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ORIGINAL ARTICLE
Year : 2013  |  Volume : 21  |  Issue : 1  |  Page : 64-66

Influence of skin grafts on oxidation-reduction processes in elderly and old people with deep burns


Burn Department of RSCUMA, Republican Research Centre of Emergency Medicine, Samarkand State Medical Institute, Samarkand, Uzbekistan

Date of Web Publication22-Nov-2013

Correspondence Address:
Bokhodir X Karabaev
2 Nor Yakubov proezd 3, Samarkand, Uzbekistan

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.121886

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  Abstract 

Introduction: Severe burns in the elderly have a much higher mortality in comparison to the younger population. The most complicated problem in burn therapy is in the treatment of patients with deep burns especially those who are elderly. Aim and Methodology: To study the different surgical treatments and test the intermediary metabolism in elderly deep burns admitted to our unit over a period of 11 years including patients from 1999 to 2009. Results: In our burn center in Uzbekistan, skin grafts were performed in 356 patients (age range, 60-92 year) with deep burns (107 in the early post-burn period of 7-15 days, plus 249 over granulating wounds). Skin grafts in extensive burns were performed in 32 patients for the purpose of achieving early closure of the burn area. In these 32 cases, a stamp graft procedure was used in 17 patients and Moule-Jackson method of skin grafting in 15 cases. Testing intermediary metabolism indicators in 102 patients before and after free skin grafting provided interesting findings. We identified common scenarios of elderly patients, which helped in treatment.

Keywords: Deep burns, elderly and old patients, intermediate metabolism, skin graft


How to cite this article:
Karabaev BX, Fayazov AM, Shakirov BM. Influence of skin grafts on oxidation-reduction processes in elderly and old people with deep burns. Indian J Burns 2013;21:64-6

How to cite this URL:
Karabaev BX, Fayazov AM, Shakirov BM. Influence of skin grafts on oxidation-reduction processes in elderly and old people with deep burns. Indian J Burns [serial online] 2013 [cited 2019 Aug 24];21:64-6. Available from: http://www.ijburns.com/text.asp?2013/21/1/64/121886


  Introduction Top


Burn trauma remains one of the real problems of modern medicine, because of its long clinical course, high mortality rate and occasional unacceptable results of treatment. According to the World Health Organization data of the years, 2002, more than 95% of fatal fire - related burns occurred in low and middle. [1]

The management of burn in the elderly patients remains a challenging problem, with several studies having focused on the outcome in this subset of the population. [2]

This is a growing and often preventable problem with the majority of burn being caused by carelessness.

Unfortunately, the majority of epidemiological studies in burn care are hospital based rather than population based. [3],[4],[5]

The most complicated problems of burn with regard to therapy are encountered in elderly patients with deep burns. 4 or 5 days following successful resuscitation, early echarectomy is usually performed on no more than 4-5% of the body area, followed by immediate skin grafting.

Since its inception, treatment with early excision and grafting is reported to significantly improve burn wound outcomes. Early excision reduces mortality in patients without inhalation injury and shortens hospital stay with burns exceeding 40% total body surface area (TBSA). Extremes of age and concomitant diseases combined to the severe metabolic stress and the limited capacity of the patient to compensate, determines the high mortality (24-63%). [6],[7],[8],[9],[10],[11],[12],[13]


  Aims Top


To study the different surgical treatments and test the intermediary metabolism in elderly deep burns.


  Materials Top


Over a period of 11 year (1999-2009), 396 patients (174 men and 222 women) aged 60-92 year with deep burns were treated in the Burns Department at the Republican Research Centre of Emergency Medicine and Burn Department of RCSUMA, Uzbekistan. Of the 396 patients, most common type of burns were scald and flame burns. Most of the scalds occurred during food preparation.

Observed concomitant diseases were previous myocardial infarction and cerebrovascular accidents in 17-15.5% respectively and diabetes and alcoholism in 11% of cases.


  Methods and Results Top


Out of an overall number of 396 burn patients, 107 presented with deep burns in 2-5% of the body surface area and 70 patients with 5-15% TBSA burns.

After 4-5 days following admission, tangential excision was performed with a drum dermatome and skin grafts were applied immediately.

Among all the patients, the burns in 77 cases healed after the first skin grafting procedure while in 25 patients, there was partial loss of the grafts. Among the patients admitted to the department, five died - those having burns of more than 10-15% of the TBSA.

Of all patients, 92 healed after the first skin grafts. A second skin grafting was performed in 15 of the patients because the skin graft was lost in places.

In 130 patients out of the 249, with burn surface area of 10-25%, skin grafting was performed on the granulating wound when the wound was ready for accepting skin graft. Indications of a good wound were bright red granulation, firm with little bleeding on touch and no oedema. Skin grafts were performed on granulating wounds, using a sheet graft, in the following manner : o0 ne stage in 30 patients; two stages in 45 patients and three stages in 55 patients (in all, 285 operations). Skin grafts in extensive burns were performed in 32 patients for the purpose of decreasing the wound area. In these 32 cases, a stamp graft procedure was used in 17 patients and Moule-Jackson method of skin grafting in 15 cases. To increase the skin grafting potential in patients with limited skin resources, meshed grafts we used in 102 patients and sheet grafts in 130. This technique was used in patients with extensive burns and in patients with various complications (e.g. pressure abnormalites, pneumonia and hepatitis). At the same time, priority was given to the preservation of the victims' life, even to the prejudice of functional outcome. Thus, priority was given to perforated skin grafts with an expansion ratio of 1:1.5 which promoted faster graft cells epithelializiation.

