RESUMEN
The Baxter formula is commonly used to calculate fluid requirements. Baxter reported that 12% of patients would require more than 4.3 mL/kg per percentage of total body surface area (%TBSA). We anecdotally observed that we frequently exceeded the predictions of the formula, and we wondered if this was unique to our practice. We studied our last 11 burn-related resuscitations and collected fluid resuscitation data from US burn centers. Twenty-eight centers were queried, and 6 centers shared data. We were therefore able to study the resuscitation data of 50 adult patients. For 29 patients (58%), 4.3 mL/kg/%TBSA was exceeded compared with the 12% reported by Baxter. These findings suggest that in actual practice, fluid volumes administered are larger than the Baxter formula predicts. This survey does not explain why. Possible reasons for the larger fluid volumes are as follows: (1) the sample is not representative; (2) the formula is used improperly; (3) burns have changed and require more fluids; (4) burn care has changed.
Asunto(s)
Unidades de Quemados/estadística & datos numéricos , Quemaduras/terapia , Fluidoterapia/métodos , Resucitación/métodos , Desequilibrio Hidroelectrolítico/terapia , Adulto , Quemaduras/mortalidad , Recolección de Datos , Técnicas y Procedimientos Diagnósticos , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Sensibilidad y Especificidad , Análisis de Supervivencia , Estados Unidos , Desequilibrio Hidroelectrolítico/etiologíaRESUMEN
Two patients with extensive destruction of the full thickness of the abdominal wall and associated intra-abdominal injuries were encountered. One case resulted from burns to a patient pinned under an automobile in contact with the muffler; the other was injured as a result of penetration of the abdominal wall by a railroad coupling and was also burned in an associated welding accident at the same time. Extensive staged debridement and repair of intra-abdominal injuries in several procedures were required in case 1. Closure was eventually achieved with serial applications of mesh and split-thickness autografting. In case 2, an initial attempt at flap closure failed. Coverage initially was obtained with silicone mesh followed by split-thickness grafting. We report successful management of two of these difficult reconstructive challenges.
Asunto(s)
Traumatismos Abdominales/cirugía , Músculos Abdominales/lesiones , Quemaduras/cirugía , Procedimientos de Cirugía Plástica , Prótesis e Implantes , Accidentes de Trabajo , Adolescente , Adulto , Desbridamiento , Femenino , Humanos , Masculino , Complicaciones Posoperatorias , Colgajos QuirúrgicosRESUMEN
A multicenter clinical study assessed the ability of an acellular allograft dermal matrix to function as a permanent dermal transplant in full-thickness and deep partial-thickness burns. The study consisted of a pilot phase (24 patients) to identify the optimum protocol and a study phase (43 patients) to evaluate graft performance. Each patient had both a test and a mirror-image or contiguous control site. At the test site, the dermal matrix was grafted to the excised wound base and a split-thickness autograft was simultaneously applied over it. The control site was grafted with a split-thickness autograft alone. Fourteen-day take rates of the dermal matrix were statistically equivalent to the control autografts. Histology of the dermal matrix showed fibroblast infiltration, neovascularization, and neoepithelialization without evidence of rejection. Wound assessment over time showed that thin split-thickness autografts plus allograft dermal matrix were equivalent to thicker split-thickness autografts.
