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Perineal burn care: French working group recommendations
burns 40 (2014) 655–663
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Perineal burn care: French working group recommendations Julien Bordes a,*, Ronan Le Floch b, Ludovic Bourdais b, Alexandre Gamelin c, Franc¸oise Lebreton d, Ge´rard Perro e a
Burn Center, Sainte Anne Military Teaching Hospital, Toulon, France Burn Center, University Hospital, Nantes, France c Burn Center, Roger Salingro Hospital, Lille, France d Burn Center, Lapeyronie Hospital, Montpellier, France e Burn Center, University Hospital, Bordeaux, France b
article info
abstract
Article history:
Objectives: Burns to the perineum are frequently exposed to faeces. Diverting colostomy is
Accepted 5 September 2013
often described to prevent faecal soiling. Because this technique is invasive with frequent complications, use of non-surgical devices including specifically designed faecal manage-
Keywords:
ment systems has been reported in perineal burns.
Perineal burns
Methods: In order to standardise the faecal management strategy in patients with perineal
Diverting colostomy
burns, a group of French experts was assembled. This group first evaluated the ongoing
Faecal management
practice in France by analysing a questionnaire sent to every French burn centre. Based on
Bowel management system
the results of this study and on literature data, the experts proposed recommendations on the management of perineal burns in adults. Results: Specifically designed faecal management systems are the first-line method to divert faeces in perineal burns. The working group proposed recommendations and an algorithm to assist in decisions in the management of perineal burns in four categories of patients, depending on total burn skin area, depth and extent of the perineal burn. Conclusion: In France, non-surgical devices are the leading means of faecal diversion in perineal burns. The proposed algorithm may assist in decisions in the management of perineal burns. The expert group emphasises that large clinical studies are needed to better evaluate these devices. # 2013 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns of the perineal area are frequently exposed to faecal contamination, which may result in sepsis, graft loss, delayed wound healing or shrinkage of scars. Although there is little literature on the management of perineal burns and faecal
diversion strategies, diverting colostomy is often described to prevent faecal soiling [1–3]. Because this technique is an invasive procedure with frequent complications, use of nonsurgical devices has been described for the management of faeces in the setting of perineal burns, such as specifically designed faecal management systems (FMSs) [4–6]. These systems allow diversion of faeces away from the perineum,
* Corresponding author at: Sainte Anne Military Teaching Hospital, Burn Centre, Boulevard Sainte Anne, 83800 Toulon, France. Tel.: +33 483162385. E-mail address: [email protected] (J. Bordes). 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.09.007
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burns 40 (2014) 655–663
Table 1 – U.S. preventive services task force grades definition. Grade
Definition
A B
C
D
I Statement
Suggestions for practice
The USPSTF recommends the service. There is high certainty that the net benefit is substantial The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined
promoting wound healing by decreasing the risk of faecal contamination. Several management systems are available, which have been designed to manage diarrhoea in highly dependent patients. Their use as an alternative to divert faeces in burn patients was published only a few years ago. This indication is an extension of the primary indication of these devices. The question of how to divert faeces in perineal burn patients remains unsolved. In order to standardise the faecal management strategy in patients with perineal burns, a group of French experts was assembled. The first aim of this group was to evaluate the ongoing clinical practice in French burn centres; this was achieved through a questionnaire sent to all French burn centres. The second aim was to review the literature on perineal burns and to develop guidelines for their management. These guidelines were presented during the French Burn Association Congress in June 2012 and in the European Burn Association Congress in August 2013.
Methods
A group of French experts was composed in 2011 to standardise the faecal management strategy in perineal burn patients. This group was composed of French burn specialists (intensivists, surgeons and nurses) working in French burn centres. They gathered their clinical judgement with the data available in the literature and provided guidance to standardise the management of perineal burns and promote clinical trials on the subject. The first step was designing a questionnaire that was sent to every burn centre in France. This questionnaire addressed their usual practice in perineal burns and was further analysed by the group. The perineal burn literature was reviewed using the indexed online databases MEDLINE/PubMed. French Burn Association and European Burn Association Congress abstracts were considered. Lists of cited literature within relevant articles were also screened. Initially, the group searched for prospective randomised controlled trials
Offer or provide this service
Offer or provide this service only if other considerations support the offering or providing the service in an individual patient Discourage the use of this service
Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms
(RCTs) and non-RCTs, systematic reviews and guidelines. In the absence of such evidence, case–control studies, observational studies and case reports were considered. Searches were limited to English and French language abstracts issued after 1990. Materials for the recommendations were mostly based on the opinion of the expert panel. Recommendations were graded according the US Preventive Service Task Force grading summarised in Table 1 [7].
3.
Results
3.1. Faecal management in perineal burns: the French practice Preliminary results of this study have already been published [8].
3.1.1.
2.
Offer or provide this service
Patients’ characteristics
Eleven centres out of 14 adults’ burn centres answered the questionnaire. The mean number of patients admitted per year and per centre was 209 (110). The mean percentage of patients with total burn surface area (TBSA) <20% was 65%; between 20% and 40% of TBSA, 25%; and >40% of TBSA, 10% (Fig. 1). Among all admissions, the rate of patients presenting perineal burns was 7% (3.6%). Table 2 shows the total number of admitted patients per year for each centre.
3.1.2.
Definition of a perineal burn
We observed that every burn centre had its own scale for defining the area of a perineal burn. The areas referred to as a perineal burn according to French burn caregivers are listed in figure.
3.1.3.
Use of FMSs in French burn centres
Two situations were considered in the questionnaire.
3.1.3.1. Prolonged diarrhoea in burn patients. In sedated patients, all centres declared using a specifically designed
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70% 60% 50% 40% 30% 20% 10% 0% <20%
20-40%
>40%
Fig. 1 – Total burn skin area in admitted patients. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% perineal area
buocks
upper thighs front
upper thighs back
lumbar area
Fig. 2 – Areas referred as perineal burns according to French burn caregivers.
FMS in case of prolonged diarrhoea. In non-sedated patients, its use concerned <50% of patients.
3.1.3.2. Management of faeces in perineal burn patients. Eight centres out of 11 (73%) declared using a specifically designed FMS in sedated patients with extensive burns to manage faeces. An FMS was used in 54% of non-sedated patients. We observed that the FMS was less frequently used in nonsedated patients (Fig. 2).
