Superior mesenteric artery syndrome - A rare presentation and challenge in spinal cord injury rehabilitation: A case report and literature review

BACKGROUND

Obstruction of the third part of the duodenum (D3) is a very rare cause of gastric outflow obstruction. Rapid weight loss is the biggest risk factor. Patients seen in acute rehabilitation settings, not uncommonly, have a period of rapid weight loss. We report two cases of superior mesenteric artery (SMA) syndrome and review the literature.

CLINICAL DETAILS

The patients presented differently, one with repeated, refractory autonomic dysreflexia and severe spasticity and one with nausea, abdominal discomfort, and vomiting. CT abdomen with contrast identified dynamic duodenal (D3) obstruction against the posterior structures by narrow angled SMA, gastric distension and, in one case, dilation of the left renal vein. Both patients responded well to optimizing nutrition in different ways. Surgery was successfully avoided.

DISCUSSION

SMA syndrome is an atypical cause of high intestinal obstruction, frequently occurring in patients who have had rapid weight loss during spinal cord injury (SCI) rehabilitation. It may co-exist with left renal vein dilation "nutcracker phenomena". The associated neurogenic bowel dysfunction due to the nature of SCI could possibly contribute to delay in diagnosis.

CONCLUSION

Clinicians should consider the risk of SMA syndrome in patients with SCI with rapid weight loss. Early diagnosis is possible by doing a CT abdomen with contrast and angiography if there is a high index of suspicion. SMA syndrome can be successfully treated by aggressive nutritional management. This may include total parenteral nutrition or feeding by a nasojejunal tube. Duodenojejunostomy could be required in refractory cases.

Osteomyelitis in burn patients requiring skeletal fixation

Deep and severe burns often present with the exposure of musculoskeletal structures and severe deformities. Skeletal fixation, suspension and/or traction are part of their comprehensive treatment. Several factors put burn patients at risk for osteomyelitis, osteosynthesis material being one of them. In order to determine the safety of skeletal fixation, we reviewed all pediatric patients treated with pin insertion during the past 10 years. Forty-one severely burned children (61+/-3% TBSA full thickness burns), had a total of 357 skeletal fixation procedures. Pins were maintained an average of 25.3+/-1.7 days. Thirteen pins (3. 6%) were loose before the expected time of removal, two patients (4. 8%) presented with cellulitis of the pin site and two patients (4. 8%) presented with osteomyelitis. Loose pins, pin site cellulitis, burn wound infection and sepsis were not associated with osteomyelitis. Skeletal fixation in severely burned patients presents with a low incidence of infectious complications. Its use should be considered in patients affected by severe burns that present with exposed deep structures and for positioning purposes. The exact timing for pin removal in burned patients is still to be defined.

Cost-efficacy of cultured epidermal autografts in massive pediatric burns

OBJECTIVE

To assess the efficacy of cultured epidermal autografts (CEA) for closure of burn wounds in pediatric burn patients with full-thickness burns of more than 90% total body surface area.

SUMMARY BACKGROUND DATA

Paucity of donor sites in massive burns makes the use of expanded skin of paramount importance. CEA techniques have been used in burned patients with differing and controversial results. The true impact and the efficacy of such techniques in massive burns remain uncertain.

METHODS

Patients with full-thickness burns of more than 90% body surface area treated between May 1988 and May 1998 were studied. Patients grafted with CEA were compared with patients grafted with conventional meshed autografts. Rates of death and complications, length of hospital stay (LOS), hospital cost, acute readmissions for reconstruction, and quality of scars were studied as outcome measures.

RESULTS

Patients treated with CEA had a better quality of burn scars but incurred a longer LOS and higher hospital costs. Both groups had comparable readmissions for open wounds, but patients treated with CEA required more reconstructive procedures during the first 2 years after the injury. The incidence of sepsis and pneumonia in both groups was comparable.

CONCLUSIONS

Conventional meshed autografts are superior to CEA for containing hospital cost, diminishing LOS, and decreasing the number of readmissions for reconstruction of contractures. However, the use of CEA provides better scar quality such that perhaps future research should focus on bioengineered dermal templates to promote take and diminish long-term fragility.

Effects of tracheostomies on infection and airway complications in pediatric burn patients

Considerable controversy exists as to whether tracheostomy is ever indicated in burn patients. New advents in the treatment of inhalation injury have improved survival, making the use of tracheostomy more usual. The purpose of this study was to analyze the outcome of tracheostomies, and the effect of time on complications. Patients requiring ventilatory support and tracheostomies were studied. Demographic data, hospital course, ventilatory parameters and complications were analyzed. Two hundred ninety patients required ventilation and 36 tracheostomy. Mean percentage of TBSA burned was 59%+/-4. Ninety percent of these patients presented with inhalation injury. Mortality in tracheostomy patients was 25 and 16% in all ventilated patients. Thirty-five percent of the patients developed late complications. Patients who had their airway converted to tracheostomy before day 10 postinjury had a significantly lower incidence of subglottic stenosis. and patients who required airway pressures over 50 cm H2O for more than 10 days had a significantly higher incidence of tracheomalacia. Pneumonia occurred at similar incidence in ventilated and tracheostomy patients. The mortality and late complications of pediatric burn patients with tracheostomy has decreased over the last decade. They do not present with higher incidence of pneumonia. Maintenance of airway pressures below 50 cm H2O and conversion of the artificial airway to tracheostomy before day 10 postinjury may be advisable in patients requiring long term ventilation to prevent late complications.

The isolated burned palm in children: epidemiology and long-term sequelae

The isolated burn of the palm is a typical injury in young children. Positioning and splinting in small hands is difficult, and long-term sequelae of these injuries are not uncommon. The objective of the present study was to assess the outcome of palm burns and to identify the risk factors for long-term sequelae. All patients admitted to our hospital affected with isolated palm injuries between January of 1988 and January of 1998 were reviewed. In total, 120 pediatric patients were admitted with isolated palm burns; 110 patients (91.7 percent) had partial-thickness burns, and 10 patients (8.3 percent) had full-thickness burns. Only four patients (3.3 percent) required excision and skin autografting, but all patients whose palms were operated on in the acute phase developed burn contractures. Sixteen patients (13.3 percent) developed palmar contractures, and more than half of them (56 percent) required reconstructive procedures. All palm burns that healed in more than 3 weeks developed scarring and sequelae (p<0.05 compared with no sequelae). Pediatric palmar burns are benign injuries with a low incidence of late sequelae. However, flame and contact burns are more prone to develop scarring. Excision and autografting should be performed on wounds that take over 3 weeks to heal, but it does not prevent late sequelae.

