今日の臨床サポート

熱傷

著者: 大塚正樹 中東遠総合医療センター皮膚科・皮膚腫瘍科

監修: 戸倉新樹 掛川市・袋井市病院企業団立 中東遠総合医療センター 参与/浜松医科大学 名誉教授

著者校正/監修レビュー済:2021/08/25
参考ガイドライン:
  1. 日本皮膚科学会:熱傷診療ガイドライン第2版
  1. 日本熱傷学会:熱傷診療ガイドライン第2版
患者向け説明資料

概要・推奨   

  1. 熱傷深度の推定方法として、臨床症状による分類を推奨する(推奨度2)。
  1. 熱傷面積の推定方法として、9の法則、5の法則およびLund & Brodwerの法則、手掌法がある(推奨度2)。
  1. 熱傷の重症度判定のツールとして、Artzの基準を用いることを推奨する(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契 約が必要 となります。閲 覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が 必要となります。閲覧にはご契約が 必要となります。閲覧に はご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
大塚正樹 : 申告事項無し[2021年]
監修:戸倉新樹 : 講演料(田辺三菱,サノフィ,マルホ,協和キリン),研究費・助成金など(ノバルティス,レオファーマ)[2021年]

改訂のポイント:
  1. 定期レビューを行い、ドレッシング材について名称変更を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 熱傷は熱による外傷であり、軽症例を含めると日常診療的によく遭遇するありふれた疾患である。
  1. 重症であれば組織障害は皮膚にとどまらず、全身の臓器に及び、生命に重篤な影響を及ぼすため、局所治療だけでは救命できないことも多い。
  1. 厚生労働省人口動態調査では2020年熱傷による年間死亡者数は10万人あたり0.7人で、減少傾向にある。
  1. 重症熱傷は、急性期、感染期、回復期に分けられ、病期に応じた治療が必要となる。
  1. 輸液療法、呼吸管理、栄養管理などの全身療法、外用療法や手術療法などの局所療法、リハビリテーションや精神管理も重要である。
問診・診察のポイント  
  1. 熱傷の深度を臨床所見から推定する
 
 
  1. 熱傷の面積を9の法則、5の法則、Lund & Browderの法則から推定する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

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文献 

著者: D Heimbach, L Engrav, B Grube, J Marvin
雑誌名: World J Surg. 1992 Jan-Feb;16(1):10-5.
Abstract/Text Despite the plethora of technologic advances, the most common technique for diagnosing burn depth remains the clinical assessment of an experienced burn surgeon. It is clear that this assessment is accurate for very deep and very shallow burns. But since clinical judgment is not precise in telling whether a dermal burn will heal in 3 weeks, efforts to develop a burn depth indicator are certainly warranted to accurately determine which dermal burns to excise and graft. This review summarizes the considerable literature in which a variety of techniques to determine burn depth have been used.

PMID 1290249  World J Surg. 1992 Jan-Feb;16(1):10-5.
著者: A B WALLACE
雑誌名: Lancet. 1951 Mar 3;1(6653):501-4.
Abstract/Text
PMID 14805109  Lancet. 1951 Mar 3;1(6653):501-4.
著者: T G BLOCKER
雑誌名: Lancet. 1951 Mar 3;1(6653):498-501.
Abstract/Text
PMID 14805108  Lancet. 1951 Mar 3;1(6653):498-501.
著者: R J Perry, C A Moore, B D Morgan, D L Plummer
雑誌名: BMJ. 1996 May 25;312(7042):1338.
Abstract/Text
PMID 8646048  BMJ. 1996 May 25;312(7042):1338.
著者: T R Nagel, J E Schunk
雑誌名: Pediatr Emerg Care. 1997 Aug;13(4):254-5.
Abstract/Text OBJECTIVE: Estimation of the surface area involved is vital to evaluation and treatment of burns. Common teaching suggests the palm approximates 1% of the total body surface area (TBSA). However, early century literature suggests the palmar surface of the entire hand approximates 1% of the TBSA. We sought to determine whether the palm or the entire palmar surface of the hand approximates 1% TBSA in children.
DESIGN: A prospective, convenience sample.
MATERIALS AND METHODS: Using height, weight, and standard nomograms, body surface area was determined. A photocopy of the hand was used to determine the surface area of the palm and the entire palmar surface of the hand.
RESULTS: In 91 children, the mean percent of the TBSA represented by the entire palmar surface was 0.94% (95% confidence interval (C.I.) 0.93-0.97), and the mean percent of the TBSA represented by the palm was 0.52% (95% C.I. 0.51-0.53).
CONCLUSION: The entire palmar surface of a child's hand more closely approximates 1% TBSA, while the palm approximate 0.5% TBSA.

