中华烧伤与创面修复杂志

Some thoughts on the coordinated development of burn department and wound repair department

Huang Yuesheng, Fu Xiaobing, Lu Shuliang, Hu Dahai, Lyu Guozhong

2020, 36(6): 411-414. doi: 10.3760/cma.j.cn501120-20200519-00273

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Focus on mental disorders induced by electrical burns

Zhang Qingfu

2020, 36(6): 415-418. doi: 10.3760/cma.j.cn501120-20200412-00221

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Clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound on the wrist

Xing Peipeng, Guo Haina, Di Haiping, Xue Jidong, Cao Dayong, Liang Zhanling, Liang Yan, Xia Chengde

2020, 36(6): 419-425. doi: 10.3760/cma.j.cn501120-20200219-00067

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Objective To explore the clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound of type Ⅱ and Ⅲ on the wrist. Methods From May 2016 to February 2019, 25 patients with deep high-voltage electrical burn wounds on the wrist were admitted to Zhengzhou First People′s Hospital, including 23 males and 2 females, aged 11-63 years. Among them, 4 cases had bilateral electrical burns on the wrist, and 21 cases had unilateral electrical burns on the wrist. There were 29 wounds in 29 affected limbs with depth of full-thickness to full-thickness with tendon and bone exposure, and 17 wounds were type Ⅱ and 12 wounds were type Ⅲ. Twenty-four patients underwent CT angiography of the upper extremities before surgery, while the other one patient did not undergo the examination due to seafood allergy. There were no obvious injury to the ulnar and radial arteries in 7 affected limbs, simple ulnar artery injury in 6 affected limbs, simple radial artery injury in 7 affected limbs, and both ulnar and radial arteries injury in 9 affected limbs. The wound areas after debridement were 10 cm×7 cm-36 cm×17 cm, and the free anterolateral thigh flaps were obtained with area of 11 cm×8 cm-37 cm×18 cm for repairing the wounds. For patients with no damage of ulnar artery and radial artery, the trunk of descending branch of lateral circumflex femoral artery of the flap or combined with the thick muscle perforating branch or lateral branch was anastomosed with the ulnar or radial artery of the wound. For patients with simple ulnar artery or radial artery injury, the trunk, lateral branch, or medial branch was anastomosed with the ulnar artery or radial artery of the wound. For patients with long injury of ulnar artery and radial artery, the ulnar artery or radial artery of the wound was reconstructed with one of the above-mentioned methods, the injured artery that was not anastomosed was reconstructed with great saphenous vein, and the transplanted blood vessel was embedded in the lateral femoral muscle. The accompanying vein of the descending branch of the lateral circumflex femoral artery of the flap was anastomosed with the accompanying vein of the ulnar artery or radial artery of the wound and/or the cephalic vein. The donor sites of flaps were sutured directly or repaired with split-thickness skin graft from the thigh. The survival condition of flap and affected limb after operation and during follow-up was observed, and hand function of the affected limb during follow-up was evaluated according to the evaluation standard after repair of peripheral nerve injury in upper limbs. Results Fifteen affected limb wounds had tissue liquefaction but healed after second debridement on 14-28 days after flap repair operation. All 29 flaps survived in the end. One patient had long ulnar artery and radial artery injuries in affected limbs and the hand was necrotic due to second embolism of the blood vessel in 1 week post operation, and the remaining affected limbs survived. During the follow-up of 6 to 30 months after operation, the flaps were slightly bloated, the affected limbs were warm with normal blood flow, and finger flexion, wrist flexion, and sensory function of hand recovered to varying degrees. The functions of the survived affected limbs were evaluated as excellent in 8 affected limbs, good in 9 affected limbs, medium in 5 affected limbs, and poor in 6 affected limbs, with an excellent and good rate of 60.71%. Conclusions The clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction is good for repairing high-voltage electrical burn wound on the wrist, and the patency restoration of the ulnar artery and/or radial artery of the upper limb in stage Ⅰ is helpful for improving the success rate of limb salvage.

Impacts of high-voltage electrical burn on serum platelet-related factors and platelet aggregation number in rats and the interventive effect of Xuebijing

Zhang Qingfu, Gao Zhijuan, Zhang Ziwei, Zhao Xuegang, Feng Jianke, Xu Yanfen, Tu Lihong, Zhang Jing