Biobrane versus 1% silver sulfadiazine in second-degree pediatric burns

Partial-thickness burns in children have been treated for many years by daily, painful tubbing, washing, and cleansing of the burn wound, followed by topical application of antimicrobial creams. Pain and impaired wound healing are the main problems. We hypothesized that the treatment of second-degree burns with Biobrane is superior to topical treatment. Twenty pediatric patients were prospectively randomized in two groups to compare the efficacy of Biobrane versus 1% silver sulfadiazine. The rest of the routine clinical protocols were followed in both groups. Demographic data, wound healing time, length of hospital stay, pain assessments and pain medication requirements, and infection were analyzed and compared. Main outcome measures included pain, pain medication requirements, wound healing time, length of hospital stay, and infection. The application of Biobrane to partial-thickness burns proved to be superior to the topical treatment. Patients included in the biosynthetic temporary cover group presented with less pain and required less pain medication. Length of hospital stay and wound healing time were also significantly shorter in the Biobrane group. None of the patients in either group presented with wound infection or needed skin autografting. In conclusion, the treatment of partial-thickness burns with Biobrane is superior to topical therapy with 1% silver sulfadiazine. Pain, pain medication requirements, wound healing time, and length of hospital stay are significantly reduced.

Massive transfusion of reconstituted whole blood is well tolerated in pediatric burn surgery

BACKGROUND

Massive transfusions can produce cardiovascular instability, metabolic abnormalities, dilutional coagulopathy, and pulmonary dysfunction. They also have been related to a higher incidence of infections. The purpose of this study was to assess the safety of massive transfusion of reconstituted whole blood.

METHODS

Twenty consecutive severely burned pediatric patients underwent near-total burn excision on admission and blood transfusion with reconstituted whole blood. Patients were studied for coagulopathies and postoperative complications related to massive transfusion.

RESULTS

Only one patient presented with postoperative bleeding related to acute renal failure. No other complications occurred. There were no septic episodes or pulmonary dysfunction. The amount of massive blood transfusion did not correlate with any laboratory or clinical disturbance.

CONCLUSION

Massive transfusion of reconstituted whole blood in severely burned pediatric patients is safe; it does not compromise hemostasis nor is it associated with an increased rate of septic episodes or pulmonary complications. A prospective randomized clinical trial comparing its effectiveness versus packed red cells is necessary.

Effect of topical and subcutaneous epinephrine in combination with topical thrombin in blood loss during immediate near-total burn wound excision in pediatric burned patients

Bleeding is a major concern during burn wound excision. To evaluate the efficacy of epinephrine to control blood loss, a prospective cohort of 42 pediatric patients were examined. Half of the patients received topical epinephrine to excised wounds and donor sites and subcutaneous epinephrine to scalp donor sites during total burn excision, while the other half did not. Both groups of patients received bovine topical thrombin sprayed at a concentration of 1000 U/ml. Mean blood loss in the epinephrine group was 1090 ml (range 20-4000), with a blood loss of 0.48+/-0.12 ml/cm2 excised, while the control group was 1271 ml (range 40-3750) and 0.51+/-0.15 ml/cm2. Differences in preoperative and postoperative hematocrits were respectively -3.4+/-7.8 and -4.6+/-7.5. The groups were not statistically different in this analysis. Subgroup analysis by age, burn size and time of burn to excision showed no differences. No complications or side effects of the use of the vasopressor solution occurred. In conclusion, no differences in blood loss were found between the groups. The routine use of local epinephrine during total wound excision in combination with topical thrombin in pediatric patients operated within 24 h after the admission may not be necessary. The effect of topical thrombin on blood loss should be analyzed separately.

Topical nystatin powder in severe burns: a new treatment for angioinvasive fungal infections refractory to other topical and systemic agents

Angioinvasive fungal infections have a significant morbidity and mortality in the immunocompromised host. Massive burns produce a profound derangement in cellular immunity along with a loss of cutaneous barrier function. Treatment of fungal burn wound infections poses a difficult therapeutic challenge. We present a new method of treatment for angioinvasive fungal infections with nystatin powder at a concentration of 6,000,000 units/g. It proved to be efficacious in four consecutive severely burned patients affected by massive angioinvasive fungal infection. Both superficial and deep tissue infections were eradicated without any other therapeutic interventions or adverse effects on wound healing.

Dural reconstruction of a class IV calvarial burn with decellularized human dermis

Calvarial burns involving the brain (Class IV) are reported to be rare. They represent a treatment challenge. Wound coverage can be accomplished with serial debridement of bone and grafting over granulating tissue, local flaps and free tissue transfer. The former techniques are often not feasible in the young infant. We present a successful case of a six-week-old female patient affected of full thickness burns involving the skull and brain. The bone, dura mater and superficial brain were debrided and the defect covered with AlloDerm and split thickness grafts. The area engrafted completely and no complications or CSF leak occurred. An acellular human allogeneic dermis (AlloDerm) can be successfully used to replace dura mater in burn patients.

Outcome of scalp donor sites in 450 consecutive pediatric burn patients

The scalp is a useful and reliable donor site in pediatric burn patients that can be multiply harvested with minimal morbidity. Healing complications, however, may include alopecia and chronic folliculitis. To investigate scalp donor-site morbidity, a consecutive series of 2478 pediatric burn patients treated over a 10-year period were reviewed. A total of 450 of these patients had scalp donor sites for wound closure. Percent of total body surface area burned was 46+/-23 percent (mean+/-standard deviation), and the mean number of sequential scalp donor-site harvests was 2.2+/-2 (range, 1 to 10) with mean intervals between harvesting of 6+/-0.6 days. Ten patients (2.2 percent) had related complications. Eight patients developed scalp folliculitis, with Staphylococcus sp as the predominant organism (80 percent). Two patients were managed successfully with wound care alone; the other six patients required surgical debridement and split-thickness skin grafting to achieve wound healing. These eight patients developed varying degrees of alopecia. Two patients developed alopecia without previous folliculitis. Six patients required reconstructive surgery, which consisted of primary closure (3), staged excision (1), and tissue expansion (2). A number of variables were examined to determine any differences in the group that had complications compared with the group of patients that did not. No differences in age, sex, race, burn type, burn size, septic episodes, time to wound closure, or number of times the scalp was harvested were detected. Healed second-degree burns to the scalp that were subsequently taken as donor sites seemed to be a risk factor (p < 0.05) for folliculitis and alopecia. Our study confirms that scalp donor sites are reliable with low morbidity. Complications include alopecia and chronic folliculitis that can be avoided by meticulous technique and avoidance of previously burned areas.

