中华烧伤与创面修复杂志

My stories in 60 years′ career of burn medicine

Chen Bi

2018, 34(10): 659-661. doi: 10.3760/cma.j.issn.1009-2587.2018.10.001

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In my 60 years′ career of burn medicine, I worked in rural areas for more than 3 years, such as joining in a touring medical team, saving lives wounded in a flood disaster, marching and camping training, carrying out open-door medical teaching, etc. All these experiences made me set up my medical ethics and enhance my medical skills under tough conditions of lacking medical services and medicines. In addition, I developed the abilities to innovate and refine my treatments for patients based on practical environments.

Review of the 60 years′ development of Jiangxi burn medicine on the 60th anniversary of Chinese burn discipline

Guo Guanghua, Li Guohui

2018, 34(10): 662-664. doi: 10.3760/cma.j.issn.1009-2587.2018.10.002

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This year marks the 60th anniversary of establishment of burn discipline in China and also the 60th anniversary of the development of burn medicine in Jiangxi. This paper reviews the development history of burn discipline in China and development history, present situation, and direction of burn medicine in the future in Jiangxi, in order to provide suggestions for burn medicine in Jiangxi.

Respecting discipline laws and innovating leaping development

Yang Minlie, Lyu Guozhong

2018, 34(10): 665-668. doi: 10.3760/cma.j.issn.1009-2587.2018.10.003

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Under the guidance of the predecessors and the efforts of the whole staff, Department of Burns and Plastic Surgery of Wuxi Third People′s Hospital has grown into a well-known regional burn diagnosis and treatment center in China after about 30 years of development. Summarizing the experience, gain, and loss in the course of department growth, following and attaching importance to the discipline development law, consolidating the foundation, strengthening the skills, and being diligent in innovation are the most important. The future trend of discipline development is as follows: wound treatment is still fundamental, burn emergency treatment system should be further improved, interdisciplinary and multidisciplinary cooperation should be further strengthened, and basic scientific research should have the potential to transform to reality.

Establishment and development of Department of Burns and Plastic Surgery of the Affiliated Hospital of Nankai University (Tianjin No.4 Hospital)

Feng Shihai

2018, 34(10): 669-671. doi: 10.3760/cma.j.issn.1009-2587.2018.10.004

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Tianjin No.4 Hospital is a general hospital featured in burns, and the Department of Burns and Plastic Surgery has six secondary clinical departments with 110 hospital beds. After hard working by several generations, the department has successively developed into a key discipline in Tianjin and Tianjin Burn Emergency Center. Tianjin Burn Research Institute was established in 1992, and then the department became master′s granting unit of Tianjin Medical University. In scientific research aspect, many researches have been completed and obtained important results, such as the mechanism and effect of integrated traditional Chinese and Western medicine in prevention and treatment of intestinal failure, early diagnosis and local treatment with fiberoptic bronchoscope, energy metabolism regularity of burn patients, and the development of irradiated biological dressings. In clinic aspect, tens of thousands of complex wounds and chronic refractory wounds were repaired by various kinds of flaps and advanced methods, and the cure rate of patients with large burn area reached 94.1%. In 2016, Tianjin No.4 Hospital became the Affiliated Hospital of Nankai University. Hereafter, a number of research intentions have collaborated between the department and the State Key Laboratory of Academy of Life Sciences of Nankai University. In the future, our department will focus on improving the treatment level of patients with large burn area, carrying out researches on comprehensive anti-shock in the early stage, inhalation injury treatment, infection treatment, comprehensive treatment of multiple organ failure, wound repair, scar treatment, rehabilitation, and the clinical application.

Reconsideration of burn scar treatment

Huan Jingning

2018, 34(10): 672-676. doi: 10.3760/cma.j.issn.1009-2587.2018.10.005

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Since the mechanisms of scar formation are not fully understood, at least to date, there is no ideal method to prevent and treat scar after burn. In recent years, on the basis of conventional treatments, such as pressure therapy, external use of silicone gel, and intralesional injections of corticosteroids, the therapeutic approaches of fractional carbon dioxide laser treatment, injection of anti-vascular endothelial growth factor antibody, autologous fat transplantation, injection of botulinum toxin A, radiation therapy etc., have been gradually applied to treat burn scars. It is very important to select various methods individually and comprehensively according to the specific conditions of patients and scars. Meanwhile, it is necessary to continue to study and explore the possibility of targeted therapy in scar management.

Application effects of CT angiography and three-dimensional reconstruction technique in repairing scar around the mouth and chin with expanded forehead axial flap

Xia Chengde, Xue Jidong, Di Haiping, Han Dawei, Cao Dayong, Li Qiang, Jing Fuqin, Niu Xihua

