Traitement des séquelles de brûlures : brûlures de la face

As a result of the development of tissue expansion techniques, the surgical treatment of facial burn sequelae has been substantially improved over these past 20 years: expanded skin is used for the reconstruction of aesthetic zones of the face, as full-thickness skin grafts and expanded local flaps. In order to complete cosmetic results, tissue expansion should be associated with aesthetic surgical techniques such as rhinoplasty, lifting, autologous fat injection or tattooing. Satisfactory social life is recovered only after multiple surgical interventions and long-term rehabilitation and physiotherapy.     

Analgésie contrôlée par le patient brûlé: effet d'épargne de fentanyl par la clonidine

ObjectifTo determine the sparing effect of clonidine (C) on fentanyl (F) demand in burned patients under PCA.Study designProspective, randomized, double blind study versus placebo.PatientsTwelve consecutive patients with mean burn surface area of 20 ± 9%, studied between the third and the eighth day post-burn.MethodsF was delivered by a PCA pump (bolus: 1 mg·kg⁻¹). In the morning, burn patients received additional F (5 mg·kg⁻¹) before hydrotherapy. After randomisation, C or placebo (P) were alternatively infused over 24 hours. Demands for F during the morning, the afternoon and the evening were noted. Pain scores were measured on a visual analogic scale. In eight patients, plasma levels of F (pF) were iteratively measured. Heart rate, arterial pressure, respiratory rate and SpO₂ were monitored.ResultsAnalgesic demands were 19.5/day under P and 9.5 under C (P < 0.0001). Pain reoccurred for pF of 4.1 under C vs 5.7 under P (P < 0.05) with same pain scores in the two groups. After a pain stimulus, pain scores were lower under F, despite lower pF (P < 0.05). Arterial pressure and heart rate were significantly lowered during the first hour of C infusion.ConclusionDoses of F and pF required to reach analgesia were very high. Adding C decreases by 50% the F demand and lowers pF. Minor haemodynamic effects were observed during the first hour of C infusion.     

Fongémie à Saccharomyces boulardii chez un brûlé grave

A case of Saccharomyces boulardii fungaemia in a burn patient is reported. S. boulardii was administered in order to improve the digestive tolerance to enteral nutrition. After a surgical procedure, a sepsis syndrome occurred, with a white blood cell count increase, abdominal meteorism and respiratory insufficiency, associated with seven blood cultures positive to S. boulardii. Digestive translocation of the yeast seems to be the most likely origin of this fungaemia. Some fungaemias from S. boulardii have been published. However it is not usual to find such severe clinical features as in our case which leads us to reconsider the therapeutic use of S. boulardii in situations including a gastrointestinal tract suffering.     

Prise en charge des brûlés graves pendant les 72 premières heures

Early and efficient management of severely burned patients facilitates outcome improvement. Pre-hospital care includes fluid loading with 2 mL-kg¹/% burn over the first six hours, sedation and analgesia, prevention of hypothermia and ventilatory support for either critically burned patients or facial, cervical or pulmonary burn injury. The transient stay in a general hospital before transfer to a burn centre allows extension of inital care, the critical investigation for associated injuries (intoxication, multiple trauma) and to perform initial local treatment with sterile coverage or vaseline gauze after a revises assessment of the burned skin area, and possibly escharotomies. The main aim of care in the burn centre is to control hypovolaemia and to obtain maximal tissue perfusion and oxygen delivery to burned tissues, as well as to healthy organs. To manage the burn shock (initially hypovolemic and later on hyperdynamic) catecholamines are often indicated when appropriate fluid loading remains insufficient. Mechanical ventilation is indicated in case of either a deep extensive burn over 60% of total body surface area, or facial and cervical burns or severe pulmonary burn injury from smoke inhalation, carbon monoxide intoxication, tracheobronchial thermal injury and blast injury.Because of the severity of burn-related pain, and the stimulous linked to intensive care, continuous sedation is usually required.Early surgical treatment such as escharotomies, excision and grafting, which cause significant pain as well as blood loss, and hydrotherapy, often require general anaesthesia. Burn injury can modify the volume of distribution and the pharmacokinetics of anaesthetic agents. Finally, chemical or electrical burn, radiation, associated CO intoxication or multiple trauma, as well as burn injury in infants, raise specific problems. With improvement in early intensive care, the survival rate of the most severely burned patients is obviously improving. New techniques in skin substitution will probably further improve the final outcome.     

