Biodebridement: a case report of maggot therapy for limb salvage after fourth-degree burns.

The wound healing and antimicrobial properties of maggots are well known. Maggot debridement therapy has been used for the treatment of various conditions. For maggot debridement therapy, the larvae of the blowfly are applied over necrotic or nonhealing wounds. We used maggot debridement therapy with the larvae of Phaenicia sericata for limb salvage after bilateral lower extremity fourth-degree burns.

Pharmacokinetics and burn eschar penetration of intravenous ciprofloxacin in patients with major thermal injuries.

Adequate penetration of antibiotics into burn tissue and maintenance of effective serum levels are essential for the treatment of patients sustaining major thermal injuries. The pharmacokinetics and burn eschar penetration of intravenous ciprofloxacin were determined in 12 critically ill patients with burn injuries. Mean age for the 12 patients was 45 +/- 17 (range 25-82 years), total body surface area burned (TBSAB) = 38 +/- 15% and Acute Physiology and Chronic Health Evaluation (APACHE) II score = 8 +/- 6. Patients received recommended doses of ciprofloxacin, 400 mg q12h iv, for three doses beginning 72 h post-burn. Serum concentrations were measured at t = 0, 0.25, 0.5, 0.75, 1.0, 1.25, 1.5, 2.0, 4.0 and 12.0 h after the first and third doses. Burn eschar biopsies were obtained after the third ciprofloxacin dose. Three of these 12 patients (25%) manifested later signs of clinical sepsis (TBSAB = 61 +/- 6% and APACHE II score = 11 +/- 3) and underwent a second infusion of three doses of intravenous ciprofloxacin, blood sampling and eschar biopsy. Serum and eschar concentrations were determined by high performance liquid chromatography. Serum ciprofloxacin concentrations were comparable to those of normal volunteers (C(max) = 4.0 +/- 1 mg/L and AUC = 11.4 +/- 2 mg.h/L) during the immediate post-burn period after dose 1 (C(max1) = 4.8 +/- 3 mg/L and AUC(0-12) = 12.5 +/- 7 mg. h/L) and dose 3 (C(max3) = 4.9 +/- 2 mg/L and AUC(24-36) = 17.5 +/- 11 mg.h/L). Mean burn eschar concentration during the 72 h post-burn was significantly lower than that found during clinical sepsis (18 +/- 17 compared with 41.3 +/- 54 microg/g; P < 0.05 by t test). Similar serum concentrations were achieved in patients with clinical sepsis (C(max1) = 4.2 +/- 0.2 mg/L and AUC(0-12) = 15.0 +/- 3 mg. h/L; C(max3) = 5.0 +/- 1 mg/L and AUC(24-36) = 22.8 +/- 9 mg.h/L). A positive correlation between burn eschar concentrations and C(max) (r = 0.71, r(2) = 0.51, P = 0.01) was found by linear regression analysis. A C(max)/MIC ratio > 10 (MIC = 0.5 mg/L) and an AUC/MIC ratio > 100 SIT(-1).h (serum inhibitory titre) (MIC = 0.125 mg/L) were achieved. High burn eschar concentrations and serum levels, similar to those found in normal volunteers, can be achieved after intravenous ciprofloxacin infusion in critically ill burns patients.

Implementation of a patient charting system: challenges encountered and tactics adopted in a burn center.

The rapid movement of information technologies into health care organizations has raised managerial concern regarding the capability of today's institutions to satisfactorily manage their introduction. Indeed, several health care institutions have consumed huge amounts of money and frustrated countless people in wasted information systems implementation efforts. Unfortunately, there are no easy answers as to why so many health informatics projects are not more successful. In this light, the aim of this study is to provide a deeper understanding of how clinical information systems are being implemented by emphasizing research efforts on the dynamic nature of the process, that is, the "how" and "why" of what happened. Using a case study methodology, we examined the implementation of a patient charting system in the Burn Center of a large, not-for-profit, teaching hospital. Based on an in-depth examination of this implementation, several insights are offered to those who have responsibility for managing complex and risky clinical information system implementation projects.

Iron and infection: new developments and their implications.

