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The experience in the treatment of patients with extensive full-thickness burns
Burns 25 (1999) 757±759
www.elsevier.com/locate/burns
The experience in the treatment of patients with extensive full-thickness burns Hongtai Tang*, Zhaofan Xia, Shikang Liu, Yulin Chen, Shengde Ge Burns Center, Changhai Hospital, Second Military Medical University, Shanghai 200433, People's Republic of China Accepted 10 May 1999
Abstract The aim of the present study is to analyze the changes of cure rate and the main causes of death in the last 40 years, and to summarize our experience in the treatment of extensive full-thickness burn patients. The clinical characteristics, cure rate and main causes of death of 73 cases with total burned area more than 90% TBSA and full-thickness burn area more than 70% TBSA were analyzed retrospectively. Among them, 21 cases (28.8%) were cured and 52 cases (71.2%) died. The cure rate increased signi®cantly in the recent years, and the main causes of death changed from shock and sepsis in the time period 1959± 1978 to sepsis and MODS in the past two decades. Due to the improvement of early comprehensive management of burn shock, aggressive surgical approach to full-thickness burn wound and potent systemic supporting measures, the survival rate increased signi®cantly. # 1999 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Burns; Shock; Resuscitation; Wound management
1. Introduction
2. Patients and methods
Patients with extensive full-thickness burn wounds usually have high incidence of burn shock, immunode®ciencies, sepsis and multiple organ dysfunction syndrome (MODS)[1]. A large amount of skin autograft is necessary in these patients, but it is usually not available due to limited skin donor sites. Hence, the survival rate of these patients is relatively poor. From 1959 through 1998, a total of 73 patients with extensive full-thickness burn wound (burns covering more than 90% of total body surface area (TBSA) and fullthickness burns more than 70%TBSA) were admitted to our Burns Center, of these 21 cases survived. The aim of the present study is to analyze the changes of cure rate and the main causes of death in dierent stages, and to summarize our experience in the treatment of patients with extensive full-thickness burn.
In the past 40 years (from 1959 to 1998), a group of 73 patients with burn wound more than 90% TBSA and full-thickness burn more than 70% TBSA were admitted to our Burns Center. Fifty-seven of them are male. The mean age was 31.7 2 13.5 years old. The average burn size was 95.7 2 3.5% TBSA, the fullthickness burn size was 85.8 27.8% TBSA; and the injury index was 90.8 2 5.1. Eighty-nine percent of the patients had inhalation injury to some extent. For comparison, the patients were divided into two groups according to the time of admission:
* Corresponding author. Tel.: 86-021-25070599; fax: 86-02189989829. E-mail address: [email protected] (H. Tang).
Group 1: December Group 2: December
patients admitted from January 1959 to 1978. patients admitted from January 1979 to 1998.
Compared with that of group 1, the main dierences in the treatment of group 2 patients lay in application of early comprehensive management of burn shock, aggressive surgical approach to full-thickness burn wound and potent systemic supporting measures.
0305-4179/99/$20.00 # 1999 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 9 9 ) 0 0 0 8 9 - 3
758
H. Tang et al. / Burns 25 (1999) 757±759
The mortality rate and main causes of death of the two groups were analyzed. Figures were expressed as mean 2 S.D. Dierence was checked using w2 and P < 0.05 was considered to be signi®cant. 3. Results 3.1. Survival rate and main causes of death Of all the 73 patients, 21 survived with a survival rate of 28.8%. The main causes of death were sepsis and/or burn wound sepsis (38.5%), burn shock (26.9%) and MODS (11.5%). Compared with patients who died, survivors had relatively less full-thickness burn wounds. 3.2. General condition during shock stage and prognosis Of all the patients, 14 died of severe burn shock. 59 survived the shock stage. Of the survivors, 27 patients were in relatively stable condition during shock stage with an incidence of early septicemia of 18.5% (5/27 patients). Thirty-two patients experienced eventful or turbulent shock phase. In these patients, the incidence of early septicemia was 50.0% (16/32), and the mortality rate was 87.5% (14/16). 3.3. Survival rates and causes of death The survival rates of group 1 and group 2 were 10.7% and 40.0%, respectively (Table 1). The main causes of death for group 1 were shock (48.0%) and sepsis (36.0%). In group 2, relatively less died of burn shock, whereas more died of sepsis (40.7%) and MODS (18.4%) (Table 2). 4. Discussion Patients with extensive full-thickness burn wounds have high incidence of burn shock, and the mortality Table 1 The survival analysis of patients with full-thickness burn e70% TBSA Area of burn
III degree Total a
70%80%90%-
Group 1
Group 2
n
Survival (%)
n
Survival (%)
4 9 15 28
2(50) 0(0.0) 1(6.67) 3(10.7)
7 24 14 45
3(42.9) 12(50) 3(21.3) 18(40.0)a
P < 0.05 vs. the former stage group.
