World j. Sarg. 16, 1, 1992
World Journal of Surgery © 1992 by the Soci~.t~
lntenmtionaJe de C b ~ e
World Progress in Surgery Progress in Burn Care Introduction Improved organization of burn care with the concentration of seriously burned patients at burn centers where the necessary multidisciplinary care can be provided, newly developed technology can be expeditiously applied, and properly stratified and cOntroLled studies can be carried out, has resulted in further extension of the improved survival of burn patients reported in the World Progress in Surgery Burn Symposium in 1978. Burn injury not only damages the skin but, when of sufficient size, adversely affects the function of all the systems in the body with the magnitude and duration of initial dysfunction proportional to the extent of the burn. In the immediate Postburn period fluid is lost from the circulation as a result of changes in permeability, transcapillary and tissue pressures, and osmotically active particles in the area of the burn. A greater understanding of these initial changes has permitted the development of fluid resuscitation regimens that meet the specific needs and take into account the physiologic status of individual patients. Similarly, laboratory and clinical studies have led to improved accuracy of diagnosis and more effective management of inhalation injury thereby ameliorating the cornh°rbid effect of inhalation injury. In addition, studies detailing nutritional and metabolic effects of injury and infection alone and of those two disease processes in combination have led to the development of nutrient formulations designed to correct disease specific deficits and regimens of metabolic SUpport customized to meet the needs of individual patients. Changes in burn wound care that have reduced the occurrence of invasive bacterial burn wound infection have been accompanied by the emergence of non-bacterial infections in those patients with extensive burn wounds that remain unclosed for long periods of time. The early diagnosis of these n°n'bacterial burn wound infections by histologic examination of biopsy tissue has permitted earlier therapeutic intervention and reduced the overall clinical impact of burn wound infections. These and other epidemiologic changes in burn patient infections have made pneumonia the most common life threatening infection of severely burned patients just as it is in other critically ill hospitalized patients. This persistence of infection as a cause of morbidity and mortality in burn patients appears to be a manifestation of the pervasive changes in both the humoral and cellular limbs of the ~mnaune system induced by burn injury. In the past decade the multiplier effects of cytokines and other inflammatory media.tors liberated by a variety of cells in response to both the initial Injury anti secondary stimuli such as infection have been defined. Monoclonal antibodies against specific cytokines or
cell receptors as well as inhibitors of other mediators, such as the metabolites of arachidonic acid, are being evaluated for effectiveness in preventing, moderating, or reversing the systemic effects of infection and the sepsis syndrome. The redundant nature of the cytokine systems and the overlapping actions of the cytokines make the success of monotherapy unlikely and spea k strongly for the development of rnultimodal therapy to inhibit uncontrolled mediator release or counteract the effects of the systemic "inflammation" characteristic of sepsis. Analysis of the spectral characteristics of light reflected from the surface of th~ wound has been used to differentiate partialthickness from full-thickness burns. Early reliable differentiation of burn depth permits early burn wound excision that reduces physiologic stress and the risk of burn wound infection and enhances functional and cosmetic outcome. New developments in the field of biomaterials have been utilized to extend the clinical usefulness of biologic dressings and design both synthetic and collagen based effective skin substitutes. Those membranes give promise of extending the benefits of early wound closure to patients with massive burns and a paucity of donor sites. Similarly, new and evermore sophisticated plastic surgical techniques permit the expansion of local tissue and the transfer of remote tissues that are so important in overcoming postburn tissue deficits and improving functional and cosmetic results in burn patients. Burn care in developed countries is characteristically organized in a hierarchical regionalized system and as such the benefits of the interaction of clinical experience and research capabilities is fully realized. It is no accident that each contribution to this symposium has originated in a burn center where the authors were able to identify a problem of clinical importance, take the problem to the laboratory, and return to the clinic with a solution that could be evaluated in an appropriately stratified and controlled study population. An effective cliniclaboratory iteration has made these recorded advances possible but each advance has revealed other previously unrecognized and often unanticipated problems that form the basis of present day research. One can predict that the answers to the questions being posed in current studies will comprise the third World Journal of Surgery Progress in Burn Care Symposium in the early 21 st century in which additional improvement in the care of burn patients and further reduction in their mortality will be documented. Basil A. Pruitt, Jr., M.D., F.A.C.S. Guest Editor