2018, 34(10): 677-682. doi: 10.3760/cma.j.issn.1009-2587.2018.10.006

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Objective To explore application effects of CT angiography (CTA) and three-dimensional reconstruction technique in repairing scar around the mouth and chin with expanded forehead axial flap. Methods From June 2013 to October 2017, 9 patients with hyperplastic scar around the mouth and chin after deep burns on face were admitted to our unit. The sizes of scars of patients ranged from 8 cm×7 cm to 13 cm×8 cm. One cylindrical skin soft-tissue dilator with nominal volume of 400 to 500 mL was implanted in forehead area of each patient. Five to six months after the dilator was implanted, scar around the mouth and chin was resected, and the dilator was removed. The secondary wound after scar resection was repaired by expanded forehead axial flap with bilateral superficial temporal vessel pedicles. Three of the nine patients received microstomia diorthosis at the same time. Before the operation, CTA and three-dimensional reconstruction were applied to obtain three-dimensional images of superficial temporal arteries and the branches in the donor site, which could identify the travel, adjacent location, and vascular anastomosis of the above-mentioned vessels to guide flap design. The sizes of flaps of patients ranged from 25 cm×9 cm to 30 cm×8 cm. Two to three weeks after the operation, flap pedicles were cut off, restored, and trimmed. The donor site was sutured directly. Ten to twelve days after the flap repair operation, the flap site received depilation treatment with semiconductor freezing point laser once a month for 4 to 6 times. Results Flaps of all patients survived well, with no blood circulation disorder. The flaps of three patients were slightly bulky, while they were with natural appearance after flap thinning operation in 3 months post flap repair operation. During follow-up of 6 months to 2 years after the operation, color, texture, and thickness of the flaps were close to normal skin around scars. The appearance of perioral and mental region, and opening function of mouth improved significantly, with no recurrence of scar. Frontotemporal incision was hidden, hair on head grew normally, and reconstructed hairline was natural. Conclusions Scar around the mouth and chin repaired with expanded forehead axial flap were with good appearance and function in operation area and good shape in donor site. CTA and three-dimensional reconstruction technique can provide clear three-dimensional images of superficial temporal arteries and the branches in expanded forehead axial flaps, which can provide reliable basis for preoperative designing of flap, reduce operative risk, and improve survival rate of flap, thus having clinical application value.

Effects of N-(4-hydroxyphenyl) retinamide lipid microbubble combined with ultrasound on human keloid fibroblasts

Wang Mengjiao, Fang Yuhui, Jin Chenglong, Jin Zhehu

2018, 34(10): 683-689. doi: 10.3760/cma.j.issn.1009-2587.2018.10.007

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Objective To explore the effects of N-(4-hydroxyphenyl) retinamide (4HPR), 4HPR liposome (4HPR-L), and 4HPR lipid microbubble (4HPR-LM) combined with ultrasound on proliferation, apoptosis, and cell cycle of human keloid fibroblasts (Fbs). Methods (1) 4HPR-L and 4HPR-LM were prepared by hydration ultrasonic method. The appearance morphology, particle size distribution, Zeta potential, loading drug concentration, encapsulation efficiency, and drug loading rate of 4HPR-L were investigated by high performance liquid chromatography, dynamic light scattering, and transmission electron microscope. (2) Human keloid Fbs were cultured and divided into 13 groups by random number table (the same grouping method below), with 6 wells in each group. Cells in control group were given no treatment, while cells in 12 ultrasound groups including 0.5 W 30 s group, 0.5 W 60 s group, 0.5 W 120 s group, 0.7 W 30 s group, 0.7 W 60 s group, 0.7 W 120 s group, 1.0 W 30 s group, 1.0 W 60 s group, 1.0 W 120 s group, 1.5 W 30 s group, 1.5 W 60 s group, and 1.5 W 120 s group were treated by ultrasound with corresponding parameters. The cells viability was measured by a microplate reader after 24 hours of routine culture. Another batch of human keloid Fbs were divided into 5 groups, with 6 wells in each group. Cells in control group were given no treatment, while cells in 1, 10, 20, and 50 μg/mL blank lipid microbubble groups were treated with blank lipid microbubbles in corresponding mass concentration. The cells viability was measured as before after 24 hours of routine culture. Another batch of human keloid Fbs were divided into 6 groups, with 12 wells in each group. Cells in control group were given no treatment, while cells in 1, 10, 20, 50, and 100 μg/mL 4HPR-L groups were added with 4HPR-L carrying corresponding mass concentration of 4HPR. The cells viability in 6 wells of each group was detected after 24 and 48 hours of routine culture, respectively. Another batch of human keloid Fbs were divided into 4 groups, with 6 wells in each group. Cells in control group were given no treatment, while cells in 4HPR, 4HPR-L, and 4HPR-LM+ ultrasound groups were treated with 4HPR, 4HPR-L, and 4HPR-LM (all the mass concentration of 4HPR was 20 μg/mL), respectively, and cells in 4HPR-LM+ ultrasound group were given 0.5 W 60 s ultrasound treatment immediately after drug administration. The cells viability was measured as before after 24 hours of routine culture. (3) Another batch of human keloid Fbs were divided into control group, 4HPR group, 4HPR-L group and 4HPR-LM+ ultrasound group, with 3 wells in each group, and the cells in each group were treated as before. Apoptosis of the cells was detected by flow cytometer after 24 hours of routine culture. (4) Another batch of human keloid Fbs were grouped and treated as in (3), and then the cell cycle distribution was detected by flow cytometer after 24 hours of routine culture. Data were processed with one-way analysis of variance and t test. Results (1) 4HPR-L particles had a spherical or spheroidal structure and were uniform in size, with particle size of (100.1±1.3) nm and Zeta potential of (-34.3±2.3) mV. The mass concentration of 4HPR in 4HPR-L solution was about 1 400 μg/mL, with the encapsulation efficiency of (95.8±1.2)% and drug loading rate of (8.3±0.4)%. (2) The viability of cells in the 12 ultrasound groups was higher than 93.0%, and the viability of cells in 1, 10, 20, and 50 μg/mL blank lipid microbubble groups was higher than 95.0%. The viability of cells in 1 μg/mL 4HPR-L group at administration hour 24 was similar to that at 48 (t=0.393, P>0.05). The viability of cells in 10, 20, 50, and 100 μg/mL 4HPR-L groups at administration hour 24 was significantly higher than that at administration hour 48 (t=44.593, 22.961, 32.224, 35.337, P<0.01). The viability of cells in 4HPR group, 4HPR-L group, and 4HPR-LM+ ultrasound group was (47.3±0.7)%, (42.3±1.7)%, and (38.6±0.8)%, respectively. The viability of cells in 4HPR group was significantly higher than that in 4HPR-L group and 4HPR-LM+ ultrasound group (t=4.551, 15.895, P<0.05 or P<0.01). The viability of cells in 4HPR-L group was significantly higher than that in 4HPR-LM+ ultrasound group (t=-3.360, P<0.05). (3) The percentages of total apoptotic cells in 4HPR group, 4HPR-L group, and 4HPR-LM+ ultrasound group were (32.8±2.4)%, (42.5±2.4)%, and (58.5±6.3)%, respectively, which were significantly higher than the percentage of control group [(14.9±1.6)%, t=8.748, 13.637, 9.500, P<0.01]. The percentages of total apoptotic cells in 4HPR-L group and 4HPR-LM+ ultrasound group were significantly higher than the percentage in 4HPR group (t=4.049, 5.393, P<0.05 or P<0.01), and the percentage of total apoptotic cells in 4HPR-LM+ ultrasound group was significantly higher than that in 4HPR-L group (t=3.371, P<0.01). (4) The percentage of G2/M phase cells in 4HPR group was higher than that in control group, but there was no statistically significant difference (t=2.107, P>0.05). The percentage of G2/M phase cells in 4HPR-L group was significantly higher than that in 4HPR group or control group (t=18.169, 30.026, P<0.01). The percentage of G2/M phase cells in 4HPR-LM+ ultrasound group was significantly higher than that in 4HPR-L group, 4HPR group, and control group (t=4.932, 25.854, 66.231, P<0.01). Conclusions 4HPR can inhibit proliferation, induce apoptosis, and arrest G2/M phase of human keloid Fbs, and the effects of 4HPR-LM combined with ultrasound are better than those of 4HPR-L and free 4HPR.