3.1.4.
3.1.5. Table 2 – Number of admitted patients for each burn centre (data for 8 centre on 11). Admitted patients/ year (n) Burn Burn Burn Burn Burn Burn Burn Burn
centre centre centre centre centre centre centre centre
1 2 3 4 5 6 7 8
197 384 73 205 206 198 70 419
Perineal burns/ year (n (%)) 15 26 7 10 15 3 9 20
(7.6%) (6.7%) (9.6%) (4.9%) (7.3%) (1.5%) (12.8%) (4.8%)
Faecal management strategies in French burn centres
In case of isolated perineal burns, six centres declared using an FMS (55%), one proposed colostomy (9%), one constipation (9%) and three centres did not consider managing faeces in this setting (27%) (Figs. 3 and 4). In case of perineal burns associated with extensive burns, eight centres out of 11 (73%) declared using a specifically designed FMS in sedated patients. One centre (10%) considered colostomy first and two centres (17%) responded that they do not decide any strategy (Fig. 3). Constipation was never considered.
Faecal management strategy in elderly patients
In elderly patients with isolated perineal burns, the faecal management strategy depends on the presence of comorbidities (Figs. 3 and 4). In sedated elderly patients without co-morbidities, five centres used an FMS (45%), one colostomy (9%), one constipation (9%) and four did not declare any strategy (37%). In sedated elderly patients with co-morbidities, no centre considered colostomy first.
3.1.6.
Insertion of the FMS
When the FMS was used, the device was inserted by a nurse in six centres out of 11 (54%), by a doctor in three centres (28%) and either by a nurse or a doctor in two centres (18%).
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burns 40 (2014) 655–663
100% 90% 80% 70% Others methods Conservative approach Artificial constipation Colostomy Faecal management system
60% 50% 40% 30% 20% 10% 0% Diarrhea
Extensive burns and Isolated perineal burns isolated perineal burns isolated perineal burns perineal burns in elderly patients in elderly patients with without comorbidities comorbidities
Fig. 3 – First line strategy to manage faeces in sedated patients.
Four centres (36%) declared using this technique only in sedated patients.
3.1.7.
Comments
This study showed that perineal burns are rare in French burn centres (<10% of admitted patients), which is concordant with previously published data. The perineum is usually well protected from thermal injury, and perineal burns occur mainly among extensive injury to the trunk and lower extremities. This study emphasised the fact that, in France, nonsurgical means of faecal diversion are widely used as a firstline strategy in case of perineal burns, although burn literature does not support such a practice as a reference method. We explain these results by the fact that FMSs are commonly used in critical care units in case of diarrhoea. Therefore, this approach is already known to physicians and nurses. Besides,
FMS has been proved to be time-efficient, practical and caregiver-friendly in this indication [9]. On the contrary, colostomy is a surgical procedure, cost and time consuming and associated with surgical and anaesthetic complications, especially in elderly patients representing a high proportion of perineal burn patients. A retrospective analysis of enteral stomas performed on 1616 people identified a 34% rate of complications [10]. Furthermore, the colostomy site might be problematic in extensive burns with a wounded abdominal wall. We observed that the FMS was less frequently used in nonsedated patients. Indeed, awake patients usually remain continent, and a residue-free diet can prevent faecal soiling. It is probable that caregivers may have a psychological reticence to insert such a device in an awake patient, considering patient comfort. However, FMS use in awake patients had already been reported without complaints. In the
100% 90% 80% 70% Others methods
60%
Conservative approach Artificial constipation
50%
Colostomy
40%
Faecal management system
30% 20% 10% 0% Diarrhea
Extensive burns and perineal burns
Isolated perineal burns
isolated perineal burns in elderly patients without comorbidities
isolated perineal burns in elderly patients with comorbidities
Fig. 4 – First line strategy to manage faeces in non sedated patients.
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burns 40 (2014) 655–663
Table 3 – MEDLINE/PubMed search results. Randomised controlled trials Not randomised controlled trials Guidelines Reviews Observational studies Case series Case reports
0 0 0 0 5 1 1
study of Padmanabhan et al., the majority of patients who were alert and responsive had no pain or discomfort with the FMS in place [9]. In the elderly patients, colostomy is thought to be associated with more complications. That is probably why we observed that FMSs were used as first-line strategy in this category of patients.
3.2.
Review of literature
Faecal management in perineal burns is a neglected topic in the literature. There is little literature about the management of perineal burns and faecal diversion techniques, although these wounds are commonly associated with larger burns. In particular, no RCTs have been published on faecal management strategy in perineal burn patients (Table 3). The highest level of evidence is the observational study. Three observational studies have been published and they have reported the use of FMSs as a strategy to divert faeces in perineal burn patients (Table 4) [4–6]. Two observational studies and one case series have been published on colostomy in perineal burns [1–3] (Table 5). As a result, materials for the recommendations were mostly based on the opinion of the expert panel.
3.2.1.
Faecal management methods in perineal burn patients
Perineal burns are exposed to faecal soiling and thereby to bacterial contamination. Management of faeces is a priority in these patients.
Different strategies have been described in this context. A conservative approach was proposed, as publications asserted that the theoretical advantage of assisting wound healing by prevention of faecal soiling was not proved [11,12]. This strategy is discouraged nowadays. Indeed, it is now admitted that a conservative approach results in an unacceptably high incidence of sepsis and graft loss [1]. The strategy of artificial constipation could be proposed, but it is not suitable for long-term-sedated patients. This can lead to bowel occlusion, translocation and systemic infection and impaired enteral nutrition. Moreover, it has been recently reported that constipation in critically ill patients was associated with longer length of stay in the intensive care unit and difficulties in reaching the nutrition target [13]. That is why diverting faeces seems to be the most pragmatic strategy. Two methods are described. Temporary diverting colostomy is a surgical method to divert faeces and avoid contamination of the burn perineal area. However, data on use of colostomy in burn patients are scant; three published studies have been listed [1–3]. These studies did not report any major complication, except for one case of fatal septic shock compounded by stomal dehiscence [3]. However, larger studies have emphasised the morbidity of colostomy. An alternative method is the use of a specifically designed FMS.
3.2.2.