Out of 317 skin grafts on granulating wounds we found complete take of the skin graft in 206 cases (65%) and graft survival of 70% in 92 cases (19%); complete loss of the skin graft was found only in 19 cases (6%). The death rate among the 356 patients was 64 cases (17.1%). Active surgical treatment, consisting of multistage of plastic operations with a short as possible intervals between them, plus primary application of skin grafts using 0.2-0.3 mm graft meshes, made it possible to coverage in the majority of elderly and extensively very burnt patients within 1.5-5 months post-trauma, even in deep burns of over 10% of the TBSA.

All patients' in our study clearly show the effect of free skin grafting on the level of erythrocytes, hemoglobin and hematocrit and on the indicators of intermediary metabolism. A significant increase in these test indicators (in 157 patients) confirms the essential role of loss of skins, function in the pathogenesis of burn. The patient's acid base balance was examined in 50 patients before and after skin grafting. Test results showed that a shift towards metabolic acidosis was frequently found in patients after 1 month post-trauma. After skin grafting there was a rapid reduction and a return to normality of the pH balance of the blood. Following the elimination of the burn trauma, the quantity of unoxidized products was reduced and tissue oxygen requirements were more adequately met.

Testing intermediary metabolism indicators in 102 patients before and after free skin grafting provided interesting findings. There was found to be a close connection between skin grafting and the blood oxygen balance. It is highly probable that regeneration of the cutaneous covering improved the organism's oxygen balance and this could contribute to intracellular oxidation.

Glutathione takes an active part in the glycolytic oxidation-reduction mechanism. As it is a donor of hydrogen ions, it maintains its content of biologically active sulfhydryl groups. Case monitoring of glutathione content and it's fractions in 75 patients showed, that from day 1 to 3 post graft the reduced glutathione content was on the increase (from 0.84 ± 0.02 to 1.35 ± 0.02 mmol/l). The increase in glutathione content in patients with early skin grafting was more marked than it was in patients who had skin grafting on granulating wounds (in 45 and 30 patients, respectively).

Glutathione takes an active part in oxidation-reduction processes by a disulfide bond reduction of enzymes to form sulphydryl groups, which are necessary for manifestation of their catalytic activity.

The increase in the reduced glutathione level should therefore be seen not as the result of an increase in the content of unoxidized product but rather as the organism's compensatory reaction in response to disturbance of the oxidation - reduction process. Hence, it became clear that the gradual increase of the total glutathione level at the expense of reduced fraction was observed only during the operative course and was attended by a gradual decrease of the quantity of unoxidized product of metabolism.

Restoration of skin function favored the increase in whole protein content value and reduced the glutathione and gradual decrease of the quantity of unutilized products, all of which confirm improvement of oxide reduction processes. Free skin grafting would appear to promote the increase of the reduced glutathione level in the blood (0.51 ± 0.1-1.18 ± 1.01 mmol/l), which stimulated the activity of blocked enzymes and thereby improved oxidation reduction processes. As we had studies the state of oxidation-reduction processes in deep burns in elderly people, we endeavored to establish the diagnostic and prognostic value of the indicators we had investigated. It became clear that oxide reduction values could be used for diagnostic purposes with regard to various complications and for graft necrosis.

It was found that concentrations of lactic and pyruvic acids were sometimes left too high and too long in elderly people with a poor prognosis of blood oxidability. A concentration of lactic acid in the blood of 3.5 mol/l or higher was a bad prognostic sign (the five patients as registered as suffering from hyperlactacidemia).


  Conclusions Top


  1. In our burn center skin grafts were performed in 356 patients with deep burns 107 in the early post-burn period of 7-15 days, plus 249 with granulating wounds. In 32 cases, a stamp graft procedure was used in 17 patients and Moule-Jackson method of skin grafting in 15 cases.
  2. After skin burns, the gradual normalization of various parameters - the glutathione level, catalase, carbonic anhydrase and concentrations of lactic and pyruvic acids-confirms that skin defect restoration by skin grafts resolves the patients lack of oxygen and improves their liver function. We can say the sooner the skin graft is performed the more rapidly the intermediate metabolism parameters return to normal values.
  3. The factors - the resudial and intermediate oxidability of the blood, concentrations of lactic and pyruvic acids and the reduced glutathione content - can be used as supplementary indicators of short and long term prognosis in burn patients.


 
  References Top

1.Brigham PA, McLoughlin E. Burn incidence and medical care use in the United States: Estimates, trends, and data sources. J Burn Care Rehabil 1996;17:95-107.  Back to cited text no. 1
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2. Redlick F, Cooke A, Gomez M, Banfield J, Cartotto RC, Fish JS. A survey of risk factors for burns in the elderly and prevention strategies. J Burn Care Rehabil 2002;23:351-6.  Back to cited text no. 2
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3. Cutillas M, Sesay M, Perro G, Bourdarias B, Castede JC, Sanchez R. Epidemiology of elderly patients' burns in the South West of France. Burns 1998;24:134-8.  Back to cited text no. 3
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6.Rao K, Ali SN, Moiemen NS. Aetiology and outcome of burns in the elderly. Burns 2006;32:802-5.  Back to cited text no. 6
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11. Maghsoudi H, Ghaffari A. Aetiology and outcome of elderly burn patients in tabriz, iran. Ann Burns Fire Disasters 2009;22:115-20.  Back to cited text no. 11
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12. Koupil J, Brychta P, Rihova H, kincovb S. Special features of burn injuries in elderly patients. Ann Med Club 2000;43:12-5.  Back to cited text no. 12
    
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