Reduction in mortality in pediatric patients with inhalation injury with aerosolized heparin/N-acetylcystine [correction of acetylcystine] therapy

Smoke-inhalation injury causes a destruction of the ciliated epithelium that lines the tracheobronchial tree. Casts produced from these cells, polymorphonuclear leukocytes and mucus, can cause upper-airway obstruction, contributing to pulmonary failure. We have reported that a combination of aerosolized heparin and a mucolytic agent, N-acetylcystine [corrected], can ameliorate cast formation and reduce pulmonary failure secondary to smoke inhalation. In this study, 90 consecutive pediatric patients between 1985 and 1995 who had bronchoscopically diagnosed inhalation injury requiring ventilatory support were studied. Forty-three children admitted between 1985 and 1989 acted as controls. Forty-seven children admitted between 1990 and 1994 received 5000 units of heparin and 3 ml of a 20% solution of N-acetylcystine [corrected] aerosolized every 4 hours the first 7 days after the injury. All patients were extubated when they were able to maintain spontaneously a PaO2/FIO2 ratio of more than 400. The number of patients requiring reintubation for successive pulmonary failure was recorded, as was mortality. The results indicate a significant decrease in reintubation rates, in incidence of atelectasis, and in mortality for patients treated with the regimen of heparin and N-acetylcystine [corrected] when compared with controls. Heparin/N-acetylcystine [corrected] nebulization in children with massive burn injury and smoke-inhalation injury results in a significant decrease in incidence of reintubation for progressive pulmonary failure and a reduction in mortality.

Lung function following thermal injury in children--an 8-year follow up

INTRODUCTION

despite the frequency of pulmonary complications and the reports of abnormal lung function as a sequela of severe thermal injury, most of the lung function studies following thermal injury have been directed at the immediate post-burn period. This investigation is designed to evaluate late residual respiratory impairment in patients with severe thermal injury.

METHODS

spirometry and lung volumes were completed on 17 children with severe thermal injury 8 years post-injury. None of the patients had pre-existing lung disease prior to injury.

RESULTS

the patient demographic data was as follows: nine male, eight female patients; mean TBSB=67+/-29%; mean third degree=62+/-32%; 13 patients had inhalation injury diagnosed by bronchoscopy. Spirometry and lung volumes at examination as a percentage of predicted values were: [see table in text]. Spirometry and lung volumes show: two patients had an obstructive disease process; nine patients had an obstructive and restrictive disease process; five patients had a purely restrictive process; and one patient had a diffusion defect.

CONCLUSION

the data indicate that children who survive severe thermal injury may not regain normal lung function.

Emergency management of pediatric burn victims

Pediatric burn injuries present a major challenge to the health care team, but an orderly, systematic approach can simplify the initial stabilization and management. A clear understanding of the pathology of burn injuries is essential in providing quality burn care in the prehospital setting and at the referring hospital. After the patient has been rescued from the offending agent, assessment of the burn victim begins with the primary survey and life-threatening injuries initially addressed first. This is followed by a secondary survey to document and treat other injuries or problems. Intravenous access may be established in concert with the local/regional medical control and appropriate fluid resuscitation begun. Burn wounds should be covered with clean, dry sheets, and the patient kept warm with blankets to prevent hypothermia. The patient should be transported to the local hospital ED in the most appropriate mode available. At the local hospital, it should be determined if the burn patient needs burn center care, using the ABA Guidelines. In preparing for and organizing the transfer of the burn victim, consideration must be given to the continued monitoring and management of the patient during transport. In transferring burn patients the same priorities developed for the prehospital management are still operative. During the initial assessment and treatment and throughout the transport, an adequate airway, breathing, circulation, fluid resuscitation, urine output, and pain control must be assured. Ideally, transport of burn victims will occur through and organized, protocol driven plan that includes specialized transport mechanisms and personnel. Successful transport of burn victims, whether in the pre-hospital phase or during inter-hospital transfer, requires careful attention to treatment priorities, protocols, and attention to detail.

Enteral feeding intolerance: an indicator of sepsis-associated mortality in burned children

OBJECTIVE

To determine if enteral feeding intolerance (EFI) is associated with sepsis and increased mortality in children with severe burns.

DESIGN

A survey.

SETTING

A pediatric burn unit.

PATIENTS

Ninety-one children surviving longer than 5 days with greater than 80% total body surface area burns.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Enteral feeding intolerance indicated by high gastric residuals (> 150 mL/h) or uncontrollable diarrhea (> 2500 mL/d); thrombocytopenia (platelet count < 100 x 10(9)/L); hyperglycemia (glucose level > 11.1 mmol/L [> 200 mg/dL]); sepsis (pathogenic bacteremia or fungemia noted on blood culture results); and mortality.

RESULTS

Neither EFI nor sepsis developed in 71 patients, EFI alone developed in 2 patients, sepsis alone developed in 5 patients, and EFI and sepsis developed in 13 patients. Enteral feeding intolerance and sepsis were associated by contingency table analysis (P<.001). Mortality was 8% (6 patients) in those with neither EFI nor sepsis, 50% (1 patient) in those with EFI alone, 60% (3 patients) in those with sepsis alone, and 77% (10 patients) in those with EFI-associated sepsis. The 2 latter groups were different from the group with neither EFI nor sepsis (P<.05). Enteral feeding intolerance was identified in 70% of patients before sepsis; thrombocytopenia, 64%; and hyperglycemia, 66%. When compared with thrombocytopenia and hyperthermia, no variables were found to be superior to others for predicting sepsis.

CONCLUSIONS

Enteral feeding intolerance was associated with the development of sepsis and increased mortality in children with greater than 80% total body surface area burns. This sign was identified in 70% of the cases before pathogens were found in the blood; no difference could be shown between the identification of EFI, thrombocytopenia, and hyperglycemia before sepsis. These data indicate that the development of EFI should be used as an indicator of infection and should prompt a search for an inciting focus.

Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or = 70% full-thickness)

OBJECTIVE

Survivors and nonsurvivors among 103 consecutive pediatric patients with massive burns were compared in an effort to define the predictors of mortality in massively burned children.

SUMMARY BACKGROUND DATA

Predictors of mortality in burns that are used commonly are age, burn size, and inhalation injury. In the past, burns over 80% of the body surface area that are mostly full-thickness often were considered fatal, especially in children and in the elderly. In the past 15 years, advances in burn treatment have increased rates of survival in those patients treated at specialized burn centers. The purpose of this study was to document the extent of improvement and to define the current predictors of mortality to further focus burn care.

METHODS

Beginning in 1982, 103 children ages 6 months to 17 years with burns covering at least 80% of the body surface (70% full-thickness), were treated in the authors' institution by early excision and grafting and have been observed to determine outcome. The authors divided collected independent variables from the time of injury into temporally related groups and analyzed the data sequentially and cumulatively through univariate statistics and through pooled, cross-sectional multivariate logistic regression to determine which variables predict the probability of mortality.