2020, 36(6): 426-432. doi: 10.3760/cma.j.cn501120-20200407-00212

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Objective To explore the effect of high-voltage electrical burn on platelet function and rheological behavior in rats and the interventive effect of Xuebijing. Methods A total of 280 Sprague Dawley rats of clean grade (aged 8-10 weeks, male and female unlimited) were divided into sham injury group, simple electrical burn group, electrical burn+ saline group, and electrical burn+ Xuebijing group according to the random number table, with 70 rats in each group. Rats in sham injury group were not conducted with electrical current to cause sham injury. Rats in the other three groups were given electrical current with output voltage of 2 kV and current intensity of (1.92 ± 0.24) A for 3 s, which caused high-voltage electrical burn wounds, each with an area of 1 cm×1 cm distributed in the left forelimb at the current inlet and the right hindlimb at the current outlet respectively. Rats in sham injury group and simple electrical burn group were not treated after injury. At post injury minute 2 and on post injury day (PID) 1, 2, 3, 4, 5, and 6, rats in electrical burn+ saline group and electrical burn+ Xuebijing group were intraperitoneally injected with 6 mL/kg saline and 6 mL/kg Xuebijing, respectively. Survival conditions of rats were recorded during the experiment. At 15 min before injury and at post injury hour (PIH) 1, 8, 24, 48, 72, and on PID 7, 10 rats in each group were respectively selected according to the random number table to sacrifice after collection of 5 mL blood under the direct vision of heart. Blood in the volume of 0.05 mL from each rat was taken to make blood smear, and platelet aggregation number was counted under 400 fold field of view using multiple projection microscope. The remaining blood samples were centrifuged to collect supernatant, and the content of platelet-derived growth factor (PDGF), thrombopoietin (TPO), and platelet activating factor (PAF) was detected by enzyme-linked immunosorbent assay. Data were statistically analyzed with analysis of variance for factorial design and Student-Newman-Keuls method. Results All rats in sham injury group and simple electrical burn group survived during the experiment. One rat in electrical burn+ saline group died on PID 6, and one rat on PID 5 and one rat on PID 6 died in electrical burn+ Xuebijing group. The levels of all indexes among the 4 groups were close at 15 min before injury. The serum content of PDGF, TPO, and PAF and platelet aggregation number of rats in the three electrical burn groups at all time points after injury were higher or more than those in sham injury group, and the first three indexes reached the peak at PIH 8. The serum platelet aggregation number of rats in simple electrical burn group reached the peak at PIH 48, and that in electrical burn+ saline group and electrical burn+ Xuebijing group reached the peak at PIH 72. Among them, the serum content of PDGF of rats in electrical burn+ Xuebijing group at PIH 48, 72 and on PID 7 ((12.8±4.0), (11.6±4.4), (11.0±3.6) ng/mL, respectively) was close to that in sham injury group ((10.4±2.0), (10.4±2.5), (9.8±3.3) ng/mL, respectively, P>0.05). The serum content of TPO of rats in electrical burn+ Xuebijing group at PIH 24, 72 and on PID 7 ((200±52), (192±36), (193±32) ng/mL, respectively) was close to that in sham injury group ((182±30) , (184±41), (183±33) ng/mL, respectively, P>0.05). The serum content of PDGF, TPO, and PAF and platelet aggregation number of rats in electrical burn+ Xuebijing group at every time point after injury was generally lower or less than that in electrical burn+ saline group and simple electrical burn group. Conclusions Application of Xuebijing treatment after high-voltage electrical burn can decrease the content of PDGF, TPO, and PAF in the serum and reduce the number of platelet aggregation, thereby inhibit platelet activation and improve platelet rheology.

Epidemiological investigation of 169 inpatients with high-voltage electrical burns on the wrist