Colostomy in burn patients
Not much data are available regarding diverting colostomy in burn patients. We listed three observational studies with a low number of patients, and mostly paediatric burns [1–3]. Quarmby et al. reported a successful series of colostomies in 13 cases of paediatric perineal burn, with wound healing in 12 out of 13 patients [1]. Nakazawa published a series of five elderly persons with successful wound healing in three [2]. Recently, a prospective study of 45 children with peri-anal burns and stomas over a 17-year period has been published [3]. The low number of reported colostomy complications may be explained by the low numbers of patients in studies. Quarmby et al. described only two patients with complications
Table 4 – Published observational studies on faecal management system. Authors
Year of publication
Country
Number of patients
TBSA %
Duration of catheterisation
Mortality rate
Successful wound healing without colostomy
2013 2008 2007
Turkey France Australia
15 8 7
40.7 16.6 41.1 11.3 NR
22.5 5.7 33 21.7 17.8
33% 0% 0%
95.7% 62.5% 100%
Kement et al. Bordes et al. Keshava et al. NR: not reported.
Table 5 – Advantages and disadvantages of faeces diverting techniques according to French working group opinion. Advantages
Disadvantages
Colostomies
Faeces diverting with low risk of leakage No regimen stool modification needed
Faecal management systems
Semi-invasive Preserve the potential skin area
Artificial constipation
Easy to plan Non invasive
Require general anaesthesia Require surgery team Decrease the potential skin surface area Stool modification regimen needed Risk of faecal fluid leakage Limited duration of catheterisation Risks of bowel obstruction Difficulties to reach nutrition target
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out of 13 (two cases of colostomy prolapse) [1]. In the cases series of Nakazawa et al., no morbidity was associated with a colostomy procedure [2]. Complications directly attributable to colostomy in the recent study of Price et al. were considered few and minor in five patients (11.1%) [3]. However, there was a case of adhesive bowel obstruction complicating stoma closure, which could be considered a major complication. Moreover, one patient developed a fatal septic shock compounded by dehiscence of the peristomal area, but the authors did not consider it. Larger studies on colostomy reported that this surgery had significant morbidity. A retrospective analysis of enteral stomas performed at Cook County Hospital on 1616 people during the period from 1976 to 1995 identified 553 (34%) cases with complications [10]. Among these, 448 (28%) occurred early (<1 month postoperatively) and 105 (6%) occurred late (>1 month postoperatively). The most common early complications were skin irritation (12%), pain associated with poor stoma location (7%) and partial necrosis (5%). The most common late complications were skin irritation (6%), prolapse (2%) and stenosis (2%). The rate of complications in this procedure has been reported to be higher in a prospective study of 97 consecutive patients undergoing colostomy (50.5% of complications) [14]. Colostomy complications may influence mortality. In a series of 345 stomas on 320 patients, a higher incidence of mortality was seen in those patients who developed stoma-specific complications (40% mortality with complication, 14% with no complication) [15].
3.2.3.
FMSs in perineal burn patients
Experience with FMSs in perineal burn patients has been reported in three observational studies for a total of 30 patients (Table 4) [4–6]. Both the FMSs used in these studies are commercialised in France and worldwide: the Zassi Bowel Management System1 (Zassi Medical Evolutions, Fernandina Beach, FL, USA) and the Flexi-Seal1 Faecal Management System (ConvaTec, Princeton, NJ, USA). Both models of tube are soft, all silicone, with a fully collapsible retention cuff, which is inflated with 45 ml of water and sealed by resting on the pelvic floor. A digital rectal examination has to be performed before insertion of the device in order to detect any faecal impaction or anorectal abnormality. The catheter can be inserted under sedation or not, by a nurse or a doctor [4]. The tubes can be left in situ for 29 days (as recommended by the manufacturers) and can be replaced after this date if necessary. Both models are attached to a collection bag, which is emptied as required and changed daily. To insure that the faeces would flow through the tube and not obstruct it, management may include enteral ingestion of an osmotic laxative, fibre-based nutrition, daily irrigation of the tube with normal saline and rectal laxative. The first published study on FMS use in perineal burn healing was that of Keshava et al. [4]. They reported a series of 20 patients, including seven perineal burns and 13 severe perineal excoriations. The grafted skin and perineal wounds of all the seven burn patients healed. Bordes et al. then reported the successful use of FMSs in perineal burns in 62.5% of their patients (5/8) [5]. The others underwent colostomy for wound healing. In this study, they described
the case of one patient who experienced graft loss due to leakage of faecal matter despite the use of an FMS, in whom regrafting was successful in keeping the endorectal tube in place. Recently, Kement et al. reported successful use of an FMS in a series of 15 patients [6]. Only one patient (4.3%) required a colostomy because of delayed burn healing. Although performance is a key consideration for the evaluation of a new device for faecal management, determining whether achievement of this goal results in undue complications is also important. Keshava et al. reported a series of 20 patients who required endorectal catheterisation for a mean duration of 14 days [4]. A proctoscopy after tube removal was systematically made; it was normal in all patients. On the contrary, the two other studies in burn patients reported more complications. Bordes et al. observed minor complications (reversible anal atony) in two patients out of eight, and major complications in two others due to bowel occlusion and anal ulceration [5]. Kement et al. described superficial mucosal erosion in the distal rectum in only two patients [6]. A mucosal wound could be favoured by a reduced mucosal blood flow due to systemic shock in the early hours of burn resuscitation. The most frequent issue with these devices is faecal leakage: this was observed in 40% of patients in the study of Kement et al., and in 78% of patients in the study of Bordes et al. [5,6]. Leakages promote colonisation of the burn by gut bacteria and may compromise the skin graft [5]. The authors emphasised the fact that a training time is necessary for the medical team to become more familiar with the device. That could explain the high percentage of leakage in the study of Bordes et al., as suggested by them [5].
4. Perineal burns and faecal management: the French working group recommendations Considering published data and expert opinion, the working group proposed to make precise the perineal burns’ definition and faecal management indications.
4.1.
Perineal burns’ definition
The working group debated the areas included in the term ‘perineal burns’. The consensus definition was: ‘burns involving pubic area, genitalia area, peri-anal area, upper posterior thigh and buttocks’. In fact, all these areas are highly impacted by the risk of faecal soiling. The working group emphasised that burn of the perineum has to be classified as a major burn. As a result, patients with perineal burns have to be transferred and managed in a specialised burn centre [16].
