Unexplained fever in burn patients due to cytomegalovirus infection.
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Adolescent↗
Biomedical subjects
B G MacMillan
Publications and source records attributed to B G MacMillan.
A silicone-nylon laminated dressing (IP-758) for closure of excised or débrided burn wounds.
A synthetic dressing (IP-758) consisting of a silicone membrane with a laminated layer of nylon fabric was evaluated in patients as a substitute for biological materials to cover excised areas of burn wounds. During a 3-day interval, the tissue developed a tightly adherent bond to the synthetic dressing. The IP-758 conformed to irregularly-shaped regions and stretched with the movements of the wound surface. Seventeen burned children from 3 to 12 years of age and 1 adult are included in this study. In 12 cases, the mean area covered with the synthetic ranged from approximately 39 to 118 cm2. The average dressing remained in place for 3 days and was replaced once. Microbiological sampling (wet swab technique) of the area under the IP-758 after application of second dressing was compared with open control sites treated with topical antibiotics. The results with Staphylococcus aureus, a frequent contaminant, were similar for the two test areas. The IP-758 site in 6 patients contained an average of 10 3 S. aureus per swab test. Immediately following removal of the adherent IP-758 and control of local bleeding, the wounds in most patients provided excellent sites for autografts. The IP-758 dressing is well-tolerated, elastic and adherent to the burn wound permitting maturation of the wound to readily accept autografts.
Adult↗
Plasma and skeletal muscle amino acids following severe burn injury in patients and experimental animals.
This study describes and analyzes sequential changes in plasma and skeletal muscle free amino acids following severe burn injury. Plasma free amino acids were determined in children (n = 9) with burns averaging 60% total body surface area and were compared with laboratory beagles (n = 44) which received a flame burn totaling 30% of their body surface area. In addition, needle biopsy specimens were obtained from the semitendonosus muscle in the animals to determine free intracellular amino acids. In both patients and animals the amount of total free amino acids in plasma fell following burn, suggesting relative protein deficiency. This drop was primarily due to a 47% drop in nonessential amino acids. However, plasma phenylalanine was consistently higher than normal following burn, and was strongly associated with death and weight loss in both animals and patients, especially when analyzed as a ratio with tyrosine. This finding suggested excessive catabolism, hepatic dysfunction, or both. Plasma levels of several amino acids correlated significantly with weight loss. Alterations in muscle free amino acids generally were similar to plasma amino acids. Exceptions were muscle alanine and glycine which strongly correlated with weight loss. However, the determination of muscle free amino acid profiles did not yield clinically useful information not available from plasma profiles. Plasma levels of liver enzymes suggested progressive hepatic dysfunction. These studies show that the laboratory beagle is a good model for studying the metabolic alterations of amino acids that accompany burn injury, since they mimic humans in many parameters which appear to be most useful with respect to clinical evaluation.
Amino Acids↗
Prophylactic antibiotics as an adjunct for skin grafting in clean reconstructive surgery following burn injury.
A randomized prospective double-blind trial was conducted to determine the effectiveness of cephalothin vs. placebo given perioperatively for prevention of infections associated with operations using skin grafts for clean reconstructive surgery following burn injury. The antibiotic was effective in reducing infection (0.8% vs. 5.7%, p less than 0.03), reducing graft loss (p less than 0.2), and shortening hospital stay (12.38 days vs. 13.66 days, p = 0.02). Factors not associated with greater graft infection included the operating surgeon, the use or nonuse of a tie-on stent, graft thickness, large size of graft, and patient age.
Bacterial Infections↗
A clinical study of antimicrobial agents delivered to burn wounds from a drug-loaded synthetic dressing.
This report is of an investigation of the release of antimicrobial agents from a solid barrier dressing when applied to second- and third-degree burn wounds. The synthetic dressings were formed by a mixture of polyethylene glycol-400 (PEG), poly-2-hydroxethyl methacrylate (PHEMA) and one of the test drugs: silver sulfadiazine (AgSD), gentamicin, silver nitrate, or nitrofurazone. The dressings were formed directly on the burn wounds of 33 patients from a paste prepared from a mixture of PEG-PHEMA and drug. These dressings remained in place for 3 days, covering 12 to 64 square inches of the wound. In six patients, the entire burn wounds were covered with the dressings in which the treated areas were each about 200 square inches. The use of drug-loaded synthetic dressings extended to cover major portions of the burn wounds reduced the work required for nursing care and lessened patient discomfort.
Adolescent↗
Breast reconstruction in the burned adolescent female (an 11-year, 157 patient experience).
