History of the Pan African Paediatric Surgery Association (PAPSA).

The Pan African Paediatric Surgery Association (PAPSA) was formed in 1994. The need for an organisation in Africa to voice children's surgery and the trials and tribulations in forming this organisation was covered in this journal 2 years ago (Heinz R, Kyambi J, Lakhoo K. Surg Int 34(5):499-504, 2018). This article covers the history of the organisation post inception in 1994 to date. The near disbanding of the organisation due to political unrest and wars in Africa, to its success in the recent decade is highlighted in this manuscript.

Scar wars.

BACKGROUND: Burn scars are common in the paediatric population. When involving the face, it diminishes quality of life. Ablative fractional laser (AFL) therapy is becoming the preferred choice for established scars due to its greater potential depth for thermal injury (4 mm), which leads to photothermolysis with subsequent neocollagenesis and collagen fibre realignment and remodelling. Combined with small z-plasties and topical steroids, it has been proven to: flatten and decrease the volume of scars, increase pliability and decrease pruritus and erythema. The purpose of the case series was to determine the clinical significance of a single session of AFL therapy, combined with small z-plasties and topical steroids on facial scars post burn injury. METHOD: Four cases of paediatric facial scarring post burns were selected to undergo a single treatment of AFL therapy, accompanied by small z-plasties and topical steroids. Modified Vancouver Scar Scores (MVSS) pre- and postoperatively at 3 and 6 months were evaluated. RESULTS: Improvement of all components of the MVSS was achieved after 6 months, with major improvement in scar pliability and symptomatology. The mean MVSS improved from 14 (range 12-16) preoperatively to 5 and 5.5 respectively at 3 and 6 months postoperatively. Non-parametric analysis with Friedman Two-Way ANOVA by Rank showed a statistical significance between the pre- and postoperative MVSS (p = 0.024). CONCLUSION: AFL should form an integral part of the burn scar armamentarium.

Infant burns: A single institution retrospective review.

Thermal injuries amongst infants are common and a cause of significant mortality and morbidity in South Africa. This has been attributed to the lack of an enabling environment (poverty-related lack of safe living conditions) and the cognitive and physical developmental immaturity of infants, who depend on their surroundings and adults to keep them safe. This is a retrospective observational study of 548 infant admissions over 48 months. Infant was defined as children below 13 months of age. The 548 infants constituted 23% of all paediatric burn admissions of ages 0-12 years. Three hundred and fourteen were males (57%) and 234 (42.7%) females. The infants were divided in a pre-ambulatory group of 143 (26%) infants of 0-6 months and an ambulatory group of 7 months to 12 months consisting of 457 (83.3%). The total body surface area (TBSA) ranged from 2-65%. Seventy-six percent (417 infants) occurred in the home environment. Scalds accounted for 86% (471 infants) and 6% (33 infants) were as a result of flame burns. Non-accidental injuries accounted for 1.2%. The anatomical distributions varied between the pre-ambulatory and ambulatory groups. Conservative management was done in 397 (72.4%) and 101(18.4%) infants underwent surgery. Infection was suspected in 76 (13.5%) infants with positive blood cultures in 15(20%) of the 76. ICU care was received in 46 (8.3%) infants and 15 (32.6%) of these had inhalation injuries. Of the inhalation injuries 11(23.9%) infants underwent mechanical ventilation of an average of 4.4 days. Ventilator associated pneumonia was diagnosed in 8(17%) of the ventilated children. The mortality rate was 0.36%. The surgically treated patients acquired more complications than the conservatively treated group. Special treatment considerations should be considered in this paediatric sub-group.

Scalp as a donor site in children: Is it really the best option?