RESULTS

The mortality rate for this series of massively burned children was 33%. Lower age, larger burn size, presence of inhalation injury, delayed intravenous access, lower admission hematocrit, lower base deficit on admission, higher serum osmolarity at arrival to the authors' hospital, sepsis, inotropic support requirement, platelet count < 20,000, and ventilator dependency during the hospital course significantly predict increased mortality.

CONCLUSIONS

The authors conclude that mortality has decreased in massively burned children to the extent that nearly all patients should be considered as candidates for survival, regardless of age, burn size, presence of inhalation injury, delay in resuscitation, or laboratory values on initial presentation. During the course of hospitalization, the development of sepsis and multiorgan failure is a harbinger of poor outcome, but the authors have encountered futile cases only rarely. The authors found that those patients who are most apt to die are the very young, those with limited donor sites, those who have inhalation injury, those with delays in resuscitation, and those with burn-associated sepsis or multiorgan failure.

Cellulitis associated with burn scars: a retrospective review

This retrospective study evaluated 55 patients with burn scar cellulitis who required hospital readmission from January 1977 to July 1994. The overall incidence of burn scar cellulitis was 1.6%, and it was highest among patients who had undergone fascial excision (17.1%) as compared to those who had undergone tangential excisions (1.5%), or those who received nonoperative therapies (0.7%). Also, the use of meshed graft 4:1 for wound coverage exhibited a higher incidence of scar cellulitis (17.1%) as compared to the use of 2:1 meshed graft (1.1%). Methicillin-sensitive Staphylococcus aureus was the most common offending organism (69%), so it was concluded that all patients should be treated initially with antibiotics having methicillin-sensitive staphylococcal coverage. The lower extremity was involved 80% of the time, and the most commonly affected age group was 11 to 15 years. All patients were healthy and displayed no vascular, immunologic, or neurologic compromise at the time of readmission.

Seizure disorders in burned children: a retrospective review

This review shows that hyponatremia is the most common cause of burn seizures in children, followed by a history of epilepsy, hypoxia, sepsis with high fever, unknown aetiology and drug toxicity or sudden drug withdrawal. This study also shows that burn seizure is most common in younger children and is related to size and degree of burn. We recommend close monitoring of metabolism, haemodynamics, arterial blood gases, wound and blood cultures, and levels of abnormalities in serum, electrolytes, glucose, Ca, P and Mg. Prompt corrections of any problems in these areas can be vital. Invasive procedures for the diagnosis of seizures, including lumbar puncture and EEG, should be reserved for infrequent non-responding cases.

The 1995 Clinical Research Award. Younger pediatric patients with burns are at risk for continuing postdischarge weight loss

Pediatric patients with severe burns exhibit growth delays. This study investigates weight history after discharge. Twenty-seven children with burns covering more than 40% of their total body surface area were studied from admission until 2 to 4 years after injury. Younger children decreased their weights for height; older patients mainly increased theirs. Alterations during the first year of follow-up correlated with alterations until 2 and 3 years (r = 0.91 and r = 0.76, respectively). Once initiated, net weight gain continued, whereas net weight losses diminished with time. Preburn equivalent weights, however, could not be reached within 3 years. Special attention must be paid to children who are close to or less than their ideal body weights at the time of injury, especially if they are young, because further weight loss may be critical. Outpatient nutritional therapy should be focused to control these developments.

Increased physiological dead space/tidal volume ratio during exercise in burned children

Exercise testing enables the simultaneous evaluation of the cardiovascular and respiratory systems' ability to perform gas exchange. The physiological responses to exercise have not been previously reported in the postburn child. This investigation was designed to evaluate residual cardiopulmonary impairment in patients convalescing from severe burns. Spirometry, lung volumes and exercise stress testing were completed on 40 children with a mean time postburn injury of 2.6 +/- 1.9 years and mean burn size of 44 +/- 22 per cent TBSA. Respiratory variables studied during exercise included expired volume, tidal volume and respiratory rate, and physiological dead space/tidal volume (VD/VT) ratios. Stress testing revealed an increased VD/VT ratio consistent with uneven ventilation-perfusion relationships. The data indicate that patients who survive thermal injury may not regain normal cardiopulmonary homeostasis.

Temperature changes during exercise stress testing in children with burns

It has been postulated that because of the extensive destruction of the skin and appendages after thermal injury, the thermoregulatory control mechanism would be impaired, and these patients would be intolerant to prolonged work. Preview studies demonstrate evidence that during work in a hot climate, patients with an extensively healed burn react with an excessive rise in body temperature. This study was designed to investigate the thermoregulatory response to exercise in pediatric patients with burns and to study changes in body temperature during exercise testing. Cardiopulmonary stress tests were completed in 32 children with a mean postburn time of 2.3 +/- 1.5 years and a mean burn size of 44% +/- 23% total body surface area. Exercise variables included expired volume, tidal volume, respiratory rate, tidal/dead space rate, heart rate, and work stage achieved. Temperature monitoring included external auditory canal temperature, burn scar, and normal skin temperature. Values were measured at baseline during and at maximum exercise. Our data indicate all patients reached the same endurance level regardless of the size of the total body surface area burn. Additionally, in a temperature-controlled environment, adequate heat dissipation in children with burns can be maintained during exercise testing without an excessive rise in body temperature.

Thermal injuries caused by ignition of volatile substances by gas water heaters

Based on the cumulative data of this tertiary care facility over the past 25 years, one out of every 70 pediatric patients admitted to our institution sustained their injuries during an explosive event instigated by the ignition of volatile substances from gas water heaters. The majority of injuries related to gas water heaters can be prevented by decreasing the temperature setpoint of the heater, by protecting the heater element itself, and by elevating the water heater to 18 inches above the floor. The first two issues have been adequately addressed; however, gas-fueled water heaters continue to be installed at floor level. Current national guidelines are too rigid and do not adequately address water-heater installation in private residences. Although general prevention campaigns target appropriate storage of volatile substances, they rarely address the explosive potential of gas water heaters in combination with combustible fumes.

Does inhalation injury limit exercise endurance in children convalescing from thermal injury?

The cardiopulmonary performance levels in children who are convalescing from thermal injury are unknown. This investigation was designed to evaluate cardiopulmonary function in children with and without inhalation injury. Forty children with a mean time since burn injury of 2.6 +/- 1.9 years and a mean burn size of 44% +/- 22% total body surface area were selected for the study and divided into two groups: inhalation injury (group 1) and non-inhalation injury (group 2). Pulmonary function studies and cardiopulmonary stress testing were completed on all patients. Both groups reached the same endurance level on the treadmill; however, patients in group 1 did so with an increased expired volume, respiratory rate, and ratio of dead space ventilation to total ventilation which indicated that there were greater demands on the respiratory system. Spirometry and lung volumes at rest showed that 64% of patients in group 1 had abnormal lung function compared with only 27% of patients in group 2.