Research on the correlation between mechanical signaling molecules of hypertrophic scar and post injury time in burn patients in scar remodeling stage

Zhang Yuting, Li Pan, Luo Lun, Li-Tsang Cecilia W. P.

2018, 34(10): 690-695. doi: 10.3760/cma.j.issn.1009-2587.2018.10.008

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Objective To analyze the correlation between integrin β₁, focal adhesion kinase (FAK), extracellular signal-regulated kinase 1/2 (ERK1/2) of hypertrophic scar (HS) and post injury time in burn patients in scar remodeling stage. Methods Thirty-four patients with 34 HS specimens admitted to Department of Burns and Plastic Surgery of Chengdu No.2 Hospital and Institute of Burn Research of the First Affiliated Hospital of Army Medical University (originally the Third Military Medical University) from May 2013 to April 2016 were recruited by convenient sampling method, and normal skin specimens were obtained from donor sites of another 6 patients from the above-mentioned departments who had scar resection and skin grafting for this cross-sectional and observational study. Vancouver Scar Scale (VSS) was used to assess the height, vascularity, pigmentation, and pliability of scars. Diasonograph was used to assess scar thickness. Immunohistochemical method was used to observe the expressions of integrin β₁, FAK, and ERK1/2 in dermis and epidermis of scar and normal skin. Correlations between the post injury time and the scar thickness, the post injury time and the expressions of integrin β₁, FAK, and ERK1/2 in epidermis of scar, the post injury time and the expressions of integrin β₁, FAK, and ERK1/2 in dermis of scar, the expressions of integrin β₁, FAK, and ERK1/2 in dermis and those in epidermis of scar were analyzed by Pearson correlation analysis. Locally estimated scatterplot smoothing curve fitting line was used to demonstrate the non-linear regression relationship between the expressions of integrin β₁, FAK, and ERK1/2 in dermis and those in epidermis of scar, the scar thickness and the post injury time. Results (1) The total VSS score of scars of patients was (8.3±2.3) points, with height scored (2.2±0.7) points, vascularity scored (2.0±0.8) points, pigmentation scored (2.3±0.7) points, and pliability scored (1.9±0.7) points. The thickness of scar was (2.8±1.1) mm. (2) The expressions of integrin β₁, FAK, and ERK1/2 in dermis and epidermis of scar were more than those in normal skin. (3) There was significantly positive correlation between the scar thickness and the post injury time (r=0.39, P<0.05). There was significantly positive correlation between the expression of integrin β₁ in epidermis of scar and the post injury time (r=0.33, P<0.05). There were no significantly correlations between the expressions of FAK and ERK1/2 in epidermis of scar and the post injury time (r=-0.03, -0.04, P>0.05). There was significantly negative correlation between the expression of FAK in dermis of scar and the post injury time (r=-0.34, P<0.05). There were no significantly correlations between the expressions of integrin β₁ and ERK1/2 in dermis of scar and the post injury time (r=0.07, -0.23, P>0.05). There were significantly positive correlation between the expressions of integrin β₁, FAK, and ERK1/2 in dermis and those in epidermis of scar (r=0.70, 0.60, 0.64, P<0.01). (4) The expressions of integrin β₁, FAK, and ERK1/2 in dermis and epidermis of scar were changed from downtrend in 1 to 2 months post injury to uptrend in 2 to 3 months post injury, which reached the peak around 3 to 4 months post injury. Hereafter the expressions of mechanical signaling molecules in epidermis of scar were gradually declined, while the expressions of mechanical signaling molecules in dermis of scar were at a quite high level within half a year post injury. Scar thickness was steadily increased after 1 month post injury. Conclusions In scar remodeling stage of burn patients, the HS thickness increases continuously along with the increasing post injury time in the early stage of scar formation. The vulnerability of integrin β₁, FAK, and ERK1/2 of HS to external mechanical stimuli increases gradually within 4 months post injury.