World Journal of Surgery © 1992 by the Soci~.t~
lntenmtionaJe de C b ~ e
World Progress in Surgery Progress in Burn Care Introduction Improved organization of burn care with the concentration of seriously burned patients at burn centers where the necessary multidisciplinary care can be provided, newly developed technology can be expeditiously applied, and properly stratified and cOntroLled studies can be carried out, has resulted in further extension of the improved survival of burn patients reported in the World Progress in Surgery Burn Symposium in 1978. Burn injury not only damages the skin but, when of sufficient size, adversely affects the function of all the systems in the body with the magnitude and duration of initial dysfunction proportional to the extent of the burn. In the immediate Postburn period fluid is lost from the circulation as a result of changes in permeability, transcapillary and tissue pressures, and osmotically active particles in the area of the burn. A greater understanding of these initial changes has permitted the development of fluid resuscitation regimens that meet the specific needs and take into account the physiologic status of individual patients. Similarly, laboratory and clinical studies have led to improved accuracy of diagnosis and more effective management of inhalation injury thereby ameliorating the cornh°rbid effect of inhalation injury. In addition, studies detailing nutritional and metabolic effects of injury and infection alone and of those two disease processes in combination have led to the development of nutrient formulations designed to correct disease specific deficits and regimens of metabolic SUpport customized to meet the needs of individual patients. Changes in burn wound care that have reduced the occurrence of invasive bacterial burn wound infection have been accompanied by the emergence of non-bacterial infections in those patients with extensive burn wounds that remain unclosed for long periods of time. The early diagnosis of these n°n'bacterial burn wound infections by histologic examination of biopsy tissue has permitted earlier therapeutic intervention and reduced the overall clinical impact of burn wound infections. These and other epidemiologic changes in burn patient infections have made pneumonia the most common life threatening infection of severely burned patients just as it is in other critically ill hospitalized patients. This persistence of infection as a cause of morbidity and mortality in burn patients appears to be a manifestation of the pervasive changes in both the humoral and cellular limbs of the ~mnaune system induced by burn injury. In the past decade the multiplier effects of cytokines and other inflammatory media.tors liberated by a variety of cells in response to both the initial Injury anti secondary stimuli such as infection have been defined. Monoclonal antibodies against specific cytokines or
cell receptors as well as inhibitors of other mediators, such as the metabolites of arachidonic acid, are being evaluated for effectiveness in preventing, moderating, or reversing the systemic effects of infection and the sepsis syndrome. The redundant nature of the cytokine systems and the overlapping actions of the cytokines make the success of monotherapy unlikely and spea k strongly for the development of rnultimodal therapy to inhibit uncontrolled mediator release or counteract the effects of the systemic "inflammation" characteristic of sepsis. Analysis of the spectral characteristics of light reflected from the surface of th~ wound has been used to differentiate partialthickness from full-thickness burns. Early reliable differentiation of burn depth permits early burn wound excision that reduces physiologic stress and the risk of burn wound infection and enhances functional and cosmetic outcome. New developments in the field of biomaterials have been utilized to extend the clinical usefulness of biologic dressings and design both synthetic and collagen based effective skin substitutes. Those membranes give promise of extending the benefits of early wound closure to patients with massive burns and a paucity of donor sites. Similarly, new and evermore sophisticated plastic surgical techniques permit the expansion of local tissue and the transfer of remote tissues that are so important in overcoming postburn tissue deficits and improving functional and cosmetic results in burn patients. Burn care in developed countries is characteristically organized in a hierarchical regionalized system and as such the benefits of the interaction of clinical experience and research capabilities is fully realized. It is no accident that each contribution to this symposium has originated in a burn center where the authors were able to identify a problem of clinical importance, take the problem to the laboratory, and return to the clinic with a solution that could be evaluated in an appropriately stratified and controlled study population. An effective cliniclaboratory iteration has made these recorded advances possible but each advance has revealed other previously unrecognized and often unanticipated problems that form the basis of present day research. One can predict that the answers to the questions being posed in current studies will comprise the third World Journal of Surgery Progress in Burn Care Symposium in the early 21 st century in which additional improvement in the care of burn patients and further reduction in their mortality will be documented. Basil A. Pruitt, Jr., M.D., F.A.C.S. Guest Editor
