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Biomedical subjects

R L Sheridan

Publications and source records attributed to R L Sheridan.

At least 19 recordsLinked to original sources
PubMed2001

Trends in blood conservation in burn care.

Traditional burn surgery is very bloody, but wide use of blood conserving strategies is becoming common. Uniform application of blood conserving techniques of burn wound excision may substantially decrease blood utilization in burn patients. We chose to examine this trend in our unit. All fresh frozen plasma (FFP) and packed red blood cell (pRBC) use in children with burns of 10% or more of the body surface who were admitted during 2-3 year intervals, separated by a decade, was reviewed in detail. Three subgroups were separately analyzed: children with 10-24% (small), 25-49% (medium) and 50-100% (large) body surface area burns. Between these two intervals a major emphasis was made in techniques of blood conservation during surgery and fresh frozen plasma was replaced by 5% albumin as the routine resuscitative colloid. In Group 1, there were 189 children, of whom 184 (97%) survived to discharge. In Group 2, there were 203 children, of whom 199 (98%) survived to discharge (N.S.). All subgroups were well matched for age, weight and burn size. Discharge hemocrits exceeded 30% in all subgroups. Reductions in FFP use were 100, 95 and 97% in the small, medium and large burn size groups, respectively. Reductions in pRBC use were 89, 63, and 80% in the small, medium and large burn size groups, respectively. These differences were all highly significant (P<0.001). Uniform application of blood conserving techniques of burn wound excision result in highly significant reductions in blood product exposure without sacrifice of clinical outcomes.

Albumins↗
PubMed2001

Initial experience with a composite autologous skin substitute.

Patients with large burns are surviving in increasing numbers, but there remains no durable and reliable permanent skin replacement. After initial favorable small animal experiments, a pilot trial of a composite skin replacement was performed in patients with massive burns. A composite skin replacement (CSR) was developed by culturing autologous keratinocytes on acellular allogenic dermis. This material was engrafted in patients with massive burns and compared to a matched wound covered with split thickness autograft. With human studies committee approval, 12 wounds in 7 patients were grafted with CSR while a matched control wound was covered with split thickness autograft. These 7 children had an average age of 6.4+/-1.4 yr and burn size of 75.9+/-5.0% of the body surface. Nine wounds were acute burns and three were reconstructive releases. Successful vascularization at 14 days averaged 45.7+/-14.2% (range 0-100%) in the study wounds and 98+/-1% (range 90-100%) in the control sites (P<0.05). Reduced CSR take seemed to correlate with wound colonization. All children survived. While CSR did not engraft with the reliability of standard autograft, this pilot experience is encouraging in that successful wound closure with this material is possible, if not yet dependable. It is hoped that a more mature epidermal layer may facilitate engraftment, and trials to explore this possibility are in progress.

Burns↗
PubMed2001

Management of the high-risk pediatric burn patient.

BACKGROUND/PURPOSE: Inhalation injury, flame burn exceeding 30%, and age under 48 months all have been cited as independent risk factors for mortality; the combination of all 3 risk factors is unusual. The authors have experienced an overall reduction in mortality rate and chose to examine this high-risk group to define techniques useful in improving outcome in pediatric burns. METHODS: A review was done of children with all 3 risk factors over a recent 9-year interval. All were treated with a system of care emphasizing precise fluid repletion, early wound excision and closure, and avoidance of injurious pulmonary inflating pressures and concentrations of oxygen. Data are expressed as mean +/- SD. RESULTS: There were 26 children admitted with all 3 risk factors. Their average age was 2.1 +/- 1.1 years (range, 5 weeks to 3.7 years), and burn size was 61% +/- 21% (range, 30% to 98%) of the body surface. All required mechanical ventilation for an average of 28 +/- 4.5 days (range, 7 to 74 days). Two children underwent tracheostomy; all others were treated with protracted oral intubation. Inhaled nitric oxide (NO) was used in 3 children, all of whom were considered for extracorporeal membrane oxygenator (ECMO) support, although none went on to ECMO. Only 7 children (27%) never had any bacteremia. Ventilator-related pneumonia occurred in 8 children (31%). Total lengths of stay, including acute and rehabilitation hospitalizations, averaged 105 +/- 10 days (1.87 +/- 0.2; range, 0.66 to 4.8 days per percent burn). After exclusion of 1 child with a 98% third-and fourth-degree burn, pre-hospital cardiac arrest, and anoxic brain injury who had support withdrawn at 6 hours, all children survived to discharge; 23 followed up in our clinic currently are alive and well with no overt residual respiratory insufficiency. CONCLUSION: A high rate of survival can be expected in young children with large burns and inhalation injury.