Asunto(s)
Quemaduras/cirugía , Matriz Extracelular/trasplante , Trasplante de Piel/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Membrana Basal/trasplante , Quemaduras/patología , Estudios de Factibilidad , Femenino , Fibroblastos/fisiología , Supervivencia de Injerto , Humanos , Puntaje de Gravedad del Traumatismo , Activación de Linfocitos , Masculino , Persona de Mediana Edad , Neovascularización Fisiológica , Proyectos Piloto , Pronóstico , Piel/irrigación sanguínea , Piel/patología , Trasplante de Piel/inmunología , Trasplante Autólogo , Cicatrización de Heridas/inmunología , Cicatrización de Heridas/fisiologíaRESUMEN
This study examined the influence of various factors on the probability that 225 persons with severe burns would return to work 12 months after being discharged from the acute care setting. By use of multivariate analysis, 4 out of 15 variables significantly increased the probability of being employed: (1) being white, (2) not blaming oneself, (3) receiving workmen's compensation, and (4) being employed before the injury. With controls for burn severity and other variables, premorbid employment accounted for a person being 171 times more likely to return to work than one who was not employed before injury. Our findings suggest that some traditionally held impressions regarding factors related to return to work after a severe burn should be revisited. Moreover, despite earlier reports concluding that burn severity was the primary predictor of return to work, we found no factors in the acute care environment or patient characteristics that were statistically significant. Instead, findings from this series underscore the importance of the preinjury environment--especially being employed at the time of injury--as the strongest predictor of return to work after a severe burn.
Asunto(s)
Absentismo , Quemaduras , Trabajo , Adulto , Quemaduras/rehabilitación , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Modelos Logísticos , Masculino , Motivación , Análisis Multivariante , Probabilidad , Calidad de Vida , Factores de Riesgo , Factores SocioeconómicosRESUMEN
OBJECTIVE: The use of hypertonic sodium solutions (HSS) and lactated Ringer's (LR) solution in the resuscitation of patients with major burns was compared. SUMMARY BACKGROUND DATA: Hypertonic sodium solutions have been recommended for burn resuscitation to reduce the large total volumes required with isotonic LR solution and their attendant complications. METHODS: To evaluate the efficacy of this therapy in our adult burn center, we resuscitated 65 consecutive patients with HSS (290 mEq/L Na) between July 1991 and June 1993 and compared them with 109 burn patients resuscitated with LR (130 mEq/L Na) between July 1986 and June 1988 (LR-1). A subsequent 39 patients were resuscitated with LR between September 1993 and August 1994 (LR-2). RESULTS: Patients receiving hypertonic sodium solutions versus LR-1 were similar with respect to age (46.0 vs. 43.6 years), total burn size (39.2% vs. 39.9%), incidence of inhalation injury (41.5% vs. 47.7%), and predicted mortality (34.6% vs. 30.2%). Total resuscitation volumes during the first 24 hours were lower among patients treated with HSS than those in the LR-1 group (3.9 +/- 0.3 vs. 5.3 +/- 0.2 mL/kg/% body surface area [BSA], p < 0.05). After 48 hours, however, cumulative fluid loads were similar (6.6 +/- 0.6 vs. 7.5 +/- 0.3 mL/kg/%BSA), and total sodium load was greater with the HSS group (1.3 +/- 0.1 vs. 0.9 +/- 0.1 mEq/kg/%BSA, p < 0.002). During the first 3 days after burn, serum sodium concentrations were moderately elevated in the HSS patients (153 +/- 2 vs. 135 +/- 1 mEq/L, p < 0.001). Patients resuscitated with HSS had a fourfold increase in renal failure (40.0 vs. 10.1%, p < 0.001) and twice the mortality of LR-1 patients (53.8 vs. 26.6%, p < 0.001). In patients resuscitated with HSS, renal failure was an independent risk factor (p < 0.001, by logistic regression). Analysis of these results prompted a return to LR resuscitation (LR-2). Age (41.6 +/- 2.9 years), burn size (37.8 +/- 3.9 %BSA), and incidence of inhalation injury (51.3%) were similar to the earlier groups. Total sodium load was less among LR-2 patients than the HSS group (0.7 +/- 0.1 mEq/kg/%BSA, p < 0.01), but similar to the LR-1 patients. Renal failure developed in only 15.4%, and 33.3% died, similar to the LR-1 group and significantly lower than patients treated with HSS (p < 0.001 and p < 0.05, respectively). CONCLUSION: Hypertonic sodium solution resuscitation of burn patients did not reduce the total resuscitation volume required. Furthermore, it was associated with an increased incidence of renal failure and death. The use of HSS for burn resuscitation may be ill advised.
