prevention of infection in patients with burns · 7 study number studied male: female ratio mean...
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O.M. OluwatosinDepartment of Surgery
Prevention of infection inpatients with burns
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Burns: definition
•An area of coagulativenecrosis usually due to
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Burn injury: aetiology
Dry heatMoist heat (scald)ChemicalElectricityFrictionRadiation: ultraviolet, XrayOthers (abroad):
cold
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Careless lanternrefill is a verycommon sourceof burning
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Study Numberstudied
Male:femaleratio
MeanTBSA
Mortality LA50value
Mungadi,(Sokoto) 2002
108children
1.6:1 6.5%
Mzezewa,(Harare)
451 46:54 13%(median)
22%
El-Badawy,(Cairo) 1998
305children
87% hadminor burns
4.3%
Kalayi, (Zaria)1996
84children
27.4%
Olabanji, (Ile-Ife)2003
474 1.75:1 25.4 21.8%
Adigun,(Ibadan) 2004
164 2:1 36 36% 68%
Sowemimo,(Lagos)
63%
Iregbulem(Enugu), 1993
644 9.87
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Study Numberstudied
Male:femaleratio
MeanTBSA
Mortality LA50value
Tokyo (Japan)1983-2003
6401(25% above
60yr)
63:37 18.8% 15.4% 53
Birmingham1989-1998
54 (for30yr old)
59 (for15 yearold)
Singapore1997-2003
2019 2.2:1 11.5% 4.6%
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Rate of epithelialisation increases if:(answer True or False)
1. the wound requires debridement2. the basal lamina is intact3. the wound is kept moist.4. the wound is managed by
exposure5. there is clinical colonization
Pre-test
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Recommended for cleaning a cleanwound before applying dressings
6. Normal saline7. Potable water8. Chlorhexidine gluconate 0.015 - 0.05% w/v
9. Povidone-iodine 10%
10.Cetrimide 0.15%
Pre-test
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T (True) or F (False) about burns11.A non-healing wound is suggestive of a
superficial infection in the wound.
12.Burn wound is initially colonized predominantlywith gram-negative organisms.
13.Pass a urethral catheter using conform glovesearly in management.
14.A urethral catheter when passed today should bechanged next week.
15.Whenever possible, cannulas should be placedthrough unburned skin.
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Post-test
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Mediators of the burn response:
• Cytokines• Oxygen radicals• Arachidonic acid
metabolites• Endotoxins
CathecholaminesAldosteroneGrowth hormoneAntidiuretic hormone5HTHistamineThyroxinAdrenocortical
steroidsGlucagon Insulin
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Skin:• Coagulative necrosis• Disruption of
basement membrane• Blistering• Vascular changes• 3 zones (Jackson):
coagulationstasishyperaemia
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• Cardiovascular• Renal• Gastro-intestinal• Respiratory• Neuro-endocrine
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Action committee onorganization of burn care
Individual care 1 patient
Burn service 2-10 patients
Burn unit 11-18 patients
Burn centre 19-26 patients
Extended burncentre
19-26 patients plus allthe supportingstructure necessary forstudy and research
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Admission:
• Burns: >10-15% BSA• Inhalation injury• Burns affecting hands, feet, face,
perineum, joint surfaces• Electrical burn• Associated injuries
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Full thickness burn
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Fluid resuscitation:
• Burns > 10% BSA in children• Burns > 15% BSA in adults• Inhalation injury• Other associated injuries
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Parkland formula
• Weight (kg) X % body burn X 4given in 1st 24 hoursmonitored by clinical appearance,urine output
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Treatment of partial thicknessburn
Change dressing 5 daysafter or as necessary
Wound heals in 14 days
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Treatment by exposure
• Areas that are difficult to dress:face, genitalia and perineum
• Minimally discharging wound• To allow for frequent monitoring:
finger tips• To allow for joint movement
(polythene bag on the hand)
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Modified exposure
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Treatment of fullthickness burn
wound
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Years ago• Burn wounds were allowed to
separate by means of human andbacterial collagenases.
• Patients who survived sepsis,pain, and misery weresubsequently subjected toautografting over granulatingtissue.
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Today• Early tangential or fascial excision
makes it possible to remove all deadtissue.
• Coverage of the burn wound withstored homologous human skin preventinfection, improve survival, andmodulate the hypermetabolicresponse.
• Permanent coverage with culturedautologous skin or widely meshed skingraft.
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Burn wound excision
Harvesting a partial thickness skin graft from the thigh
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A SHEET OF CULTURED KERATINOCYTESREADY FOR CLINICAL APPLICATION
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Other aspects of management of acuteburn injury:
Initial investigationAnaelgesic, antitetanus,
antibioticsAntiulcer drugs, anticoagulants.
