By C. Ilja. Concordia College, Austin Texas.

    Integra Integra is a bilayer material: the inner layer is a combination of bovine collagen and glycosaminoglycan chondroitin-6-sulfate; the outer layer is a polysiloxane polymer that functions as a temporary epidermis order aciclovir 400mg without prescription. Integra was developed in the early 1980s by researchers from the Massachusetts General Hospital and Massa- chusetts Institute of Technology order 200mg aciclovir otc, and is now approved by the US Food and Drug Administration for use in life-threatening burns order aciclovir 200mg on line. Early studies of its use found no significant immunoreactivity [21,22], which led to its adoption as a viable temporary wound coverage. Many studies support tout its is for massive burns [23,24], purpura fulminans, neck contracture, burn scars [27,28], and other complex wounds [29–31]. At the University of Washington Burn Center we have used Integra on over 100 patients and have placed it on every part of the body except the face, palms, and soles of the feet. We believe it provides our patients with better long-term skin integrity, pliability, durability, and cosmetic results. Our process for the application of Integra on an excised burn wound is outlined below: 1. Integra is prepared for use in the operating room following the manufac- turers recommendations. It is then meshed 1:1 and applied to an excised bed that is clean and hemostatic. It is imperative that all areas of the bed be able to provide an adequate blood supply to the Integra. The meshed Integra is then applied without opening the interstices of the mesh, and great care is taken to ensure that no wrinkles are present. The sheets of Integra are held in place with staples, then Spandage (Medi-Tech International Corp. Theareasarethencoveredwithgauzedressingsand5%mafenideacetate is applied immediately, and added every 4 h to keep the dressing soaked. Areas where Integra is over joints are splinted with temporary devices that allow the 5% mafenide acetate to be applied. On postoperative day 4, the dressings are removed down to the Span- dage and any fluid under the Integra is expelled. Dressings are changed every 3 days and administration of 5% mafenide acetate continues until autograft is applied. On or about postoperative day 14 Integra is usually ready to be grafted. It will be adherent, have a somewhat contracted appearance, and will have a pink tone of varying degrees throughout. A synthetic, meshed dressing (Conformant, Smith & Nephew, Largo, FL) is used to cover the grafted area and is held in place with staples. Dressings, as described above, with 5% mafenide acetate then cover the Conformant. By postoperative day 7, good graft take is appreciated and range- of-motion exercises are begun. Thinly meshed autograft gives us excellent results with minimal residual mesh pattern, good skin durability, excellent skin pliability, and happy patients (Fig. TREATMENT OF SPECIFIC AREAS OF THE BODY Not all areas of the body are as easy to excise and graft as others. It is fortunate that the perineum and perianal areas are burned infrequently as these are the most Principles of Burn Surgery 151 FIGURE8 Autograft meshed 2:1 placed on the Integra after removal of the Silastic membrane. Integra is an option for wound coverage in all of the areas described below. Posterior Trunk Treatment of the posterior trunks includes the following: Shallow burns are allowed to heal spontaneously.