Asunto(s)
Lesión Renal Aguda/etiología , Quemaduras/terapia , Fluidoterapia , Soluciones Isotónicas/uso terapéutico , Solución Salina Hipertónica/efectos adversos , Lesión Renal Aguda/mortalidad , Adulto , Quemaduras/complicaciones , Quemaduras/mortalidad , Humanos , Persona de Mediana Edad , Resucitación , Lactato de Ringer , Solución Salina Hipertónica/uso terapéutico , Sodio/sangre , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
This article describes and analyzes major conceptual and methodologic problems that occurred during the implementation and evaluation of a new home-based burn treatment modality. Problems described include those of conceptualization, measurement, patient sampling, and follow-up, data collection, and analysis. The origins of each specific problem are discussed along with their effects on the implementation of the project and project outcomes. Solutions for each set of problems are suggested.
Asunto(s)
Quemaduras/rehabilitación , Servicios de Atención de Salud a Domicilio , Ensayos Clínicos Controlados Aleatorios como Asunto , Atención Ambulatoria , Quemaduras/epidemiología , Quemaduras/enfermería , Protocolos Clínicos , Recolección de Datos/métodos , Estudios de Seguimiento , Humanos , Modalidades de Fisioterapia , Estudios Prospectivos , Proyectos de InvestigaciónRESUMEN
Burn center development in North America began in the mid 1940s, surged in the 1970s, and had reached virtually every distinct medical market by 1985. The authors present chronologies of the establishment of 137 currently active burn centers in the United States and 27 burn facilities in Canada, discuss public policy and other influences on burn center development, and review burn admissions trends. Another 46 U.S. hospitals are identified as having shown interest in caring for serious burn injuries in recent decades. Since national admissions data first became available in 1970, the proportion of U.S. patients with burns treated in burn centers has increased from 10% to 40%. Data were obtained from a survey of 197 hospitals in the United States and Canada listed in recent Burn Care Resources directories of the American Burn Association and annual surveys of the American Burn Association and the National Center for Health Statistics. Further study of burn centers in both institutional and societal contexts and submittal of archival material are encouraged.
Asunto(s)
Unidades de Quemados/historia , Quemaduras/historia , Sociedades Médicas/historia , Quemaduras/terapia , Canadá , Historia del Siglo XX , Humanos , Estados UnidosRESUMEN
This article attempts to predict the federal government's response to the cost of burn care in the 1990s by examining the explosive growth of health care costs in the 1980s and the impact that this had on hospitals with burn centers. The Prospective Payment System (PPS) was enacted in 1983, which limited the government's liability to hospitals by effectively capping the amount of federal dollars in the system. The inequities of the classification of burn patients by the PPS is discussed and a proposal for modification is outlined.
Asunto(s)
Unidades de Quemados/economía , Quemaduras/economía , Financiación Gubernamental , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Medicare/economía , Acampadores DRG , Sistema de Pago Prospectivo , Estados UnidosRESUMEN
A 2-year experience with laboratory and clinical applications of fibrin glue is presented. An autologous technique, which eliminates the danger of multidonor preparations, has been developed in our blood bank. While one can obtain different fibrinogen concentrations from the same amount of a patient's blood, in vitro mechanical testing demonstrated that at higher fibrinogen concentrations there is an increase in shear adhesive strength. Evaluation of skin-graft take in 16 Sprague-Dawley rats did not demonstrate significant differences in healing when adhesive use was compared with suture technique. In a clinical study, four different groups of patients (facial burns, hand burns, difficult graft sites, and miscellaneous surgical applications) benefited from autologous or single-donor fibrin glue for a total of 82 cases. There are several distinct advantages to the use of fibrin adhesive: The autologous technique eliminates the risk of transmissible viral diseases (AIDS, hepatitis); it can be used as a sealant in the treatment of seromas, dural leaks, and lymphoceles; and it improves hemostasis and early graft adherence. Face and hands are resurfaced with sheet grafts in a single procedure, obtaining a better aesthetic result with complete graft take and immediate start of physical therapy. Neither sutures nor pressure dressings are required. The minimal postoperative care associated with early return to normal activities seems to increase the satisfaction of patients and nurse personnel.