Longitudinal hand grip and pinch strength recovery in the child with burns

Hand strength of seven patients was evaluated prospectively. A range-of-motion exercise program, compression therapy, and splinting schedules were provided. Fine prehension; lateral, tip-to-tip, and tripod pinch were measured by pinch meter. Grip strength was measured by dynamometer. Comparisons were made between test strengths and published norms for age and sex with analysis of variance. Significance was accepted at p < 0.05. At discharge, all four strength measurements were significantly less than normal for age and sex. Grip and tripod strengths were improved by 6 weeks. All measurements were improved at 6 months after discharge, although grip and lateral pinch remained significantly less than norms. In conclusion, the measurements of tip-to-tip and tripod pinch at 6 months may not signify limitations in performance of activities of daily living. In spite of significantly lower than normal grip and lateral strength measurements at 6 months, it cannot be determined whether this hinders performance of daily living skills.

Caloric requirements of patients with burns under one year of age

Formulas for estimating the caloric requirements of pediatric patients with burns have been suggested. However, the needs of infant patients with burns have not been specifically addressed. This study was undertaken to determine the caloric intake required to maintain weight in patients under 1 year of age who had burns covering more than 25% total body surface area. Thirty patients were studied, and a comparison was made between the actual intake required for weight maintenance and the suggested calorie levels provided by published pediatric caloric formulas. The results indicated that a new formula was needed. Multivariate regression analysis indicated that body surface area and burn surface area were significant predictors of caloric requirements, but body surface area was the more important predictor in this infant population. The equation resulting from the regression provides 2100 kcal/m2 body surface area/day plus 1000 kcal/m2 body surface area burned/day.

The effect of erythropoietin in normal healthy volunteers and pediatric patients with burn injuries

BACKGROUND

Surgical procedures result in blood loss that can require replacement transfusions. Such therapy may result in multiple adverse sequelae, including transmission of infectious diseases and immune impairment. Alternative therapies are therefore desirable.

METHODS

We evaluated the ability of recombinant human erythropoietin (rEPO) to increase red blood cell production in both normal healthy volunteers and patients with burn injuries. The effect of rEPO on immune function in the volunteers was also evaluated. The volunteers received 150 units/kg rEPO daily for 7 days, with immune function and hematopoiesis assayed on days 0, 7, and 14. The patients with burn injuries received either 500 units/kg/day rEPO with iron supplementation or merely the iron.

RESULTS

rEPO increased erythropoiesis in both the volunteers and the patients with burn injuries. Failure to provide iron supplementation to the volunteers resulted in significant depletion of iron stores with a concomitant impairment in immune function that paralleled the iron depletion.

CONCLUSIONS

rEPO therapy offers the potential to increase red blood cell production in surgical patients. Failure to provide iron supplementation in patients receiving rEPO can lead to a rapid depletion of iron stores and may contribute to an immune dysfunction.

Incidence of HIV seroconversion in paediatric burn patients

A retrospective review of paediatric patients treated for acute burn injuries and receiving blood/blood products between 1978 and 1985, identified 52 patients at risk for HIV infection. Over 50 per cent of the identified population had received 3 or more units of blood/blood products during their acute hospital stay. A total of 214 patients (36.8 per cent) have been tested for HIV seroconversions: five tested HIV positive by ELISA and four were confirmed by Western Blot, yielding a 1.9 per cent incidence. The four confirmed patients received 2-9 total body blood volume turnovers during their postburn period in hospital. At 4 years post-exposure, two patients show active disease, one is currently asymptomatic and one has died from AIDS-related sepsis.

Exercise stress testing for the pediatric patient with burns: a preliminary report

There is no literature concerning postburn exercise tolerance among pediatric patients. In an effort to quantify the endurance capabilities of pediatric burn victims, stress testing of 59 patients was carried out with a modified Bruce protocol. This treadmill test consists of eight 3-minute stages with incremental increases in speed and incline. Fifty-nine patients (37 boys and 22 girls) were tested. The mean burn surface area was 46%; an average of 33% consisted of full-thickness burns. The average time since burn injury at which patients were tested was 2.9 +/- 1.9 years. The average age of the patients at the time of test was 11.4 +/- 3.9 years. No differences in exercise tolerance were found among these children irrespective of the presence of inhalation injury, method of excision, or burn size. If these trends continue as more data are accumulated, the long-term prognosis for the child with severe burns will be encouraging.

Candida infection with and without nystatin prophylaxis. A 11-year experience with patients with burn injury

The incidence of opportunistic infections after thermal injury is high. Since 1985, we have been practicing Candida prophylaxis using nystatin "swish-and-swallow" and topical therapy. Patients treated between 1980 and 1984 served as controls and received no Candida prophylaxis. Although mean burn size, full-thickness injury, and age were comparable, the incidence of Candida colonization (26.7% vs 15.6%), infection (21.3% vs 10.0%), and sepsis (12.2% vs none) was significantly different between control and nystatin-treated groups, respectively. With prophylaxis, the incidence of Candida wound infection has been significantly reduced, and systemic candidiasis has been eradicated, eliminating the need for toxic systemic antifungal agents.

The role of gentamicin iontophoresis in the treatment of burned ears

Ear cartilage heals slowly, and limited vascularity in cartilage precludes use of systemic antibiotics. Iontophoresis electrically induces drugs in solution to migrate into target tissues. Fifteen patients were randomized to receive gentamicin iontophoresis (n = 7) plus dressing changes every 6 hours and cleaning or routine care alone (n = 8) for treatment of ear burns. There were no differences between the groups in incidence of chondritis (43% vs 50%) or cartilage loss (11% vs 16%). However, gentamicin-resistant organisms developed in 29% of the patients who received iontophoresis, but in none of the patients in the control group (p less than 0.05). To identify the etiology of the resistant organisms, 10 New Zealand white rabbits receive 7 cm2 contact burns to each ear. Gentamicin iontophoresis was performed on one ear, and the other ear served as the control. Serum gentamicin levels were always subtherapeutic. Additionally, gentamicin tissue levels in both the treated and control ears were subtherapeutic. Gentamicin iontophoresis appears to offer no additional salutary effects beyond those that are provided by routine care and may encourage the development of antibiotic resistance.