Unsaturated transferrin in plasma ensures that the amount of free ferric iron available to bacteria is about 10(-18) mol/L. This low iron environment is essential for the bacteriostatic and bactericidal systems in blood, lymph, and exudates. Antibacterial systems are abolished when iron becomes freely available. This results in rapid extracellular bacterial growth and greatly increased bacterial virulence. In human plasma, a fall in Eh (oxidation-reduction potential) or pH results in the abolition or marked reduction of its bactericidal properties. This is highly relevant to infection after trauma, where a fall in Eh and pH frequently accompanies tissue damage. Bacterial resistance to antibiotics has put the treatment of serious infections in jeopardy. Reinforcement of natural means of resistance needs to be explored, as well as examining new antibacterials that interfere with bacterial iron metabolism.

Comparison of length of hospital stay to mortality rate in a regional burn center.

Data were collected prospectively from 196 patients admitted to our regional burn center during a 10-month period. Fifteen patients died during hospitalization, for a mortality rate of 7.7%. The mean hospital stay of the 181 patients who survived was 13.9 days (+/- 13.7 SD), ranging from 2 to 89 days. The mean burn size was 9.2% (+/- 11% SD), ranging from 0.5% to 60% total body surface area. One hundred ten patients received at least 1 day of antibiotic treatment, and 22 patients required ventilatory support during hospitalization. Hospital stay was longer for those requiring antibiotics (18.6 days vs 7 days) or ventilatory support (34.4 days vs 11.2 days). When these and other variables were entered into a linear regression model, the most powerful predictors of hospital stay were burn size and duration of antibiotic use (p = 0.0001), followed next by the presence of other traumatic injuries (p = 0.047).

The use of Technetium-99 pyrophosphate scanning in management of high voltage electrical injuries.

The surface thermal burn associated with high voltage (HV) electrical injuries represents only the tip of the iceberg. Occult muscle damage may not become apparent for 5 to 10 days. In this study, the efficacy of Technetium-99m (Tc) pyrophosphate scanning was investigated. Early scanning (within 3 days of injury) of 19 limbs in 15 patients demonstrated a sensitivity of 75 per cent, with a specificity of 100 per cent. The predictive value of a positive test, however, was 100 per cent. Compared to a control group of 17 patients treated without Tc scan, the scan was not associated with reduced hospital length of stay or with decrease in the number of surgical procedures.

The role of Eh, pH and iron in the bactericidal power of human plasma.

The bactericidal power of fresh human plasma against Klebsiella pneumoniae and Escherichia coli was extremely sensitive to changes in Eh and pH. At a high Eh (approx. +200 mV) the bacteria were destroyed, but rapid regrowth occurred when the Eh was lowered to approx. -400 mV. Abolition of the bactericidal effect was also produced by adding ferric iron at a high Eh (approx. +200 mV). Lowering the pH to 6.50 reduced or prevented the bactericidal effect. These results are probably related to the availability of iron for bacterial growth, and could be important for understanding the development of infection in injured or diseased tissue.

The relationship of burn wound fluid to serum creatinine and creatinine clearance.

A case is presented with emphasis on creatinine clearance and burn wound closure. It suggests that the burn wound acts as an extrarenal site for creatinine loss. As a result, renal creatinine clearance may be falsely elevated while the burn wound is open, and closure of the burn wound may affect creatinine clearance.

"The die is cast": telling patients they are going to die.

The decision not to resuscitate a patient with burns is an issue of concern, with advocates both for and against. Most patients have not had previous experience with major burn injuries. It is therefore unreasonable to expect them or their families to act from a position of knowledge. There is a subset of patients considered for "do not resuscitate" orders who are nonsurvivors. If the outcome is predictable, the responsibility of the burn team is to inform patients and their families. Such discussion should come within the first few hours of admission, when the patient is fully awake and able to understand, to respond, and to make plans.

Burns in octogenarians.