Yin Kai, Cheng Lin, Du Weili, Hu Xiaohua, Shen Yuming

2020, 36(6): 433-439. doi: 10.3760/cma.j.cn501120-20200304-00119

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Objective To analyze the epidemiological characteristics of inpatients with high-voltage electrical burns on the wrist in Beijing Jishuitan Hospital (hereinafter referred to as the author′s unit), so as to provide reference for the prevention and treatment of high-voltage electrical burns on the wrist. Methods The medical records of inpatients suffered from high-voltage electrical burns on the wrist in the author′s unit from January 2008 to December 2019 were collected. The patients′ gender, age, population category, injury situation, injury season, total burn area, electrical burn type on the wrist of the affected limbs, the time from injury to first flap/myocutaneous flap transplantation, vascular reconstruction and flap/myocutaneous flap transplantation of the affected limbs, the total amputation rate of the affected limbs and the amputation rate of the affected limbs with type Ⅲelectrical burns on the wrist, the number of operation, postoperative infection rate of flap/myocutaneous flap, length of hospital stay, hospitalization expense, and treatment outcome were retrospectively analyzed. Comparison of the aforementioned statistical items between patients admitted from January 2008 to December 2013 (hereinafter referred to as the pre-stage) and January 2014 to December 2019 (hereinafter referred to as the post-stage) except gender, the total amputation rate of the affected limbs, treatment outcome were performed. Data were statistically analyzed with chi-square test, Fisher′s exact probability test, and Wilcoxon rank-sum test. Results During the 12 years, a total of 169 patients with high-voltage electrical burns on the wrist were admitted to the author′s unit, including 162 males and 7 females, aged (35±13) years, and 75.15% (127/169) of patients were 21-50 years old. The top three groups in population category from high to low were workers, migrant workers, and primary and secondary school students, accounting for 48.52% (82/169), 28.99% (49/169), and 9.47% (16/169), respectively. At work of non-electric power accounted for 47.93% (81/169) and ranked the first in the proportion of injury situation. The injury occurred mostly in summer and autumn, accounting for 39.05% (66/169) and 28.99% (49/169), respectively. About 65.09% (110/169) of the patients were with total burn area less than 10% total body surface area. There were totally 216 affected limbs with high-voltage electrical burns on the wrist, of which the numbers of wrist with type Ⅲ and type Ⅳ injury were 25 (11.57%) and 21 (9.72%), respectively. The time from injury to first flap/myocutaneous flap transplantation was 6.00 (3.75, 8.00) d. There were 45 affected limbs operated with vascular reconstruction, 75 affected limbs transplanted with pedicled axial flap, and 86 affected limbs transplanted with free flap/myocutaneous flap. The total amputation rate of affected limbs was 12.96% (28/216), and the amputation rate of the affected limbs with type Ⅲ electrical burns on the wrist was 28% (7/25). The number of operation was 4 (3, 5) times, the postoperative infection rate of flap/myocutaneous flap was 7.18% (13/181), the hospitalization time was 39.00 (25.00, 50.00) d, and the hospitalization cost was 123 553.00 (50 656.50, 216 003.00) yuan. Compared with those of the pre-stage, the time from injury to first flap/myocutaneous flap transplantation was significantly shortened (Z=-4.038, P<0.01), the ratio of free flap/myocutaneous flap transplantation on affected limbs was significantly increased (χ²=13.478, P<0.01), the ratio of pedicled axial flap transplantation on affected limbs was significantly decreased (χ²=10.242, P<0.01), the number of operation was significantly reduced (Z=-5.903, P<0.01), the postoperative infection rate of flap/myocutaneous flap was significantly decreased (χ²=4.492, P<0.05), the length of hospital stay was significantly shortened (Z=-2.723, P<0.01), and the hospitalization expense was significantly decreased among patients hospitalized in the post-stage (Z=-2.121, P<0.05). The other items were close between patients hospitalized in the pre-stage and those in the post-stage. Conclusions Men were more likely than women to suffer from high-voltage electrical burns on the wrist in the author′s unit. Young workers and migrant workers may be the key groups for the prevention of high-voltage electrical burns on the wrist. It is very important to strengthen the management of high voltage safety education for non-electric power staff, warn and protect the surrounding area of high voltage environment, and prohibit non staff for entering the high voltage environment, especially in summer and autumn. In the last 6 years, the patients with high-voltage electrical burns on the wrist may benefit from the active vascular reconstruction at early stage and free flap/myocutaneous flap repair in the author′s unit.

2020, 36(6): 425-425. doi: 10.3760/cma.j.issn.1009-2587.2020.06.101

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2020, 36(6): 425-425. doi: 10.3760/cma.j.issn.1009-2587.2020.06.102

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2020, 36(6): 439-439. doi: 10.3760/cma.j.issn.1009-2587.2020.06.104

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2020, 36(6): 439-439. doi: 10.3760/cma.j.issn.1009-2587.2020.06.103

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Effects of two dimensional gray-scale blood flow imaging combined with color Doppler flow imaging in guiding arterial puncture and catheterization through wounds in patients with large burns

Cai Duo, Wu Weiwei, Zhang Dandan, Chi Mingyun, Ma Yan, Cheng Dan, Zhou Yan, Zhao Qiuyan