BACKGROUND: Since 2003 we have used the scalp as a donor site for split skin grafts (SSGs) in major burns when there was a shortage of conventional donor areas. However, we seen a high incidence of complications, contrary to international experience. OBJECTIVE: The aim of this study was to analyze the results and complications related to the scalp as a donor site and to determine whether there is an association between our specific patient population and the complications encountered. METHODS: A retrospective review of our scalp donor site outcomes over a 12-year period was conducted. The cohort included 25 patients, 15 of black African descent, nine of mixed race and one Caucasian. The various hair types were identified based on ethnicity and classified into eight types. Most of our patients had hair types VI-VIII. None of these patients had scalp burns and all received standard burn treatment. The SSGs were taken with an electric dermatome with a standard micrometric setting of 0.2mm. Complications were categorized into short- or long-term, with a mean follow-up time of 1.59years. RESULTS: The mean age of the 25 children was 5.7years. Nineteen sustained flame burns and 6 sustained hot water burns, with a mean total body surface area of 44.9%. A total of 43 scalp procurements were performed in the 25 patients studied. The group of 15 black African patients (hair types VI-VIII) had a total of 22 procurements, the nine patients of mixed race (hair types III-V) had 18 procurements and the single Caucasian patient (hair types II-III) had two procurements. The median healing time was 15days, 11.8days and 8.5days, respectively, per group. Significant complications were encountered, including folliculitis 44%, non-healing wounds 52%, alopecia 16% and visible, hypopigmented scars 3%. One patient had a hypertrophic scar and no hair transfers to the recipient areas were observed. The various hair types correlated with the complications encountered. Five children, with an average burn size of 65.2% (range: 40-85%) died of sepsis. Due to the small sample size, the only statistically significant findings were related to the total body surface area of the burn and the number of times skin was harvested from the scalp, with a p-value of 0.005. The p-values for the healing times related to the first, second and third croppings, were p=0.022, p=0.00032 and p<0.001 respectively. CONCLUSION: Our study suggests that in pediatric patients of black African descent (hair types VI-VIII) the scalp is not an ideal donor area, due to the unacceptably high incidence of complications. Hence, every precaution should be taken when it becomes necessary to harvest donor skin from the scalp.

The value of WhatsApp communication in paediatric burn care.

BACKGROUND: Telemedicine is increasingly applied in developed settings to facilitate transfer of information to and from burn surgeons across vast geographic areas. WhatsApp is a widely available and extremely user-friendly encrypted smartphone application that does not require the expensive physical and personnel infrastructure that characterizes many of these telemedicine systems. The aim of this study was to review the use of WhatsApp to facilitate paediatric burn injury consultations to a regional burn centre in a developing country, where burn care continues to be thwarted by administrative apathy, poor resource allocation and lack of attention to medical and nursing education at all levels. METHODS: A retrospective review was undertaken of all consultations using WhatsApp over an 18-month period, received by the burn centre's two senior medical practitioners. The specific origin and nature of the telemedicine requests for advice, transfer or follow-up were collected, as were data relating to the demographics of the patients, the aetiology, mechanism and extent of the burn injury. The impact of the system of communication in terms of reductions in admissions and clinic visits was assessed, and a cost analysis was undertaken. Feedback was also obtained from those health practitioners regularly using the service. RESULTS: 838 communications occurred during the study period, which included 1562 distinct clinical queries. 486 interactions (58%) originated from within the hospital, the majority of which were initiated by surgeons in training or burn nurse practitioners. 352 (42%) consultations were from outside the hospital. Queries related to the full spectrum of burn care, including emergency management and stabilization, triage and transfer, the need for escharotomy, fluid resuscitation, wound care, the timing and nature of surgical intervention, as well as follow-up and rehabilitation. While no significant changes in the number of surgical interventions or admissions were observed when compared to the five years prior to the intervention, outpatient visits reduced significantly during the study period. It was estimated that over 150 unnecessary admissions were also avoided as a result of the triage made possible by WhatsApp, which translated into considerable cost saving for the institution. DISCUSSION: Incorporating WhatsApp technology into the daily processes of burn care has significantly improved the quality of paediatric burn care referrals to specialist burn services. Specifically, WhatsApp has contributed to reductions in unnecessary referrals and outpatient visits, facilitated opportunities for continuing medical education, improved the care of major burn injuries through more effective prehospital communication, and enabled greater allocation of scarce specialist resources at the burn centre. This study motivates for the wider application of WhatsApp for burn care referrals, especially in developing countries.

Assessing guidelines for burn referrals in a resource-constrained setting: Demographic and clinical factors associated with inter-facility transfer.

AIM: The aim was to assess demographic and clinical factors associated with inter-facility referrals for patients with burns in a resource-constrained setting. METHODS: This was a cross-sectional case review of patients presenting with a burn at the trauma unit at the Red Cross War Memorial Children's Hospital (RXH) in Cape Town, South Africa. RESULTS: Six hundred and eleven-(71%) children were referred to the burns or the intensive care unit and 253 children were treated and discharged from the trauma unit. Of those admitted as inpatients 94% fulfilled at least one of the criteria for referral and 80% of those treated and discharged fulfilled the criteria for referral. CONCLUSIONS: Almost three out of four children evaluated at the trauma unit were referred to the burns unit for further management. However, a large number of patients were treated and discharged from the trauma unit despite being eligible for referral.

Experience and outcomes of micrografting for major paediatric burns.

