gms | German Medical Science

Prof. Dr. W. Eisenmenger, Munich, held the commemorative speech sheding light onto the critical issues of intensive care medicine, prolonging life and life support. Increasingly, intensive care specialists as well as burn specialists are facing problems arising from patients' last wishes and detailed orders in case of their inevitable death. The juridical background regarding this topic is dealt with in the verdict of March 17^th 2003 of the 12^th Senat of the German BGH (Bundesgerichtshof) [1].

Reconstructive Surgery is an essential part in modern burn therapy. Hypertrophic scars still remain challenging for the burn specialist (Strasser, Zurich). Despite the pressure of patients and their relatives towards early corrective surgery, only "mellow" scars should be operated on (roughly after 1 year). Children who are prone to problematic scar formation due to thoracic burns need definitive plastic surgical management from the beginning of their treatment (Fette, Regensburg). Also, exact surgical timing is crucial for the development of the female breast as shown by Öhlbauer, Innsbruck. The indication for the use of biological skin substitutes (i.e. artificial dermis, Integra^®…) was once more critically discussed by the participants, finally reaching a consensus for the use of these substitutes on large areas of the trunk and extremities (v. Spiegel, Munich). Regarding burned hands and their long term results, Kamolz, Vienna, showed that the amputation rate was 14%, in 9% of the patient population presented, flap coverage was necessary and in 22% of the cases contractures were noted. Most important again is early excision and replacement of the skin on the third day post-burn, as well as subsequent functional therapy such as physio- and ergotherapy together with mandatory external compression. The recurring problem of exposed tendons are best dealt with by free microvascular fascial flaps (Sauerbier, Ludwigshafen) enabling the restoration of important gliding layers. These microvascular free tissue transfers often times represent the only possibility for covering defects resulting from high voltage burns as well (Baumeister, Ludwigshafen). Despite modern concepts of surgical reconstructive therapy, extremities are endangered by amputation at very high rates after high voltage injuries.

The current concept of skin replacement therapies using artificial dermis (Integra^®) was illustrated in a retrospective meta-analysis by 15 burn centres of the last 6 years. Here, an increasing use for 3^rd degree burns was noted as well as the use in reconstructive burn surgery (Heitland, Aachen). Using Integra^® in infants showed to produce superior results and represents a valuable treatment option. Fixing this device onto wounds is facilitated by the low pressure VAC^® system, which has previously shown to be effective in infections, haematomas and lymphoedemas. The VAC^® system is an excellent means of fixing skin transplants as well (Stiefel, Zurich). Wound coverage with membranes containing polylactid (Suprathel^®) is recommended for skin transplant donor sites and 2^nd degree burns significantly improving pain management as compared to conventional dressing changes. Supraderm^® has proven to reduce pain at dressing changes as well. Acticoat^®, a new silver-containing dressing, was successfully used on autologous and heterologous skin transplants and artificial dermis. Surgiwrap^®, is reduced by 90% due to hydrolysis within 9 months presented by five different investigators who were able to show significantly less wound contracture (Rennekampf, Tübingen). How to improve the use of autologous keratinocyte-transplants was discussed by Kolokythas et. al (Halle/Saale). By seeding one to two layers of keratinocytes onto a fibrin matrix the take was enhanced, even when used for extremities (Kamolz, Vienna). In general, when humane keratinocytes and fibroblasts are mixed with fibrin glue the time needed for cultivation is reduced and applicability is improved. The stem-cell compartment of dermo-dermal substitutes is of great clinical importance, because high-proliferative cells are becoming ready for use (Reichmann, Zurich). The identification of these stem cells, their enrichment and culture was successfully reported by these investigators. Another use of humane fibroblasts in multi-layer skin substitutes was achieved by composite grafts made of a collagen matrix with silicon sheaths and a two-layer dermal equivalent (Integra^®). Here, the researchers showed that multi-layer transplants were produced within 10 to 15 days successfully (Cedidi, Wuppertal).