2020, 36(6): 440-445. doi: 10.3760/cma.j.cn501120-20190309-00099

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Objective To explore the effects of two dimensional gray-scale blood flow imaging (hereinafter referred to as " B-flow" ) combined with color Doppler flow imaging (CDFI) in guiding arterial puncture and catheterization through wounds in patients with large burns. Methods Sixty-seven patients with large burns who met the inclusion criteria and hospitalized in the First Hospital of Jilin University from January 2017 to January 2019 were enrolled in the prospectively randomized control study. According to the random number table, CDFI alone group was allocated with 35 patients (23 males and 12 females) and B-flow+ CDFI group with 32 patients (22 males and 10 females), aged 19-60 and 18-58 years, respectively. According to the progress of the disease, arterial puncture and catheterization were performed in the right time. During the operation, CDFI was used alone for guidance in patients of CDFI alone group, while B-flow and CDFI were used together for guidance in patients of B-flow+ CDIF group. Based on the first time of catheterization, the catheterization location, one-time catheterization success rate, post-back stitching re-catheterization success rate, catheterization failure rate, catheterization duration, and incidences of wound sepsis, catheter-related bloodstream infection, and arterial thrombosis within post catheterization day (PCD) 3 of patients in the two groups were recorded. Data were statistically analyzed with the independent-sample t test, chi-square test or Fisher′s exact probability test. Results (1) All the patients underwent catheterization through wounds, and there was no statistically significant difference in catheterization location of patients between the two groups (χ²=0.574, P>0.05). The one-time catheterization success rate of patients in B-flow+ CDFI group was 81.25% (26/32), which was obviously higher than 51.43% (18/35) in CDFI alone group (χ²=6.594, P<0.05). The catheterization failure rate of patients in B-flow+ CDFI group was 3.12% (1/32), which was obviously lower than 20.00% (7/35) in CDFI alone group (P<0.05). The post-back stitching re-catheterization success rate of patients was similar between the two groups (χ²=1.029, P>0.05). (3) The catheterization duration of patients was (15.7±1.1) min in B-flow+ CDFI group, which was obviously shorter than (17.1±2.2) min in CDFI alone group (t=11.316, P<0.01). (4) Within PCD 3, the incidences of wound sepsis and catheter-related bloodstream infection of patients in CDFI alone group were 2.86% (1/35) and 0, close to 0 and 3.12% (1/32) in B-flow+ CDFI group (P>0.05); the incidence of arterial thrombosis of patients in B-flow+ CDFI group was 0, which was obviously lower than 20.00% (7/35) in CDFI alone group (P<0.05). Conclusions Compared with CDFI alone, B-flow combined with CDFI can improve the success rate of arterial puncture and catheterization through wounds in large area burn patients, shorten the catheterization duration, and effectively reduce the incidence of arterial thrombosis after catheterization, with a good clinical application value.

Analysis of causes of death and etiological characteristics of skin tissue donors

Ye Ziqing, Xie Weiguo, Lu Xiongbing, Chen Xin, Zhao Chaoli, Ruan Qiongfang, Zhang Wei

2020, 36(6): 446-450. doi: 10.3760/cma.j.cn501120-20190307-00085

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Objective To investigate the causes of death and etiological characteristics of skin tissue donors, and to provide reference for allogeneic skin transplantation. Methods From October 2008 to October 2018, 49 skin tissue donors accepted by the Burn Department of Wuhan Third Hospital met the inclusion criteria of this study, and a cross-sectional study was conducted. According to the cause of death, the donors were divided into accidental death group (19 cases) and non-accidental death group (30 cases). The sex and death age of 49 donors were recorded, and the death age between different sex donors and that of donors between accidental death group and non-accidental death group were compared. Diseases or circumstances that caused the death of donors, hepatitis B, hepatitis C, acquired immunodeficiency syndrome, syphilis virus carrying status, and peripheral blood microbial culture results of 49 donors were recorded, and the detection of blood-borne infectious risk factors of donors between accidental death group and non-accidental death group was compared. Abnormal skin tissue was also selected during allogenic skin graft preparing for pathological examination. Data were statistically analyzed with Mann-Whitney U test and continuity correction chi-square test. Results (1) Out of the 49 donors in this group, 38 were male (77.55%) and 11 were female (22.45%). The death age was 42.00 (24.00, 55.00) years, and the death age of male donors was similar to that of female donors (Z=0.120, P>0.05). The death age of donors in accidental death group was lower than that in non-accidental death group, but the difference was not statistically significant (Z=-1.581, P>0.05). (2) Among the causes and circumstances of the 49 donors in this group, there were 19 cases (38.78%) of injury, poisoning, and some other consequences of external causes, 11 cases (22.45%) of circulatory system diseases, 9 cases (18.37%) of tumors, 3 cases (6.12%) of nervous system diseases, 2 cases (4.08%) of respiratory system diseases, and 2 cases (4.08%) of congenital malformation, deformation, and chromosome abnormality, 1 case (2.04%) of blood and hematopoietic organ diseases and some diseases related to immune mechanism, 1 case (2.04%) of digestive system disease, and 1 case (2.04%) of genitourinary system disease. (3) There were 9 donors (18.37%) with blood-borne infectious risk factors among the 49 donors in this group, including 8 cases (16.33%) of blood-borne infectious diseases, which were 5 cases (10.20%) of hepatitis B, 2 cases (4.08%) of syphilis, and 1 case (2.04%) of hepatitis C, respectively. Blood microorganism culture was positive in 1 case (2.04%), in which multi-drug resistant Pseudomonas aeruginosa was detected. Risk factors of blood-borne infection were detected in 2 donors in accidental death group, with detection ratio lower than that in non-accidental death group (7 cases), but the difference was not statistically significant (χ²=0.562, P>0.05). (4) A total of 8 donors′ abnormal skin tissue were selected, including 4 cases of intradermal pigmented nevus, 1 case of scar, 1 case of pseudoepithelioma hyperplasia, 1 case of epidermal verrucous hyperplasia, and 1 case of large amount of pigment granules in dermis. Conclusions Non-accidental death caused by diseases is the main cause of death of skin tissue donors, and the risk of donor-derived infection of non-accidentally dead donors is slightly higher than that of accidentally dead donors. Before the allogeneic skin is obtained and transplanted, the cause of death of the donor should be carefully investigated, and the health status should be evaluated, so as to avoid the occurrence of donor-derived infection.