Burns↗
PubMed2001

Antibiotic prophylaxis for group A streptococcal burn wound infection is not necessary.

BACKGROUND: Historically, group A beta-hemolytic streptococci (GAS) burn wound infection has been a major source of morbidity and mortality in burn patients and has prompted the prophylactic administration of antibiotics to children with burns. Wound monitoring, surveillance cultures, and early excision of deep wounds may have changed this. Our objective in this project was to determine the efficacy of routine antibiotic prophylaxis in the era of early excision and closure of deep burn wounds. METHODS: Two cohorts of burned children were compared: all children admitted during calendar years 1992 through 1994 (group 1) and during calendar years 1995 through 1997 (group 2). All group 1 children received routine GAS antibiotic prophylaxis. Only those group 2 children with documented positive admission or surveillance cultures for GAS were treated. RESULTS: There were 511 children in group 1 and 406 children in group 2. They were well matched for age (4.7 +/- 0.21 years vs. 5.3 +/- 0.26 years, p = 0.06) and burn size (11.0% +/- 0.7% vs. 12.4% +/- 0.8%, p = 0.18). GAS species were recovered at admission or during hospitalization from 11 (2.6%) of group 1 children and 18 (4.4%) of group 2 children (p = 0.05), indicating a marginally higher rate of carriage in group 2. Nevertheless, in group 1 there were three (0.6%) who developed GAS wound infection and in group 2 there were four (0.98%, p = 0.71). The incidence of GAS infection in those patients with positive admission cultures was three (27%) of group 1 and four (22%) of group 2. No child developed fulminant GAS infection. CONCLUSION: Routine antibiotic prophylaxis of burn wounds in children in not effective in further reducing a low baseline incidence of GAS wound infection if admission screening by culture is used to identify those children who carry the organism and early excision of deep burns is practiced.

Administration, Oral↗
PubMed2000

Long-term outcome of children surviving massive burns.

CONTEXT: Major advances in treatment of burn injuries in the last 20 years have made it possible to save the lives of children with massive burns, but whether their survival comes at the cost of impaired quality of life is unknown. OBJECTIVE: To investigate the long-term quality of life in children who have survived massive burns. DESIGN AND SETTING: Retrospective, cross-sectional study conducted in a regional pediatric burn center. PATIENTS: Eighty subjects who were younger than 18 years at the time of injury, who survived massive burns involving > or =70% of the body surface, and who were admitted to the burn center between 1969 and 1992 were evaluated an average (SD) of 14.7 (6.0) years after injury. MAIN OUTCOME MEASURES: Short Form 36 (SF-36) scores of the 60 patients aged at least 14 years were compared with national norms and the impact of clinical variables on individual domain scores was assessed. RESULTS: The SF-36 domain scores of the study patients, who had survived massive burns at a mean (SD) age of 8.8 (5.5) years, were generally similar to the normal population). However, 15% and 20% of the burn patients had scores in the physical functioning and physical role domains, respectively, that were more than 2 SDs below the relevant norm, indicating that a few patients had continuing serious physical disability. Better functional status of the family predicted a higher score in physical role (P = .04). The child's early reintegration with preburn activities predicted higher scores in general health (P = .03), physical functioning (P = .003), and physical role (P = .01). Children followed up consistently in the multidisciplinary burn clinic for 2 years had higher physical functioning (P = .04). CONCLUSIONS: In this study, while some children surviving severe burns had lingering physical disability, most had a satisfying quality of life. Comprehensive burn care that included experienced multidisciplinary aftercare played an important role in recovery.

Adult↗
PubMed2000

Current expectations for survival in pediatric burns.