Epidemiological investigation on 1 946 hospitalized pediatric patients with burns

He Shan, Zuo Zelan

2018, 34(10): 696-700. doi: 10.3760/cma.j.issn.1009-2587.2018.10.009

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Objective To investigate the epidemiological characteristics of hospitalized pediatric patients with burns and explore the prevention and treatment strategy of pediatric burns. Methods Medical records of pediatric burn patients hospitalized in multiple departments of Children′s Hospital of Chongqing Medical University from January 2012 to December 2016 were retrospectively analyzed. Data including gender, age, residence, ways of paying, total burn area, burn severity, cause, time, and place of burns, prehospital treatment ways, clinical outcome, length of hospital stay were collected and processed with chi-square test, Kruskal-Wallis H test, and Bonferroni correction. The factors which influence wound healing were processed with multivariate logistic regression analysis. Results (1) A total of 1 946 pediatric burn patients with complete medical records were hospitalized in Children′s Hospital of Chongqing Medical University during the 5 years, with 1 127 boys (57.91%), which were more than 819 girls (42.09%). Pediatric patients≤3 years old were with the highest incidence of burns of 87.15% (1 696/1 946). There was no significantly statistical difference in gender composition ratio among pediatric patients of different ages (χ²=2.294, P= 0.318). (2) The residence of 1 536 pediatric patients (78.93%) were in town, and most of them used urban resident essential medical insurance for medical cost. Most of the pediatric patients living in rural areas paid the medical cost at their own expense. There was significantly statistical difference in way of paying between pediatric patients living in urban and those in rural areas (χ²=658.324, P<0.05). (3) The pediatric patients with total burn surface area≥5% total body surface area (TBSA) and<15% TBSA were the most (1 200 cases, accounting for 61.66%). The pediatric patients with moderate burns were the most (1 225 cases, accounting for 62.95%), followed by mild burns (494 cases, accounting for 25.39%), severe burns (124 cases, accounting for 6.37%), and extremely severe burns (46 cases, accounting for 2.36%). (4) The pediatric patients with scald caused by hot water were the most (1 801 cases, accounting for 92.55%), followed by flame burns (69 cases, accounting for 3.55%), chemical burns (44 cases, accounting for 2.26%), and electrical burns (32 cases, accounting for 1.64%). There was significantly statistical difference in cause of injury among pediatric patients of different ages (χ²=85.471, P<0.05). (5) The incidence of burns of pediatric patients in Spring was 27.95% (544/1 946), which was slightly higher than those in other seasons. There was significantly statistical difference in the burn season among pediatric patients admitted to the hospital in different years (χ²= 23.172, P< 0.05). As to burn place, most of burns of pediatric patients happened at home (1 776 cases, accounting for 91.26%). (6) There was significantly statistical difference in clinical outcome among pediatric patients with different prehospital treatments (H=16.005, P<0.05). There was significantly statistical difference in clinical outcome between pediatric patients with reasonable prehospital treatments and those with unreasonable prehospital treatments (H=-64.990, P<0.05), and between pediatric patients with reasonable prehospital treatments and those without any treatment (H=-74.775, P<0.05). There was no significantly statistical difference in clinical outcome between pediatric patients with unreasonable prehospital treatments and those without any prehospital treatment (H=-9.785, P>0.05). (7) The median of length of hospital stay of pediatric patients was 8 days. The pediatric patients with length of hospital stay≤7 days were the most (834 cases, accounting for 42.86%), and the pediatric patients with length of hospital stay>30 days were the least (39 cases, accounting for 2.00%). (8) The way of prehospital treatment and cause of injury were independent risk factors influencing wound healing (χ²=7.946, 12.977, P<0.05). With no prehospital treatment as benchmark, reasonable prehospital treatments promoted wound healing (odds ratio=1.662, 95% confidence interval=1.129-2.447, P<0.05). With chemical burns as benchmark, electrical burn wounds were harder to heal (odds ratio=0.144, 95% confidence interval=0.028-0.734, P<0.05). Conclusions Pediatric burn patients hospitalized in Children′s Hospital of Chongqing Medical University were mainly boys≤3 years old with moderate scald caused by hot water at home in urban areas. Timely and reasonable prehospital treatments are beneficial to wound healing.