Selection and effects of flap/myocutaneous flap repair methods for the defect after perineum tumor resection

Song Dajiang, Li Zan, Zhou Xiao, Zhang Yixin, Peng Xiaowei, Feng Guang, Zhou Bo, Lyu Chunliu, Wu Peng, Tang Yuanyuan, Peng Wen, Mao Huangxing, Liu Zeyang, Han Weiqing, Chen Yile, Tang Dihong, Zhou Yanjie, Zhang Keqiang

2020, 36(6): 451-457. doi: 10.3760/cma.j.cn501120-20190320-00129

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Objective To explore the selection and effects of flap/myocutaneous flap repair methods for the defect after perineum tumor resection. Methods From January 2011 to February 2017, 31 patients with vulvar tumor who were admitted to Hunan Cancer Hospital underwent repair of wound after tumor resection with various flaps/myocutaneous flaps. The patients were composed of 5 males and 26 females, aged 39-76 years, with 27 vulvar cancer and 4 Paget′s disease in primary diseases. The size of defects after vulvar tumor radical resection ranged from 8.0 cm×4.5 cm to 27.5 cm×24.0 cm. According to the theory of perforasome, the defects were repaired by the external pudendal artery perforator flap, deep inferior epigastric artery perforator flap, rectus abdominis myocutaneous flap, anterolateral thigh flap, internal pudendal artery perforator flap, gracilis myocutaneous flap, and profunda artery perforator flap based on the specific size and location of perineum and groin where the defect was located. According to the blood supply zone of flap, totally 17 local translocation flaps, 18 axial flaps/myocutaneous flaps, and 7 V-Y advancement flaps were resected, with an area of 7.0 cm×4.0 cm to 21.0 cm×13.0 cm. All the flaps/myocutaneous flaps were transferred in pedicled fashion, and the donor sites were closed without tension. The number of flaps/myocutaneous flaps, wound closure, flaps/myocutaneous flaps survival, and follow-up were observed and recorded. Results Altogether 42 flaps/myocutaneous flaps were harvested in 31 patients. Two flaps/myocutaneous flaps were used in 11 cases for large circular defect repair. All the defects achieved tension-free primary closure. The blood supply of 32 flaps/myocutaneous flaps was good, while insufficient blood supply was noted in the other 10 flaps/myocutaneous flaps. Seventeen flaps/myocutaneous flaps survived smoothly. Wound dehiscence occurred in 5 flaps/myocutaneous flaps 8 to 14 days postoperatively, which was healed with dressing change. Temporary congestion was noted in 7 flaps/myocutaneous flaps 2 to 5 days postoperatively, which recovered without special treatment. Three flaps/myocutaneous flaps had infection 7 to 15 days postoperatively, two of which recovered after dressing change, while the other one had partial necrosis and received debridement and direct closure. Two flaps/myocutaneous flaps were totally necrotic 8 to 15 days postoperatively, which were repaired with pedicled rectus abdominis myocutaneous flap after debridement. Seven flaps/myocutaneous flaps had partial necrosis 7 to 20 days postoperatively and were healed after dressing change. Twenty-four patients were followed up for 9-38 months. The color of flaps/myocutaneous flaps was similar to that of the surrounding skin, the shape of vulva was natural, the movement of hip joint was not limited, the function of micturition and defecation was not affected, and tumor recurrence was noted in 3 patients. Conclusions For the complicated large defect after perineum tumor resection, the flexible application of different forms of flaps/myocutaneous flaps to repair according to different areas regains the appearance and function. However, there are many complications, so it is necessary to further strengthen the postoperative care.

Meta-analysis of the effects of dexmedetomidine combined with ketamine during dressing changes in burn patients

