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Innovation and clinical specialities: burns
reduce swelling and prevent stiffening.
There exist many other less expensive options worthy of
mention. Honey has well established antimicrobial properties, and
has demonstrated effectiveness in limited studies. 34 Tannins, as
found in tea leaves, have also been shown to have antibacterial
properties and may reduce the incidence of hypertrophic
scarring. 64,65 Amniotic membrane, used as a biologic wound
coverage has also been shown to be more effective than
nitrofurazone in decreasing the incidence of wound infection 35 , as
well as being cost-effective in reducing the length of stay and
increasing epithelialization 36 . Obvious caution regarding the risk of
disease transmission with the use of human tissue should be used
and comprehensive donor viral screening performed prior to widespread
adoption of this technique. Another innovative way to
minimize cost yet still provide an occlusive dressing to prevent
dehydration has been demonstrated in India with the use of
Banana leaves. 37 Gore et al have shown an acceptable level of
patient acceptance, in comparison to potato peels. Both options
provide wound protection and healing at a fraction of the cost of
conventional dressings.
If despite vigilance, an invasive wound infection becomes
evident on serial observations, one must consider altering the
current treatment protocol. An invasive wound infection can be
determined by clinical expertise or suggestive by wound cultures
showing >10 5 organism per gram or invasion seen on tissue
biopsy. Invasion of microorganism into viable tissues may lead to
progression of the burn or systemic sepsis. It should be noted that
elevated temperatures per se are not necessarily indicative of
sepsis, but are common secondary to the inflammatory
component of the burn wound process. The same organisms
have been identified in serial wound cultures in both low and
middle income countries, with Staph aureaus, Proteus, Klebsiella,
E.coli and Pseudomonas being the most common. The problem
of drug resistance is not confined to high income countries 38 . A
recent Nigerian study, looking at serial wound cultures, concluded
that systemic prophylactic antibiotics did not reduce invasive
infection, but may in fact select more virulent, resistant strains of
bacteria 39 , a notion which has gained wide spread acceptance.
We should therefore guide our antimicrobial use by evidence of
invasive infection, organism culture and sensitivities when these
are known. Prophylactic antibiotics at the time of initial admission
are not routinely advised.
Medical management
Severe burn wounds are known to induce systemic inflammatory
response syndrome (SIRS) through the release of a series of proinflammatory
endotoxins, exotoxins from infectious sources or
from the wound itself. Although the exact mechanism is not well
understood, it is clear that there is a systemic response which can
lead to progressive infection, immuno-suppression, sepsis and
eventually multi-organ failure. Supportive measures are needed
early in the care of the severely burned patient to minimize the
progression and attenuate the hypermetabolic response to burn
injury.
Nutritional support
Early nutritional support is essential in burn patients, even more so
in low-middle income countries where many patients present
malnourished. Burn patients demonstrate levels of metabolism
that can be as high as 200% normal and that are proportional to
the severity of the burn. The metabolic rate does not return to
normal until wound closure. Supporting this high metabolic rate
with diets rich in carbohydrate and protein without overfeeding
patients can decrease muscle wasting, and poor wound healing
consequences of chronic malnutrition. Early feeding also avoids
mucosal atrophy and bacterial translocation. 40 This is particularly
important for intubated patients, for whom feeding is often not
initiated at presentation, increasing the risk of bacterial sepsis.
Strategies to achieve this goal include tube feeding, which should
begin within 6 hours, weekly monitoring patients’ weights, and the
creation of high protein high-caloric feeds from locally available
produce. The frequency of the feeds should be adjusted to the
severity of the burn (%TBSA) and the patient’s pre-existing
nutritional status. 11
Anemia
Unfortunately the prevalence of underlying disease in burn patients
is common in low to middle income countries and may influence
treatment options. A Liberian study found that 61% of their
patients had underlying medical co-morbidities, including epilepsy,
anemia as a result of malaria, or iron deficiency and malnutrition 41 .
Anemia and malnutrition contribute to infectious complications in
these burn patients; however grafting was possible, albeit
delayed, in this study, with surgery being performed between 5-96
days (average 29.8 days) with reasonable graft take (mean 81%).
There is no question that the benefits of early excision must be
weighted against the risk of blood loss and physiological needs of
these specific patients. However, new understanding of the
potentially infectious complications of blood transfusion is
emerging as a result of large prospective multi-centered ICU
trials 42 . A recent multicentre retrospective cohort study that has
shown an associated 13% rise in infectious complications per unit
of blood transfused and an associated increased mortality rate
even when accounting for burn severity 43 . This study underlined
the importance of further research to establish appropriate
transfusion guidelines. Strategies should be undertaken to
minimize blood loss during surgery. Some techniques for
minimizing blood loss are discussed in the surgical management.
HIV
Another important consideration in many low-income countries is
the burn patient who is HIV positive. Until recently, little was known
regarding clinical outcomes in this specific patient population.
James et al conducted a study in a burn unit in Malawi 44 , showing
a 31% HIV prevalence rate in their adult burn population (34 of 112
patients) and in 3% of the pediatric burn patients (6 of 231 patients
under the age of 15). The researchers found that HIV status was
an independent risk factor for death, mostly from infectious
complications with more marked immunosuppression, as
indicated by a lower mean CD 4 count (383mm 3 vs. 937 mm 3 in
HIV negative patients). They found no differences in bacterial
cultures, need or outcome of skin grafting, transfusion or antibiotic
requirements or length of stay. In a case-controlled study out of
South Africa 45 , no differences in mortality or morbidity was found
when comparing 33 patients with and without HIV, when matched
for age, sex, burn severity and inhalational injury. Two patients with
clinical AIDS died of infectious complications leading the authors
to conclude that HIV positive patients, without the stigmata of
60 Hospital and Healthcare Innovation Book 2009/2010