Biologic dressing in burns

Advances in cellular biology and knowledge in wound healing and growth factors have given us a wide variety of choices to attack the problem of the complex burn wound. Split-thickness skin grafting with autograft is at present the standard of care. It, however, is not an ideal substitute and frequently is not available for full-burn coverage. This article will review honey, human amnion, xenograft, allograft, cultured epithelial autograft, and various engineered commercial products for use in the biologic treatment of burn wounds

Abdominal Distension and Feeding Intolerance

The most salient dilemma in the post-surgical patient with abdominal distention and feeding intolerance is whether the bowel is obstructed. If the index of suspicion is high the questions of whether it is a functional or mechanical obstruction and where is the location of the obstruction needs to be addressed. If there is no bowel obstruction the diagnostic question turns towards the location and cause of the suspected ileus. The definitive cause of abdominal distention and feeding intolerance may be due to a variety of factors that include mechanical or functional small or large bowel obstruction, adynamic/paralytic ileus, or sepsis from a variety of causes including both intra- and extra-peritoneal etiologies. Radiographic studies play an important role in determining the etiology, evaluating for complications, and in monitoring resolution once the cause has been treated. The initial radiographic examination for evaluation and triage of patients with abdominal distention is the plain abdominal film. Computed tomography is the imaging modality of choice to confirm the diagnosis of small bowel obstruction and to identify its cause. If the initial radiograph or CT is inconclusive the differential diagnoses of low-grade, partial SBO or of an ileus should be considered and an imaging technique with increased sensitivity and specificity for distinguishing between the two has to be selected. Functional studies can reveal subclinically obstructed segments. This chapter will cover all these issues in detail

New Onset of Fever and Leukocytosis

The development of fever and leukocytosis in a post-surgical patient is a common clinical scenario that may arise due to a considerable number of various differential etiologies, including infection, inflammation, thromboembolic disease, as well as others. This often necessitates targeted diagnostic imaging to refine the suspected clinical diagnosis, which can aid in providing prompt specific therapy. Here, we discuss general related concerns of an intensivist, as well as specific imaging modalities such as Computerized Tomography, Radiography, Ultrasound, Nuclear Medicine, Interventional Radiology, and Magnetic Resonance Imaging. Specific etiologies and a proposed diagnostic imaging algorithm for the patient with fever and sepsis in the Intensive Care Unit are also discussed. Multiple figures as well as selected illustrative case examples are provided for added perspective

Enterocutaneous Fistulas

Enterocutaneous fistulas (ECF) represent a catastrophic problem for patients and continue to be complex and labor intensive for healthcare providers. In addition to the many physiologic and mental stressors the patients must endure, the development of ECFs also puts a strain on healthcare systems resulting in prolonged hospital stays, multiple readmissions, and increased resource consumption. The management of ECFs has improved significantly, resulting in decreased mortality rates, from 50% in the 1950s to approximately 5%–15% at present. As many as 85% of ECFs present as a complication after abdominal surgery, providing further challenges to already compromised postoperative patients. Most ECFs develop as a result of one of the following conditions: extension of bowel disease to surrounding structures, extension of disease of the surrounding structures to the bowel, unrecognized bowel injury, or breakdown of a gastrointestinal tract anastomosis. Multiple preoperative patient factors can increase the likelihood of ECF development