Hu Zaichang, Xu Gang, Zhang Xiaowei, Ma Kun, Jin Junjun, Li Pingsong

2020, 36(6): 458-464. doi: 10.3760/cma.j.cn501120-20190327-00145

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Objective To systematically evaluate the safety and efficacy of dexmedetomidine combined with ketamine during dressing changes in burn patients using meta-analysis. Methods Foreign language databases including PubMed, Cochrane Central, Embase, and Web of Science were searched with the terms of " burns, dexmedetomidine, ketamine, and dressing" , and Chinese databases including Chinese Journal Full-Text Database, Wanfang Data, and China Academic Journal Network Publishing Database were searched with the terms in Chinese version of "右美托咪定,氯胺酮,烧伤,烫伤,热力伤,换药" to retrieve the publicly published randomized controlled trials on the application of dexmedetomidine combined with ketamine for sedation and analgesia during dressing changes in burn patients from the establishment of each database to March 2019. The outcome indexes included systolic blood pressure at 5 minutes after administration, arousal restlessness score, ketamine dosage, dressing change time, body movement/recovery time, pain score, Ramsay sedation scores at 10 minutes after the start of dressing change and 1 hour after dressing change, physician satisfaction score, neuropsychological symptoms, nausea and vomiting times, nausea and vomiting score. RevMan 5.3 and Stata 14.0 statistical software were used to conduct a meta-analysis of eligible studies. Results A total of 396 burn patients were included in 7 articles, including 198 patients in dexmedetomidine+ ketamine group who received dexmedetomidine and ketamine for sedation and analgesia, and 198 patients in ketamine alone group who received ketamine alone for sedation and analgesia. The bias risks of the seven studies included were uncertain. Compared with those of ketamine alone group, the systolic blood pressure at 5 minutes after administration, arousal restlessness score, nausea and vomiting score of patients in dexmedetomidine+ ketamine group were significantly decreased, with standardized mean differences of -13.89, -0.84, and -0.99 (95% confidence interval=-20.89--6.89, -1.17--0.52, -1.31--0.68, P<0.01), the Ramsay sedation score at 10 minutes after the start of dressing change and that at 1 hour after dressing change were significantly increased, with standardized mean differences of 1.53 and 0.72 (95% confidence interval=1.05-2.02, 0.13-1.31, P<0.05 or P<0.01), and the number of neuropsychological symptom and number of nausea and vomiting were significantly reduced, with relative risks of 0.20 and 0.16 (95% confidence interval=0.07-0.58, 0.05-0.58, P<0.01). The patients in the two groups were similar in ketamine dosage, dressing change time, body movement/recovery time, pain score, and physician satisfaction score. There was no publication bias in dressing change time or ketamine dosage (P>0.05), while the other indexes might have publication bias (P<0.05). Conclusions Compared with ketamine alone, combination of dexmedetomidine and ketamine during dressing changes in burn patients can reduce the occurrence of restlessness, nausea and vomiting, neuropsychological symptoms, and other complications, better stabilize blood pressure, and enhance sedation effect.

Recommendations for normalizing the medical practices of burn treatment during the outbreak of coronavirus disease 2019

Ma Siyuan, Yuan Zhiqiang, Peng Yizhi, Luo Qizhi, Song Huapei, Xiang Fei, Tan Jianglin, Zhou Junyi, Li Ning, Hu Gaozhong, Luo Gaoxing

2020, 36(6): 465-469. doi: 10.3760/cma.j.cn501120-20200224-00083

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Pay attention to the exposure risk of patients with chronic wounds on the way to hospital during coronavirus disease 2019 epidemic prevention and control

Zhou Jingqi, Dong Wei, Xu Honglian, Cai Yunmin, Sheng Donghai, Wu Fangyi, Liu Yingkai, Tang Jiajun, Lin Weidong, Huang Lifang, Lu Shuliang

2020, 36(6): 469-471. doi: 10.3760/cma.j.cn501120-20200218-00065

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Advances in the research of mechanism and related immunotherapy on the cytokine storm induced by coronavirus disease 2019

Chen Cheng, Zhang Xiaorong, Ju Zhenyu, He Weifeng

2020, 36(6): 471-475. doi: 10.3760/cma.j.cn501120-20200224-00088

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Clinical effect of X-N advancement flap in repairing pressure ulcer on the buttock or back

Cui Zelong, Shou Jiabao, Liu Bo, Wang Haihan, Lin Yangyang, Zeng Jiaxing, Long Zhaozhong, Chen Yingbin, Zhang Xuemei

2020, 36(6): 476-479. doi: 10.3760/cma.j.cn501120-20191011-00399

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Objective To explore the clinical effect of X-N advancement flap in repairing pressure ulcer on the buttock or back. Methods From June 2018 to June 2019, 20 patients with grade Ⅳ pressure ulcers on the buttock or back were hospitalized and treated in the Department of Traumatology, Burns and Plastic Surgery of Fourth Affiliated Hospital of Guangxi Medical University, including 15 males and 5 females, aged 48-89 years. The area of the patient′s wound was 8 cm×5 cm-15 cm×12 cm after debridement, and all were repaired with the X-N advancement flap designed by the author. The flap was designed according to the direction of skin relaxation on both sides of the wound, and the skin was incised in X-shape and sutured in N-shape. The width and advancement distance of the flap were recorded, and the ratio of the advancement distance to the width of the flap was calculated. The flap survival, complication, and follow-up were observed and recorded. Results The width of the flap was (5.9±1.2) cm, the advancement distance of the flap was (10.3±2.5) cm, and the ratio of the advancement distance to the width of the flap was 1.8±0.4. All the flaps survived, and none of the flaps had blood flow disorder. Local dehiscence occurred in the flap of one patient 1 week after surgery, which was healed after laying on the floating bed, strengthened care, and wound dressing change. The flap of one patient developed infection 5 days after surgery, which was healed after partial suture removal, smooth drainage, and replacement with sensitive antibiotics. The wounds of the remaining 18 patients were all cured. After 3 months of follow-up, the flaps survived well with good elasticity and texture. Conclusions The X-N advancement flap can make the skin and soft tissue move forward effectively. It is simple and effective to repair pressure ulcers on the back or buttock of patients with this flap, which is worthy of clinical promotion and application.