Observation on the effects of multidisciplinary comprehensive intervention in integrated treatment of patients with extremely severe burns

Zhou Qin, Wang Qing, Li Shuangshuang, Lu Ying, Wang Xue, Zhang Rui, Chen Yuan, Shi Xueqin, Jiao Xiaochun, Hu Dahai

2018, 34(10): 701-706. doi: 10.3760/cma.j.issn.1009-2587.2018.10.010

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Objective To explore the effects of multidisciplinary comprehensive intervention in integrated treatment of patients with extremely severe burns. Methods One hundred and ten patients hospitalized in our center from July 2013 to August 2017 met the criteria for inclusion in this study, and their medical records were retrospectively analyzed. According to the medical model at that time, 56 patients hospitalized from July 2013 to July 2015 received routine comprehensive treatment led by doctors, and they were included in the conventional intervention group. From August 2015 to August 2017, 54 patients were treated with integrated multidisciplinary interventions performed by a team consisting of physicians, intensive care nurses, burn nurses, intravenous infusion nurses, wound stoma nurses, and rehabilitation therapists, and they were included in the integrated intervention group. Acute Physiological and Chronic Health Assessment Ⅱ (APACHE Ⅱ) scores on admission and 4 weeks after treatment, incidences of pressure injury, wound sepsis, lung infection, and catheter-related infection during hospitalization, length of stay in intensive care unit (ICU) and total length of hospital stay, and Abbreviated Burn Specific Health Scale (BSHS-A) scores at discharge and 3 months after discharge were analyzed. Data were processed with t-test and chi-square test. Results The APACHE Ⅱ scores of patients in the two groups were close on admission (t=0.573, P>0.05). Four weeks after treatment, the APACHE Ⅱ scores of patients in the two groups were obviously lower than those on admission within the same group (t=5.697, 4.853, P<0.01), and the score of the integrated intervention group was obviously lower than that of the conventional intervention group (t=2.170, P<0.05). No pressure injury was observed in patients of any group during hospitalization. The incidences of wound sepsis, lung infection, and catheter-related infection of patients in the integrated intervention group were 18.5% (10/54), 3.7% (2/54), and 9.3% (5/54), respectively, significantly lower than 42.9% (24/56), 21.4% (12/56), and 26.8% (15/56) of the conventional intervention group, χ²=4.073, 6.075, 3.962, P<0.05. The length of stay in ICU of patients in the integrated intervention group was (50±5) d, obviously shorter than (62±4) d of the conventional intervention group (t=2.852, P<0.01). The total length of hospital stay of patients in the integrated intervention group was (115±8) d, obviously shorter than (140±7) d of the conventional intervention group (t=16.885, P<0.01). At discharge and 3 months after discharge, the scores of BSHS-A, physical function, psychological function, and general health status of 50 patients in the integrated intervention group were significantly higher than those of 48 patients in the conventional intervention group (t=2.886, 3.126, 2.416, 2.544, 2.033, 3.471, 2.588, 2.210, P<0.05 or P<0.01), while the scores of social function of patients in the two groups were close (t=1.570, 1.350, P>0.05). Conclusions Integrative treatment of patients with extremely severe burns by multidisciplinary comprehensive intervention can significantly alleviate the severity of burns, reduce the incidences of wound sepsis, lung infection, and catheter-related infection, shorten the length of stay in ICU and total length of hospital stay, and improve the quality of life.

Study on the application of dexmedetomidine combined with remifentanil in dressing change of conscious patients with non-intubation in burn intensive care unit

Yang Zhibin, Shen Jiangyong, Mi Kede, Ma Qiang, Wu Yinsheng, Yao Ming

2018, 34(10): 707-713. doi: 10.3760/cma.j.issn.1009-2587.2018.10.011

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Objective To observe the analgesic and sedative effect and safety of application of dexmedetomidine combined with remifentanil in dressing change of conscious patients with non-intubation in burn intensive care unit. Methods Forty patients conforming to the study criteria hospitalized in our burn intensive care unit from April 2015 to April 2017 were selected. Prospective, randomized, and double-blind method was used for the design. Patients were divided into dexmedetomidine group and dexmedetomidine+ remifentanil group according to the random number table, with 20 cases in each group. Patients in the two groups were respectively given corresponding drugs during dressing change. The frequency and time of dressing change, Verbal Rating Scale (VRS) score of patients during dressing change (at drug administration for 25 minutes) and after dressing change (25 min after dressing change), Ramsay Sedation Score (RSS) during dressing change, satisfaction level for anesthesia of the patients and physicians after dressing change, dosage of remifentanil, and various adverse effects during and after dressing change were recorded. The heart rate, mean arterial blood pressure (MAP), respiratory rate, and pulse oxygen saturation (SpO₂) before drug administration and at 10, 15, and 25 minutes after drug administration were also recorded. Data were processed with analysis of variance for repeated measurement, t test, chi-square test, and Fisher′s exact probability test. Results (1) Totally 38 patients completed the trial. There were no statistically significant differences between patients in two groups in gender, American Association of Anesthesiologist Grading, age, weight, and total burn area (χ²=0.230, 0.146, t=0.224, 0.351, 0.367, P>0.05). (2) The frequency of dressing change of patients in two groups were both 48 times. The time of dressing change and VRS scores during dressing change of patients in two groups were similar (t=0.821, 1.522, P>0.05). The VRS score of patients in dexmedetomidine+ remifentanil group after dressing change was (3.1±0.4) points, obviously lower than (3.8±0.8) points in remifentanil group (t=2.213, P<0.05). The RSS, satisfaction level scores for anesthesia of the patients and physicians after dressing change in dexmedetomidine+ remifentanil group were (3.13±0.32), (3.44±0.41), and (3.13±0.25) points, respectively, obviously better than (1.82±0.24), (2.71±0.23), (2.53±0.41) points in remifentanil group (t=2.226, 2.684, 7.702, P<0.01). The dosage of remifentanil of patients in dexmedetomidine+ remifentanil group was (282±19) μg, obviously less than (340±31) μg in remifentanil group (t=9.896, P<0.01). There were no statistically significant differences between patients in two groups in rates of respiratory inhibition and hypotension (χ²=0.211, 0.154, P>0.05). Compared with those in remifentanil group, the rates of nausea, vomiting, and other gastrointestinal symptoms of patients in dexmedetomidine+ remifentanil group were obviously reduced (P<0.05), but the rate of bradycardia was obviously increased (χ²=6.008, P<0.05). (3) There were no statistically significant differences between patients in two groups in heart rate, MAP, respiratory frequency, and SpO₂ before drug administration (t=0.444, 0.892, 1.059, 1.039, P>0.05). The heart rates of patients in dexmedetomidine+ remifentanil group at 10, 15, and 25 minutes after drug administration were (83±11), (78±10), and (82±14) times per minute, respectively, significantly lower than (95±10), (87±12), and (89±12) times per minute in remifentanil group (t=5.592, 3.992, 2.630, P<0.05 or P<0.01). The MAP of patients in dexmedetomidine+ remifentanil group at 15 and 25 minutes after drug administration were (69.4±3.1) and (73.8±2.2) mmHg (1 mmHg=0.133 kPa), respectively, significantly lower than (75.4±3.0) and (78.1±3.5) mmHg in remifentanil group (t=9.181, 7.206, P<0.01). There were no statistically significant differences between patients in two groups in respiratory frequency at each time point after drug administration (t=1.489, 1.862, 1.963, P>0.05). The SpO₂ of patients in dexmedetomidine+ remifentanil group at 15 minutes after drug administration was 0.972±0.018, obviously lower than 0.979±0.015 in remifentanil group (t=2.070, P<0.05). Conclusions Application of remifentanil with small dosage has effective analgesia for conscious burn patients with non-intubation during dressing changes, however, adverse effects such as nausea and vomiting are likely to occur. Remifentanil combined with dexmedetomidine not only guarantee the analgesic effect, but also reduce the dosage of analgesics, improve the sedative effect and satisfaction of the patients for anesthesia, and reduce various adverse effects. However, it will increase the incidence of bradycardia and has some inhibition effect on circulation at the same time.