4.2.
Management of perineal burns
4.2.1.
General considerations
Perineal burns are exposed to the risk of faecal soiling, which may lead to wound infections, graft loss, systemic sepsis and urinary tract infection. As a result, the faecal management strategy has to be discussed early in the burn care unit.
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burns 40 (2014) 655–663
Isolated Deep partial Perineal Burns
Residue-free diet
Healed on day 10?
Yes
No
Faecal diversion by FMS
Healed on day 21?
Yes
No
End Consider grafting
Fig. 5 – Use of a specifically designed faecal management system on a air-fluidised bed.
Moreover, prone position, pressure and friction on conventional support may also compromise perineal burn healing or grafting. An air-fluidised therapy has been used since the late 1960s and it has been proved that this support could decrease pressure, shearing forces and moisture of perineal and posterior sites [17,18]. The working group argued that this system would be staffed early in perineal burn care. Use of FMSs has already been described with this support (Fig. 5).
4.2.2.
Faecal management methods
Based on clinical experience and the literature, the working group specified which methods of faecal management could be considered in perineal burns. Experts examined the following methods:
- artificial constipation; - colostomy; and - specifically designed FMS. The advantages and disadvantages for each method are listed in Table 3.
4.2.3.
Indication for faecal diversion
The working group recommended that faecal diversion in burn patients should be considered in two situations:
- perineal burns associated or not with extensive burns (grade C) and
Fig. 6 – Deep partial perineal burns management.
- profuse diarrhoea in sedated patients when faecal matters are at risk of wound soiling (grade C).
4.2.4.
Perineal burns and faecal management strategy
Four categories of patients have been considered by the working group:
-
partial thickness perineal burns; isolated deep perineal burns; perineal burns associated with extensive burns; and deep peri-anal burns.
4.2.4.1. Isolated, deep, partial perineal burns. We recommend that a residue-free diet should be proposed in patients with isolated, deep, partial perineal burns (grade C). If burns are not healed, faecal diversion with an FMS should be considered (grade C). In the absence of healing despite faecal diversion, grafting should be considered (Fig. 6). 4.2.4.2. Isolated deep perineal burns. In patients with isolated full-thickness perineal burns, grafting is necessary (Fig. 7). We recommend that preoperative preparation associate residuefree diet and colonoscopy like preparation in order to avoid skin graft contamination (grade C). If long-lasting healing is probable or in patients with comorbidities (defined by an American Society of Anesthesiologists (ASA) score >2), faecal diversion by an FMS has to be proposed in the postoperative period (grade C). Experts have
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burns 40 (2014) 655–663
Isolated Full thickness Perineal Burns
Residue-free diet
Grafting mandatory
Pre operative preparing “colonoscopy like”
Grafting
Short lasting healing likely ASA I or II
Short lasting healing unlikely ASA > II
Faecal diversion by FMS
Constipation
Surgery failure (stool soiling despite FMS) Patient discomfort
Consider colostomy
Fig. 7 – Deep perineal burns management.
considered that artificial constipation may be risky in patients with co-morbidities. If grafting fails, colostomy has to be considered (grade C).
Deep perianal Burns
4.2.4.3. Perineal burns associated with extensive burns. In perineal burns associated with extensive burns, faecal Perineal burn and
First stools
Consider colostomy if embarrassing stools
Faecal diversion with FMS Fig. 8 – Perineal burns management associated with extensive burns.
Fig. 9 – Perianal deep burns management.
burns 40 (2014) 655–663
diversion by an FMS has to be considered (grade C). The delay between admission and FMS insertion was discussed. It was proposed to insert the system after the first stools, but some experts thought it was more accurate to insert in the first 48 h, before the first stools (Fig. 8).
4.2.4.4. Peri-anal deep burns. The working group argued that peri-anal deep burns might be contraindications to insertion of an FMS (grade C). Indeed, it has been considered that device friction on a mucosal wound may compromise wound healing (Fig. 9).
5.
Conclusion
Reviewing the perineal burn literature makes the term ‘recommendations’ difficult to headline such an article. Indeed, it is not possible to recommend a ‘gold standard’ treatment of perineal burns based on scientific data. Although the number of RCTs is increasing, these are still few in burns practice, making evidence-based medicine difficult to generate. These ‘recommendations’ are mostly based on expert opinion and local experience. This emphasises the great need to promote large-volume clinical trials in our population of burn patients.
Conflict of interest ConvaTec offered logistic support to organise the meetings. The working group attended congresses in June 2012 and August 2013.
references
[1] Quarmby CJ, Millar AJ, Rode H. The use of diverting colostomies in paediatric peri-anal burns. Burns 1999;25(7):645–50. [2] Nakazawa H, Ito H, Morioka K, Kikuchi Y, Honda T, Isago T. The use of temporary diverting colostomy to manage elderly individuals with extensive perineal burns. Burns 2002;28(6):595–9. [3] Price CE, Cox S, Rode H. The use of diverting colostomies in paediatric peri-anal burns: experience in 45 patients. S Afr J Surg 2013;51(3):102–5.