The experience accumulated after reconstruction of 157 burned breast patients has led to the development of surgical principles and techniques tailored to this problem. Most important among these principles is that the surgeon recognize and preserve viable breast bud tissue in the debridement phase of the acute burn. Reconstruction should begin when the burned breast envelope is insufficient and restricts normal growth. Best results are obtained if contracture release is complete, if defects are covered by thick split-thickness skin grafts, and if nipple-areola reconstruction is obtained from a normal opposite breast if present. Postoperative management should continue until wounds are mature and should include techniques to prevent contracture recurrence.
Adolescent↗
Correction of postburn syndactyly: an analysis of children with introduction of the VM-plasty and postoperative pressure inserts.
An analysis of 190 operations for correction of postburn syndactyly in children showed that none of the procedures commonly used was entirely satisfactory because of partial recurrence of the lesion or less than optimal cosmetic results. Complete correction of the dorsal slant was a particular problem. Because of this, a new operation, designated the VM-plasty, was devised specifically for correction of postburn syndactyly, and this procedure was evaluated in 24 deformities. Our experience suggests that incision of the web with simple closure, simple YV-plasties, and simple or complex Z-plasties should not be used for postburn correction of webs 2, 3, and 4. The five-flap technique of Rousso and, occasionally, Z-plasties are suitable for correction of simple webs of the thumb space, and rotational flaps are suitable in some instances for correction of webs 2, 3 and 4. However, the VM-plasty now appears to be preferable in all instances of volar or dorsal webs where there is no limitation of the back of the hand at or distal to the metacarpophalangeal joints with the fist clenched. Contractures limiting the clenched fist usually require a graft to achieve complete anatomic correction. An adjunctive procedure of graded interdigital pressure inserts was evaluated following the correction of 28 webs and appeared to prevent the appearance of hypertrophic scar formation with improved cosmetic appearance and preservation of the dorsal slant.
Bandages↗
Viral infections in pediatric burn patients.
Bacterial and fungal infections are frequent complications of burns, but the frequency of viral infections has not been defined. In a retrospective survey of serum for viral antibodies in pediatric burn patients, 22% had fourfold increases in antibodies to cytomegalovirus (CMV); 8% had increases to herpes simplex virus and to Epstein-Barr virus; and 5% had increases to varicella-zoster virus. None of the patients had evidence of adenovirus or hepatitis B virus infection. On the basis of these observations, a prospective study of viral infections, using both serologic and viral culture techniques, was performed. This study showed that in 33% of the children CMV infection developed; in 25%, herpes simplex infection; and in 17%, adenovirus infection. In all of the most severely burned children CMV infections developed, and both primary and reactivation infections were observed. Unexplained fevers are common in pediatric burn patients, and this study shows that some of these may be due to CMV infection.
Adolescent↗
The control of burn wound sepsis.
This presentation reviews the course of burn wound sepsis in a group of 621 acute patients treated at the Shriners Burns Institute, Cincinnati Unit, between 1970 and 1976. During this period of time, the overall mortality rate fell from 14% in 1970 to 3 and 5%, respectively, in 1975 and 1976. Staphylococcus aureus was the most commonly recovered organism from the burn wound, colonizing 85% of the burn patients. Beta hemolytic streptococcus represented a potential threat despite the fact that it was recovered from only 5 to 10% of the patients. Pseudomonas aeruginosa showed a decrease in colonization during the period of this study, from 50% of the wounds in 1970 to 21% in 1976. Candida albicans was the fungal organism most commonly recovered from the burn wound and from the blood stream. Fifteen deaths occurred in this group as a result of invasive infection, one from S. aureus, five from P. aeruginosa, two from Klebsiella-Enterobacter, and one from Escherichia coli, as well as six fungal deaths, five from Candida albicans and one from mucormycosis. Therapeutic measures used to control burn wound sepsis consisted of prevention of contamination from exogenous sources, control of burn wound pathogens, early recognition of invasive burn wound sepsis, aggressive management of the burn wound, and optimal nutritional support. During this period the extent of burn associated with a survival of 50% has risen from 50% in 1970 to 80% in 1976. This improvement in survival is directly related to progressive improvement in local and systemic measures available for the control of infection.
Burns↗
A pathophysiologic study of the hypertension associated with burn injury in children.