Table 2 Analysis of main causes of death Causes
Shock Sepsis ARDS MODS ARF Brain edema Major bleeding Noma Asphyxia
Group 1
Group 2
n
%
n
%
12 9 0 1 1 2 0 0 0
48.0 36.0 0.0 4.0 4.0 8.0 0.0 0.0 0.0
2 11 3 5 2 0 2 1 1
7.4 40.7 11.1 18.4 7.4 0.0 7.4 3.8 3.8
is extremely high. Moreover, patients who experienced eventful or turbulent shock phase had a high incidence of early septicemia, and mortality. In the patients summarized in this article, burn shock accounted for 26.9% of the mortality. Hence, suitable management of burn shock remains one of the most important approaches to burn patients. Fluid resuscitation is a basic step for burn shock management. There are still many disputes regarding immediate ¯uid replacement in the acute phase of severe burns. As had been recommended by Desai et al. [2], 1.5 ml/kg/%TBSA colloid and crystalloid solution with 50 ml/kg electrolytefree water is usually sucient to maintain vital organ perfusion for ®rst 24 h ¯uid therapy. However, the resuscitation formulae are only guidelines to ¯uid replacement and adequacy of resuscitation must be constantly monitored. In our experience, an urine output of 0.5±1 ml/kg/h, heart rate less than 120 beats/ min and a clear sensorium all indicate adequate response to ¯uid therapy. Delays in resuscitation and inhalation injury require more ¯uid for adequate resuscitation [3]. Although ¯uid replacement therapy is of great importance in the treatment of hypovolemia, additional combined treatment may also play an important role in treating many pathophysiological changes. In recent years, such measures as low-dose dopamine (2±5 mg/ kg/min)[4], H2-receptor antagonist and selective intestinal decontamination of the digestive tract (SDD)[5] are successfully used in our burns center to prevent complications frequently seen in the early postburn period. As shown in the present study, with the improvement of burn shock management less patients died of burn shock. Following successful resuscitation, the most dicult, painstaking and important task in burn treatment is local burn management. It is obvious that the devitalized tissue is a culture medium for growth and proliferation of microorganisms, which can result in invasive and systemic infection. In 1960s and 1970s,
H. Tang et al. / Burns 25 (1999) 757±759
conservative debridement was widely used, invasive infection and other fatal complications were usually seen in extensive full-thickness burn patients. In the last two decades, an aggressive approach to burn wound excision was the standard of wound care. The present study showed that early excision and wound closure increased the survival rate from 10.7% of group 1 to 40.0 of group 2. However, all surgical excision must be tailor to the individual circumstance. In our experience, surgical excision can be performed 48± 96 h postburn for extensive burn patients, and an excision covering more than 40% TBSA is feasible and bene®cial. Once the burn wound is excised rapid wound closure is essential. In the case of extensive fullthickness burn, where there is a shortage of skin donor sites, total coverage of the resultant wound with autograft is impossible. Then complete wound closure can be achieved by a combination of autograft and allograft. The method of intermingled transplantation using autograft and allograft (the `Chinese method') and micrograft technique [6], which has a wound coverage area up to 10-fold and 18-fold, respectively, are regularly used for the closure of extensive deep burn wound in our burns center. In the present study, infection was one of the main causes of death in both groups. It seems that early excision and wound closure did not reduce the incidence of infection. However, if we take the patients who died of burn shock into account, the infectionprevention function of early excision and wound closure will be seen. Burn injury, particularly extensive deep burns, is considered as a systemic disease rather than as skin damage alone. The pathophysiological changes resulting from major burns have an extensive and profound in¯uence on almost every system of the victim. Thereby, such measures as nutritional support, maintenance of homeostasis, rational administration of