BACKGROUND: The deficit of donor sites in major burns over 50% of the total body surface area has necessitated the application of methods besides traditional meshed autografting to achieve definitive skin cover. The Meek micrografting technique was introduced at this hospital in 2011, especially in the absence of a reliable source of deceased donor allograft skin. The purpose of this study was to evaluate this strategy with reference to its technical execution, efficacy and indications in the context of major paediatric burn surgery. METHODS: A cohort study was performed of all paediatric patients with major burn who underwent Meek micrografting at a dedicated paediatric burn centre in a developing country over a five year period. Demographics, details of their burns, operative management and clinical course and outcomes were collected from patient records and operative notes and analysed. RESULTS: Thirty-five patients were managed using the micrografting technique during the study period. The mean patient age was 4.1 years (range 3 months-11 years) and their mean total body surface area (TBSA) burn was 49.7% (range 15-86%). Eleven patients sustained inhalation injuries and five developed a re-feeding syndrome on account of delayed referral. The mean abbreviated burn severity index (ABSI) was 8.5 (range 2-13). The hospital length of stay in the 27 survivors was a mean of 75.5 days, equating to 1.4 days per percentage burn. Eight patients died during the course of treatment, with a mean TBSA burn of 67.75% (range 38-86%). Graft take one month after surgery was documented to be more than 90% in 24 patients, of whom 3 subsequently died. Eleven patients had less than 90% graft take at this time, of whom 5 died. CONCLUSION: There is a considerable 'learning curve' associated with this technique. In order to achieve success one must ensure a completely viable, non-infected bed, obtained by tangential or fascial excision, followed by allografting as temporary coverage and to 'test the wound bed' for definitive coverage. Infection resulted in the majority of autograft loss in this series, and in addition to risk factors like burn size and inhalation injury, accounted for many of the deaths in this series. Meek micrografting offers high expansion ratios, thereby facilitating durable wound cover in the presence of limited donor sites. It is unlikely that a lethal dose, 50% (LD50) of almost 70% TBSA would have been possible in this context without the regular application of this technique. This study advocates for the widespread availability of Meek micrografting and deceased donor allograft skin in developing countries.

A review of the peri-operative management of paediatric burns: Identifying adverse events.

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

The hospital costs associated with acute paediatric burn injuries.

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

Fatal non-occlusive mesenteric ischemia and the use of propranolol in paediatric burns.

Abdominal complications without abdominal injury are infrequently seen in children with major burns. They are divided into those that occur early during the emergency phase of treatment and those that occur late in the course of treatment. One of the most serious late onset complications is non-occlusive mesenteric ischaemia associated with the use of vasoactive drugs. We report on 2 children who late in the course of their burn injury developed ischaemic necrosis of their entire intestine. Both were on propranolol, the administration of which was continued with even during the periods of septic shock which preceded their demise. We are of the opinion that endogenous catecholamine release during hypotensive and septic episodes in conjunction with ß-adrenergic blockage from propranolol could lead to severe splanchnic vasoconstriction from unopposed α-adrenergic activity and hence critical circulation impairment to the bowel in the 2 children.

Measurements in wound healing with observations on the effects of topical agents on full thickness dermal incised wounds.

INTRODUCTION: A multitude of topical wound treatments are used today. Although it is well established that the micro-environment of healing wounds can be altered to improve healing, it is difficult to measure the subtle differences in outcome where therapies are compared. METHOD: We compared wound healing properties between four different topical agents in surgically incised wounds in a pig model. The four topical agents, 5% Povidone-Iodine cream, 1% Silver-Sulphadiazine, 2% Mupirocin, and 1% Silver-Sulphadiazine plus 1mg/100g recombinant-human epithelial growth factor (EGF) were randomly assigned to four test animals each. Test agents were compared to each other and to untreated controls. We investigated existing and new methodologies of measurement of wound healing: clinical and histological visual scoring systems, immuno-histochemistry, and computerized image analysis of the wounds on days 3, 7, and 28. RESULTS: All agents were found to have improved healing rates with better cellular architecture. Healing was faster, histological appearance resembled normal architecture sooner, clinical appearance improved, mitotic activity was stimulated and more collagen was deposited in comparison to the wounds with no agents. EGF-treated wounds showed an increased rate of epithelisation, but the rate of healing did not correlate well with evaluation of cosmetic outcome. CONCLUSION: Topical agents improve all aspects of wound healing. The addition of a human recombinant EGF to Silver-Sulphadiazine increases epithelial growth and amounts of collagen in the regenerating wounds at day 7.

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

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

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

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