PMID 9291511  Pediatr Emerg Care. 1997 Aug;13(4):254-5.
著者: Dilip D Madnani, Natalie P Steele, Egbert de Vries
雑誌名: Ear Nose Throat J. 2006 Apr;85(4):278-80.
Abstract/Text Early identification of smoke inhalation patients who will require intubation is crucial. We conducted a retrospective chart review to identify predictors of respiratory distress in patients who present with smoke inhalation injury. Our study involved 41 patients who had been treated in the emergency room at a regional burn center. Eight of these patients required intubation. Intubation was positively correlated with physical examination findings of soot in the oral cavity (p < 0.001), facial burns (p = 0.025), and body burns (p = 0.025). The need for intubation was also predicted by fiberoptic laryngoscopic findings of edema of either the true vocal folds (p < 0.001) or the false vocal folds (p < 0.01). No statistically significant correlation was found between intubation and any of the classic symptoms of smoke inhalation: stridor, hoarseness, drooling, and dysphagia (all p = 1.0). Also, multivariate analysis revealed that facial burns correlated significantly with edema of the true vocal folds (p = 0.01) and body burns correlated significantly with edema of both the true (p = 0.047) and false (p = 0.003) vocal folds. We conclude that patients with soot in the oral cavity, facial burns, and/or body burns should be monitored closely because these findings indicate a higher likelihood of laryngeal edema and the need for intubation.

PMID 16696366  Ear Nose Throat J. 2006 Apr;85(4):278-80.
著者: American Burn Association
雑誌名: J Am Coll Surg. 2003 Feb;196(2):307-12.
Abstract/Text
PMID 12632576  J Am Coll Surg. 2003 Feb;196(2):307-12.
著者: B Venus, T Matsuda, J B Copiozo, M Mathru
雑誌名: Crit Care Med. 1981 Jul;9(7):519-23.
Abstract/Text Burn mortality statistics are influenced by age and degree of total surface body burn. The addition of an inhalation injury to a cutaneous burn results in a significant increase in mortality rate. Nine hundred fourteen patients with acute thermal injury were screened for positive history of burn in a closed space, facial or oropharyngeal burn, singed nasal vibrisae, carbonacious sputum, and clinical signs of upper airway involvement. On admission, 84 patients (9.2%) had more than one of the previously mentioned factors. They were prophylactically intubated and placed on optimum level of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV). The mortality rate among patients without inhalation injury was 7.1%, while 54.7% of patients with inhalation injury died. Comparison of burn patients with inhalation injury to those without pulmonary involvement at the same age group and with the same percentage of burn showed significantly higher mortality rate in patients with inhalation injury. The main cause of death in the first 72 h postburn (stage 1) in patients without inhalation injury was peripheral shock (10.1%) and in patients with inhalation injury was peripheral shock (15.2%) and cardiac failure (10.8%). No pulmonary related death occurred in this stage. In 3-10 days postburn period (stage 2), burn wound sepsis (10.1%) and cardiac failure (11.8%) were the major causes of death in patients with inhalation injury. In patients with inhalation injury, pulmonary sepsis (26%) was the major cause of death in this stage. Major causes of death after 10 days postburn (stage 3) in patients without inhalation injury were pulmonary sepsis (20%) and burn wound sepsis (22%). In patients with inhalation injury, burn wound sepsis (21.7%) was the main cause of death. These data suggest that prophylactic intubation and CPAP therapy in burn patients with suspected inhalation injury prevent pulmonary related death in early stage of burn. Irrespective of presence of inhalation injury, sepsis originating from the wound or respiratory tract is the main cause of death in the late stage of burn.