    How- ever effective aciclovir 800 mg, the hormonal environment of the burn patient causes such a great degree of endogenous lipolysis that the extent to which excess lipid can be utilized in the burned patient is limited buy aciclovir 800 mg visa. Increased peripheral lipolysis results in fatty infiltra- tion of the liver that can be exacerbated by overfeeding and the use of total parenteral nutrition order aciclovir 800 mg line. Released free fatty acids are oxidized for energy and re- esterified to triglycerides in the liver. They are either deposited in the liver or further packaged for transport to other tissues. Liver weight of burn children is increased up to twice that of age- and gender-matched controls. Omega-6 fatty acids, derived from vegetable and animal oils, are metabolized to yield prostaglandin E1 (PGE1) and PGE2, which possess immunosuppressive properties. Omega-3 fatty acids from fish oil are metabolized to yield PGE3, which is immunologically inert. Postburn immunosuppression might be improved by replacing omega-6 with omega-3 fatty acids. ENVIRONMENTAL FACTORS The high latent heat of vaporization of water normally causes large amounts of heat to be dissipated at the surface of the burn wound. This loss of heat is offset by an increased hypermetabolic response by the patient in the form of futile substrate cycling to generate heat. Modification of the patient’s environment by heating allows environmental heat to provide energy for this obligatory water loss, thus reducing the metabolic demand on the patient. In large burns, loss of water can be appreciable, up to 2000 cc/m2 burn/day [40,41]. Thermal equilibrium can be achieved by elevating the external environmental temperature to 30–33 C (thermal neutrality). Given the ability to regulate environmental temperature, the burn-injured patient would select a temperature in the range 28 –38 C to achieve thermal neutrality and minimize metabolic demands on the body. Conversely, attempts to decrease the patient’s temperature with antipyretics merely exacerbate the hypermetabolic response. The metabolic requirements of the patient with burns greater than 40%TBSA is reduced from twice the REE to only 1. Ade- quate analgesia is frequently not achieved for the burn-injured patient. Back- ground pain results from the burn and is accentuated by surgical burn debridement at the recipient site and autograft harvesting. Procedural interventions that are painful for the patient include dressing changes, application of topical antimicro- bial agents, and physiotherapy. Trauma and metabolic requirements can be effec- tively minimized by liberal usage of opioid analgesics such as morphine and fentanyl analogues, sedative agents, and anxiolytics [42a]. Psychological support of the burned patient is crucial in addition to pharmacotherapy. PHYSICAL EXERCISE PROGRAM Accretion of lean muscle mass requires, in addition to a high-carbohydrate diet, a resistance exercise program. Formal supervision of this program by a physiotherapist or occupational therapist is required to direct attention to specific areas requiring greater attention, to prevent and minimize the effects of burn scar contracture and to ensure compliance. A supervised, coordinated 12 week inpa- tient program of resistance exercises has shown 50% greater accretion of lean muscle in patients who completed this program than in patients who followed standard exercise regimens as outpatients (Fig. Exercise programs in burned children undergoing rehabilitation appear to be safe, since children effec- tively dissipate the heat generated during exercise. Children not only show significantly improved peak torque and stamina after undertaking an exercise program but also have notably improved pulmonary function. COMPLICATIONS Localized infection of the burn wound very frequently results in generalized septicemia. Sepsis can markedly increase the metabolic demands in the burned patient. Prevention of infection and sepsis are critical therapeutic manoeuvers to decrease the hypermetabolic response.

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    In some cases surgical intervention is The SSRIs are helpful for neuropsychiatric comorbid required cheap 400 mg aciclovir, but surgical treatment is limited due to the conditions order aciclovir 400 mg with visa, such as depression and panic and anxiety likelihood of postsurgical painful sequelae 400mg aciclovir. Occipital disorders, but generally do not have a strong antimi- nerve injection is effective in treating some attacks, graine influence. Some patients with migraine-related and subcutaneous occipital stimulation has recently headaches benefit from the antidopaminergic influence been reported as anecdotally effective (D. Dodick, of the new neuroleptics,17 although the potential for personal communication, 