759
antibiotics, and prevention for MODS are all essential [7]. In conclusion, over a 40-year period the survival rate of patients with extensive full-thickness burns has increased signi®cantly in our burns center due to the improvement of early comprehensive management of burn shock, aggressive surgical approach to full-thickness burn wound and potent systemic supporting measures. Acknowledgements The authors would like to thank all the sta of Burn Intensive Care Unit, Changhai Hospital, for their arduous work and cooperation. Also thanks to Weirong Yu M.D. and Jijiang Wang M.D. for the help during the preparation of the manuscript. References [1] Fang ZY, Sheng ZY, Li N, Ge SD. Modern treatment of severe burns, 1st ed. Berlin Heidelberg: Springer-Verlag, 1992. [2] Desai MH, Herndon DN, Broemeling LM, et al. Early burn wound excision signi®cantly reduces blood loss. Ann Surg 1990;211:753. [3] Herndon DN, Traber DL, Traber LD. The eect of resuscitation on inhalation injury. Surgery 1986;100:248. [4] Graves TA, Cio WG, Vaughan GM, et al. The renal eects of low-dose dopamine in thermally injured patients. J Trauma 1993;35:97. [5] Mackie DP, van Hertum WA, Schumburg T, et al. Prevention of infection in burns: preliminary experience with selective decontamination of the digestive tract in patients with extensive injuries. J Trauma 1992;32:570. [6] Ge SD. Management of full-thickness burns. In: Fang ZY, Sheng ZYM, Li N, Ge S, editors. Modern treatment of severe burns, 1st ed. Berlin Heidelberg: Springer-Verlag, 1992. p. 64. [7] Rose JK, Herndon DN. Advances in the treatment of burn patients. Burns 1997;23:S19.
www.elsevier.com/locate/burns
The experience in the treatment of patients with extensive full-thickness burns Hongtai Tang*, Zhaofan Xia, Shikang Liu, Yulin Chen, Shengde Ge Burns Center, Changhai Hospital, Second Military Medical University, Shanghai 200433, People's Republic of China Accepted 10 May 1999
Abstract The aim of the present study is to analyze the changes of cure rate and the main causes of death in the last 40 years, and to summarize our experience in the treatment of extensive full-thickness burn patients. The clinical characteristics, cure rate and main causes of death of 73 cases with total burned area more than 90% TBSA and full-thickness burn area more than 70% TBSA were analyzed retrospectively. Among them, 21 cases (28.8%) were cured and 52 cases (71.2%) died. The cure rate increased signi®cantly in the recent years, and the main causes of death changed from shock and sepsis in the time period 1959± 1978 to sepsis and MODS in the past two decades. Due to the improvement of early comprehensive management of burn shock, aggressive surgical approach to full-thickness burn wound and potent systemic supporting measures, the survival rate increased signi®cantly. # 1999 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Burns; Shock; Resuscitation; Wound management
1. Introduction
2. Patients and methods
Patients with extensive full-thickness burn wounds usually have high incidence of burn shock, immunode®ciencies, sepsis and multiple organ dysfunction syndrome (MODS)[1]. A large amount of skin autograft is necessary in these patients, but it is usually not available due to limited skin donor sites. Hence, the survival rate of these patients is relatively poor. From 1959 through 1998, a total of 73 patients with extensive full-thickness burn wound (burns covering more than 90% of total body surface area (TBSA) and fullthickness burns more than 70%TBSA) were admitted to our Burns Center, of these 21 cases survived. The aim of the present study is to analyze the changes of cure rate and the main causes of death in dierent stages, and to summarize our experience in the treatment of patients with extensive full-thickness burn.