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[4] Keshava A, Renwick A, Stewart P, Pilley A. A nonsurgical means of fecal diversion: the Zassi Bowel Management System. Dis Colon Rectum 2007;50(7):1017–22. [5] Bordes J, Goutorbe P, Asencio Y, Meaudre E, Dantzer E. A non-surgical device for faecal diversion in the management of perineal burns. Burns 2008;34(6):840–4. [6] Kement M, Acar HA, Barlas IS, Aksakal N, Gezen C, Duzci U, et al. Clinical evaluation of a temporary fecal containment device for non-surgical fecal diversion in perineal burns. Ulus Travma Acil Cerrahi Derg 2011;17(2):123–7. [7] Agency for Healthcare Research and Quality R, MD. Appendix A: How the U.S. Preventive Services Task Force Grades Its Recommendations: Guide to Clinical Preventive Services; 2012, http://www.ahrq.gov/professionals/ clinicians-providers/guidelines-recommendations/guide/ appendix-a.html, February 2013. [8] Bordes J, Gamelin A, Le Breton F, Perro G, Bourdais L, Lauwers M, et al. Faecal management in the perineal burns: the French experience. Burns 2013;39(3):528–9. [9] Padmanabhan A, Stern M, Wishin J, Mangino M, Richey K, DeSane M. Clinical evaluation of a flexible fecal incontinence management system. Am J Crit Care 2007;16(4):384–93. [10] Park JJ, Del Pino A, Orsay CP, Nelson RL, Pearl RK, Cintron JR, et al. Stoma complications: the Cook County Hospital experience. Dis Colon Rectum 1999;42(12):1575–80. [11] Weiler-Mithoff EM, Hassall ME, Burd DA. Burns of the female genitalia and perineum. Burns 1996;22(5):390–5. [12] Alghanem AA, McCauley RL, Robson MC, Rutan RL, Herndon DN. Management of pediatric perineal and genital burns: twenty-year review. J Burn Care Rehabil 1990;11(4):308–11. [13] Nguyen T, Frenette AJ, Johanson C, Macleon RD, Patel R, Simpson A, et al. Impaired gastrointestinal transit and its associated morbidity in the intensive care unit. J Crit Care 2013;28(4):e11–7. [14] Arumugam PJ, Bevan L, Macdonald L, Watkins AJ, Morgan AR, Beynon J, et al. A prospective audit of stomas – analysis of risk factors and complications and their management. Colorectal Dis 2003;5(1):49–52. [15] Harris DA, Egbeare D, Jones S, Benjamin H, Woodward A, Foster ME. Complications and mortality following stoma formation. Ann R Coll Surg Engl 2005;87(6):427–31. [16] Alsbjorn B, Gilbert P, Hartmann B, Kazmierski M, Monstrey S, Palao R, et al. Guidelines for the management of partialthickness burns in a general hospital or community setting – recommendations of a European working party. Burns 2007;33(2):155–60. [17] Ryan DW. The fluidised bed. Intensive Care Med 1995;21(3):270–6. [18] VanGilder C, Lachenbruch CA. Air-fluidized therapy: physical properties and clinical uses. Ann Plast Surg 2010;65(3):364–70.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Perineal burn care: French working group recommendations Julien Bordes a,*, Ronan Le Floch b, Ludovic Bourdais b, Alexandre Gamelin c, Franc¸oise Lebreton d, Ge´rard Perro e a
Burn Center, Sainte Anne Military Teaching Hospital, Toulon, France Burn Center, University Hospital, Nantes, France c Burn Center, Roger Salingro Hospital, Lille, France d Burn Center, Lapeyronie Hospital, Montpellier, France e Burn Center, University Hospital, Bordeaux, France b
article info
abstract
Article history:
Objectives: Burns to the perineum are frequently exposed to faeces. Diverting colostomy is
Accepted 5 September 2013
often described to prevent faecal soiling. Because this technique is invasive with frequent complications, use of non-surgical devices including specifically designed faecal manage-
Keywords:
ment systems has been reported in perineal burns.
Perineal burns
Methods: In order to standardise the faecal management strategy in patients with perineal
Diverting colostomy
burns, a group of French experts was assembled. This group first evaluated the ongoing
Faecal management
practice in France by analysing a questionnaire sent to every French burn centre. Based on
Bowel management system
the results of this study and on literature data, the experts proposed recommendations on the management of perineal burns in adults. Results: Specifically designed faecal management systems are the first-line method to divert faeces in perineal burns. The working group proposed recommendations and an algorithm to assist in decisions in the management of perineal burns in four categories of patients, depending on total burn skin area, depth and extent of the perineal burn. Conclusion: In France, non-surgical devices are the leading means of faecal diversion in perineal burns. The proposed algorithm may assist in decisions in the management of perineal burns. The expert group emphasises that large clinical studies are needed to better evaluate these devices. # 2013 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns of the perineal area are frequently exposed to faecal contamination, which may result in sepsis, graft loss, delayed wound healing or shrinkage of scars. Although there is little literature on the management of perineal burns and faecal
diversion strategies, diverting colostomy is often described to prevent faecal soiling [1–3]. Because this technique is an invasive procedure with frequent complications, use of nonsurgical devices has been described for the management of faeces in the setting of perineal burns, such as specifically designed faecal management systems (FMSs) [4–6]. These systems allow diversion of faeces away from the perineum,
* Corresponding author at: Sainte Anne Military Teaching Hospital, Burn Centre, Boulevard Sainte Anne, 83800 Toulon, France. Tel.: +33 483162385. E-mail address: [email protected] (J. Bordes). 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.09.007
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Table 1 – U.S. preventive services task force grades definition. Grade
Definition
A B
C
D
I Statement
Suggestions for practice
The USPSTF recommends the service. There is high certainty that the net benefit is substantial The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined
promoting wound healing by decreasing the risk of faecal contamination. Several management systems are available, which have been designed to manage diarrhoea in highly dependent patients. Their use as an alternative to divert faeces in burn patients was published only a few years ago. This indication is an extension of the primary indication of these devices. The question of how to divert faeces in perineal burn patients remains unsolved. In order to standardise the faecal management strategy in patients with perineal burns, a group of French experts was assembled. The first aim of this group was to evaluate the ongoing clinical practice in French burn centres; this was achieved through a questionnaire sent to all French burn centres. The second aim was to review the literature on perineal burns and to develop guidelines for their management. These guidelines were presented during the French Burn Association Congress in June 2012 and in the European Burn Association Congress in August 2013.
Methods
A group of French experts was composed in 2011 to standardise the faecal management strategy in perineal burn patients. This group was composed of French burn specialists (intensivists, surgeons and nurses) working in French burn centres. They gathered their clinical judgement with the data available in the literature and provided guidance to standardise the management of perineal burns and promote clinical trials on the subject. The first step was designing a questionnaire that was sent to every burn centre in France. This questionnaire addressed their usual practice in perineal burns and was further analysed by the group. The perineal burn literature was reviewed using the indexed online databases MEDLINE/PubMed. French Burn Association and European Burn Association Congress abstracts were considered. Lists of cited literature within relevant articles were also screened. Initially, the group searched for prospective randomised controlled trials
Offer or provide this service
Offer or provide this service only if other considerations support the offering or providing the service in an individual patient Discourage the use of this service
Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms
(RCTs) and non-RCTs, systematic reviews and guidelines. In the absence of such evidence, case–control studies, observational studies and case reports were considered. Searches were limited to English and French language abstracts issued after 1990. Materials for the recommendations were mostly based on the opinion of the expert panel. Recommendations were graded according the US Preventive Service Task Force grading summarised in Table 1 [7].