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Management in the subacute phase
• Blood transfussion• Treatment of fever• Treatment of psychiatric
manifestations• Physiotherapy• Nutrition
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Sources of organisms
• Endogenous (patient’s own normalflora)
• Exogenous (environmental or fromhealth care personnel).
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Organisms associated withinfection in burn patients• Gram-positive• Gram-negative• Anaerobes• Yeasts• Molds• Viruses• Distribution of organisms changes
over time in individual patients31
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• Wound initially colonized predominantlywith gram-positive organisms
• Rapidly replaced by antibiotic-susceptiblegram-negative organisms usually within aweek of the burn injury.
• If wound closure is delayed and thepatient becomes colonized and requirestreatment with broad-spectrumantibiotics, these organisms may bereplaced by yeast, fungi and antibiotic-resistant bacteria 32
Organisms associated withinfection in burn patients
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Organisms ofparticular concern• Methicillin-resistant
Staphylococcus aureus (MRSA)• Enterococci• Group A b-hemolytic
streptococcus• Gram-negative rods such as
Pseudomonas aeruginosa andEscherichia coli
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Modes of transmission
• Contact• Droplet• Airborne.• Primary mode is direct or indirect
contact:• By the hands and gowns of
personnel caring for the patient or• from contact with inappropriately
decontaminated equipment. 34
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• Beds• Side rails• Tables• All equipment used on the patient
(blood pressure cuffs,thermometers, wheelchairs, IVpumps)
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Other sources
• Contaminated hydrotherapyequipment
• Common treatment areas• Contaminated equipment, such as
mattresses
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Infection control protocols:
• Surveillance cultures as needed• Cohort patient care teams• Strict enforcement of patient and staff
hygiene• Alcohol-based hand washing product
dispensers throughout the burn unit• Patient isolation• Monitoring of antibiotic use and
monitoring antibiotic-susceptibilityresults.
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Prevention of burn wound infection
• involves assessment of the wound at eachdressing change for changes in the character,odor or amount of wound drainage.
• Strict aseptic technique should be used whenhandling the open wound and dressingmaterials and frequency of dressing should bebased on wound condition.
• If the wound has necrotic material present, adebriding dressing should be chosen,whereas a protective dressing is preferablefor clean healing wounds. 41
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• Treatment of an existing wound infectionincludes considering changes to the topicalagent being used along with changing thefrequency of the dressing changes.
• In cases where invasive infection is present,surgical debridement of the infected woundand appropriate systemic antimicrobialtherapy may be required
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Prevention of burn wound infection
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Prevention of bloodstream infection
• Appropriate care of the burn wound, tominimize the extent of haematogenousseeding
•• Appropriate handling of intravascular devices.
Whenever possible, cannulas should beplaced through unburned skin, preferably at asufficient distance from the wound to preventcontamination of the insertion site.
• Frequent change of the catheter may berequired.
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INFECTIONINFLAMMATION
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Diagnosis of infection
NERDS
• Nonhealing
• Exudative
• Red and bleedingsurface
• Debris (yellow orblack necrotictissue)
• Smell or unpleasantodor
STONES
• Size is bigger
• Temperatureincreased
• Os [probe to orexposed bone]
• New or satellite areasof breakdown
• Exudate, erythema,edema
• Smell.45
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Investigation of a burn patient with fever
• Wound swab• Wound biopsy• Throat swab• Urine M/C/S• Blood culture• Full Blood Count• Blood film for malaria parasites
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Treatment of infection
• Antibiotics• Topical antiseptics• Debridement• Escharectomy• Dressings• Skin graft• Nutrition
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1. the wound requires debridement2. the basal lamina is intact3. the wound is kept moist.4. the wound is managed by
exposure5. there is clinical colonization
Post-test
Rate of epithelialisation increases if:(answer True or False)
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Recommended for cleaning a cleanwound before applying dressings
6. Normal saline7. Potable water8. Chlorhexidine gluconate 0.015 - 0.05% w/v
9. Povidone-iodine 10%
10.Cetrimide 0.15%
Post-test
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T (True) or F (False) about burns11.A non-healing wound is suggestive of a
superficial infection in the wound.
12.Burn wound is initially colonized predominantlywith gram-negative organisms.
13.Pass a urethral catheter using conform glovesearly in management.
14.A urethral catheter when passed today should bechanged next week.
15.Whenever possible, cannulas should be placedthrough unburned skin.
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Post-test
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1. F2. T3. T4. F5. F
6. T7. T8. F9. F10.F
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Test answers
11.T12.F13.F14.F15.T