In the past 40 years (from 1959 to 1998), a group of 73 patients with burn wound more than 90% TBSA and full-thickness burn more than 70% TBSA were admitted to our Burns Center. Fifty-seven of them are male. The mean age was 31.7 2 13.5 years old. The average burn size was 95.7 2 3.5% TBSA, the fullthickness burn size was 85.8 27.8% TBSA; and the injury index was 90.8 2 5.1. Eighty-nine percent of the patients had inhalation injury to some extent. For comparison, the patients were divided into two groups according to the time of admission:
* Corresponding author. Tel.: 86-021-25070599; fax: 86-02189989829. E-mail address: [email protected] (H. Tang).
Group 1: December Group 2: December
patients admitted from January 1959 to 1978. patients admitted from January 1979 to 1998.
Compared with that of group 1, the main dierences in the treatment of group 2 patients lay in application of early comprehensive management of burn shock, aggressive surgical approach to full-thickness burn wound and potent systemic supporting measures.
0305-4179/99/$20.00 # 1999 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 9 9 ) 0 0 0 8 9 - 3
758
H. Tang et al. / Burns 25 (1999) 757±759
The mortality rate and main causes of death of the two groups were analyzed. Figures were expressed as mean 2 S.D. Dierence was checked using w2 and P < 0.05 was considered to be signi®cant. 3. Results 3.1. Survival rate and main causes of death Of all the 73 patients, 21 survived with a survival rate of 28.8%. The main causes of death were sepsis and/or burn wound sepsis (38.5%), burn shock (26.9%) and MODS (11.5%). Compared with patients who died, survivors had relatively less full-thickness burn wounds. 3.2. General condition during shock stage and prognosis Of all the patients, 14 died of severe burn shock. 59 survived the shock stage. Of the survivors, 27 patients were in relatively stable condition during shock stage with an incidence of early septicemia of 18.5% (5/27 patients). Thirty-two patients experienced eventful or turbulent shock phase. In these patients, the incidence of early septicemia was 50.0% (16/32), and the mortality rate was 87.5% (14/16). 3.3. Survival rates and causes of death The survival rates of group 1 and group 2 were 10.7% and 40.0%, respectively (Table 1). The main causes of death for group 1 were shock (48.0%) and sepsis (36.0%). In group 2, relatively less died of burn shock, whereas more died of sepsis (40.7%) and MODS (18.4%) (Table 2). 4. Discussion Patients with extensive full-thickness burn wounds have high incidence of burn shock, and the mortality Table 1 The survival analysis of patients with full-thickness burn e70% TBSA Area of burn
III degree Total a
70%80%90%-
Group 1
Group 2
n
Survival (%)
n
Survival (%)
4 9 15 28
2(50) 0(0.0) 1(6.67) 3(10.7)
7 24 14 45
3(42.9) 12(50) 3(21.3) 18(40.0)a
P < 0.05 vs. the former stage group.
Table 2 Analysis of main causes of death Causes
Shock Sepsis ARDS MODS ARF Brain edema Major bleeding Noma Asphyxia
Group 1
Group 2
n
%
n
%
12 9 0 1 1 2 0 0 0
48.0 36.0 0.0 4.0 4.0 8.0 0.0 0.0 0.0
2 11 3 5 2 0 2 1 1
7.4 40.7 11.1 18.4 7.4 0.0 7.4 3.8 3.8
is extremely high. Moreover, patients who experienced eventful or turbulent shock phase had a high incidence of early septicemia, and mortality. In the patients summarized in this article, burn shock accounted for 26.9% of the mortality. Hence, suitable management of burn shock remains one of the most important approaches to burn patients. Fluid resuscitation is a basic step for burn shock management. There are still many disputes regarding immediate ¯uid replacement in the acute phase of severe burns. As had been recommended by Desai et al. [2], 1.5 ml/kg/%TBSA colloid and crystalloid solution with 50 ml/kg electrolytefree water is usually sucient to maintain vital organ perfusion for ®rst 24 h ¯uid therapy. However, the resuscitation formulae are only guidelines to ¯uid replacement and adequacy of resuscitation must be constantly monitored. In our experience, an urine output of 0.5±1 ml/kg/h, heart rate less than 120 beats/ min and a clear sensorium all indicate adequate response to ¯uid therapy. Delays in resuscitation and inhalation injury require more ¯uid for adequate resuscitation [3]. Although ¯uid replacement therapy is of great importance in the treatment of hypovolemia, additional combined treatment may