3.
Results
3.1. Faecal management in perineal burns: the French practice Preliminary results of this study have already been published [8].
3.1.1.
2.
Offer or provide this service
Patients’ characteristics
Eleven centres out of 14 adults’ burn centres answered the questionnaire. The mean number of patients admitted per year and per centre was 209 (110). The mean percentage of patients with total burn surface area (TBSA) <20% was 65%; between 20% and 40% of TBSA, 25%; and >40% of TBSA, 10% (Fig. 1). Among all admissions, the rate of patients presenting perineal burns was 7% (3.6%). Table 2 shows the total number of admitted patients per year for each centre.
3.1.2.
Definition of a perineal burn
We observed that every burn centre had its own scale for defining the area of a perineal burn. The areas referred to as a perineal burn according to French burn caregivers are listed in figure.
3.1.3.
Use of FMSs in French burn centres
Two situations were considered in the questionnaire.
3.1.3.1. Prolonged diarrhoea in burn patients. In sedated patients, all centres declared using a specifically designed
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70% 60% 50% 40% 30% 20% 10% 0% <20%
20-40%
>40%
Fig. 1 – Total burn skin area in admitted patients. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% perineal area
buocks
upper thighs front
upper thighs back
lumbar area
Fig. 2 – Areas referred as perineal burns according to French burn caregivers.
FMS in case of prolonged diarrhoea. In non-sedated patients, its use concerned <50% of patients.
3.1.3.2. Management of faeces in perineal burn patients. Eight centres out of 11 (73%) declared using a specifically designed FMS in sedated patients with extensive burns to manage faeces. An FMS was used in 54% of non-sedated patients. We observed that the FMS was less frequently used in nonsedated patients (Fig. 2).
3.1.4.
3.1.5. Table 2 – Number of admitted patients for each burn centre (data for 8 centre on 11). Admitted patients/ year (n) Burn Burn Burn Burn Burn Burn Burn Burn
centre centre centre centre centre centre centre centre
1 2 3 4 5 6 7 8
197 384 73 205 206 198 70 419
Perineal burns/ year (n (%)) 15 26 7 10 15 3 9 20
(7.6%) (6.7%) (9.6%) (4.9%) (7.3%) (1.5%) (12.8%) (4.8%)
Faecal management strategies in French burn centres
In case of isolated perineal burns, six centres declared using an FMS (55%), one proposed colostomy (9%), one constipation (9%) and three centres did not consider managing faeces in this setting (27%) (Figs. 3 and 4). In case of perineal burns associated with extensive burns, eight centres out of 11 (73%) declared using a specifically designed FMS in sedated patients. One centre (10%) considered colostomy first and two centres (17%) responded that they do not decide any strategy (Fig. 3). Constipation was never considered.
Faecal management strategy in elderly patients
In elderly patients with isolated perineal burns, the faecal management strategy depends on the presence of comorbidities (Figs. 3 and 4). In sedated elderly patients without co-morbidities, five centres used an FMS (45%), one colostomy (9%), one constipation (9%) and four did not declare any strategy (37%). In sedated elderly patients with co-morbidities, no centre considered colostomy first.
3.1.6.
Insertion of the FMS
When the FMS was used, the device was inserted by a nurse in six centres out of 11 (54%), by a doctor in three centres (28%) and either by a nurse or a doctor in two centres (18%).
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100% 90% 80% 70% Others methods Conservative approach Artificial constipation Colostomy Faecal management system
60% 50% 40% 30% 20% 10% 0% Diarrhea
Extensive burns and Isolated perineal burns isolated perineal burns isolated perineal burns perineal burns in elderly patients in elderly patients with without comorbidities comorbidities
Fig. 3 – First line strategy to manage faeces in sedated patients.
Four centres (36%) declared using this technique only in sedated patients.
3.1.7.
Comments
This study showed that perineal burns are rare in French burn centres (<10% of admitted patients), which is concordant with previously published data. The perineum is usually well protected from thermal injury, and perineal burns occur mainly among extensive injury to the trunk and lower extremities. This study emphasised the fact that, in France, nonsurgical means of faecal diversion are widely used as a firstline strategy in case of perineal burns, although burn literature does not support such a practice as a reference method. We explain these results by the fact that FMSs are commonly used in critical care units in case of diarrhoea. Therefore, this approach is already known to physicians and nurses. Besides,
FMS has been proved to be time-efficient, practical and caregiver-friendly in this indication [9]. On the contrary, colostomy is a surgical procedure, cost and time consuming and associated with surgical and anaesthetic complications, especially in elderly patients representing a high proportion of perineal burn patients. A retrospective analysis of enteral stomas performed on 1616 people identified a 34% rate of complications [10]. Furthermore, the colostomy site might be problematic in extensive burns with a wounded abdominal wall. We observed that the FMS was less frequently used in nonsedated patients. Indeed, awake patients usually remain continent, and a residue-free diet can prevent faecal soiling. It is probable that caregivers may have a psychological reticence to insert such a device in an awake patient, considering patient comfort. However, FMS use in awake patients had already been reported without complaints. In the
100% 90% 80% 70% Others methods
60%
Conservative approach Artificial constipation
50%
Colostomy
40%
Faecal management system
30% 20% 10% 0% Diarrhea
Extensive burns and perineal burns
Isolated perineal burns
isolated perineal burns in elderly patients without comorbidities
isolated perineal burns in elderly patients with comorbidities
Fig. 4 – First line strategy to manage faeces in non sedated patients.
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Table 3 – MEDLINE/PubMed search results. Randomised controlled trials Not randomised controlled trials Guidelines Reviews Observational studies Case series Case reports
0 0 0 0 5 1 1
study of Padmanabhan et al., the majority of patients who were alert and responsive had no pain or discomfort with the FMS in place [9]. In the elderly patients, colostomy is thought to be associated with more complications. That is probably why we observed that FMSs were used as first-line strategy in this category of patients.
3.2.
