World journal of surgery
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Topical chemotherapy, prompt excision, and timely closure of the burn wound have significantly reduced the occurrence of invasive burn wound infection and its related mortality. Since wound protection is imperfect and invasive wound infection may still occur in patients with massive burns in whom wound closure is delayed, scheduled wound surveillance and biopsy monitoring are necessary to assess the microbial status of the burn wound and identify wound infections caused by resistant bacteria or non-bacterial opportunists at a stage when therapeutic intervention can control the process. ⋯ The organisms causing bacteremia that exert a species specific effect on the mortality related to extent of burn injury and patient age have changed in concert with changes in wound flora. Infection control procedures, including scheduled surveillance cultures, utilization of cohort patient care methodology, strict enforcement of patient and staff hygiene, and patient monitoring have been effective in eliminating endemic resistant microbial strains, preventing the establishment of newly introduced resistant organisms, diagnosing infection in a timely fashion, instituting antibiotic and other necessary therapy in a prompt manner, and documenting the effectiveness of present day burn patient care and the improved survival of burn patients.
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The goal of fluid resuscitation in the burn patient is maintenance of vital organ function at the least immediate or delayed physiological cost. To optimize fluid resuscitation in severely burned patients, the amount of fluid should be just enough to maintain vital organ function without producing iatrogenic pathological changes. The composition of the resuscitation fluid in the first 24 hours postburn probably makes very little difference; however, it should be individualized to the particular patient. ⋯ The failure rate for adequate initial volume restoration is less than 5% even for patients with burns of more than 85% of the total body surface area. These improved statistics, however, are derived from experience in burn centers, where there is substantial knowledge of the pathophysiology of burn injury. Inadequate volume replacement in major burns is, unfortunately, common when clinicians lack sufficient knowledge in this area.
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World journal of surgery · Jan 1992
ReviewPrevention and treatment of postburn scars and contracture.
The management of postburn reconstruction is complicated by the frequent occurrence of multiple reconstructive needs in a single patient. This article presents a simple, comprehensive approach to burn scar reconstruction. The primary aim of the surgeon is to prevent burn scar deformity by rapid wound closure, correction of tissue deficiencies, and assiduous attention to postoperative splinting and compression therapy. ⋯ These areas need to be reconstructed as aesthetic units and each requires individualized management of donor tissue. The reconstruction of the burn patient is often a long process requiring multiple procedures. The approach presented here advocates a stepwise, prioritized approach aiming at both maximum function as well as optimal appearance.
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Smoke inhalation, defined as airway or pulmonary parenchymal injury resulting from the inhalation of toxic combustion products, presents with a wide range of severity in patients with and without skin burns. In patients with severe injuries, the diagnosis is obvious on the basis of the history and clinical presentation; in patients with less severe injuries or those in whom the clinical consequences are delayed, diagnostic precision is difficult because diagnostic clues provide only indirect information. There is no specific treatment so diagnosis is not critical for patient management. ⋯ A translaryngeal tube can be converted to a tracheotomy safely in burn victims; tracheotomies are easier to manage if burns of the neck are excised and grafted prior to placement. Mechanical ventilation with positive end expiratory pressure (PEEP) is the treatment for the pulmonary injury. The early lesions of smoke inhalation often progress in the context of sepsis and other complications of the burn illness to a clinical state consistent with adult respiratory distress syndrome.
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Hepatic encephalopathy is a major complication of portal-systemic shunts with an incidence ranging up to 52%. A small fraction of these patients are refractory to medical therapy. Shunt ligation and colonic procedures are the main surgical approaches. ⋯ The fourth still needs medication to control a persistent, although improved, encephalopathy that required 2 further hospitalizations. Colon exclusion is a useful intervention in very selected cases. It has a lower operative mortality than total colectomy and the advantage over shunt ligation of not reestablishing hypertension in the portal system.