difference was noted in relation to mortality amongst the septicaemic patients, whether or not on prophylactic antibiotic. Fifty-six (70%) of the 80 patients had 139 sessions of skin grafting and survived. Of the 52 MRSA patients, 40 had 101 sessions of skin grafting and 33 of them survived. The apparent low mortality was probably due to early detection of the organism, appropriate antibiotic therapy, care for nutrition and early wound cover. This study indicates a high incidence of staphylococcal septicaemia (especially due to MRSA) in the burn unit. A surface wound is the likely source of entry to the blood stream in these immunocompromised patients. The organism could be detected in blood as early as 48 h postburn and in as little TBSA burn as 1% in this MRSA endemic unit. Inhalation injury with major burns and added staphylococcal septicaemia invariably proved to be fatal.

Liquid ammonia injury.

The toxic effects of a gas depend on the time of exposure, concentration and its chemical nature. Pressurized liquids and gases exert an additional cold thermal injury and this may complicate the clinical picture. A patient who had an accidental exposure to liquid ammonia over a prolonged period, manifesting in cutaneous, respiratory and ocular damage in addition to a severe cold thermal injury (frostbite) with a fatal outcome is presented. The patient had flaccid quadriparesis and episodes of bradycardia, which has not been reported previously. These manifestations raise the possibility of the systemic toxicity in patients with prolonged exposure to ammonia.

Burn mortality during 1982 to 1997 in Kuwait.

The study group is comprised of 234 patients (6.4%) who died out of 3680 patients treated for burn injuries during the period January 1982 to December 1997 in Kuwait. There were 112 (47.9%) males and 122 (52.1%) females and their mean age was 30 years (range 1-93) when compared with 24 years among survivors. The high mortality amongst two age groups 0-5 years (39 deaths, 16.7%) and 16-35 years (109 deaths, 46.6%) shows their vulnerability in the society. In 190 patients (81.2%) the burn injuries occurred at home. A total of 216 patients (92.3%) sustained flame burns mainly due to clothes on fire (40.6%) and cooking gas accidents (25.2%), and in 18 patients (7.7%) the burns were due to scalds. The suicidal burns occurred in 22 female and 5 male patients mainly of younger age groups. The mean percentage of burns was 71% (range 9-100%) as against 20% amongst survivors, and 195 patients (83.3%) had > or = 50% total body surface area (TBSA) burn. Four patients (1.7%) had superficial dermal burns, 94 (40.2%) had full thickness and 136 (58.1%) had mixed with full thickness burns predominance. The associated inhalation injury was diagnosed in 132 patients (56.4%). A total of 61 patients (26.1%) had either single or multiple pre-existing diseases and 51 of them sustained flame burns. The day of death varied from 1 to 103 days (mean 16 days) but 58 patients (24.8%) died within 48 hours of post burn. A total of 120 patients (51.3%) died due to septicaemia, 83 (35.5%) due to renal failure, 28 (10.2%) due to multi-organ failure, and 7 (3.0%) due to bronchopneumonia. The overall mortality rate was 6.4%, but this has significantly lowered to 4.4% (p = < 0.01) during last four years probably due to better burn care. The study thus shows that age group 0-5 and 16-35 years, domestic accidents, flame burn, inhalation injury, and pre-existing diseases are risk factors and septicaemia as the dominant cause of death in our patients.

Pseudomonas aeruginosa septicaemia in burns.

Out of 1415 patients treated as inpatients at Al-Babtain Center for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait spanning over a period of 6 years from June 1992 to June 1998, 102 developed clinically and microbiologically proven septicaemia. Only 15 out of them had either single or multiple episodes of septicaemia due to Pseudomonas aeruginosa and were studied during their stay in the hospital. Five of them were males and 10 females, with a mean age of 26 years (range 3-51 years) and mean total body surface area of burns (TBSA) of 66% (range 25-90%). All of them had flame burns and resuscitation was found to be difficult in eight patients either due to delayed hospitalization or accompanied inhalation injury. Seven patients were intubated, four due to inhalation injury and three for septicaemic complications. Among the 15 patients under study, a total of 36 septicaemic episodes were detected of which 21 were due to P. aeruginosa. This organism was found in the first episodes in nine patients, in second episodes in six, in third episodes in three and fourth, fifth and sixth episodes in one patient, each at a variable postburn day. Ten patients had 38 sessions of excision and skin grafting, six of them survived. Nine of the 15 patients under study died due to septicaemia, but only six of them had P. aeruginosa as the last isolate. Except for one, all patients had > 40% TBSA burn, two had difficult resuscitation and four were intubated. The day of death varied between 3 to 52 days postburn (mean 19 days). This study showed that females with flame burns are susceptible to P. aeruginosa septicaemia. Difficult resuscitation and intubation also proved to be important risk factors. Septicaemia could occur quite early in the postburn days and the mortality due to this organism was quite high. Early excision and grafting with other effective management may result in a better outcome.