Effects of minimally invasive tangential excision in treating deep partial-thickness burn wounds on trunk and limbs in pediatric patients in the early stage post burn

Li Feng, Chi Yunfei, Hu Quan, Yin Huinan, Liu Wei, Chen Qi, Zhang Qinxue, Chen Xin, Cao Feichao, Liang Zhanling, Sun Yingjie

2018, 34(10): 714-718. doi: 10.3760/cma.j.issn.1009-2587.2018.10.012

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Objective To observe the effects of minimally invasive tangential excision in treating deep partial-thickness burn wounds on trunk and limbs in pediatric patients in the early stage post burn. Methods Clinical data of 40 children with deep partial-thickness burn wounds on trunk and limbs, admitted to our burn ward from January 2016 to June 2017, conforming to the study criteria, were retrospectively analyzed. They were divided into conventional treatment group (CT, n=19) and minimally invasive tangential excision group (MITE, n=21) according to the different treatments. The patients in group CT were treated with eschar-reserving therapy firstly. When tangential excision was performed, the roller knife was used, and no necrotic tissue left on the wound bed was considered the proper depth of excision. Razor-thickness skin grafting was performed to cover the wound when adipose tissue exposed markedly after tangential excision. Dressing change was performed within 48 h after the operation and repeated every 2 days. Unhealed wounds were covered by razor-thickness skin grafting. The patients in group MITE were treated with tangential excision in the early stage post burn. The tangential excision was operated with electric dermatome, and the thickness was set at 0.1 mm to excise the surface of eschar until the sporadic punctate hemorrhage on wound surface was observed and some necrotic tissue was left on the wound bed. Porcine acellular dermal matrix was applied after tangential excision. The first dressing change was often performed about 1 week after the operation. Razor-thickness skin grafting was performed to cover the unhealed wounds. The length of wound healing, high fever, antibiotic usage, and hospital stay, times of later operation, and hospitalization expenses of patients in the 2 groups were recorded. The excisional eschar and wound bed tissue of patients in group MITE were harvested for pathological observation. Data were processed with t test and Fisher′s exact probability test. Results (1) There were no statistically significant differences in length of high fever and length of hospital stay and hospitalization expenses between patients in the 2 groups (t=-1.67, -1.93, 0.31, P>0.05). The lengths of wound healing [(24.8±2.5) d] and antibiotic usage [(4.4±0.7) d] of patients in group MITE were significantly shorter than those in group CT [(33.3±2.5) and (7.0±0.7) d, t=-2.44, -2.44, P<0.05], and times of later operation of patients in group MITE [(0.29±0.14) times] were significantly less than those in group CT [(0.79±0.21) times, t=-2.03, P<0.05]. (2) The thickness of the excisional eschar of patients in group MITE was about 150 μm. The eschar has epidermis and upper dermis. Some necrotic tissue was left on the wound bed. Conclusions The treatment for pediatric deep partial-thickness burn wounds on trunk and limbs with minimally invasive tangential excision using electric dermatome in the early stage post burn can accelerate wound healing, shorten length of antibiotic usage, and reduce times of later operations.