Lack of long-term durability of cultured keratinocyte burn-wound coverage: a case report

Cultured epithelial autografts have been advocated for permanent closure of skin surfaces after massive thermal injuries. A 10-year-old boy sustained a nearly 100% total body surface area burn (98% full-thickness) in an explosion accident. Cultured epithelial autograft was used to cover 70% of the total body surface area on postburn day 26. In spite of early success of coverage, 60% of cultured epithelial autograft areas blistered and sloughed over the ensuing weeks. Electron microscopic examination of a biopsy specimen of the healed cultured epithelial autograft (80 days after placement) revealed a lack of dermal attachments of the anchoring fibrils. Additionally, blister fluid that was taken from the bullae of the cultured epithelial autograft revealed levels of 18 ng/ml thromboxane and 24 ng/ml prostaglandin E2. These levels are significantly higher than those seen in acute burn blister fluid and indicate an ongoing inflammatory process. Cultured keratinocytes, although they provide early wound closure, may not provide adequate long-term coverage for patients with massive burns.

Conservative treatment of scald burns is superior to early excision

Early excision of deep burns has been advocated; however, it is difficult to clinically determine the depth of scald burns during the early postburn period. This prospective, randomized study was designed to determine whether early excision was superior to conservative treatment of scald injuries. Patients with scald injuries (which were not caused by grease) of clinically indeterminant depth were randomized to early (n = 12) or late (n = 12) excision; all patients with obvious superficial and full-thickness injuries were excluded. In the early excision group, all deep wounds were tangentially excised and grafted within 72 hours of admission, whereas in the late treatment group wounds were excised and grafted after 2 weeks had passed since injury. Area excised, postburn day of excision, percent graft take, operating-room time, blood replacement, incidence of infection, and length of hospital stay were compared. No patient experienced a significant wound infection or systemic sepsis. A significantly smaller area of excision was necessary for those patients who were treated with delayed surgery, and concomitant decreases in operating-room time and blood loss were observed. Notably, only one half of the patients who were randomized to the delayed excision group ultimately required surgical intervention to achieve wound closure. Graft take was comparable for both groups, as was length of hospital stay. Early clinical evaluation of scald injuries appears to be equivocal, and later evaluations reveal a less severe injury. Financial gains can be made when surgical excision of scald injuries is delayed until 2 weeks after injury because of a related reduction in hospital expenditures.

Ischemic intestinal complications in patients with burns

Enteral bacterial translocation has been implicated as a major cause of morbidity in instances of trauma, but little clinical evidence of the loss of intestinal mucosal integrity has been documented. A retrospective review of the medical and autopsy records of all patients admitted between 1982 and 1988 was performed to describe the incidence of intestinal pathologic findings. Of all deaths, a total of 53 per cent of adults (greater than 18 years old) and 61 per cent of children (zero to 17 years old) were noted to have ischemic intestinal pathologic findings on autopsy, ranging from superficial necrosis to full thickness mucosal necrosis extending into the omentum. More than 80 per cent of these patients were septic at the time of death, with endogenous intestinal flora species most frequently identified as the causative agent. Less than 1 per cent (n = 16) of the patients admitted were clinically identified with intestinal pathologic examination, surgically explored and underwent resection of the intestine. Despite intervention, this group suffered a 69 per cent mortality rate. Although the documentation of bacterial translocation in a human model may be obscured by other potential sources of contamination, for example, burn wound, in combination with the immunosuppression inherent to the thermally injured, may lead to bacterial contamination of the systemic circulation and, therefore, may be a significant contributor to morbidity and mortality after thermal injury.

The efficacy of pediatric blood culture sets in the determination of burn bacteremia

A blood culture is an essential laboratory procedure necessary to confirm a septic episode. However, it is important to collect the blood sample at the appropriate time with an acceptable technique. The standard method is to collect at least 5 to 10 ml blood per culture bottle from patients with fevers. However, this volume of blood is an unrealistic amount to take from the frequently febrile pediatric patient. Alternatively, the pediatric blood culture bottle allows the collection of 1 ml blood per bottle to perform the same evaluation. We evaluated the two techniques of blood-culture collection over a 9-month period and compared the results between adult and pediatric blood culture bottles. Seventy-six patients, from November 1988 through February 1989, had blood cultures performed with the adult culture bottles, which produced a total of 1314 samples. A total of 113 patients, from March through July 1989, had blood cultures performed with the pediatric culture bottles, which produced a total of 758 samples. Percent recovery for the adult bottles versus the pediatric bottles was 13.95% versus 22.8% (p less than 0.0001). Since the amount of blood necessary to isolate an infectious agent is critical not only for laboratory identification but also for the volume of blood of pediatric patients, these data clearly establish the efficacy of pediatric blood culture bottles and the utilization of smaller amounts of blood. Not only did this approach significantly enhance organism recovery rate, but it may well be more cost-effective because fewer cultures need to be performed to isolate the infectious organism.

Comparison of resting energy expenditures and caloric intake in children with severe burns

Nutritional support is provided to children after severe burn injuries in amounts derived from empirical formulas or measurements of resting energy expenditure. To scrutinize these methods, indirect calorimetry measurements were performed on 74 survivors of burns (greater than or equal to 40% total body surface area) and compared to their actual caloric intake, percent weight change, and optimal caloric requirements formulated from the Curreri and Shriners' equations. These parameters showed that in spite of an initial deficit in actual caloric intake as compared to formulated goals, weight was maintained, whereas resting energy expenditures ranged from 30% to 40% below the actual caloric intake. Furthermore, a subgroup of patients (n = 42) who met +/- 20% of their formulated needs were stratified by extent of burn; this illustrated a significant weight gain in the more severely burned children. In conclusion, nutritional formulas in popular use overestimate caloric requirements in severe burns, whereas resting energy expenditure measurements require an additional factor of 30% to maintain body weight.

Current treatment reduces calories required to maintain weight in pediatric patients with burns

A previous study indicated that formulas for determining caloric requirements of severely burned children overestimated their needs. This study was undertaken to determine the caloric intake required to maintain weight in patients under 12 years of age with burns over more than 30% total body surface area. The 102 patients studied were divided into two groups according to weight changes. A comparison of the actual caloric intakes of these groups was conducted. Multivariate regression analysis indicated that body surface area in square meters and burn surface were significant predictors of caloric requirements to maintain weight in these patients. It was determined that 1800 kcal was a plausible value for the calories per body surface area. Therefore the regression was formed with 1800 kcal as the multiplier of body surface area, and the multiplier of burn surface area was estimated. The resulting formula provides 1300 kcal/m2 burned, which is 900 kcal/m2 burned less than our previously suggested formula.