Promising future perspectives were outlined in multiple additional presentations of experts in their fields of burn treatment. A multi-center study presenting the VAC^® system showed decreased time needed for healing, reduced bacterial load and reduced local lymphoedema by application of low pressure (Schrank, Munich). Often times, burn wounds "deepen" within the first few days after the trauma. By applying this system, increasing burn depth could be reduced.

Current concepts of burn treatment were a major topic as well. Primary care and secondary transfer of severely burned patients should be conducted wisely. Taking additional trauma and injuries into account, a study dealing with nightly helicopter transfers showed that distances of less than 100 km to the next burn centres are too much of a risk (Trupkovic, Ludwigshafen). In another study (Mühlbauer, Munich) no advantage of initially treating burn patients suffering from inhalation injury with hyperbaric oxygenation was seen.

Some patients need additional forms of specialized therapy such as ECMO (extracorporal membrane oxygenation), nitric-oxide respiration (NO), kinetic bedding (Andel, Vienna), urodilatin and application of surfactant to be rescued from multiple-organ failure and ARDS (Cedidi, Wuppertal). The "open-lung" concept on burn intensive-care units does not improve the outcome (Wolter, Aachen), this is seen in contrast to the correlation of absolute peep and mortality. A study presented by the group of Bogenhausen, Munich, stressed the importance of treating towards normoglycemia significantly resulting in better outcome in severely burned patients. A high correlation of mortality and the extent of hyperglycemia was proven, a blood glucose level of 80 to 110 mg/dl should be aimed at. What does wine vinegar has to do with burns? The bactericide effect of a 3% wine vinegar solution against traditional antiseptics was tested and the investigators concluded that an equal or even better effect of the vinegar was found (Flügel, Ludwigshafen).

The role of humane histones in a burn model in vivo and in vitro against gram-positive and Gram-negative bacteria compared to protegrins and antibiotics was investigated. They showed to be effective, the disadvantages were in cost and restricted use (Steinsträsser, Bochum). Another experimental study focussed on gene transfer for improvement of topic host defense against bacteria in burns. Dr. Lars-Uwe Lahoda, Hannover Medical School, was honoured with the prize of the German burn society for the best presentation for his work "intracutanuous adenoviral gene transfer reduces bacterial pseudomonas-load in infected standardized deep partial thickness burns". An essential protein (LBP) needed to reduce Gram-negative infections was locally expressed by adenoviral gene transfer in LBP-knockout mice and wild types acting as control, both of which were burned and infected with a multiresistant strain of Pseudomonas aeruginosa, a most problematic bacterium for burn wound infections.

Patients suffering high voltage injuries have corrupted haemostasis (and fibrinolysis), related to increased prothrombin and factors TAT, F1+F2, PA1 and t-PA as demonstrated by Lichtenegger and investigators from Aachen. This could result in the observed progressive tissue damage following high-voltage electrical burns. Hyaluronan (Ulrich, Aachen), was discovered as a prognostic factor for hypertrophic scar formation. Another study focussing on scar quality following burns dealt with the effect of external compression therapy. Whenever the compression applied reached or exceeded 15 mm Hg, increased scar maturation even after one month was noted (Van den Kerckhove, Leuven). Modern methods of compression therapy involve silicon sheet application for burned hands (compression gloves with silicon inlays) as discussed by Gerlach, Passau. The group of Prof.Schaller, Tübingen, presented a new device for more "sophisticated" necrosectomy using a hydro-jet system. Its indication is regarded in hardly accessible and small areas of the skin such as interdigital spaces. The computerized digitalisation and documentation of burn patients reaches new spheres as presented by the "Burn Case 3D" study group by Haller from Linz.