2002) adverse effects limits their widespread use. Tizanidine, an α-adrenergic agonist, has been shown effective in an adjunctive, preventive role. Numerous uncontrolled studies support effi- cacy, but there is a paucity of control data at this time. Treatment is directed at both the daily or almost daily pain and periodic TABLE 25–3 Recommended 7-Day Prednisone Program* attacks. Because of the likely pr esence of a progres- BREAKFAST LUNCH DINNER sive course, medication overuse, and neuropsychiatric DAY (mg) (mg) (mg) comorbidity in this population, a more comprehensive 1 20 (4 pills) 20 20 approach beyond medications alone21,22 is required. Organic illness must be ruled out with appropriate testing in 6 10 5 (1 pill) 5 patients with frequent or daily headache and in those with neurologic findings (see Table 25–4 later). DIAGNOSTIC TESTING AND Hospitalization is required for many complex patients SECONDARY HEADACHE DISORDERS whose medication misuse or the presence of intractable pain and behavioral/neuropsychiatric More than 300 entities may produce symptoms of symptomatology has reached an intensity and com- headache, many of which mimic the primary plexity that makes outpatient therapy no longer headache disorders. Aggressive and thorough ruling in and ruling out potentially relevant conditions diagnostic assessment is mandatory to either rule out in patients with recurring or persistent headache. Disturbances of CSF pressure, ischemic disease, and allergic conditions must be considered. Table 25–4 HOSPITALIZATION lists diagnostic tests that should be considered in intractable or variant cases. Symptoms are severe and refractory to outpatient Because of the relevance of the cervical spine to the treatment. Premature or excessive use of interventional proce- Confounding medical illness is present. Even more advanced treatments, such as Interrupt daily headache pain with parenteral proto- implantable stimulators, are on the horizon. Physical examination Treat behavioral and neuropsychiatric comorbid Metabolic evaluation conditions. Toxicology (drug screens, etc) A variety of parenteral agents can be used during hos- Standard x-rays pitalization to control attacks, particularly during Neuroimaging CT rebound withdrawal: MRI/MRA/MRV Dihydroergotamine (0. Ketorolac (10 mg IV or 30 mg IM, three times daily) 140 VI REGIONAL PAIN Valproic acid (250–750 mg IV, three times daily) 8. Periaqueductal gray matter dysfunction in Magnesium sulfate (1 g IV, twice daily) migraine: Cause or the burden of illness. PET and MRA findings WHEN TO USE OPIOIDS in cluster headache and MRA in experimental pain. Use in acute situations when other treatments are blind pilot study with parallel groups. Short-lasting primary headaches: Focus on When all else fails following a full range of trigeminal autonomic cephalgias and indomethacin-sensitive headaches. When contraindications to other agents exist 2a Plasticity of 5-HT serotonin receptor in patients with anal- In the elderly or during pregnancy gesic-induced transformed migraine. Nearly 75% of refrac- (serotonin 5-HT1b/1d agonist) in acute migraine treatment: A tory patients placed on daily opioids fail to gain meta-analysis of 53 trials. What matters is not the differences between trip- maintained on opioids demonstrated noncompliant tans, but the differences between patients. Olanzapine 1,27,28 in the treatment of refractory migraine and chronic daily in a significant percentage of patients. Chronic daily headache prophylaxis with tizanidine: A double-blind, placebo-controlled, multicenter outcome study.

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    The used the Children’s Somatization In- ventory safe 800 mg aciclovir, which assesses the frequency and severity of a comprehensive set of physical complaints aciclovir 200 mg for sale, to compare children in Nashville with a large group of 10- to 12-year-olds in Kyiv discount aciclovir 200mg free shipping, Ukraine, including many who had been evacu- ated from Chernobyl after the nuclear power plant accident there. Remarkably, the Ukrainian children reported fewer physical symptoms than the Ameri- can ones of the same age, but their mothers reported nearly three times as many symptoms in their own children than those in Nashville. It is uncer- tain, of course, whether this reflects a generalized difference in awareness of bodily symptoms between American and Ukrainian women, developing at a later stage in life, or whether the Chernobyl incident fostered a more vigilant pattern in the latter group. Overall concern scores ranged from a high of 51 in Portugal to a low of 19 in Sweden, but the nature of the concerns also showed large inter-nation variability. Israeli patients were particularly con- cerned about pain and suffering whereas the Portuguese subjects worried about social