Asunto(s)
Adhesivo de Tejido de Fibrina , Trasplante de Piel/métodos , Adolescente , Adulto , Anciano , Animales , Quemaduras/cirugía , Niño , Preescolar , Traumatismos Faciales/cirugía , Genitales Masculinos/cirugía , Traumatismos de la Mano/cirugía , Hidradenitis/cirugía , Humanos , Masculino , Persona de Mediana Edad , Ratas , Ratas Endogámicas , Estudios Retrospectivos , Resistencia a la TracciónRESUMEN
This study was designed to evaluate the relative severity and resource consumption of hospitalized patients with burns in a national cross section of hospitals, both with and without burn centers. We investigated to determine whether clinical variables or severity of illness measures not recorded in the Uniform Hospital Discharge Data Set are significant in explaining variation in length of stay, total cost, and mortality for patients with burns. The ability of the six burn diagnosis-related groups (DRGs) to explain variation in patients' length of stay was 20% and their ability to predict total costs was 24%. For the same patient population, the explanatory power of the DRGs improved to 54% for length of stay and 44% for costs when these variables were adjusted by the Severity of Illness Index. We also investigated whether hospitals with burn centers treated a more severely ill population of patients with burns than did hospitals without such centers. Significantly higher levels of severely ill patients with burns (p less than or equal to 0.0001) were found at burn center hospitals. Other patients or treatment variables, combined with a case-mix severity measure, were evaluated for their ability to further increase the explanatory power of DRGs. We also discuss here the use of the study results for reevaluating reimbursement policy.
Asunto(s)
Quemaduras/clasificación , Grupos Diagnósticos Relacionados , Sistema de Pago Prospectivo , Índice de Severidad de la Enfermedad , Unidades de Quemados , Quemaduras/economía , Quemaduras/mortalidad , Economía Hospitalaria , Humanos , Tiempo de Internación , Análisis de Regresión , Estados Unidos/epidemiologíaRESUMEN
With the subcutaneous injection of a saline-vasopressor solution under donor sites and debrided areas, a significant reduction in intraoperative blood transfusions was accomplished. No problems in healing of donor sites or skin grafts were encountered. Vasodilating anesthetics and ketamine can overcome the local vasopressor action. Discontinuing or reducing the concentration of these agents results in less bleeding from the wound.
Asunto(s)
Pérdida de Sangre Quirúrgica/prevención & control , Quemaduras/cirugía , Complicaciones Intraoperatorias/prevención & control , Desbridamiento , Epinefrina/administración & dosificación , Epinefrina/uso terapéutico , Humanos , Inyecciones , Solución Salina Hipertónica/administración & dosificación , Solución Salina Hipertónica/uso terapéuticoRESUMEN
This study was designed to test the hypothesis that auricular acupuncture-like transcutaneous electrical nerve stimulation would significantly reduce the pain experienced by patients with burns immediately after wound debridement, other wound care, and dressing changes. Subjects were 11 inpatients at the University of Alabama Hospital Burn Unit. A two-period crossover design was used, and each patient received one experimental treatment consisting of bilateral acupuncture-like transcutaneous electrical nerve stimulation to six ear points and one control treatment consisting of a placebo pill. The Visual Analogue Scale was used as a measure of pain and was completed immediately before and after treatments and at 15, 30, and 60 minutes after treatment. A two-factor repeated measures ANOVA indicated significant effects of measurement time (p less than 0.001) and treatment by time (p = 0.002). Post hoc analysis revealed significant differences (p less than 0.05) between experimental and control conditions at all times after treatment but not at pretreatment baseline. These results indicate that auricular acupuncture-like transcutaneous electrical nerve stimulation may be an effective pain management technique in patients with burns.