Another emphasis was to present case reports of various burn centres dealing with uncommon and interesting patient constellations. Can topically applied silver reach systemically toxic levels? A case of silver-releasing Acticoat^® was reported having led to toxic systemic silver-levels and subsequently increased liver enzymes, which was normalized after removing the dressing (Trop, Graz). Another report of white phosphor which leads to very painful burns was presented. Dating back to the last world war, white phosphor tends to self-ignite on open air. The treatment involves soaking in water and the application of an antidote (a solution of 5% sodium bicarbonate, 3% copper sulfate, 1% hydroxy-ethyl cellulose 400 and 1% sodium lauryl sulfate) which itself is toxic (Rapp, Stuttgart). A case of a chromic acid burn leading to 3000-times increased toxic levels of absorption in the blood ended lethally in multi-organ failure (Akbas, Duisburg). The chemic industry occasionally uses hydrofluoric acid. Injuries with this substance best is dealt with interdisciplinary where the key to success is aggressive necrosectomy and immediate application of 10% calcium gluconate locally and systemically, supported by iv-magnesium in high doses (Öhlbauer, Innsbruck). A case of subcorneal staphylococcal peeling syndrome, a rare bacterial infection, ended lethally due to large areas of epidermolysis (96% TBA) as presented by Özdogan/Steen, Halle/Saale.

Summarizing the last 10 years of advance in burn treatment retrospectively ended the meeting. The national initiative of burn patients (Bundesinitiative für Brandverletzte) with their speaker, Fr.Krause-Wloch, Salzhemmendorf, cares about burn patients and relatives offering meetings and advice together with collaborative work with rehabilitation institutions, medical care organizations, insurance companies, workers compensation institutions, psychologist, emergency care organizations, red cross and the like http://www.brandverletzte-leben.de/. Psychological care and support is increasingly important for post-traumatic stress disorders patients (Fritsche, Bd.Klosterlausitz). First evaluation is the basis for extensive psychotherapeutic treatment in rehabilitation. A review regarding current therapeutic strategies presented by Dorfmüller, Bogenhausen/Munich, concluded that despite the major disruptive incidence of the trauma, significant improvement was achieved for burn victims over the years. Attempts to measure health-related quality of life (SF36 health survey) following burns were presented (Ziegenthaler, Bd.Klosterlausitz). Another tool following this idea is the EFL (Evaluation der Funktonellen Leistungsfähigkeit, evaluation of functional efficiency), currently used to gather data for socio-medical capabilities of burn patients (Kosel, Bd.Griesbach). Summarizing 35 years of experience in a single burn centre, the University of Zurich, it was reported that over the years on one hand the inpatient days decreased, but suicide attempts on the other increased. Still, individual experience in treating these demanding and complex injuries is the major parameter for quality and success, directly related to the prognosis (Guggenheim, Zurich).

A critical and even more demanding topic is dealing with children and burns. Burns reaching up to 5% TBA (total body area) can be treated ambulatory, with instructing parents and relatives, which is most important. Use of analgetics should best be reduced to the ones´ very well known to the therapist and reduced in number (Busching, Rothenburg/Wümme; Jester, Mannheim). Schintler from Graz showed examples of delayed treatment of two infants having suffered major burns in the Iraky war, who presented with contractures, burn wound superinfections and protein and electrolyte dysbalance. If child abuse is a possibility resulting in burns, interdisciplinary management is crucial. A program dealing with and investigating suspected child abuse was presented by the childrens´ department of the University of Zurich (Schiestl, Zurich). The topic of preventing domestic accidents and burns was discussed by Fette (Luzern, Regensburg, Sinzing). Even 10 years of post-burn therapy and rehabilitation, treatment such as reconstructive surgery was still going on and not ended, as shown by Schintler, Graz. Children who suffer burns of their palms of the hand are typical for the age where crawling and forward motion starts, since hands are used for moving at that age. Today, multiple plastic surgical options for coverage of defects are handy for each stage of the burn, enabling higher success rates in restoring the complexity of the hand (Grundhuber, Munich). It must be said though, that rehabilitative means are inevitable tools in reaching the goal, as well as early involvement of the parents (Zemp, Zurich).

(Figure 1 [Fig. 1] and Figure 2 [Fig. 2])