INTRODUCTION:For extensive burns, autologous donor skin may be insufficient for early debridement and grafting in a single stage. A novel, synthetic polyurethane dermal template (NovoSorb® Biodegradable Temporising Matrix, BTM) was developed to address this need. The aim of this study was to evaluate use of BTM for primary dermal repair after deep burn injury. METHODS:A multicentre, prospective, clinical study was conducted from September 2015 to May 2018. The primary endpoint was % split skin graft take over applied BTM at 7-10 days after grafting. Secondary endpoints included % BTM take, incidence of infection and adverse events, and scar quality to 12 months after BTM application. RESULTS:Thirty patients were treated with BTM and delayed split skin grafting. The % graft take had a mean of 81.9% and % BTM take had a mean of 88.6%, demonstrating effective integration of BTM. When managed appropriately, it was possible for BTM to integrate successfully despite findings suggestive of infection. Scar quality improved over time. DISCUSSION:These results provide additional clinical evidence on the safety and performance of BTM as an effective dermal substitute in the treatment of patients with deep burn injuries.

Burns of the limbs affect 48.6% of burn patients. Injury mechanisms condition their depth and degree of extension. Injury of the hands and/or the joint areas entails considerable risk of retraction. Coverage is consequently doubly challenging, it is a matter not only of compensating for a soft tissue defects, but also of striving to prevent early (infectious) and late (amplitude limitation, pain, loss of function…) complications. Thoroughgoing assessment of the initial injury and associated lesions is conducive to rapid determination of a therapeutic strategy tailored to the relevant functional issues and subsequent rehabilitation. Following a summary of the epidemiological elements and the medical context of management, a review of existing treatments has been drawn up based on the data in the literature and current professional recommendations. Emergency procedures, the different types of excision and the possibilities of autologous covering and skin substitutes are reported. Last but not least, routinely validated indications are synthesized.

La cobertura de las pérdidas de sustancia cutáneas es una problemática que se plantea diariamente. Las técnicas clásicas de cirugía reparadora recurren a los injertos y a los diferentes colgajos para conseguir el cierre quirúrgico de las heridas. A partir de la década de 1970, aparecieron nuevas vías de investigación para garantizar la supervivencia de los pacientes con grandes superficies quemadas. Se trataba de los cultivos celulares de queratinocitos, desarrollados por Grienwald y Green. Desde entonces, se han explorado nuevas vías relacionadas con la epidermis, pero también con la parte dérmica de la piel. Poco a poco han ido apareciendo en el mercado diferentes sustitutos biológicos, sintéticos o biosintéticos, puestos a disposición de los cirujanos para permitirles garantizar la sustitución parcial o total del revestimiento cutáneo, de forma transitoria o definitiva. En la actualidad, su uso continúa esencialmente en los grandes quemados, pero debería ofrecer nuevas oportunidades quirúrgicas para el tratamiento de las heridas profundas y extensas que se producen en los politraumatismos, en dermohipodermitis bacterianas necrosantes o en las resecciones oncológicas amplias.

La copertura delle perdite di sostanze cutanee è una problematica posta quotidianamente. Le tecniche classiche di chirurgia riparatrice fanno ricorso agli innesti e ai diversi lembi per arrivare alla chiusura chirurgica delle ferite. Dagli anni ′70, nuove vie di ricerca sono emerse per assicurare la sopravvivenza di pazienti ustionati su grandi aree. Si trattava delle colture cellulari di cheratinociti sviluppate da Grienwald e Green. In seguito, nuove vie sono state esplorate relativamente all’epidermide, ma anche alla porzione dermica della cute. Differenti sostituti, biologici, sintetici o biosintetici, sono a poco a poco comparsi sul mercato e sono stati messi a disposizione dei chirurghi per permettere loro di assicurare la sostituzione parziale o totale del rivestimento cutaneo, in modo transitorio o definitivo. Il loro attuale utilizzo resta ancora destinato essenzialmente ai grandi ustionati, ma dovrebbe fornire nuove opportunità chirurgiche per la gestione di ferite profonde ed estese che avvengono al momento di politraumi, di dermoipodermiti batteriche necrotizzanti o di vaste exeresi oncologiche.