Measurements of cardiac output, blood volume, plasma renin activity (PRA), serum aldosterone, plasma and urinary catecholamine levels, serum and urinary electrolyte levels, and of transfusion and fluid therapy have been made in eight hypertensive and seven normotensive burned children. Studies were conducted during the acute phase of burn injury when hypertension was first diagnosed and were repeated just before discharge from the hospital. Hypertensive patients perfused at an inappropriately high total peripheral resistance and hypervolemia was demonstrated in the hypertensive patients. No differences could be demonstrated between hypertensive or normotensive patients in PRA, aldosterone, catecholamine, or electrolyte levels. These data indicate that both the hypervolemia and the vasoconstrictor activity of PRA and/or catecholamines are present when hypertension develops in these patients. These data suggest that the renin-angiotension-aldosterone system is directly stimulated as part of the neuroendocrine response to trauma.
Acute Disease↗
A challenge to resurface major burns.
Ten patients with greater than 70% body surface burn from a group of 113 pediatric thermal injury admissions were studied. Of these children 70% had exision of their burn eschars by carbon dioxide laser and the remaining 30% by scalpel. Burn wounds in all these patients were covered by the expansion autograft technique in an attempt to reduce the resurfacing period in these major burn patients. Survival rate in this small group of patients was 67%.
Adolescent↗
Surgical correction of postburn flexion contractures of the fingers in children.
One-hundred forty-eight operative procedures for flexion contractures of the finger(s) following burn injury in children have been studied in detail with follow-up from 6 months to 8 years. Intramedullary K-wires, used for 53 procedures where a graft was done, were associated with a significantly worse long-term result, and graft take was not improved by using K-wires. Length of time between burn injury and reconstruction, age at time of operation, the use of full-thickness versus partial-thickness grafts, and the digit involved had an apparent effect on final result. The use of postoperative topical steroids could not be evaluated adequately in this study. The preferred operative techniques for this condition are discussed.
Bandages↗
Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay.
A major factor limiting survival following extensive thermal injury is insufficient availability of donor sites to provide enough skin for the required grafting procedures. While 3:1 expanded mesh autograft have aided greatly in better utilization of available sites, a 6:1 or greater expanded mesh graft is often accompanied by significant loss of the graft. A technique has been developed in which widely meshed autograft (6:1 or greater) is covered by a 1.5 or 3:1 expanded mesh allograft to provide better take. Fourteen patients have been treated using this technique covering areas of 1 to 15% body surface area, and the results compared with the take and ultimate coverage of 3:1 expanded mesh autografts. The size of burn of these patients varied between 25% total/11% 3 degrees and 98% total/95% 3 degrees (average 58%/47%). Eleven procedures were done after excision to fascia, four after tangential excision, and the remaining seven grafts were placed on granulating wounds. The allograft used for overlay had been preserved by freezing and storage in liquid nitrogen. Epithelial outgrowth from the autograft was more rapid than from the allograft, but both types of graft took and became vascularized initially. There was an average of 99% autograft take and 95% allograft take. However, three patients subsequently had graft loss as a result of burn wound sepsis. The allografts gradually rejected 3 to 30 days post-grafting with the time of 50% loss averaging 14 days. Rejection of the allograft was not associated with acute inflammation or loss of autograft. The ultimate cosmetic appearance and function was acceptable in all. This new technique appears to offer significant advantages for the grafting of extensively burned patients with limited donor sites.
Adolescent↗
Improved survival in severely burned animals using intravenous Corynebacterium parvum vaccine post injury.
This study was designed to determine the potential benefit or toxicity of an immunomodulator, Corynebacterium parvum vaccine, when it is given after severe burn injury. Forty conditioned beagles received a 33% total body surface 3-degree flame burn and were resuscitated with Ringer's lactate solution (3 ml/kg/% burn). Wounds were treated daily for 10 days with silver sulfadiazine cream. Two days and nine days after burn, 21 of the animals received C. parvum vaccine (10 mg/kg IV) in a saline infusion, while 19 control animals were given only saline infusion according to a double-blind protocol. Serial measurements were made of temperature, weight, food intake, hematocrit, hemoglobin, red blood count, white blood count, differential, platelet count, fibrin degradation products, activated partial thromboplastin time, clot retraction, C3, blood cultures, neutrophil function, monocyte function, opsonic index, Na, K, Cl, BUN, glucose creatinine, total protein albumin, albumin/globulin ratio, alkaline phosphatase, SGPT, and SGOT. During 45 days of observation, only 16% of the saline control dogs survived compared to 47% of the treated animals. Total white counts and neutrophil function were the only values which were significantly better in animals receiving C. parvum. However, their correlation with increased survival was marginal This preclinical trial suggests that C. parvum is an effective immunodulator for prevention of fatal infection following burn injury. There were no demonstrable toxic effects of the material in this study.