BACKGROUND: Conventional wisdom and published reports suggest that children, particularly those younger than 48 months, have higher mortality rates after burns than young adults. However, coincident with refinements in resuscitation, operative techniques, and critical care, survival rates for children with burns seem to have improved. To document this change and to define current expectations, a review of deaths during two 7-year intervals separated by a decade was done. DESIGN: We examined the clinical course of children who died after admission for care of acute thermal burns during two 7-year intervals: calendar years 1974 to 1980 inclusive (group 1) and 1991 to 1997 inclusive (group 2). Dying children were stratified by total body surface area (TBSA) burned: small (0%-39%), midsize (40%-59%), and large (60%-100%) TBSA burns. Children who arrived with anoxic brain injury or in a moribund state with refractory shock were excluded from analysis (4 children in group 1 and 5 in group 2); 2 of these children in group 2 died and became solid organ donors. SETTING: Regional pediatric burn center. PATIENTS: Six hundred seventy-eight children in group 1 and 1150 children in group 2. MAIN OUTCOME MEASURE: Survival. RESULTS: In children with 0% to 39% TBSA burns, mortality was 0.6% in group 1 and 0% in group 2 (Fisher exact test, P = .04; chi2 test, P = .02). In children with 40% to 59% TBSA burns, mortality was 7.7% in group 1 and 0% in group 2 (Fisher exact test, P = .07; chi2 test, P = .047). In children with 60% to 100% TBSA bums, mortality was 33.3% ingroup 1 and 14.3% in group 2 (Fisher exact test, P = .04; chi2 test, P = .02). Although 59% of the children in group 2 were younger than 48 months, including 55% of those with 40% to 59% TBSA burns and 41% of those with 60% to 100% TBSA burns, there were no deaths in this age group. CONCLUSION: Survival rates after burns have improved significantly for children. At present, most children, even young children and children with large burns, should survive.

Adult↗
PubMed2000

Cutaneous herpetic infections complicating burns.

Many people harbor herpes simplex virus, often with a known history of "cold sores". During the relatively immunosuppressed state associated with a serious burn, recrudescence of such infections can occur. We report four adults and two children who developed severe herpetic ulceration, over the face and neck in five patients and in a partial thickness wound in one patient. Herpetic infection was diagnosed by culture and direct immunofluorescence testing and treatment was immediately instituted with systemic and topical Acylovir(R) (Zovirax, Glaxo Wellcome). Ulceration healed under treatment and did not leave visible scarring in any of the patients. Although these infections are rapidly progressive, they respond to prompt treatment with antiviral chemotherapy. Rapidly progressive vesicles and ulceration appearing on the face or in the wounds of burn patients should prompt immediate evaluation for herpetic infection.

Acyclovir↗
PubMed2000

Evaluating and managing burn wounds.

Central to successful management of those who have suffered a burn of any size or depth is proper and effective evaluation and management of the wound. If a careful initial evaluation is made, basic principles of management are applied, and the response to therapy is regularly monitored, reliably excellent results can be expected for the large majority of patients.

Burns↗
PubMed1999

A 15-year experience with varicella infections in a pediatric burn unit.

Because of their well described global immunosuppression, varicella infection may be hazardous in burned children. It is therefore important to prevent cross-infections within pediatric burn units. We describe a 15-year experience with varicella in a pediatric burn unit, focusing on the morbidity associated with the infection and measures that have been effective in the prevention of cross-infection. We found that varicella infection in acutely burned children is associated with pneumonitis, but little wound related morbidity. Despite the deceptively long incubation period, prompt identification and isolation of index cases was associated with an extremely low incidence of cross-infection. Until widespread administration of varicella vaccine confers herd immunity, varicella remains a threat to hospitalized young children, highlighting the importance of a well planned and executed index case isolation strategy.

Boston↗
PubMed1999

Staged high-dose epinephrine clysis is safe and effective in extensive tangential burn excisions in children.

Prodigious blood loss commonly accompanies extensive tangential burn excisions. Staged high-dose epinephrine clysis may facilitate blood conserving excisional burn surgery. Prospective data was collected in 25 consecutive children who underwent tangential excision over the torso of at least 10% of the body surface with staged high dose epinephrine clysis. The children had an average age of 6.3 +/- 1.1 years and burn size of 45.7 +/- 3.9%. Total operative wound size (excision plus donor site) averaged 2 +/- 0.8% of the body surface. Total dose of epinephrine averaged 24.6 +/- 2.8 mcg/kg. Based on pre- and postoperative hematocrit and known volume of transfusion, the percent of the total blood volume lost per percent total wound generated averaged 0.98 +/- 0.19% of the blood volume per % of the body surface; 18 of the children (72%) required no blood in the perioperative period. There were no complications related to epinephrine use, graft take averaged 98 +/- 0.6% and all children survived and have been discharged home in good condition. Due to its rapid metabolism, subcutaneous epinephrine at high doses can be repetitively administered as long as time is allowed for its metabolism to occur. Use of this technique facilitates a marked reduction in blood requirements for these traditionally bloody operations.

Adolescent↗