Le cytomégalovirus (CMV) est un virus ubiquitaire. L'infection à CMV est liée soit à une primo-infection, soit à une réactivation. Celle-ci est provoquée par un « stress » qui va consommer les ressources du système immunitaire (SI) et permettre la réplication virale, ou à un déficit de ce même SI. Chez le patient de réanimation, l'infection à CMV est associée à une augmentation de la durée de séjour en réanimation, de la durée de ventilation mécanique, de la mortalité [1]. Le patient brûlé grave est caractérisé par une immunodépression acquise multifactorielle. Sur des modèles murins, il a été montré que les sujets brûlés étaient susceptibles de présenter une infection à CMV [2]. D'un point de vue clinique, elle reste encore mal documentée chez ces patients. L'objectif de notre étude était d'évaluer l'incidence de l'infection à CMV chez les patients brûlés graves. Nous avons inclus les patients avec une surface cutanée brûlée (SCB) supérieure à 15 % admis dans le centre de traitement des brûlés de l'HIA Sainte-Anne, Toulon, entre septembre 2008 et septembre 2011. Une sérologie CMV était réalisée à l'admission, puis une détection de la virémie par real time quantitative PCR (RTqPCR) était effectuée une à deux fois par semaine pendant le séjour en réanimation. L'infection à CMV était définie par une RTqPCR positive en cours de séjour. La réactivation du CMV était définie par une RTqPCR positive chez un patient séropositif à l'admission. Au total, 58 patients étaient inclus. L'âge moyen des patients était de 51 ± 21 ans. La SCB moyenne était de 31 ± 15 %. La brûlure était d'origine thermique dans 89 % des cas. 36 patients étaient séropositifs pour le CMV à l'admission, 20 séronégatifs (64 % et 36 % respectivement). Une infection à CMV était diagnostiquée chez 22 des patients séropositifs (61 %), et chez un seul des patients séronégatifs (5 %). L'infection à CMV était plus fréquente chez le patient séropositive que séronégatif (p < 0,0001). Chez les patients séropositifs, l'infection à CMV était associée à un âge supérieur (p = 0,03), à une durée de séjour moyenne prolongée en réanimation (53 jours versus 28 jours, p = 0,02). La SCB n'était pas différente (33 % versus 29 %, p = 0,5). Le taux de mortalité en réanimation n'était pas différent entre les patients ayant présenté une infection à CMV et les autres (27 % versus 21 %, p = 1). Notre étude montre que l'infection à CMV est plus fréquente chez le patient séropositif pour le CMV à l'admission que chez le patient séronégatif, suggérant que le mécanisme de cette infection est principalement lié à une réactivation plutôt qu'une primo-infection. Chez le patient brûlé séropositif, l'infection à CMV est fréquente, 61 % dans notre cohorte. Cette incidence est supérieure à celle observée dans d'autres groupes de patients de réanimation. En analyse statistique univariée, l'infection à CMV chez ces patients est associée à une durée de séjour en réanimation prolongée. Sur ces données, il n'est pas possible de déterminer si l'infection à CMV est la cause de l'augmentation de durée de séjour, ou bien la conséquence. En revanche, nous n'avons pas observé d'impact sur la mortalité.