Review of literature
Faecal management in perineal burns is a neglected topic in the literature. There is little literature about the management of perineal burns and faecal diversion techniques, although these wounds are commonly associated with larger burns. In particular, no RCTs have been published on faecal management strategy in perineal burn patients (Table 3). The highest level of evidence is the observational study. Three observational studies have been published and they have reported the use of FMSs as a strategy to divert faeces in perineal burn patients (Table 4) [4–6]. Two observational studies and one case series have been published on colostomy in perineal burns [1–3] (Table 5). As a result, materials for the recommendations were mostly based on the opinion of the expert panel.
3.2.1.
Faecal management methods in perineal burn patients
Perineal burns are exposed to faecal soiling and thereby to bacterial contamination. Management of faeces is a priority in these patients.
Different strategies have been described in this context. A conservative approach was proposed, as publications asserted that the theoretical advantage of assisting wound healing by prevention of faecal soiling was not proved [11,12]. This strategy is discouraged nowadays. Indeed, it is now admitted that a conservative approach results in an unacceptably high incidence of sepsis and graft loss [1]. The strategy of artificial constipation could be proposed, but it is not suitable for long-term-sedated patients. This can lead to bowel occlusion, translocation and systemic infection and impaired enteral nutrition. Moreover, it has been recently reported that constipation in critically ill patients was associated with longer length of stay in the intensive care unit and difficulties in reaching the nutrition target [13]. That is why diverting faeces seems to be the most pragmatic strategy. Two methods are described. Temporary diverting colostomy is a surgical method to divert faeces and avoid contamination of the burn perineal area. However, data on use of colostomy in burn patients are scant; three published studies have been listed [1–3]. These studies did not report any major complication, except for one case of fatal septic shock compounded by stomal dehiscence [3]. However, larger studies have emphasised the morbidity of colostomy. An alternative method is the use of a specifically designed FMS.
3.2.2.
Colostomy in burn patients
Not much data are available regarding diverting colostomy in burn patients. We listed three observational studies with a low number of patients, and mostly paediatric burns [1–3]. Quarmby et al. reported a successful series of colostomies in 13 cases of paediatric perineal burn, with wound healing in 12 out of 13 patients [1]. Nakazawa published a series of five elderly persons with successful wound healing in three [2]. Recently, a prospective study of 45 children with peri-anal burns and stomas over a 17-year period has been published [3]. The low number of reported colostomy complications may be explained by the low numbers of patients in studies. Quarmby et al. described only two patients with complications
Table 4 – Published observational studies on faecal management system. Authors
Year of publication
Country
Number of patients
TBSA %
Duration of catheterisation
Mortality rate
Successful wound healing without colostomy
2013 2008 2007
Turkey France Australia
15 8 7
40.7 16.6 41.1 11.3 NR
22.5 5.7 33 21.7 17.8
33% 0% 0%
95.7% 62.5% 100%
Kement et al. Bordes et al. Keshava et al. NR: not reported.
Table 5 – Advantages and disadvantages of faeces diverting techniques according to French working group opinion. Advantages
Disadvantages
Colostomies
Faeces diverting with low risk of leakage No regimen stool modification needed
Faecal management systems
Semi-invasive Preserve the potential skin area
Artificial constipation
Easy to plan Non invasive
Require general anaesthesia Require surgery team Decrease the potential skin surface area Stool modification regimen needed Risk of faecal fluid leakage Limited duration of catheterisation Risks of bowel obstruction Difficulties to reach nutrition target
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out of 13 (two cases of colostomy prolapse) [1]. In the cases series of Nakazawa et al., no morbidity was associated with a colostomy procedure [2]. Complications directly attributable to colostomy in the recent study of Price et al. were considered few and minor in five patients (11.1%) [3]. However, there was a case of adhesive bowel obstruction complicating stoma closure, which could be considered a major complication. Moreover, one patient developed a fatal septic shock compounded by dehiscence of the peristomal area, but the authors did not consider it. Larger studies on colostomy reported that this surgery had significant morbidity. A retrospective analysis of enteral stomas performed at Cook County Hospital on 1616 people during the period from 1976 to 1995 identified 553 (34%) cases with complications [10]. Among these, 448 (28%) occurred early (<1 month postoperatively) and 105 (6%) occurred late (>1 month postoperatively). The most common early complications were skin irritation (12%), pain associated with poor stoma location (7%) and partial necrosis (5%). The most common late complications were skin irritation (6%), prolapse (2%) and stenosis (2%). The rate of complications in this procedure has been reported to be higher in a prospective study of 97 consecutive patients undergoing colostomy (50.5% of complications) [14]. Colostomy complications may influence mortality. In a series of 345 stomas on 320 patients, a higher incidence of mortality was seen in those patients who developed stoma-specific complications (40% mortality with complication, 14% with no complication) [15].
3.2.3.
FMSs in perineal burn patients
Experience with FMSs in perineal burn patients has been reported in three observational studies for a total of 30 patients (Table 4) [4–6]. Both the FMSs used in these studies are commercialised in France and worldwide: the Zassi Bowel Management System1 (Zassi Medical Evolutions, Fernandina Beach, FL, USA) and the Flexi-Seal1 Faecal Management System (ConvaTec, Princeton, NJ, USA). Both models of tube are soft, all silicone, with a fully collapsible retention cuff, which is inflated with 45 ml of water and sealed by resting on the pelvic floor. A digital rectal examination has to be performed before insertion of the device in order to detect any faecal impaction or anorectal abnormality. The catheter can be inserted under sedation or not, by a nurse or a doctor [4]. The tubes can be left in situ for 29 days (as recommended by the manufacturers) and can be replaced after this date if necessary. Both models are attached to a collection bag, which is emptied as required and changed daily. To insure that the faeces would flow through the tube and not obstruct it, management may include enteral ingestion of an osmotic laxative, fibre-based nutrition, daily irrigation of the tube with normal saline and rectal laxative. The first published study on FMS use in perineal burn healing was that of Keshava et al. [4]. They reported a series of 20 patients, including seven perineal burns and 13 severe perineal excoriations. The grafted skin and perineal wounds of all the seven burn patients healed. Bordes et al. then reported the successful use of FMSs in perineal burns in 62.5% of their patients (5/8) [5]. The others underwent colostomy for wound healing. In this study, they described
the case of one patient who experienced graft loss due to leakage of faecal matter despite the use of an FMS, in whom regrafting was successful in keeping the endorectal tube in place. Recently, Kement et al. reported successful use of an FMS in a series of 15 patients [6]. Only one patient (4.3%) required a colostomy because of delayed burn healing. Although performance is a key consideration for the evaluation of a new device for faecal management, determining whether achievement of this goal results in undue complications is also important. Keshava et al. reported a series of 20 patients who required endorectal catheterisation for a mean duration of 14 days [4]. A proctoscopy after tube removal was systematically made; it was normal in all patients. On the contrary, the two other studies in burn patients reported more complications. Bordes et al. observed minor complications (reversible anal atony) in two patients out of eight, and major complications in two others due to bowel occlusion and anal ulceration [5]. Kement et al. described superficial mucosal erosion in the distal rectum in only two patients [6]. A mucosal wound could be favoured by a reduced mucosal blood flow due to systemic shock in the early hours of burn resuscitation. The most frequent issue with these devices is faecal leakage: this was observed in 40% of patients in the study of Kement et al., and in 78% of patients in the study of Bordes et al. [5,6]. Leakages promote colonisation of the burn by gut bacteria and may compromise the skin graft [5]. The authors emphasised the fact that a training time is necessary for the medical team to become more familiar with the device. That could explain the high percentage of leakage in the study of Bordes et al., as suggested by them [5].