Topical Bactroban (mupirocin): efficacy in treating burn wounds infected with methicillin-resistant staphylococci

Bacterial antimicrobial susceptibility predictors such as the minimal inhibitory concentration (MIC) assay and Nathans Agar Well Diffusion (NAWD) assay provide essential information relevant to the therapeutic approach in burn-wound sepsis. The susceptibilities of 68 gram-positive burn-wound isolates were tested against topical Bactroban (mupirocin) (Beecham Laboratories, Bristol, Tenn.) and compared with other topical antimicrobials such as mafenide acetate, silver sulfadiazine, and bacitracin/neomycin/polymyxin (BNP). Topical susceptibility data were obtained with a modification of NAWD assay. Bactroban's antimicrobial activity was greater than that of mafenide acetate (100% vs 97%), and significantly greater than that of silver sulfadiazine and that of BNP (p less than 0.001). Of the 68 isolates that were susceptible to Bactroban, 51 were predominately methicillin-resistant staphylococci (MRSA). Bactroban showed in vitro activity against 71% of the 85 gram-negative isolates tested. Mafenide acetate showed activity against 89% of these isolates, a significant difference compared with Bactroban (p less than 0.02). In general, no significant difference was found between the activities of Bactroban and silver sulfadiazine against the gram-negative isolates. The activities of mafenide acetate and silver sulfadiazine against isolates of Pseudomonas aeruginosa were significantly greater than that of Bactroban (p less than 0.05). Bactroban may be used in the treatment of documented staphylococcal burn-wound infections. On the basis of the in vitro data, 13 patients with MRSA burn-wound infections susceptible to Bactroban were evaluated. Quantitative wound biopsies were employed to determine the efficacy of this therapeutic approach. The outcome of these infections was correctly predicted by the NAWD assay in 92.3% of the patients treated (p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

Early burn wound excision significantly reduces blood loss

The hypothesis that near-total early excision of large burns in children can be performed safely with a reduction in blood loss was tested. Of 1662 acutely burned patients admitted to this institution between 1982 and 1989, 594 underwent near-total excision of cutaneous flame or scald burn injuries in a single procedure. Operations took less than 3 hours and there were no operative deaths. Blood losses in burns of more than 30% total body surface area (TBSA) were significantly less at 0.40 +/- 0.06 mL/cm2 and 0.49 +/- 0.49 mL/cm2 excised when surgery was performed within the first 24 hours or after the 16th day after burn, respectively, when compared to 0.75 +/- 0.02 mL/cm2 for those excised between 2 and 16 days after burn (p less than 0.05). Blood loss for burns of less than 30% TBSA was of 1.19 +/- 0.13 mL/cm2. Early excision did not increase mortality rate when compared to later excision times. We suggest that near-total excision of large burns within the first 24 hours reduces blood requirements and morbidity without adversely altering hemodynamic stability or increasing mortality risks.

The scalp as a donor site: revisited

The scalp cannot be used as skin graft donor site with impunity. A review of 2,620 charts identified 194 pediatric patients whose scalps served as donor sites for split-thickness skin grafts for the treatment of acute burns. The overall incidence of alopecia was 32%. However, the incidence of alopecia in unburned scalps was 13%. The occurrence of alopecia in this group was associated with larger burn area requiring more frequent use of the scalp and shorter intervals between graft harvests (p less than 0.05). Among this group of patients (n = 15), nine had mild spotty alopecia, four had surgically correctable alopecia, and two had global patchy alopecia not amenable to surgical correction. In the patients with concomitant burns to their scalps, the incidence of alopecia was 61%. Whether the burn or the graft harvest caused alopecia could not be established. Meticulous donor site care is mandatory in this latter group when the scalp donor site is indicated.

Pulmonary embolism in burned children

There are occasional reports in the literature concerning the incidence of pulmonary embolism in the postburn population, but reports of burned children are especially rare. The clinical diagnosis of pulmonary embolism is particularly difficult in these populations due to the postburn pulmonary complications of pneumonia, bronchopneumonia, respiratory distress syndrome, and changes incurred through inhalation injury. A retrospective review of all patient deaths occurring at this institution during the past 22 years was performed in order to document the incidence of pulmonary embolism in burned children. Of the 6589 patients admitted during this time, 178 patients died (2.7%) and three (1.7%) deaths were attributable to pulmonary embolism. Two other deaths (1.1%) were associated with deep vein thrombosis. The incidence of pulmonary embolism can then be calculated at 46 per 100,000 admissions in this population of burned children. Burned patients always pose an increased risk for the development of pulmonary embolism. These patients are traumatized, require multiple venous and/or arterial cannulations, undergo multiple surgical procedures, are immobile for prolonged periods, prone to infectious processes and fluid and electrolyte imbalances. Despite all these risk factors, the incidence of pulmonary embolism is less than 2 per cent of all deaths in this postburn paediatric population.

Managing smoke inhalation injuries

Inhalation injuries most often occur with cutaneous burns, and the likelihood of an inhalation injury increases incrementally with age of the patient and size of the burn. Damage to the pulmonary parenchymal tissue manifests as increased capillary permeability leading to excessive lung fluid formation and increasing hypoxia. An inhalation injury may be diagnosed using observation of indirect criteria in conjunction with fiberoptic bronchoscopy, xenon 133 radiospirometry, and/or measurement of extravascular lung water. Initially, carbon monoxide poisoning threatens the patient's oxygenation capacity. High-flow oxygen therapy reduces the half-life of carbon monoxide to an acceptable period. The patient proceeds through three stages: pulmonary insufficiency, pulmonary edema, and bronchopneumonia. Treatment is directed toward supporting oxygenation using endotracheal intubation with mechanical ventilation, humidification of inspired air, early mobilization, chest physiotherapy, antibiotics for documented infection, and adequate systemic hydration.

The efficacy of nystatin combined with topical microbial agents in the treatment of burn wound sepsis

Pilot in vitro studies demonstrated that nystatin combined with Silvadene (silver sulfadiazine 1% [Marion Laboratories, Inc., Kansas City Mo.]) or Furacin in a 1:1 ratio was equally effective against Candida albicans and ATCC strains of Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli, but Sulfamylon (Winthrop Pharmaceuticals, Winthrop, N.Y.) combined with nystatin demonstrated an antagonistic response. Therefore we examined the susceptibility to nystatin of 165 clinical isolates, both gram-positive and gram-negative, to nystatin combined with Silvadene or Sulfamylon and 144 isolates to nystatin and Furacin. Both Silvadene and Furacin combined with nystatin were equally effective against the microorganisms as were the individual drugs. Conversely, Sulfamylon combined with nystatin lost its antimicrobial capability (93.3% resistance, p less than 0.001). On the basis of the in vitro results, 93 patients with acute burns were treated with the appropriate topical antimicrobials from April 1988 to September 1988. Of the 93 patients treated, 90 had neither a major systemic bacterial nor a Candida sepsis, and none of these patients had associated localized burn wound sepsis during their hospital stays. These 90 patients were discharged without any documented signs of infection. The average burnsize was greater than or equal to 29.44% total body surface area. These data suggest that the antimicrobial properties of nystatin, when combined with Silvadene and Furacin, remain effective. Consequently, such combinations have been effective in controlling both local and systemic Candida and bacterial burn wound sepsis.