Beta-haemolytic Streptococcus infection in burns.

Group A beta haemolytic Streptococcus has been one of the most serious infections in the burn patients resulting in severe cellulitis and sepsis. Penicillin has been used ever since its introduction as prophylaxis against these conditions. Penicillin prophylaxis was used in our burn unit as well without any serious evaluation until December 1992. This prospective study was therefore, undertaken to evaluate the incidence of beta haemolytic Streptococcus infection in burn patients, and its clinical outcome over a period of 5 years in the absence of prophylaxis with penicillin. 14 of the 1213 burn patients admitted to the Al-Babtain Centre for Plastic Surgery and Burns from January 1993 to December 1997 had either colonization or infection with Streptococcus spp. Their mean age was 15 years (range 1 month to 52 years) and the mean burn surface area was 20% (range 5 to 90%). Streptococci were isolated from burn wounds in 10 patients, throat in 3 and blood culture in 1. Group A Streptococcus was found in 5, group C in 3 and group D in 6 patients. In all patients except one the organisms were isolated > or =72 h post burn. The infections were successfully controlled by antibiotic and no detrimental effect was observed either on wound healing or skin graft take. There was no mortality amongst these 14 patients. The study showed that only 1.1% of the burn patients in our unit acquired Streptococcus of which only one third comprised of group A. This study thus demonstrates that the practice of penicillin prophylaxis during the first five post burn days may not be of any value and therefore, deserves discontinuation in units where the incidence of this organism is minuscule.

Burn septicaemia: an analysis of 79 patients.

Out of 943 patients treated from June 92 to May 96 at the burns unit of the Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, 280 (30%) required admission to the burns intensive care unit (ICBU) and were studied retrospectively. Seventy-nine (28.2%) developed clinically and microbiologically proven septicaemia. Forty-four (56%) were males, 35 (44%) females with a mean age of 26 years (range 45 days to 75 years) and mean total body surface area burn (TBSA) of 46% (range 10-90%). Sixty-two had flame burns, 16 a scald and one had an electric burn. These 79 patients had a total of 118 septicaemic episodes. Sixty (76%) had only one and 19 (24%) had multiple episodes of septicaemia. Fifty-four (68%) had their first episode within 2weeks, though the maximum number of episodes was between 6 and 10 days postburn. Septicaemia was also observed in 13% of patients within 3 days postburn. Out of the 118 episodes, 48 were due to methicillin resistant Staphylococcus aureus (MRSA), 17 due to methicillin resistant Staphylococcus epidemidis (MRSE), 15 to Pseudomonas, 12 to Acinetobacter, four to Streptococcus, another four to Enterococci, two to Klebsiella, one due to Serratia and 15 to more than one organism. Once the septicaemia was diagnosed appropriate therapy was instituted. Fifty-six (71%) patients had 143 sessions of skin grafting and the mortality was low in operated patients. Twenty-three (29.1%) patients died. The low mortality rate was probably due to factors such as continuous clinical and microbiological surveillance leading to quick detection of aetiology, appropriate antibiotic therapy, care for nutrition and early wound cover. This study suggests that flame burn patients are more vulnerable to sepsis. Onset of septicaemia may be as early as 3 days and commonly within 2 weeks. A surface wound is the likely source of entry to the blood stream. Gram positive organisms are dominant in the aetiology. Early detection and appropriate treatment including wound coverage result in a better outcome.

Repair of large, multiple, and recurrent ventral hernias: an analysis of 124 cases.

OBJECTIVE: To present our technique for repairing large, multiple, and recurrent ventral hernias, and describe our experience. DESIGN: Retrospective study. SETTING: Teaching hospital, Kuwait. SUBJECTS: 124 patients (4 men and 120 women, age range 25-60) who presented with recurrent (n = 34), multiple (n = 27), or large (n = 63) ventral hernias. INTERVENTION: Abdominoplasty through a bikini crease incision together with a diamond shaped incision to preserve the umbilicus on its vascular pedicle. After wide dissection the hernia was repaired by two layer, tension-free plication using the available lax tissues. Redundant tissue was excised. MAIN OUTCOME MEASURES: Duration of healing, depth of stay in hospital, complications, and recurrence. RESULTS: Most of the hernias (113, 91%) had healed within 12 days, and over the three quarters of patients had left hospital within 10 days (median duration of stay 8 days). There was one severe wound infection, 10 patients developed minimal necrosis of fat or skin (4 of which developed secondary infection), and there were 3 seromas. 3 Hernias (2%). CONCLUSION: We recommend this technique of abdominoplasty for large, multiple, or recurrent hernias, particularly in those patients who have pronounced prolapse of the abdominal wall.

Scalds among children in Kuwait.