Effects of human erythropoietin on transforming growth factor β1/Smad3 signal transduction pathway in acute wounds of rats

Lyu Dalun, Xu Shujuan, Chen Lei, Ding Wei, Wang Heli, Zhang Wei, Wang Shuai, Xu Xiang

2018, 34(10): 719-726. doi: 10.3760/cma.j.issn.1009-2587.2018.10.013

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Objective To explore the effects of human erythropoietin (hEPO) on healing related transforming growth factor β₁ (TGF-β₁)/Smad3 signal transduction pathway in acute wounds of rats. Methods Seventy-two healthy Sprague Dawley rats were divided into normal saline control group, low dose group, middle dose group, and high dose group according to the random number table, with 18 rats in each group, after round acute wounds with diameter of 2.5 cm were inflicted on the back of rats. Rats in the 4 groups had debridement routinely. Wounds of rats in normal saline control group were covered by gauzes infiltrated with 1 mL normal saline, while wounds of rats in low dose group, middle dose group, and high dose group were respectively covered by gauze infiltrated with 1 mL hEPO in doses of 50, 100, and 150 U every day, and then the wounds were bandaged with 6 layers of dry gauze. Dressing change was performed once every day. On treatment day (TD) 3, 7, and 14, 6 rats from each group were taken for general observation and calculation of wound healing rate. Then the wound tissue samples were harvested after the rats were sacrificed for observation of expressions of CD31 and transforming growth factor β₁ (TGF-β₁) with immunohistochemical method. Protein expression of phosphorylated Smad3 of the wound tissue of 3 rats were detected by Western blotting. Data were processed with analysis of variance of factorial design, one-way analysis of variance, least-significant difference test, and Bonferroni correction. Results (1) On TD 3, obvious exudation and scab were observed in the wounds of rats in the 4 groups. On TD 7, the wounds of rats in low dose group, middle dose group, and high dose group were reduced compared with those in normal saline control group. On TD 14, all wounds of rats in the 4 groups were healed. On TD 7, the wound healing rates of rats in middle dose group and high dose group were significantly higher than the rate in normal saline control group (P<0.01). At the other time points, the wound healing rates of rats in the 4 groups were close (P>0.05). (2) CD31 mainly expressed in blood vessels. Except for those in low dose group on TD 3 and 7 (P>0.05), the expressions of CD31 in wound tissue of rats in low dose group on TD 14 and in middle dose group and high dose group on TD 3, 7, and 14 were significantly higher than those in normal saline control group (P<0.01). Except for those on TD 3 (P>0.05), the expressions of CD31 in wound tissue of rats in middle dose group and high dose group on TD 7 and 14 were significantly higher than those in low dose group (P<0.01). Except for that on TD 3 (P>0.05), the expressions of CD31 in wound tissue of rats in high dose group on TD 7 and 14 were significantly higher than those in middle dose group (P<0.01). (3) Except for that in low dose group on TD 3 (1.9±0.7, P>0.05), the expressions of TGF-β₁ in wound tissue of rats in low dose group on TD 7 and 14 (3.3±1.0, 3.7±0.7), and in middle dose group and high dose group on TD 3, 7, and 14 (3.3±1.0, 3.6±1.0, 3.9±0.9, 3.4±0.7, 3.8±0.8, 4.2±0.4) were significantly higher than those in normal saline control group (1.7±0.5, 2.7±1.0, 3.0±0.9, P<0.01). Except for those on TD 7 (P>0.05), the expressions of TGF-β₁ in wound tissue of rats in middle dose group and high dose group on TD 3 and 14 were significantly higher than those in low dose group (P<0.01). Except for that on TD 14 (P<0.01), the expressions of TGF-β₁ in wound tissue of rats in high dose group on TD 3 and 7 were close to those in middle dose group (P>0.05). (4) Except for those in low dose group on TD 3 and 14 and in middle dose group and high dose group on TD 14 (P>0.05), the protein expressions of phosphorylated Smad3 in wound tissue of rats in the 3 groups at the other time points were significantly higher than those in normal saline control group (P<0.01). Except for those on TD 14 (P>0.05), the protein expressions of phosphorylated Smad3 in wound tissue of rats in middle dose group and high dose group on TD 3 and 7 were significantly higher than those in low dose group (P<0.01). Except for that on TD 14 (P>0.05), the protein expressions of phosphorylated Smad3 in wound tissue of rats in high dose group on TD 3 and 7 were significantly lower than those in middle dose group (P<0.01). Conclusions Exogenous hEPO can increase the expressions of CD31, TGF-β₁, and phosphorylated Smad3 in acute wounds of rats, promote angiogenesis of wounds, and activate TGF-β₁/Smad3 signal transduction pathway to promote wound healing.

One patient with chronic refractory wound caused by bamboo sticks in lower leg

Li Debao, Zhang Zhijia, Tian Hengjin

2018, 34(10): 727-728. doi: 10.3760/cma.j.issn.1009-2587.2018.10.014

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One patient with chronic refractory wound in right lower leg was admitted to our department in June 2017, which experienced repeated ulceration for 4 years. On 4 days post admission, two bamboo sticks were taken out from the deep muscle of the right lower leg. The wound was repaired by perforator flap of posterior tibial artery in the right lower leg. The donor site was covered with split-thickness skin in the upper leg of the same side. On 7 days post operation, the flap and skin graft survived. During follow-up of 12 months, the flap had good appearance. This case suggests that the first thing for the treatment of chronic refractory wound is to find out the cause of wound.