OBJECTIVE:Acute respiratory distress syndrome (ARDS) is a leading cause of mortality in burn patients. Smoke inhalation, pneumonia and inflammation process are the major causes of ARDS in burn patients. The American European Consensus Conference (AECC) definition proposed in 1994 has recently been revised by the Berlin definition. Our objective was to describe the epidemiology of ARDS comparing the Berlin definition with the AECC definition in a retrospective cohort of burn patients. METHODS:We reviewed admitted burn adult patients for a two year period, and investigated patient who received mechanical ventilation for more than 48 h and in whom pneumonia was diagnosed. RESULTS:40 patients were analyzed. According to the AECC definition, 11 patients met criteria for ALI (27.5%), and 29 patients for ARDS (72.5%). According to the Berlin definition, all patients met criteria for ARDS: 4 (10%) for a severe ARDS, 25 (62.5%) for a moderate ARDS, 11 (27.5%) for a mild ARDS. Inhalation injury was diagnosed in 10 patients (25%). Categorizing patients with the Berlin definition showed statistically significative difference of mortality within the three groups, but not with the AECC definition. CONCLUSION:The Berlin definition seems to be more accurate than the AECC definition to assess the severity of ARDS in term of outcome in burn patients. This definition may facilitate prompt recognition of ARDS in burn patients, and promote protective ventilation strategy to a larger number of patients.

Introduction: Face and/or neck burn (FNB) exposes patients to the double respiratory risk of obstruction and hypoxia, and these risks may require a tracheal intubation. This study aims to describe the incidence and the characteristics of difficult intubation in FNB patients.Methods: We conducted a 5-year retrospective, single-center study including all patients meeting the following criteria: 18 years of age or older, an FNB at least 1% of burned surface area with a severity equal to or greater than the superficial second degree, and intubation and a burn center admission within the first 24 hours after the burn. Patients were compared according to the difficulty of their intubation.Results: Between January 2007 and December 2011, we included 134 patients. The incidence of difficult intubation was 11.2% but was greater in the burn center than in the pre-burn center: 16.9% vs 3.5% (P = .02). The most important difference between patients with or without difficult intubation was the time between the burn injury and the intubation: 210 (105-290) vs 120 (60-180) minutes (P = .047). After multivariate analysis, an intubation performed at a burn center was independently associated with difficult intubation: odds ratio = 3.2; 95% confidence interval, 1.1-528.Conclusions: This study underlines the high incidence of difficult intubation in FNB patients, greater than 11.2%, and demonstrates that intubation is more difficult when realized at a burn center, probably because it is performed later, allowing for development of cervical and laryngeal edema. (C) 2014 Elsevier Inc. All rights reserved.

Cytomegalovirus (CMV) reactivation is widely documented in non-immunosuppressed critically ill patients and was reported in a previous issue of Critical Care to be associated with poor outcomes [1]. Although the question of the causative role of CMV remains under debate, a clinical trial aiming to evaluate the efficacy and safety of prophylactic treatment for prevention of CMV reactivation in immunocompetent patients in critical care has started [2]. To date, few data on patients with burns have been published. However, we know that patients with burns are predisposed to herpes virus infection and that they are good ‘candidates’ for CMV reactivation. As expected, data show a high CMV reactivation rate in patients with burns, from 55 % to 71 % [3,4]. Moreover, CMV reactivation seems to be intense, as 67 % of patients reactivated CMV with a plasma viral load of greater than 1,000 copies/mL and 33 % did so with av iral load of greater than 10,000 copies/mL in the study by Bordes and colleagues [4]. However, available data in the literature are extracted from a subgroup of 20 patients with burns among a cohort of 120 critically ill patients for the study by Limaye and colleagues [3] and from a cohort of 29 patients with severe burns for the study by Bordes and colleagues [4]. These preliminary results emphasize the fact that it is absolutely necessary to better investigate the natural history of CMV reactivation in burns, as antiviral prophylaxis is being evaluated in critically ill patients. Indeed, if antiviral therapy is proved to be efficient on the CMV reactivation, should we treat more than 50 % of our burn patients with antiviral treatment? That is why we think that CMV reactivation still has to be studied in patients with burns, with the aim of answering the following questions: Is CMV reactivation as frequent as previously reported in patients with severe burns? What are the risk factors for CMV reactivation in patients with burns? Is CMV reactivation associated with a poor outcome? And is there a quantitative association between CMV reactivation and poor outcome? The community of burn caregivers should promote large and prospective cohorts of patients in order to investigate CMV reactivation in severe burns as a first step to support the potential indication of antiviral therapy in the coming years.