Caloric needs of adolescent patients with burns

Formulas for estimating the caloric requirements of pediatric and adult patients with burns have been suggested. However, the needs of adolescent patients with burns have not been specifically addressed. This study was undertaken to determine the calorie intake required to maintain weight of adolescent patients with burns over more than 35% of the total body surface area. The 29 patients studied were divided into two groups according to sex. Caloric requirements were determined with the use of the Galveston surface area formula and the Curreri formula. The comparison of these estimations with the actual intake required to maintain weight indicated that there is a significant difference between the calories indicated by the formulas and the actual intake. A surface area formula that also correlates with the results of indirect-calorimetry studies is suggested for this adolescent population with burns.

A comparison of conservative versus early excision. Therapies in severely burned patients

Early excision and grafting of small burn wounds is a generally accepted treatment. Early excision of burn injuries greater than 30% total body surface area (TBSA) in adults, however, has not been universally accepted. In this study, 85 patients whose ages ranged from 17 to 55 years with greater than 30% total body surface area (TBSA) burns were randomly assigned to either early excision or topical antimicrobial therapy and skin grafting after spontaneous eschar separation. Mortality from burns without inhalation injury was significantly decreased by early excision from 45% to 9% in patients who were 17 to 30 years of age (p less than 0.025). No differences in mortality could be demonstrated between therapies in adult patients older than 30 years of age or with a concomitant inhalation injury. Children (n = 259) with similar large burns treated by early excision showed a significant increase in mortality with increasing burn size and with concomitant inhalation injury (p less than 0.05). The mean length of hospital stay of survivors was less than one day per per cent of TBSA burn in both children and adults.

Long-term psychosocial adjustment following burn injury

Young adult survivors of severe childhood burn injuries were assessed for indicators of psychopathology and for factors that might enhance psychosocial adjustment. The results describe this group of burn victims as young people of average intelligence, still in school or otherwise employed and within normal limits on the measures of psychological adjustment. Some individuals, however, did evidence significant indicators of psychological disturbance. The only factors identified as significantly differentiating the most obviously disturbed subjects from the better-adjusted or well-adjusted victims were the perceptions held by those subjects that their families are less cohesive and less independent. These results emphasize the need to promote the familial support system and to encourage the values of autonomy and self-sufficiency. The results also affirm that severely injured burn victims can be expected to develop acceptably happy lives.

Reassessing caloric requirements in pediatric burn patients

New formulas for estimating the caloric requirements of burned children have been suggested. These formulas appeared to exceed the caloric estimates made by the Galveston Shriners Burns Institute formula. This study was undertaken to compare the Curreri Junior formulas and the Galveston Shriners Burns Institute formula with the actual intake required by pediatric patients with burns greater than 30% total body surface area to maintain weight. The 121 patients studied were divided into three age groups to coincide with those in the Curreri Junior formulas and calorie requirements as estimated by both formulas were determined. The comparison of these estimations with the actual intake required to maintain weight indicated that there is a significant difference in the caloric requirement per m2 burn between the age three and under group and the older age group. The results also suggest that overfeeding may occur with the historic formulas.

An unusual donor site, a lifesaver in extensive burns

The availability of donor sites is a limiting factor in autologous skin grafting and, therefore, the survival of patients with large total body surface area (TBSA) burns. Of 19 males admitted to our facilities with burns greater than 80% TBSA, eight had the scrotum spared injury. The remaining 11 patients served as a control population to study the efficacy of scrotal donor harvests. The scrotal skin was expanded using the Pitkin syringe and harvested at a depth of 5/1000 to 8/1000 in, with a mean yield of 73 +/- 8 sq cm. Expanded 4:1, this tissue covered an area of 280 +/- 33 sq cm. The scrotum was harvested 2 +/- 0.4 times, compared to 4 +/- 1 harvests of the other donor group. There were no statistical differences in the number of surgical procedures or the length of hospitalization between the two groups. The scrotal donor sites healed within the same length of time as other donor sites and were harvestable as frequently. Due to the natural expandability of scrotal skin, a large surface area of usable donor site is available and their harvest may be lifesaving in male patients with large TBSA burns.

Eradication of Candida burn wound septicemia in massively burned patients

The increased incidence of Candida burn wound infection and septicemia in massively burned patients is well known. One thousand thirty six patients were admitted from January 1982 through December 1986. Nystatin prophylaxis, both oral and topical, was initiated in October 1984 and 472 patients were treated. The control group was comprised of the 564 patients treated January 1982 through September 1984. There was a significant difference (p less than 0.005) between the groups in the number of Candida colonized patients, the numbers of Candida burn wound infections, the incidence of multi-organ system involvement/failure, and the occurrence of Candida sepsis. There has not been a Candida burn wound infection in this institution since June 1985. Nystatin, given orally as a 'swish and swallow' or mixed 1:1 with either silver sulfadiazine or polymyxin B/bacitracin, has eradicated Candida burn wound infections and septicemia from this institution and thus obviated the need for systemic antifungals such as amphotericin B.

Candida infection in massively burned patients

Immunosuppressed burned patients receiving antibiotics for suppression of bacterial infection are ideal hosts for opportunistic fungi. Massive excision of burns with autograft and homograft coverage has radically changed the course of disease. Three hundred ninety-three patients were admitted to the Shriners Burns Institute, of whom 125 patients had fungus cultured during their hospitalization and 42 patients subsequently developed involvement of three or more organs. Twenty-one of the 42 patients developed Candida septicemia requiring amphotericin B or flucytosine therapy. The mean third-degree burn in patients with Candida septicemia was 65% total body surface area compared to three-organ involvement/no clinical sepsis at 38% mean third-degree burn. Patients developing candidemia did so during the first week postburn and 7 days after excision therapy. It is hypothesized that massive burns with immunosuppression are further suppressed by repeated surgical intervention, anesthesia, and perioperative use of broad-spectrum antibiotics, further predisposing these patients to early development of Candida septicemia. With early recognition of burn wound invasion by routine biopsies, wound swabs, and early amphotericin therapy, the mortality has been reduced to 14% compared to 60-90% reported in other series.