Traitement des séquelles de brûlures : généralités

Management of burn sequelae must comply with two fundamental therapeutic principles: the first is functional, the other cosmetic. Surgical reconstruction of such lesions may be considered after scar maturation is achieved. During the maturation process, the use of specific drugs may be helpful in treating some of the symptoms associated with burn sequelae. Crenotherapy may improve the softness of the scars and facilitate subsequent surgery. Early surgery may be considered in a child when growth is likely to be compromised or in case of functional impairment due to burn sequelae. Local flaps and full-thickness grafts are the most commonly used means for the surgical correction of burn sequelae, whatever the time necessary for their management.     

Chirurgie des séquelles de brûlures du cuir chevelu

The sequelae of scalp burns may result in alopecia, more or less extended on a spontaneously unexpandable tissue. Treatment of such sequelae requires the alopecia plaques being replaced with local and regional hair flaps. Tissue expansion allows treating extended alopecia through large flaps which cannot be obtained by standard procedures. The techniques used are described; they often combine flaps of different types. Results are provided through clinical cases. Scalp expansion should strictly comply with rules and guidelines; it may induce complications. This technique may be reiterated.     

Infections nosocomiales dans un service de brûlés. Résultats d'une enquête prospective d'un an

ObjectivesTo assess nosocomial infections in a burn care centre, to identify patients' infection risk factors at the time of admission and factors of monthly variations of infection incidence.Study designProspective survey, from October 1992 to September 1993.Patients and methodThe study included 140 patients staying for more than two days in a 22-bed burn unit. Nosocomial infection criteria were derived from the 1988 CDC critera. Incidence rates of infection were calculated. Infected and noninfected patients were compared. Each monthly infection incidence was compared with six unit activity indicators.ResultsFifty-six patients developed 132 infections. The overall incidence was 94%. Incidence density was 25 infections per 1,000 days of care. The distribution of infected sites was: skin (30%), intravascular catheters (25%), blood (22%), urinary tract (18%), respiratory tract (5%). The most frequent pathogens were Pseudomonas sp (49%), Staphylococcus sp (18%), Escherichia coli (18%), and Streptococcus faecalis (10%). They were characterized by a good antibiotic sensitivity. Each common burn severity index was predictive of nosocomial infections. Facial, perineal and respiratory lesions were also linked to infection. There was a positive correlation between the peak of nosocomial infections in the unit during a month and the peak of activity during the foregoing one.ConclusionIncidence rates of infection were high, as 40% of the population was concerned. Choosing reliable infection criteria was the most difficult problem to solve.     

Protéines nutritionnelles et catabolisme musculaire chez le brûlé grave. Effets comparatifs de petits peptides ou d'acides aminés libres

The beneficial effects of hight caloric and protein enteral diet on wound healing and prevention of infection in severly burned patients is well documented. However, the relative proportion of each nutrient and especially the form of nitrogen supply have not yet been clearly established. The aim of this study was to compare, in severely burned patients, the efficiency of a partial protein hydrolysate and free amino acid formula during a 15-day enteral feeding. Twenty burned patients ranging in age from 18 to 67 years with a mean burn size of 40 ± 12 % of total body surface area, of which 31 ± 14 % was deep dermal, were studied prospectivly and randomised in two groups. Group A received the free amino acid diet which was obtained by hydrolysis of the protein hydrolysate given to Group B (60 % small peptides). All diets contained a nitrogen source of similar amino acid composition. Nitrogen balance was measured daily and serum protein concentrations were determined on days 0, 4, 8, 11 and 15. Anthropometric parameters, urinary 3 methylhistidine/creatinine ratio and plasma amino acid concentration were assessed on days 0, 8 and 15. Daily and cumulative nitrogen balance at D15 did not differ between the two groups. In group A, the circulating visceral proteins increased at all times of the study without decrease of acute phase reactant, whereas only transthyretin and retinol binding protein increased at D11 and D15 with a significant decrease of C-reactive protein at the same time in the other group. In group A, the musculary circumference had decreased at D8 and D15 without change of the 3 methylhistidine/creatinine ratio, whereas in group B the anthropometric parameters did not change with a decrease of the 3 methylhistidine/creatinine ratio at D8. Comparisons of D8 or D15 with D0 values showed that 14 amino acids, from which 6 essential amino acids increased significantly with the free amino acid diet, but only one amino acid increased with the protein hydrolysate diet. We conclude that in severely burned patients, enteral feeding with small peptides decreases muscular breakdown without change in hepatic protein synthesis. The enteral support containing free amino acids is more effective on serum protein levels, probably by increasing the production of endogenous amino acids.