Patients with face and neck burns (FNBs) often undergo prehospital intubation, or sustain inhalation injury which are risk factors for pneumonia in specific populations. Early onset pneumonia (EOP) might be caused by initial management. The primary goal of this study was to find risk factors for EOP in FNB patients. This is a retrospective, single-center trial. We screened all FNB patients for EOP with the Clinical Pulmonary Infection Score. Pneumonia diagnosis was with culture from a mini broncho-alveolar lavage. Potential risk factors for EOP were recorded. We included 152 patients, EOP was diagnosed in 58 (38.2%). EOP patients had a greater burned surface area median (20±17% vs. 10±17%; p<0.001), were more frequently intubated during prehospital care (65.5% vs. 21.3%; p<0.001), had more abnormal fiberoptic bronchoscopy at admission (58.6% vs. 19.1%; p=0.002) and a lower initial PaO2/FiO2 ratio (median 314±118.6 vs. 365±105.7; p=0.01). Multivariate analysis showed that only prehospital intubation was independently associated with EOP (odds ratio 3.6; 95% confidence interval, 1.34-10). Prehospital intubation appears to be an independent risk factor for EOP in severe burn patients. Assessments of the risk-benefit ratios of intubating and of not intubating those patients are indicated.

Background: Hypothermia remains one of the major factors limiting surgery in extensively burned patients. We evaluated the effectiveness of an intravascular rewarming technique using CoolGard 3000 (TM) system and Icy (TM) catheter to maintain normothermia during surgeries of severe burned patients and compared these findings to a historical control group.Methods: This was a controlled non-randomised trial conducted between March 2008 and August 2009. Patients with burns greater than or equal to 40% of the total body surface area were included. Before the first burn excision, the Icy (TM) catheter was placed in the inferior vena cava via the femoral vein. Warming was then initiated and maintained until the bladder temperature reached over 37.5 degrees C. The bladder temperature was recorded every 30 min during surgery and for the first hour post-operatively and compared to a historical control group.Results: We enrolled 4 patients and 11 surgeries in the CoolGard (TM) group and compared them to 3 patients and 10 surgeries in the historical cohort. All intraoperative bladder temperatures from T = 30 were statistically different in the two groups. In the CoolGard (TM) group, no patient became hypothermic and no surgery was aborted because the patient's temperature had rapidly fallen below the threshold temperature (35.5 degrees C). No device-related complication was reported.Conclusion: The use of an intravenous warming catheter is a novel approach to maintain normothermia during surgery in burn victims and may be more effective than traditional methods. (C) 2010 Elsevier Ltd. All rights reserved.

The therapeutic management of the sequelae of deep burns always relies in principle on dermal-epidermal grafts. The latter, the price of which to pay is heavy scarring, cannot always be performed because the surface of skin available may not be sufficient. Research pathways have turned towards the creation of skin substitutes to minimise the scarring and improve the cosmetic quality of the grafts. We review the technical characteristics of collagen matrixes (Intégra(®) - Matriderm(®)) and their method of use.

Background: Cytomegalovirus (CMV) infection has been shown to occur not rarely in critically ill patients in the past decade. However, little data are available on CMV infection in burn patients whereas their susceptibility to CMV infection has been proved.Methods: We prospectively assessed CMV viremia by real-time polymerase chain reaction and clinical outcome in immunocompetent burn patients with total burn surface area greater than 15%.Results: Twenty-nine patients were enrolled. The rate of CMV infection was of 71% in CMV seropositive burn patients, and of 12.5% in CMV seronegative burn patients. CMV reactivation was associated with a higher IGS 2 score on admission. High grade CMV viremia was associated with longer mechanical ventilation duration, higher infection number, higher transfused red blood cell number, and longer ICU stays. There were no differences on mortality rate between patients with and without CMV reactivation.Conclusion: CMV infection rate is considerable in burn patients with TBSA greater than 15%. This infection seems to be mostly due to reactivation of latently existing virus. (c) 2010 Elsevier Ltd and ISBI. All rights reserved.