St Andrew's COVID-19 surgery safety (StACS) study: The Burns Centre experience

Background

The COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has the potential to significantly impact burns patients both directly through infective complications of an immunocompromised cohort, and indirectly through disruption of care pathways and resource limitations. The pandemic presents new challenges that must be overcome to maintain patient safety; in particular, the potential increased risks of surgical intervention, anaesthesia and ventilation. This study comprehensively reviews the measures implemented to adapt referral pathways and mitigate the risk posed by COVID-19 during the height of the pandemic, within a large Burns Centre.

Methods

A prospective cohort study was designed to assess patients treated at the Burns Centre during the UK COVID-19 pandemic peak (April–May 2020), following implementation of new safety measures. All patients were analysed for 30-day mortality. In addition, a prospective controlled cohort study was undertaken on all inpatients and a random sample of outpatients with telephone follow-up at 30 days. These patients were divided into three groups (operative inpatients, non-operative inpatients, outpatients). COVID-19 related data collected included test results, contact with proven cases, isolation status and symptoms. The implemented departmental service COVID-19 safety adaptations are described.

Results

Of 323 patients treated at the Burns Centre during the study period, no 30-day COVID-19 related deaths occurred (0/323). Of the 80 patients analysed in the prospective controlled cohort section of the study, 51 underwent COVID-19 testing, 3.9% (2/51) were positive. Both cases were in the operative group, however in comparison to the non-operative and outpatient groups, there was no significant increase in COVID-19 incidence in operative patients.

Conclusions

We found no COVID-19 related mortality during the study period. With appropriate precautions, burns patients were not exposed to an increased COVID-19 risk. Similarly, burns patients undergoing operative management were not at a significantly increased risk of contracting COVID-19 in comparison to non-operative groups.

Prognostic scoring systems in burns: a review

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve. The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.

Purpura fulminans skin loss: surgical management protocols at a regional burns centre

SUMMARY

People with significant skin loss after sepsis frequently require skin grafting; as such, they are often referred to regional burns units for definitive soft-tissue cover. Such individuals have complex requirements after severe sepsis, and usually have complicated wounds. We have developed a protocol for managing these patients and their wounds within a high dependency, intensive-care unit, using allograft as an adjunct in preparing the tissue bed before autografting. This protocol includes optimisation of nutritional needs, microbiological surveillance and definitive soft tissue cover. We retrospectively reviewed all children referred over 18 months for management of skin and soft tissue loss after meningitis purpura fulminans. We reviewed the initial management of the septicaemia, associated co-morbidities, site and size of soft tissue defect, time to presentation for definitive skin cover, surgical procedure performed, timing of surgical intervention, and recovery of the patient's wounds. A total of six people (all children), with a mean age of 7 months (age range 4-21 years) were admitted to our unit between March 2004 and September 2005. Total percentage skin loss was 12% (6-20%). All of the children underwent debridement, received allograft to areas of skin loss and necrosis as a primary procedure, and subsequently underwent autograft. Two children required amputation of one or more limbs, and the stumps were covered with allograft followed by skin autograft. All patients had excellent autograft skin taken using this protocol.

Successful free flap transfer following venous thrombectomy in recipient vessel

We report the case of a 53-year-old male patient who suffered a high velocity multiple trauma with bilateral open tibial fractures. At definitive orthopaedic and plastic surgical reconstruction 5 days post initial trauma, he was found peroperatively to have an existing deep venous thrombosis in his popliteal vein on one side. He underwent venous thrombectomy and had subsequent successful latissimus dorsi flap transfer using the unblocked popliteal vein as a recipient vessel.

Successful partial ear replantation after prolonged ischaemia time

We present the case of a 34-year-old male patient who had successful replantation of upper pole of pinna 33 h after amputation. As no vein was anastomosed, systemic heparinisation and subcutaneous injection of heparin to the replanted ear were used to encourage outflow. Complications included arterial spasm and bleeding. Management of similar cases as planned urgent cases rather than emergency cases is discussed.