also play an important role in treating many pathophysiological changes. In recent years, such measures as low-dose dopamine (2±5 mg/ kg/min)[4], H2-receptor antagonist and selective intestinal decontamination of the digestive tract (SDD)[5] are successfully used in our burns center to prevent complications frequently seen in the early postburn period. As shown in the present study, with the improvement of burn shock management less patients died of burn shock. Following successful resuscitation, the most dicult, painstaking and important task in burn treatment is local burn management. It is obvious that the devitalized tissue is a culture medium for growth and proliferation of microorganisms, which can result in invasive and systemic infection. In 1960s and 1970s,
H. Tang et al. / Burns 25 (1999) 757±759
conservative debridement was widely used, invasive infection and other fatal complications were usually seen in extensive full-thickness burn patients. In the last two decades, an aggressive approach to burn wound excision was the standard of wound care. The present study showed that early excision and wound closure increased the survival rate from 10.7% of group 1 to 40.0 of group 2. However, all surgical excision must be tailor to the individual circumstance. In our experience, surgical excision can be performed 48± 96 h postburn for extensive burn patients, and an excision covering more than 40% TBSA is feasible and bene®cial. Once the burn wound is excised rapid wound closure is essential. In the case of extensive fullthickness burn, where there is a shortage of skin donor sites, total coverage of the resultant wound with autograft is impossible. Then complete wound closure can be achieved by a combination of autograft and allograft. The method of intermingled transplantation using autograft and allograft (the `Chinese method') and micrograft technique [6], which has a wound coverage area up to 10-fold and 18-fold, respectively, are regularly used for the closure of extensive deep burn wound in our burns center. In the present study, infection was one of the main causes of death in both groups. It seems that early excision and wound closure did not reduce the incidence of infection. However, if we take the patients who died of burn shock into account, the infectionprevention function of early excision and wound closure will be seen. Burn injury, particularly extensive deep burns, is considered as a systemic disease rather than as skin damage alone. The pathophysiological changes resulting from major burns have an extensive and profound in¯uence on almost every system of the victim. Thereby, such measures as nutritional support, maintenance of homeostasis, rational administration of
759
antibiotics, and prevention for MODS are all essential [7]. In conclusion, over a 40-year period the survival rate of patients with extensive full-thickness burns has increased signi®cantly in our burns center due to the improvement of early comprehensive management of burn shock, aggressive surgical approach to full-thickness burn wound and potent systemic supporting measures. Acknowledgements The authors would like to thank all the sta of Burn Intensive Care Unit, Changhai Hospital, for their arduous work and cooperation. Also thanks to Weirong Yu M.D. and Jijiang Wang M.D. for the help during the preparation of the manuscript. References [1] Fang ZY, Sheng ZY, Li N, Ge SD. Modern treatment of severe burns, 1st ed. Berlin Heidelberg: Springer-Verlag, 1992. [2] Desai MH, Herndon DN, Broemeling LM, et al. Early burn wound excision signi®cantly reduces blood loss. Ann Surg 1990;211:753. [3] Herndon DN, Traber DL, Traber LD. The eect of resuscitation on inhalation injury. Surgery 1986;100:248. [4] Graves TA, Cio WG, Vaughan GM, et al. The renal eects of low-dose dopamine in thermally injured patients. J Trauma 1993;35:97. [5] Mackie DP, van Hertum WA, Schumburg T, et al. Prevention of infection in burns: preliminary experience with selective decontamination of the digestive tract in patients with extensive injuries. J Trauma 1992;32:570. [6] Ge SD. Management of full-thickness burns. In: Fang ZY, Sheng ZYM, Li N, Ge S, editors. Modern treatment of severe burns, 1st ed. Berlin Heidelberg: Springer-Verlag, 1992. p. 64. [7] Rose JK, Herndon DN. Advances in the treatment of burn patients. Burns 1997;23:S19.