In a prospective study of 560 children treated for burns as in-patients over a period of four-and-a-half years in specialized hospitals responsible for the majority of burn cases in Kuwait, 388 patients (69%) had sustained scalds. The mean age of these 388 children, between 0 to 12 years, was 3.02 +/- 2.08, and male to female ratio 1.5 to 1. They were categorized into three age groups, first, up to 1 year comprised 17.5% cases, who were solely dependent on parents or childminder; second 2 to 5 years of age, who were inquisitive, independent, pre-school children, and constituted the majority of cases (73%), and third 6 to 12 years who were 9.5% school children. The pre-school children (2-5 years) thus formed a highly vulnerable group in the country. Accidents (99.4%) occurred at home and the kitchen being the commonest place. The hot water from pan and pots in the kitchen was the most common etiologic factor in 229 cases (59%), followed by tea/coffee 20.7%, soup 9.0%, hot oil 6.7%, and milk 4.6% patients. The most common circumstance was the child upsetting the pan of hot fluid in the kitchen. The mean total body surface areas of second and third degree burns were 14.21 +/- 9.66 (range 1 to 60%). The average length of stay in the hospital was 16.90 +/- 15.74 days, varying from one to 109 days. Thirty-nine children were ill prior to burn, and the commonest disease was respiratory tract infection. Three patients (0.8%) with 3rd degree burns were treated with primary excision and grafting, and 137 (35.3%) needed secondary skin grafting for residual burn wounds. Four patients (1%) died, one due to burn shock, two due to septicemia and one due to multiorgan failure. There is need for general awareness through public education, which may lead to the prevention of significant number of such accidents.

Epidemiology and mortality of 162 major burns in Kuwait.

The burns intensive care unit at IBN Sina Hospital reopened in July 1991, following the Iraqi occupation of Kuwait and the Gulf War. Epidemiology and mortality of 162 burn patients with 30 per cent and over total body surface area (TBSA) burns, treated from July 1991 to December 1994, is presented. There were 91 males and 71 females with a ratio of 1.3 to 1. The median age was 30 years (range 4 months to 93 years) and 44 per cent of the patients were 15-40 years of age. 124 (76.5 per cent) accidents occurred at home and the flame burn was the commonest involving 131 (80.9 per cent) patients. The median burn surface area was 45.5 per cent and the majority of them sustained deep burns. The hospital stay of the surviving patients ranged from 11 to 174 days (median 38 days), while the day of the death was from 1 to 134 days. Forty-six deaths represent an overall mortality rate of 28.4 per cent amongst our patients. All the patients whose Baux score was 130 and above died. Burn shock was responsible for 10 deaths, and out of them eight were not actively resuscitated due to high Baux score. Sixteen deaths occurred within 48 h postburn. Septicaemia and its related effects were responsible for the majority of the deaths.

Caecal perforation in a burn patient.

A 30-year-old female with a 38 per cent TBSA flame burn developed caecal perforation due to non-specific colonic ulceration. Only one such case has so far been reported in the literature by Still et al. (Burns 1994; 20: 85). The caecal perforation in our patient was treated using a right hemicolectomy. She deteriorated postoperatively and died day 21 postburn due to septicaemia, the perforation of the caecum contributed to the mortality.

Keloid and hypertrophic scars: trace element alteration.

The state of excessive fibroblastic proliferation for wound healing results in hypertrophic and keloid scars. It has been well established that some of the trace elements (such as zinc) are essential in wound healing, and there are appreciable changes in trace elements in various disease states. The levels of zinc (Zn), copper (Cu), manganese (Mn), and selenium (Se) in serum, normal skin and scar of 40 keloid and hypertrophic scar patients were assessed. There was a significant increase of manganese (Mn) level in skin of burn, trauma, and surgical incision patients compared to controls with p < 0.0013, p < 0.0001, and p < 0.046, respectively. Furthermore, the zinc, copper, and selenium contents of the skin in incision patients were decreased significantly when compared to other groups. No significant changes occurred regarding serum levels of zinc, copper, manganese, and selenium in the different groups. From this study, no relationships between the hypertrophic and keloid scar to trace elements were found; however, because of the limited numbers of patients, a definite conclusion could not be drawn.

Penile oedema induced by continuous condom catheter use and mimicking keloid scar.

Continuous use of condom catheter for urinary incontinence in a patient with neurogenic bladder gave rise to localized chronic oedema on the dorsum of the penis, mimicking keloid scar, and urethral fistula on the ventral surface. These unusual combined complications on the penile surfaces were due to pressure effect.

T flap hypospadias repair in circumcised patients.

Single stage repair of distal penile hypospadias with chordee in circumcised patients is described. A ventral 'T' flap is used, the horizontal part of the T flap forming the complete circumference of the new urethra and lying in the defect created due to chordee release. The vertical part of the T flap, in conjunction with the grooved glans, forms the neourethra like the flip flap procedure. Of 22 patients repaired in this way, 2 (9.0%) developed fistula and one (4.5%) had meatal stenosis, thus in 86.5% successful repair was achieved.