Effect of pedicled thoracodorsal artery perforator flap on the repair of moderate to severe axillary scar contracture deformity

Jiang Conghang, Wang Xiancheng, Li Xiaofang, Xiong Xiang, Sun Yang, Meng Xianxi

2020, 36(6): 480-483. doi: 10.3760/cma.j.cn501120-20190322-00133

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Objective To investigate the effect of pedicled thoracodorsal artery perforator (TDAP) flap on the repair of axillary moderate to severe scar contracture deformity. Methods From January 2012 to January 2017, 29 patients with axillary moderate to severe scar contracture deformity were admitted to the the Second Xiangya Hospital of Central South University, including 18 females and 11 males, aged 14-42 years. There were 3 patients with cicatricial contracture deformity of bilateral axillas and 26 patients with cicatricial contracture deformity of unilateral axilla. After relevant preoperative examinations were completed and basic diseases were controlled, axillary scar was removed or released under the anesthesia of endotracheal intubation. The areas of wounds ranged from 7.5 cm×5.0 cm to 21.0 cm×8.5 cm after the operation. The pedicled TDAP flaps were used to repair the defects, which were thinned based on demand of the recipient sites before being transferred. The areas of flaps ranged from 9.0 cm×6.0 cm to 22.0 cm×10.0 cm. The donor sites were sutured directly. The status of thinned flaps, the survival of flaps after the operation and during follow-up, and the shoulder joint function during follow-up were observed. Results Thirty-two pedicled TDAP flaps were harvested for repairing the defects. Among them, 14 flaps were transferred directly without thinning and the thickness of the flaps ranged from 9.0 mm to 15.0 mm, with average thickness of 13.6 mm.While the other 18 flaps were thinned, and the thickness of the thinned flaps ranged from 5.0 mm to 8.0 mm, with average thickness of 7.5 mm. The distal parts of 3 flaps in 3 patients showed small size of blackening or necrosis within 72 hours after the operation, and 2 of them were thinned and the other one was not. Finally, the 3 flaps were healed after hyperbaric oxygen therapy, dressing change, or other treatments. One flap occurred vein congestion 8 hours after the operation caused by pressure on the pedicle, and the color of the flap turned back to normal after the pressure was relieved. The rest of the flaps survived well. All the patients were followed up for 9 to 36 months, with an average of 18 months. All the flaps survived well, the color of the flaps was nearly the same as the recipient sites, and none of the flaps developed obvious contraction. The shoulder joint function of all patients was significantly improved compared with that before operation, with abduction angles of shoulder joints ranged from 90.0-145.0°, with an average of 130.0°. Conclusions Pedicled TDAP flap is an relatively ideal choice for the repair of moderate to severe axillary scar contracture deformity, and better results will be achieved if the flaps are thinned to a appropriate thickness according to the condition of axillary defects.

Clinical strategies for preservation of the exposed implant in chronic wounds and wound repair

Chu Wanli, Hao Daifeng, Zhao Jingfeng, Feng Guang, Zhang Haijun, Li Tao, Li Shanyou, Chen Zequn, Zhao Fan, Yao Dan