Asunto(s)
Quemaduras/fisiopatología , Oído Externo , Dolor/prevención & control , Estimulación Eléctrica Transcutánea del Nervio , Vendajes , Quemaduras/terapia , Desbridamiento , Método Doble Ciego , Electroacupuntura , Femenino , Humanos , Masculino , Dimensión del Dolor , Proyectos PilotoRESUMEN
Biological adhesive fixation of skin grafts has been performed successfully on patients with facial burns and burns at difficult sites by using autologous human fibrin adhesive, which eliminates the danger of multidonor pool preparations. There are several distinct advantages to the use of fibrin glue: There is no danger of multidonor pool preparations. Wounds do not require any sutures or pressure dressings in the immediate postoperative period. Grafts demonstrate excellent take with minimal postoperative care. The patients can maintain normal ambulation. Fibrin glue seems to be an important factor in the application of skin grafts to burned areas in these two groups of patients.
Asunto(s)
Quemaduras/cirugía , Traumatismos Faciales/cirugía , Adhesivo de Tejido de Fibrina/uso terapéutico , Trasplante de Piel , Supervivencia de Injerto , Humanos , Trasplante Autólogo , Cicatrización de HeridasRESUMEN
The effects of enflurane or isoflurane anesthesia on the systemic circulation and whole-body oxygen (O2) uptake (VO2) of 15 burn patients undergoing wound excision and skin grafting procedures were studied. The possibility that burn wound excision might adversely affect pulmonary circulation was also investigated. The patients were preanesthetically in a hyperdynamic-hypermetabolic state, characterized by a resting cardiac index (CI) of 6.2 +/- 0.9 L.min-1.m-2 (mean +/- SD), a VO2 (calculated using the Fick principle) of 213 +/- 44 mL.min-1.m-2, a normal mean systemic arterial pressure (MAP) (92 +/- 15 mm Hg), and markedly decreased systemic vascular resistance (SVR) (570 +/- 162 dynes.sec.cm-5). Mean pulmonary arterial pressure (MPAP) preanesthetically was slightly increased (21 +/- 3 mm Hg), while pulmonary vascular resistance (PVR) was in the low-normal range (59 +/- 16 dynes.sec.cm-5). No difference among the effects of enflurane and isoflurane on systemic and pulmonary hemodynamics and metabolic rate was detected. Induction of anesthesia was associated with a decrease in VO2, CI, MAP, and MPAP (P less than 0.001), while SVR and PVR did not change. The decrease in CI paralleled the decrease in VO2, thereby maintaining whole-body O2 supply-demand balance. VO2 decreased most likely because of lessened tissue O2 requirements. When anesthesia was discontinued, all metabolic and hemodynamic variables promptly returned to preanesthetic values. No effect of burn wound excision on pulmonary circulation was detected.
Asunto(s)
Quemaduras , Enflurano/farmacología , Hemodinámica/efectos de los fármacos , Isoflurano/farmacología , Consumo de Oxígeno/efectos de los fármacos , Adulto , Quemaduras/metabolismo , Quemaduras/fisiopatología , Quemaduras/cirugía , Femenino , Humanos , Masculino , Circulación Pulmonar/efectos de los fármacosRESUMEN
Delayed wound closure should be used in wounds that are contaminated or contain devitalized tissue. The wound should be left open for three to four days for observation to determine if infection is present or if the tissues are devitalized. This management technique allows the physician to control infection and provide surgical debridement. Leaving the wound open provides the opportunity to inspect and evaluate the wound to determine if a problem is present. The wound then can be repaired with minimal risk. It is beneficial that the wound healing process is not delayed using this technique of wound closure.