4. Perineal burns and faecal management: the French working group recommendations Considering published data and expert opinion, the working group proposed to make precise the perineal burns’ definition and faecal management indications.
4.1.
Perineal burns’ definition
The working group debated the areas included in the term ‘perineal burns’. The consensus definition was: ‘burns involving pubic area, genitalia area, peri-anal area, upper posterior thigh and buttocks’. In fact, all these areas are highly impacted by the risk of faecal soiling. The working group emphasised that burn of the perineum has to be classified as a major burn. As a result, patients with perineal burns have to be transferred and managed in a specialised burn centre [16].
4.2.
Management of perineal burns
4.2.1.
General considerations
Perineal burns are exposed to the risk of faecal soiling, which may lead to wound infections, graft loss, systemic sepsis and urinary tract infection. As a result, the faecal management strategy has to be discussed early in the burn care unit.
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Isolated Deep partial Perineal Burns
Residue-free diet
Healed on day 10?
Yes
No
Faecal diversion by FMS
Healed on day 21?
Yes
No
End Consider grafting
Fig. 5 – Use of a specifically designed faecal management system on a air-fluidised bed.
Moreover, prone position, pressure and friction on conventional support may also compromise perineal burn healing or grafting. An air-fluidised therapy has been used since the late 1960s and it has been proved that this support could decrease pressure, shearing forces and moisture of perineal and posterior sites [17,18]. The working group argued that this system would be staffed early in perineal burn care. Use of FMSs has already been described with this support (Fig. 5).
4.2.2.
Faecal management methods
Based on clinical experience and the literature, the working group specified which methods of faecal management could be considered in perineal burns. Experts examined the following methods:
- artificial constipation; - colostomy; and - specifically designed FMS. The advantages and disadvantages for each method are listed in Table 3.
4.2.3.
Indication for faecal diversion
The working group recommended that faecal diversion in burn patients should be considered in two situations:
- perineal burns associated or not with extensive burns (grade C) and
Fig. 6 – Deep partial perineal burns management.
- profuse diarrhoea in sedated patients when faecal matters are at risk of wound soiling (grade C).
4.2.4.
Perineal burns and faecal management strategy
Four categories of patients have been considered by the working group:
-
partial thickness perineal burns; isolated deep perineal burns; perineal burns associated with extensive burns; and deep peri-anal burns.
4.2.4.1. Isolated, deep, partial perineal burns. We recommend that a residue-free diet should be proposed in patients with isolated, deep, partial perineal burns (grade C). If burns are not healed, faecal diversion with an FMS should be considered (grade C). In the absence of healing despite faecal diversion, grafting should be considered (Fig. 6). 4.2.4.2. Isolated deep perineal burns. In patients with isolated full-thickness perineal burns, grafting is necessary (Fig. 7). We recommend that preoperative preparation associate residuefree diet and colonoscopy like preparation in order to avoid skin graft contamination (grade C). If long-lasting healing is probable or in patients with comorbidities (defined by an American Society of Anesthesiologists (ASA) score >2), faecal diversion by an FMS has to be proposed in the postoperative period (grade C). Experts have
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Isolated Full thickness Perineal Burns
Residue-free diet
Grafting mandatory
Pre operative preparing “colonoscopy like”
Grafting
Short lasting healing likely ASA I or II
Short lasting healing unlikely ASA > II
Faecal diversion by FMS
Constipation
Surgery failure (stool soiling despite FMS) Patient discomfort
Consider colostomy
Fig. 7 – Deep perineal burns management.
considered that artificial constipation may be risky in patients with co-morbidities. If grafting fails, colostomy has to be considered (grade C).
Deep perianal Burns
4.2.4.3. Perineal burns associated with extensive burns. In perineal burns associated with extensive burns, faecal Perineal burn and
First stools
Consider colostomy if embarrassing stools
Faecal diversion with FMS Fig. 8 – Perineal burns management associated with extensive burns.
Fig. 9 – Perianal deep burns management.
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diversion by an FMS has to be considered (grade C). The delay between admission and FMS insertion was discussed. It was proposed to insert the system after the first stools, but some experts thought it was more accurate to insert in the first 48 h, before the first stools (Fig. 8).
4.2.4.4. Peri-anal deep burns. The working group argued that peri-anal deep burns might be contraindications to insertion of an FMS (grade C). Indeed, it has been considered that device friction on a mucosal wound may compromise wound healing (Fig. 9).
5.
Conclusion
Reviewing the perineal burn literature makes the term ‘recommendations’ difficult to headline such an article. Indeed, it is not possible to recommend a ‘gold standard’ treatment of perineal burns based on scientific data. Although the number of RCTs is increasing, these are still few in burns practice, making evidence-based medicine difficult to generate. These ‘recommendations’ are mostly based on expert opinion and local experience. This emphasises the great need to promote large-volume clinical trials in our population of burn patients.
Conflict of interest ConvaTec offered logistic support to organise the meetings. The working group attended congresses in June 2012 and August 2013.
references
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