Trauma is the fifth leading cause of death for the elderly. Approximately 7.4 million (3% of the population) are more than 80 years old (the so-called "old" old). More than 40% of Americans will reach the age of 80 years, and those who do can expect to live an average of 8 years more. The advanced elderly burn victim creates special demands because of a greater morbidity and mortality associated with a smaller body surface area burn. From September 1982 through August 1990, there were 29 patients 80 years old or older treated at our burn center. The mean age was 83 years, and 72% of the patients were women. The most common preexisting medical problems were hypertension and diabetes. Seventeen (59%) survived. The mean percentage of body surface area (BSA) burned was 6% among the survivors, with a mean length of hospital stay of 24 days. The mean BSA burned was 32% among those who died, with a mean stay of 17 days. Five of the 12 deaths were due to burns of less than 20% BSA, below the standard commonly used to define a "major" burn. The abbreviated burn severity index (ABSI) was a good indicator of survival. Eleven of 12 with an ABSI of 7 or less survived, and nine of 11 with an ABSI of 9 or more died. Twelve patients had operation; seven survived. Of the 15 survivors living independently before the injury, 11 were discharged home and four were transferred to nursing facilities. In this age group, even small burns can be problems, and indications for hospital admission should be broadened. The advanced elderly also cause financial burdens to burn centers because of inadequate diagnosis-related group (DRG) reimbursement. For those surviving, there is a good chance for maintaining independent function and for being discharged home.

Hemochromatosis, iron and septicemia caused by Vibrio vulnificus.

Vibrio vulnificus is killed by normal human blood but grows rapidly in blood from patients with hemochromatosis. It also grows in normal blood if the saturation of the transferrin is increased or if hematin, which contains iron, is added. It is suggested that the increased availability of iron in the blood of patients with chronic iron overload is responsible for their enhanced susceptibility to infection with V vulnificus.

The critical role of iron in some clinical infections.

The role of iron in certain clinical infections is revealed. In normal persons the antibacterial and antifungal properties of blood and other tissue fluids cannot be maintained unless there are exceptionally low levels of available iron. This is controlled by the presence of the unsaturated iron-binding proteins, transferrin and lactoferrin. In several clinical conditions an abnormal availability of iron is responsible for fatal septicaemia. This is because the phagocytic system is overwhelmed by rapidly growing organisms when iron is freely available.

The bactericidal power of the blood and plasma of patients with burns.

Patients with burns are unusually susceptible to bacterial infections, but so far there is no satisfactory explanation for this lack of resistance. Since resistance to infection involves many different mechanisms, examination of individual components of the immune system may not sufficiently explain the underlying reasons for increased susceptibility. The use of whole blood for antibacterial tests has the advantage that all the immune systems present in that fluid compartment can take part in the bactericidal effect. Tests with Klebsiella pneumoniae and Staphylococcus aureus showed no evidence that the bactericidal power of the blood and plasma of patients with burns was less than that of normal control plasma. This suggests that the solution to the problem of increased susceptibility to infection in patients with burns does not lie with the blood but must be looked for elsewhere.

Clinical evaluation of a computer-based patient monitoring and data management system.

Clinical information systems can extend the scope of computerization beyond laboratory data collection and storage. An automated and computerized intensive care unit flowsheet and patient chart can reduce nonnursing work and improve the quality, quantity, and recall of clinical information.

Bacterial virulence and host selection: bacteria "select" patients to infect.

A clinically lethal strain of Pseudomonas aeruginosa was tested and its growth patterns in normal plasma and in normal whole blood clotted with thrombin were compared. Two stock cultures were used; one was maintained in liquid nitrogen and one was passed from plate to plate 24 times on blood agar plates at room temperature. The results showed that plasma alone and whole blood controlled the growth of a clinically pathogenic strain of P. aeruginosa consistently and uniquely for each donor, dependent on size of inoculum, length of incubation, and means by which the culture was maintained. The changing virulence of an organism and its unique growth patterns in different individuals' plasma and whole blood may explain why patients exposed to the same organisms within the same environment vary in susceptibility to clinical infection.

Predictive value of historical and physical characteristics for the diagnosis of child abuse.

Child abuse by burning may be difficult to recognize, especially since the injuries are often small. Historical and physical findings that can be elicited in the initial examination can be helpful in initiating a more in-depth investigation. An injury inconsistent with the history given or a delay in seeking medical treatment were the two most frequent reports that elicited suspicion. As isolated findings, however, they had a low predictive value. The presence of two or more of 13 factors increased the yield in child abuse identification to more than 60%.

A qualitative comparison of paper flowsheets vs a computer-based clinical information system.

Demonstrating the value of computerized clinical information systems (CIS) relative to its cost has been difficult. Decreased mortality in the intensive care unit or a reduction in nursing staff have not been apparent, but CIS does lead to a significant improvement in documentation over handwritten flowsheets, both in volume and accuracy. This may have a medicolegal and quality assurance impact, as well as enhancing patient care.