2020, 36(6): 484-487. doi: 10.3760/cma.j.cn501120-20190215-00027

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Abstract:
Objective To explore the clinical strategies for preservation of the exposed implant in chronic wounds and wound repair. Methods From January 2016 to January 2019, totally 8 patients (4 males and 4 females, aged 10 to 73 years) sustaining postoperative chronic wounds with exposed implants were admitted to the Fourth Medical Center of PLA General Hospital. There were 2 cases of abdominal patch exposure after abdominal trauma surgery, 2 cases of titanium plate exposure post craniocerebral surgery, 3 cases of internal fixator exposure post orthopedic surgery, and 1 case of cerebrospinal fluid drainage tube exposure after craniocerebral surgery. The wound exudate was collected for bacterial culture on admission. On the basis of glycemic control and correction of anemia and hypoproteinemia, thorough wound debridement was performed as soon as possible and the wound area after debridement ranged from 2.0 cm×0.5 cm to 6.0 cm×5.0 cm. The wounds of 4 patients were immediately closed after debridement, including 1 case by primary closure, 1 case by primary closure after local filling of platelet rich plasma gel, and 2 cases by local flap transplantation, with flap size of 10.0 cm×8.0 cm and 12.0 cm×8.0 cm, respectively. The donor sites of flaps were sutured directly and all the incisions were treated with continuous vacuum sealing drainage (VSD) after surgery. The other 4 patients were treated with continuous VSD after debridement to improve the wound bed. The wound of 1 case healed gradually, 1 case received direct wound suturing, and the wounds of 2 cases were repaired with thin split-thickness skin grafts from the thigh or the head. The results of bacterial culture of wound exudate on admission, wound healing post surgery, and follow-up were observed and recorded. Results The bacterial culture of wound exudate on admission was positive in 6 patients, and 10 strains of bacteria were isolated with Staphylococcus epidermidis as the main pathogen. All the skin grafts or flaps of patients survived post surgery, with the incisions and wounds healed and all the implants preserved. After 1 to 3 years of follow-up, no recurrence of wound was found in any patient. Conclusions The postoperative chronic wounds with exposed implants can be closed in primary stage by direct suturing or flap transplantation if it is clean enough on the basis of thorough debridement. The wounds with large defects or serious infection can be treated with continuous VSD firstly and then closed with direct suturing or skin grafting for delayed wound closure, thereby to reach the treatment goal of preserving the implants and repairing the wounds simultaneously.

Practice of nosocomial infection management in burn department based on the American hospital evaluation standard of the Joint Commission International

Chen Huaqing, Shen Mingyan, Shao Huawei, Han Chunmao

2020, 36(6): 488-492. doi: 10.3760/cma.j.cn501120-20190206-00020

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Abstract:
Objective To explore the role of continuous quality improvement measures based on the American hospital evaluation standard of the Joint Commission International (JCI) in prevention and control of nosocomial infection in Burn Department of the Second Affiliated Hospital of Zhejiang University School of Medicine (hereinafter referred to as the author′ s department). Methods From 2013 to 2018, based on 11 JCI standards related to infection prevention and control and the current situation of the author′ s department, more than 50 doctors, nurses, and nursing assistants from the author′ s department participated in continuous improvement of the three-level management system of nosocomial infection in the author′ s department, focusing on implementing of management of patient with multidrug resistant bacteria infection, optimizing the infection control management of instrument and cloth, and implementing target management on 5 indicators such as hand hygiene implementation rate, and carrying out inspection, quality management, and improvement on 11 items of prevention and control of nosocomial infection. The implementation rate of hand hygiene from 2013 to 2018 and the accuracy rate of hand hygiene from 2016 to 2018 of medical staff in the author′ s department, and incidences of catheter-related bloodstream infection (CRBSI) of central venous, catheter-associated urinary tract infection (CAUTI), and ventilator associated pneumonia (VAP) of burn intensive care unit in the author′s department from 2013 to 2018 were monitored.The following 7 indicators were monitored from 2013 to 2018, including false negative rate of nosocomial infection, incidence of hyperglycemia during intensive insulin treatment for severely burned patients, the implementation rate of CRBSI preventive measures, the specification rate of surface fixation of indwelling catheter, the implementation rate of VAP preventive measures, the accuracy rate of bed temperature during the use of suspended bed, and the implementation rate of hand hygiene of standardized training medical staff in the author′ s department before and after improvement. Data were statistically analyzed with chi-square test. Results The implementation rate of hand hygiene of medical staff in the author′ s department was 88.0%-89.5% from 2013 to 2018, the correct rate of hand hygiene of medical staff in the author′ s department was 95.10%-97.35%, and both reached the target values. The incidences of CRBSI in 2015, VAP in 2017, and CAUTI in 2013, 2014, and 2017 of burn intensive care unit failed to reach the respective target value and reached the respective target value after quality improvement, and the above-mentioned 3 indicators reached the respective target value in other years. From 2013 to 2018, the false negative rate of nosocomial infection and the incidence of hyperglycemia during intensive insulin treatment of severely burned patients in the author′ s department after improvement were significantly lower than those before improvement (χ²=24.50, 4.74, P<0.05 or P<0.01), the implementation rate of CRBSI preventive measures, the specification rate of surface fixation of indwelling catheter, the implementation rate of VAP preventive measures, and the accuracy rate of bed temperature during the use of suspended bed after improvement in the author′ s department were significantly higher than those before improvement (χ²=13.78, 6.50, 20.37, 13.92, P<0.05 or P<0.01), and the implementation rate of hand hygiene of standardized training medical staff in the author′ s department after improvement was similar to that before improvement (χ²=1.71, P>0.05). Conclusions The introduction of JCI standard can improve the implementation rate and accuracy rate of hand hygiene of medical staff in burn department, reduce the incidences of CRBSI, CAUTI, and VAP, and improve the effect of prevention and control of nosocomial infection in burn department.

Clinical application of self-made drainage tubes in different layers of soft tissue for negative-pressure wound therapy in 33 patients