stigma. Given the many behavioral consequences of chronic pain (McCracken, Zayfert, & Gross, 1992; Turk, Okifuji, Sinclair, & Starz, 1996), it is imperative to fully explore the sensory, affective, and cognitive reactions of pain patients, irrespective of ethnic background. ETHNOCULTURAL VARIATIONS IN PAIN 167 International studies of pain, particularly ones that focus on supposed ethnic or cultural differences, are influenced by differences in litigation or compensation systems in different countries. Hadjistavropoulos (1999), in a broad review of litigation and compensation, included a number of cross- cultural studies. Carron, DeGood, and Tait (1985), for example, found that back pain patients in the United States used more medication, experienced more disphoric mood states, and were more hampered in social-sexual, rec- reational, and vocational functioning than ones in New Zealand. In- dividuals in both countries who were receiving pretreatment compensation were less likely to report a return to full activity, although the relationship appeared more pronounced among those in the United States. Other studies that demonstrate that certain expensive interventions are more likely to reduce acute pain (e. Many of the published studies of ethnocultural factors and pain have made broad generalizations based upon exceedingly small sample sizes. Thomas and Rose (1991) asked 28 African Caribbean males and females, 28 Anglo-Saxons, and 28 Asians in London, England, who were having an ear pierced with a piercing gun, to complete the McGill Pain Questionnaire. Asian subject scores were nearly twice those of the African Caribbeans, with Anglo-Saxon scores nearly as high, leading them to con- clude, “the present results provide clear evidence that there are ethnic dif- ferences in pain experience in this test situation” (pp. Their subject pool consisted of 10 or 11 chronic low back pain pa- tients from each of the six countries. Likewise, Brena, Sanders, and Moto- yama (1990), evaluating 11 back pain patients from Tokyo and a like number of patients from Atlanta, reported, “Japanese low back pain patients were less psychosocially, vocationally, and avocationally impaired than similar American patients” (p. Sheffield, Kirby, Biles, and Sheps (1999) evaluated 124 Caucasians and 18 African Americans who had taken an exercise treadmill test which showed certain electrocardiographic abnormalities. Because 9 of the latter but only 34 of the former had angina during testing, they concluded, “African Ameri- 168 ROLLMAN cans reported anginal pain at twice the rate of Caucasians” (p. A sub- sequent study of pain perception (Sheffield, Biles, Orom, Maixner, & Sheps, 2000) using a contact thermode to deliver noxious levels of heat to 27 Whites and 24 African Americans, showed that the latter group gave higher ratings than the former to each of 5 temperatures, leading them to indicate that “these data suggest that different pain mechanisms underlie race dif- ferences in pain perception” (p. Edwards and Fillingim (1999), testing 30 Whites and 18 African Ameri- cans, also found that the Whites had a greater thermal pain tolerance and gave lower unpleasantness ratings at the lower two of four temperatures in a scaling study, with no group differences in intensity ratings. There were also no group differences in questionnaire measures of pain reactivity or in pain complaints over the preceding month, although African Americans re- ported greater average pain severity and two pain sites rather than the Whites’ number of 1. The two unpleasantness rating differences led to the proposal that there are racial differences in the affective-motivational di- mension of pain. A significant correlation between pain tolerance and pain symptoms brought the suggestion that ethnic variation in affective-moti- vational judgments may account for the severity and number of pain sites. The authors presented the admittedly speculative suggestion that African Americans may require quantitatively greater degrees of pain treatment than Whites. In a subsequent study of 68 African Americans and 269 Whites attending an interdisciplinary pain clinic, the African Americans reported significantly greater pain severity and pain-related disability than Whites (Edwards, Doleys, Fillingim, & Lowery, 2001), although no differences in the McGill Pain Questionnaire or measures of pain interference or affective distress. As well, the African Americans had shorter ischemic pain tolerance times for a tourniquet test (about 5 minutes vs. The large difference in the latter, compared to a much smaller difference in clini- cal pain, led to the suggestion that coping styles, attitudes toward pain measurement, or differences in central pain modulating systems may distin- guish the two groups.

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