Predicting factors influencing the fatal outcome of burns in Kuwait.

A prospective study was carried out on a total of 2111 burn patients admitted at the Burn Center in Kuwait, during 1993 to 2001, with the purpose of predicting the risk factors influencing the fatal outcome. A total of 111 (5.3%) patients died, giving an annual average of 12 deaths, and a mortality rate of 0.64/100,000 population. The data, from the in-patient records, included the most commonly available demographic features viz. age, gender and nationality, as well as best recorded clinical factors, such as cause of burn, total body surface area (TBSA), duration of hospital stay and outcome, for analysis. Kolmogorov-Smirnov z test showed the median age (30 years) and TBSA (80%) significantly higher (p < 0.001) among those died as compared to 24 years and 10%, respectively in patients survived. The Chi-square test revealed a fatal outcome associated with gender and cause of burn. The multiple logistic regression model predicted patients, aged 60 years and above (OR: 9.9, p < 0.001), female gender (OR: 2.2, p < 0.016), Flame burns (OR: 3.5, p < 0.035), and TBSA > 90% (OR: 23.5, p < 0.001), as the most influencing risk factors for a fatal outcome at this burn center. Patients with these characteristics need to be given special attention during in-patient care.

An unusual case of scalp laxity following weight reduction.

The advent of fast foods, increased mechanization,advanced telecommunication and improved living standards have caused human beings to adopt sedentary life styles leading to lesser means of expending calories, accumulation of body fat and tendency to be obese. Plastic surgery can be of great help in supporting patients in their attempts at weight reduction by removing resistant body fat and excising redundant skin that may not succumb to other means of weight reduction. The authors present an unusual case of a young gentleman who developed a rare laxity of the scalp following a drastic weight reduction. Scalp reduction led to a significant cosmetic improvement and psychological acceptance of body image. A review of literature and discussion on the management of this unusual case follows.

Burn septicaemia in Kuwait: associated demographic and clinical factors.

OBJECTIVE: To study the demographic and clinical factors associated with burn septicaemia patients in Kuwait. MATERIALS AND METHODS: All burn in-patients, who developed septicaemia at the Burns Unit, Al-Babtain Centre for Burns and Plastic Surgery, Kuwait, during a 9-year period (June 1992 to May 2001) were included in the study. The data were recorded for age, sex, nationality, cause and percentage of burns, inhalation injury, resuscitation, number of episodes, septicaemia on post-burn day, the microorganisms responsible in each episode, treatment and outcome for statistical analysis. Using SPSS (PC version 11.0) software, a probability level of p < 0.05 was considered significant. RESULTS: Of the 2,082 patients treated in the Burns Unit, 166 [8%; 99 (60%) males and 67 (40%) females] with a mean age of 26 years (range 1-70) had septicaemia. Significantly higher (p < 0.001) cases were recorded among Kuwaiti children (< or =14 years) and non-Kuwaitis (25-59 years) than other corresponding age groups. The total body surface area burned ranged from 2 to 95% (mean 42%) and the main cause of burn was flame (77.1%). Inhalation injury was diagnosed in 39 (23.5%) patients. A total of 253 septicaemic episodes occurred in all patients. The majority, 123 (74.1%), had a single episode and the remaining 43 (25.6%) had multiple (2-10) episodes. One hundred and fifty-five (61.3%) episodes were due to gram-positive organisms, mainly methicillin-resistant Staphylococcus aureus, and 32 (12.7%) were polymicrobial. One hundred and twenty-four (74.7%) patients had wound excision and skin grafting procedures and their survival was significantly higher (OR = 4.3; 95% CI: 1.98-9.31) than non-surgically treated patients. Thirty-nine (23.5%) patients died mainly due to multi-organ failure. CONCLUSION: The findings indicate that the patients with extensive flame burns were prone to developing septicaemia due mainly to gram-positive bacteria. The surgical excision of eschar and wound covering improved the outcome of the patients while prophylactic antibiotic treatment had no role in the incidence and outcome of the burn patients.

Heterotopic calcification in burn scars and non-healing ulcers.

Heterotopic calcification (HC) is abnormal deposition of calcium salts in tissues other than bone and enamel. The heterotopic calcification in the burn patients is commonly found either in periarticular region or in the muscles, but the occurrence of heterotopic calcification of the burn scar itself in the presence of normal serum calcium, phosphate and alkaline phosphatase is not reported earlier. We present four adult male patients of lower limbs heterotopic calcification in burn scars with unusual presentation of non-healing ulcers with a latent period of 15-20 years. In one of the patient it was Marjolin's ulcer although the lesion was away from the calcified area. Excision of the calcified scars and the release of contracture have cured the non-healing ulcers and this may prevent re-calcification in future.

Radiological manifestation of pulmonary complications in deceased intensive care burn patients.

The chest radiographs of 46 burn patients who died in the burn intensive care unit (BICU) were retrospectively analyzed to study the spectrum of pulmonary complications and their contribution to patient's mortality. There were 25 male and 21 female patients and their mean ages were 34 and 30 years, respectively. Forty-three patients had flame burns, two chemical, and one scald with a mean total burn surface area (TBSA) of 71%. Thirty-six of them had inhalation injury and of these 25 patients developed septicaemia. Out of these 46 patients, 39 had a total of 60 pulmonary complications on various postburn days. The commonest complications were consolidation (28.3%) and adult respiratory distress syndrome (ARDS) (26.7%) mainly due to inhalation injury and/or following septicaemia. The majority of these complications (46.7%) occurred in the late phase (postburn day 5 onwards). Forty-one (89.2%) patients died due to multi-organ failure (MOF) and a good number of them had secondary respiratory failure. The flame burn patients with large TBSA, presence of inhalation injury, and occurrence of septicaemia, are at risk for pulmonary complications that equally affect adult males and females. Pulmonary complications irrespective of the cause significantly contribute to the mortality. This study suggests that serial chest X-rays done in BICU form an important diagnostic tool for pulmonary complications from postburn day 1 onwards, and is useful for subsequent monitoring of the treatment. All burn intensive care units may not be privileged to have a full time radiologist, and intensivist. Therefore, the burn surgeon needs to metamorphose into an intensivist and double as a burn radiologist for early detection and quick treatment if his surgical skills are to be adequately rewarded.

Only some septicaemic patients develop hypernatremia in the burn intensive care unit: why?

From April 1993 to January 2000, 105 patients in the burn intensive care unit (BICU) that developed septicaemia in the course of their treatment were studied retrospectively to investigate as to why only 36 septicaemic patients (34%) developed hypernatremia (serum sodium >150mmol/l). Septicaemic burn patients who developed hypernatremia were found to have a higher incidence of inhalation injury and a larger burn area (TBSA) signifying greater free water losses in the face of increasing fluid requirements. Patients who developed hypernatremia showed a characteristic pattern of septicaemia: early onset, multiple episodes, polymicrobial, need for multiple antibiotics, longer duration and a higher mortality, indicating a more severe degree of sepsis. The level of incapacitation either from the burn itself, mechanical ventilation or from impaired mental status leading to an inadequate free water intake was more in septicaemic patients who developed hypernatremia. Increased urinary free water losses and solute diuresis from hyperglycemia were significant factors in the development of hypernatremia. Patients who were treated with early wound excisions were less prone to develop hypernatremia when compared to those who did not undergo early wound excision. The close association between the onset of hypernatremia and the onset of septicaemia noted in this study suggests the use of hypernatremia as a marker for septicaemia in burn patients. Hypernatremia in a septicaemic burn patient is multi-factorial and a thorough understanding of the underlying factors will help prevent the onset and progress of hypernatremia.