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CNAA / Theses / 2007 / May /

Active precocious surgical treatment in prophilaxis and therapy of visceral affections in patients with serious thermal lesions


Author: Anatolie Taran
Degree:doctor habilitat of medicine
Speciality: 14.00.27 - Surgery
Year:2007
Scientific adviser: Mihai Corlăteanu
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Scientific consultant: Andrei Alexeev
doctor habilitat, professor
Institution:
Scientific council:

Status

The thesis was presented on the 16 May, 2007
Approved by NCAA on the 14 June, 2007

Abstract

Adobe PDF document1.65 Mb / in romanian

Thesis

CZU 616-001. 5-07-08-617-001.17

Adobe PDF document 4.70 Mb / in romanian
238 pages


Keywords

Thermal injuries, toxic-septic shock, chemical necrotomy, multi-organ failure, tegumentary autoplasty, split graft, grid beds, abacterial environment, organic pathology score, algorithm of assessment, deep and extensive burns, mummification of scars

Summary

Our study focused on multidimensional (clinical, developmental, pathomorphological and bacteriological) examination data, as well as on the results of complex and early treatment of deep and extensive burns in 477 patients hospitalized at the National Centre of Thermal Injuries (NCTI) in the period 1992-2003.

The pathologo-anatomic investigations carried out on a total number of 186 cadavers examined during the last decade and the retrospective study of necropsy protocols related to different affections of visceral organs systems that evolved asymptomatically. Among these were affections of 2 organs in 37,2 % patients, 3 organs – 21,7%, 4 organs - 17% and 5 – in 7,2% patients. In 56(30,1%) cases neurological system was affected, 67(36%) - urosector, 64(34,4%) - gastrointestinal, 97(52%) - hepatobiliar, 74(39,7%) - cardiovascular, with a prevalence in the pulmonary system of 108(58%), including 37- 75% of patients with extensive burns which evolved asimtomatically.

The organo-visceral injuries of those traumatized thermally are of remarkable incidence and carry vital danger. Therefore, both the diagnosis and definition of developmental characteristics anticipating the development of visceral injuries due to major burns represent an inherent condition for sequencing of offensive curative actions, while the algorithm for the multi-organic failure is a way to recognise and thus to anticipate the degradation of patients with severe burns to multi-organic failure by means of adequate therapeutic actions. The algorithm for the multi-organic failure system of estimation proved to be reliable for the assessment of acute thermal traumatism severity, in prediction of development of visceral organs injuries and mortality rate from the perspective of surgical solution. The most severe organic touches are the pulmonary ones, that were the most frequently diagnosed in the structure of multi-organ failure syndrome met in examined patients, that was transferred by hypostatic and septic pneumonia, interstitial pulmonary and alveolar oedema diagnosed in 143(30%) out of a total number of 477 investigated patients. The algorithm for the multi-organic failure developed by us to monitor patients with severe thermal injuries proved to be useful and adaptable both for the evaluation of post-burn organic injuries’ impact and to detect specific disorders and to anticipate their effects on curative outcomes and mortality rate.

The treatment of severe burns with sol. Betadini of 10% (EGIS) favours early formation of crusts within 3-5 days and reduces the percentage of pathogen germs. These were the effects registered under this study in 60% of patients, as compared with 39% of patients from the First Lot, where iodine drugs were not used. Further treatments with sol. Betadini of 10% (EGIS) reduced even more the intensity of microbial pollution of burn wounds. In the lot of patients assisted traditionally, the first phase of chemical necrectomy applied in the first 9-12 post-burn days was successful in 35,7 % patients only, as compared with the lot where sol. Betadini of 10% (EGIS) were applied and where this curative gesture was facilitated in 63,7% of cases and where full epithelization of split grafts was possible in 89,5%. Thus, the new procedure of extensive and deep wounds treatment aimed at rapid mummification of burned crust to precocious avoidance, by means of surgical or chemical treatment of mortified structures, and subsequent extemporaneous autodermoplasty of residual defect represents a curative way that results in rapid epithelization and plenary recovery of the affected persons.

In the second lot basseted with antiseptic solutions of Betadini of 10% (EGIS) and where the precocious necrectomy of burn crusts followed by autodermoplasty the absolute epithelization of free split grafts in 92,5% of patients as compared with the second lot a with 87,7% cases of complete epithelization. The treatment of patients with major burns in grid beds favours the curative access to all damaged areas and creates optimal conditions for asepsis and early formation of crusts and coverage of defects with tegumentary grafts. The autodermoplasty with mesh grafts contributes to the diminishing of terms for their engraftment allowing thus to switch earlier to the actions of functional recuperation, to decrease the incidence of stiffness and to ameliorate the curative results, manages full coverage of tegumentary defects on average in post-burn day 31,8 onwards, while the period of hospitalisation constituted on average 41,4 days/bed. The relationship between the method of care and the incidence of organic failure was remarked. Out of 147 victims assisted by traditional methods, 92(62,5%) developed visceral affections and only 19 (47,5%) of those who benefited from treatment in grid beds, i.e. by integral exposure of burn area to infrared radiation and free access to applications, including to the usual programme, are perfect conditions of qualitative remedy. In case of deep and extensive burns, it is inherent to use some up-to-date means of metabolic re-equilibration of the body fighting with bacterial proliferation in the burn wound and immunocorrection to insure prevention of any complications, while the systemic antibiotic therapy like cephalosporins of 2nd and 3rd generation is operative for the treatment of patients with extensive burns, that can be thus protected from infectious visceral complications and treatment of multi-organ failure. Usually, the severe gastrointestinal haemorrhages in burn patients are produced in the context of deep thermal injuries with an average total burn area of over 30% and can be avoided by early administration of the necessary volume of perfusions, stomach decompressions, and administration of antacid medicines and dosed precocious enteral food.