Surgical correction of contractural arachnodactyly deformity of a child with Marfan syndrome

Xia Zhou, Qiu Wei, Xu Youxin, Zhao Ya′nan

2018, 34(10): 728-730. doi: 10.3760/cma.j.issn.1009-2587.2018.10.015

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A Marfan syndrome child with contractural arachnodactyly deformity of both hands was admitted to our unit in June 2015. The left and right middle fingers and ring fingers of the child received the continuous " Z" skin flap and " V-Y" plasty to reduce the palmar tension on the skin and release the contracture. Due to the improper therapeutic strategy and the underestimation of effect of underlying lesions of Marfan syndrome on the therapeutic strategy, the right middle finger of child was with ischemic necrosis and amputated, and the finger tip was accompanied with distension and paroxysmal neuropathic pain at a specified future date. The skin flaps of the other three surgical fingers were with local necrosis and scar healing. The child was complicated by distal interphalangeal joints stiffness and some serious complications post-discharge. Combined with this case, the similar disorders are not recommended to carry out one-stage operation.

Investigation and analysis of the difference between the nursing needs of adult burn patients and nurses′ cognition

Jiang Xiaosheng, Xu Le, Li Lin, Zhang Lingqian

2018, 34(10): 731-735. doi: 10.3760/cma.j.issn.1009-2587.2018.10.016

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Objective To explore the difference between the nursing needs of burn patients and nurses′ cognition in order to adjust the nursing service behavior and improve the nursing quality. Methods The convenience sampling method was adopted to select 400 burn inpatients admitted to the Department of Burns of the 180th Hospital of the People′s Liberation Army from January to September 2017, and 38 nurses from the same department were selected by cluster sampling method. On the day of or the day before hospital discharge after instruction to discharging patients, the self-designed questionnaire was adopted to investigate the nursing needs of patients during hospitalization. The cognitive differences between patients and nurses in the overall level and specific dimensions of nursing needs were compared, and items of the nursing needs of patients which were higher than the cognition of nurses with statistically significant differences were recorded. The five most important nursing needs items considered by both patients and nurses were recorded and compared. Data were processed with independent sample t test. Results The effective recovery rates of questionnaire for patients and nurses were 94.8% (379/400) and 100.0% (38/38), respectively. The total score of patients′ nursing needs was (3.9±0.4) points, which was similar to (4.1±0.5) points of nurses′ cognition of patients′ nursing needs (t=1.611, P>0.05). The scores of patients′ physiological needs and self-esteem needs dimensions were (4.0±0.6) and (3.9±0.6) points, respectively, significantly lower than (4.2±0.4) and (4.3±0.5) points of nurses (t=-2.476, -4.160, P<0.05 or P<0.01). The scores of patients′ safety needs, love and belonging needs, and self-realization needs dimensions were similar to those of nurses (t=0.228, 1.356, -1.010, P>0.05). The scores of the patients in nursing needs items of the introduction of patients in the same room, medical staff accompanying them during the examination, leisure and recreational activities, the theoretical and technical proficiency of nurses, the guidance of anti-scar exercise, and the propaganda of drug knowledge were respectively (4.2±0.9), (3.3±1.2), (4.2±0.9), (4.5±0.7), (4.2±0.9), and (4.0±1.0) points, significantly higher than (3.5±0.9), (2.7±1.0), (3.5±1.3), (4.1±0.8), (3.8±1.0), and (3.6±0.9) points of the nurses (t=4.147, 3.515, 3.374, 3.282, 2.546, 2.265, P<0.05 or P<0.01). The five most important items for patients and nurses were pain nursing, the theoretical and technical proficiency of nurses, treating patients equally, instruction to discharging patients, timely visiting wards and privacy protection, pain nursing, introduction of medical staff, introduction of safety issues, getting the daily expenses listing, respectively. Only pain nursing was the same between patients and nurses. Conclusions There are some differences between burn patients and nurses in the dimensions and items of nursing needs and the most important items of nursing needs. Nursing staff should focus on improving the nursing service items with insufficient cognition, adjusting the service supply, meeting the reasonable needs of patients, and improving the nursing satisfaction of patients.

Problems and suggestions for the application of diagnosis-related groups system in burn surgery

Zhu Hao, Zhao Hongliang, Cui Kangle

2018, 34(10): 736-736. doi: 10.3760/cma.j.issn.1009-2587.2018.10.017

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The diagnostic codes of diagnosis-related groups system used in our country are different from the clinical diagnostic criteria of burns. The author suggests that the diagnostic codes should be improved according to clinical criteria in terms of the total area and depth of burns and inhalation injury, and the diagnosis of burns with related special causes and sites should be added to the clinical criteria.

Advances in the research of application of pulse contour cardiac output monitor technology in patients with large area of burns

Li Yi, Zhou Junli

2018, 34(10): 737-740. doi: 10.3760/cma.j.issn.1009-2587.2018.10.018

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Pulse contour cardiac output (PiCCO) monitor as an invasive monitoring technology has been widely applied to various kinds of critical patients. It can reliably reflect actual hemodynamics of critical patients and monitor parameters such as cardiac output. Fluid resuscitation is of great importance for patients with large area of burns. On account of its easy operation as well as precise and comprehensive parameters, PiCCO has been widely used in circulation monitoring of patients with large area of burns. This article briefly introduces PiCCO monitor technology and reviews its application in fluid resuscitation monitoring, diagnosis and identification of pneumonedema in patients with large area of burns, as well as the new theory and knowledge.

2018 Vol. 34, No. 10

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