Sheridan Management of Burns, An Issue of Surgical Clinics, E-Book

1. Auflage 2014
ISBN: 978-0-323-32044-3
Verlag: Elsevier HealthScience EN
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, 348 Seiten

Editor Robert Sheridan and authors review the latest in Management of Burns. Articles will include Reflection: evolution of the field over 50 years, Acute burn procedures and operations, Special injuries and illnesses, Initial evaluation and fluid resuscitation, Critical care of burns, Biology and principles of scar management and burn reconstruction, Management of common post-burn deformities, Burn recovery-physical and emotional rehabilitation, Anesthesia and pain control for burns, Outpatient burn management, Measuring burn outcomes, Burn care in disasters and austere settings, On the horizon--research priorities for the next decade, and more!

Autoren/Hrsg.

Sheridan, Robert

Leseproben

Reflection
Evolution of the Field over Seven Decades
Basil A. Pruitt, Jr., MD*[e-mail],     U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Building 3611, JBSA, Fort Sam Houston, TX 78234-6315, USA *Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900. Marked expansion of physiologic understanding and the improvement of burn patient outcomes have resulted from multidisciplinary clinical/laboratory research programs at burn centers in the United States and elsewhere. Keywords Burns Fluid resuscitation Inhalation injury Burn wound care Metabolic response to injury Organization of burn care and research Key points
• Fluid resuscitation has moved from inadequate to excessive and is now returning to adequate. • Reliable diagnosis and improved ventilatory management have reduced the comorbid effect of inhalation injury. • The microbial ecology of the burn wound is constantly changing, with fungi now prominent and viruses emerging. • Clinically effective biologic dressings require a bilaminate construction. • Burn patients are internally warm, and the hypermetabolic response is wound directed. • Multidisciplinary integrated clinical/laboratory research programs have provided the data that have improved burn care and significantly increased burn patient survival. Both evolutionary and revolutionary changes have advanced the organization and delivery of burn care over the past 7 decades. Those changes have refined resuscitation, improved the diagnosis and treatment of smoke inhalation injury, virtually eliminated invasive bacterial burn wound sepsis, validated burn wound excision, defined full service metabolic support, expanded the goals of rehabilitation, and led to the development of a regionalized hierarchical system of burn treatment facilities. In 1959, I was drafted after the second year of my surgical residency and reported to the US Army Surgical Research Unit (USASRU) to begin my 2 years of obligated military service as a member of the surgical staff of the Army Burn Center. I was impressed by the standard of care the burn patients received, which consisted of formulaic fluid resuscitation, prophylactic antibiotics, daily hydrotherapy and burn wound debridement, use of canine cutaneous xenografts for temporary wound coverage, and infusion of fat emulsions to supplement the diet of the extensively burned. The patients were nursed on rotating beds, and physical therapy consisting of functional splinting and both active and passive exercise was carried out daily. Physician-led aeromedical evacuation teams were also used to transfer patients from other military facilities and civilian hospitals. Fluid resuscitation
The historically high incidence of acute renal failure in patients with extensive burns or high-voltage electric injuries was recognized by the inclusion of a renal section within the USASRU and the presence of a Brigham-Kolff dialysis machine in that section. Even then, a greater understanding of the pathophysiology of burn injury, acquired in the first half of the twentieth century, had decreased the need for hemodialysis in burn patients. The clinical studies of Haldor Sneve1 at the turn of the nineteenth century, the studies of Frank Underhill in patients from the Rialto Theater fire of November 1921 and in the laboratory, the clinical experience of the surgeons at the Boston City Hospital and the Massachusetts General Hospital with the patients from the Coconut Grove nightclub fire in November 1941, and earlier clinical experience at the USASRU, combined with the results of the animal studies of Henry Harkins, Alfred Blalock, and E.I. Evans had rationalized the fluid resuscitation of burn patients.2 The analysis of those study results identified the biphasic omni-system response to burn injury (Table 1) and the sigmoid dose-response relationship of those changes to the extent of the burn injury (Fig. 1). An understanding of those relationships provided the scientific infrastructure for the research programs that have generated the data used to develop present-day burn care. Table 1 Biphasic organ system response to injury Organ System Early Change Later Status Cardiovascular Shock Hyperdynamic Urinary Oliguria Diuresis Gastrointestinal Ileus Hypermotility Musculoskeletal Hypoperfusion Hyperperfusion Pulmonary Hypoventilation Hyperventilation Endocrine Catabolism Anabolism Immunologic Inflammation (SIRS) Suppression (CARS) CNS Agitation Obtundation Abbreviations: CARS, compensatory antiinflammatory response syndrome; CNS, central nervous system; SIRS, systemic inflammatory response syndrome.
Fig. 1 The magnitude of the pathophysiologic response to injury in burn patients is proportional to the extent of the burn as described by this sigmoid dose–response curve. Appreciation of the relationships between the extent of burn and the volume of resuscitation fluid needed led to the development of formulae to predict burn patient resuscitation fluid needs. Arguably the first formula, based only on the extent of the burn, was recommended by the National Research Council at a meeting chaired by I. S. Ravdin in January 1942 for members of the military with burns sustained in combat in WWII.3 Subsequently, formulae based on the extent of the burn and body weight were proposed and used as the Burn Budget Formula of Cope and Moore (1947), the Evans Formula (1952), and the Brooke Formula (1953).2 Use of those formulae essentially eliminated burn shock and acute renal failure; but success led to excess, and the earlier complications of inadequate resuscitation were replaced by an increasing occurrence of acute pulmonary edema and compartment syndromes (Box 1).4 Box 1   Complications of excessive resuscitation 1. Pulmonary compromise a. Airway edema b. Pulmonary edema 2. Compartment syndromes a. Muscle compartments of burned and unburned limbs b. Cerebral edema c. Anterior ischemic optic neuropathy d. Abdominal compartment syndrome As recently as 1994, Sheridan and colleagues5 reported 5 cases of intracompartmental sepsis as a consequence of prolonged unrecognized elevation of compartment pressure. Those investigators recommended frequent examination of burned limbs during resuscitation, prompt decompression as indicated, and evaluation of muscle compartments during the excision or debridement of burn wounds. Reduction of Resuscitation Volume
A program of integrated clinical/laboratory research conducted at the US Army Institute of Surgical Research (USAISR) (the USASRU had been renamed the USAISR), identified the hazards of colloid solutions and excessive crystalloid infusion and the limitations of hypertonic resuscitation.6 Those findings led to the development of a Modified Brooke Formula as detailed in Box 2 to reduce both the protein content and volume of the infused resuscitation fluid. That formula recognizes the findings of studies showing that in the first 3 hours after injury, burn wound edema is most strongly affected by intravascular pressure and later most strongly by capillary permeability.7 The initially increased capillary permeability decreases across time and establishes a new transcapillary equilibrium 24 hours after the burn at which time water and protein content of the burn wound peak.8 The use of the Modified Brooke Formula, with careful attention to preventing fluid overload, reduced the occurrence of acute renal failure to a level whereby only 10 (0.3%) of 3266 burn patients treated at the USAISR between 1994 and 2004 required dialysis for early or late-onset renal failure. Recently, investigators at the USAISR have developed a computerized burn patient resuscitation program in which the necessary adjustment of the fluid infusion rate is related to urinary output measured at 10-minute or lesser intervals.9 In early studies, the use of that program has further refined resuscitation as indexed by...