Animals↗
Infections following burn injury.
Those factors that have contributed most to the control of burn wound sepsis in the burn patient since 1930 have been the advent of penicillin, the institution of burn center care, the availability of aminoglycosides and antifungal agents, the advent of topical therapy, the aggressive treatment of the burn wound by excisional therapy, a better understanding of respiratory therapy, the support of immune competence, and the recognition of the importance of nutritional support (Fig. 1). At the Shriners Cincinnati Unit, the extent of burn associated with a survival rate of 50 per cent has risen from 70 per cent in 1970 to 80 per cent in 1978. The better chance of survival for burn patients during this period can be directly related to a progressive improvement in the local and systemic measures available for the control of infection.
Burns↗
Clinical characteristics of hypertension in burned children.
Although systemic arterial hypertension has been recognized as a common complication of thermal injury in children, its clinical characteristics have not been defined. This review of 987 burned children, treated over an 11-year period, documents development of hypertension in 195 patients (19.8%). The problem occurs most frequently in males and in the 7--10-year age group, but does not correlate with racial origin. Incidence increases with burn severity up to a 40% total surface burn. The incidence did not vary with the year of treatment when changes in patient population were eliminated. Fifteen of the 195 patients had hypertensive encephalopathy and seizure problems. No other complication or change in mortality could be related to hypertension. The problem could not be related to location of the burn wound, drug treatment, or differences in transfusion and fluid therapy. Comparison of the highest daily blood pressure measurements between matched hypertensive and normotensive groups demonstrated that the hypertensive and normotensive groups demonstrated that the hypertension is limited to the acute phase of burn wound treatment and that blood pressures are normal after complete autografting. The encephalopathy and seizure problems indicate the need for careful blood pressure monitoring and effective antihypertensive therapy in the treatment of burned children.
Adolescent↗
Beneficial effects of aggressive protein feeding in severely burned children.
To determine any potential benefit of feeding increased amounts of protein to hypermetbolic burned patients, 18 children with burns averaging 60% total surface area were randomized into two matched groups and studied serially for at least six weeks: the first group was given a normal diet with a balanced nutritional supplement, and the second group was supplemented with milk whey protein. The normal protein group received 87.1% of their desired caloric intake with 16.5% of calories from protein compared to 77.7% of desired caloric intake with 23.0% of calories from protein for the high protein group. Despite a higher caloric intake, the normal protein group had a worse opsonic index compared to the high protein group (0.42 +/- 0.04 vs. 0.62 +/- 0.05, p < 0.0007), lower levels of C3 (1371 +/- 55 vs. 1585 +/- 64 micrograms/ml, p < 0.01), lower levels of IgG (805 +/- 52 vs. 975 +/- 56 micrograms/ml, p < 0.03), lower levels of transferrin (200 +/- 10 vs. 283 +/- 18 mg/dl, p < 0.0001), lower levels of total serum protein (5.5 +/- 0.1 vs. 6.3 +/- 0.2 g/dl, p < 0.005), more bacteremic days (11% vs. 8%, p < 0.005) and worse survival (5/9--56% vs. 9/9--100%, p < 0.03). Patients receiving the high protein diet had significantly higher plasma levels of valine, lysine, threonine, leucine, aginine, isoleucine, proline, serine, asparagine, tryptophane, and tyrosine. Asparagine levels were significantly (p < 0.01) associated with better neutrophil function and opsonic index. Except for phenylalanine, significant associations were found for serum levels of each of the amino acids with concentrations of one or more serum proteins. These studies provide evidence that many immunologic functions are dependent upon optimal availability of specific amino acids, and that routine diets do not provide sufficient protein to satisfy the needs of seriously burned children.
Age Factors↗
Tracheoplasty for tracheal stenosis in the pediatric burned patient.
Until recently, the only therapy available for a tracheal stricture has been repeated dilations of the stenotic area or resection and anastomosis. Upper-airway burns in the pediatric patient have occasionally resulted in tracheal stenosis. Two children with a long tracheal stenosis secondary to inhalation injury have been successfully treated surgically. A costal cartilage graft has been used in these two children in the management of a long tracheal stenosis. Both have an adequate airway, and future surgical correction of a subglottic stenosis is planned for both. The results, although initially successful, will need to be tested by time before they can be considered the definitive treatment for long areas of tracheal stenosis.
Burns, Inhalation↗