PMID 7016441  Crit Care Med. 1981 Jul;9(7):519-23.
著者: Tam N Pham, Leopoldo C Cancio, Nicole S Gibran, American Burn Association
雑誌名: J Burn Care Res. 2008 Jan-Feb;29(1):257-66. doi: 10.1097/BCR.0b013e31815f3876.
Abstract/Text
PMID 18182930  J Burn Care Res. 2008 Jan-Feb;29(1):257-66. doi: 10.109・・・
著者: Bishara S Atiyeh, S William Gunn, Shady N Hayek
雑誌名: World J Surg. 2005 Feb;29(2):131-48. doi: 10.1007/s00268-004-1082-2.
Abstract/Text Optimal treatment of burn victims requires deep understanding of the profound pathophysiological changes occurring locally and systemically after injury. Accurate estimation of burn size and depth, as well as early resuscitation, is essential. Good burn care includes also cleansing, debridement, and prevention of sepsis. Wound healing, is of major importance to the survival and clinical outcome of burn patients. An ideal therapy would not only promote rapid healing but would also act as an antiscarring therapy. The present article is a literature review of the most up-to-date modalities applied to burn treatment without overlooking the numerous controversies that still persist.

PMID 15654666  World J Surg. 2005 Feb;29(2):131-48. doi: 10.1007/s0026・・・
著者: G D Warden
雑誌名: World J Surg. 1992 Jan-Feb;16(1):16-23.
Abstract/Text The goal of fluid resuscitation in the burn patient is maintenance of vital organ function at the least immediate or delayed physiological cost. To optimize fluid resuscitation in severely burned patients, the amount of fluid should be just enough to maintain vital organ function without producing iatrogenic pathological changes. The composition of the resuscitation fluid in the first 24 hours postburn probably makes very little difference; however, it should be individualized to the particular patient. The utilization of the advantages of hypertonic, crystalloid, and colloid solutions at various times postburn will minimize the amount of edema formation. The rate of administration of resuscitation fluids should be that necessary to maintain satisfactory organ function, with maintenance of hourly urine outputs of 30 cc to 50 cc in adults and 1-2 cc/kg/% burn in children. When a child reaches 30 kg to 50 kg in weight, the urine output should be maintained at the adult level. With our current knowledge of the massive fluid shifts and vascular changes that occur, mortality related to burn-induced hypovolemia has decreased considerably. The failure rate for adequate initial volume restoration is less than 5% even for patients with burns of more than 85% of the total body surface area. These improved statistics, however, are derived from experience in burn centers, where there is substantial knowledge of the pathophysiology of burn injury. Inadequate volume replacement in major burns is, unfortunately, common when clinicians lack sufficient knowledge in this area.

PMID 1290260  World J Surg. 1992 Jan-Feb;16(1):16-23.
著者: W W Monafo
雑誌名: N Engl J Med. 1996 Nov 21;335(21):1581-6. doi: 10.1056/NEJM199611213352108.
Abstract/Text
PMID 8900093  N Engl J Med. 1996 Nov 21;335(21):1581-6. doi: 10.1056/・・・
著者: George Kramer, Steve Hoskins, Nick Copper, Jiin-Yu Chen, Michelle Hazel, Charles Mitchell
雑誌名: J Trauma. 2007 Jun;62(6 Suppl):S71-2. doi: 10.1097/TA.0b013e318065aedf.
Abstract/Text
PMID 17556988  J Trauma. 2007 Jun;62(6 Suppl):S71-2. doi: 10.1097/TA.0・・・
著者: C R Baxter, T Shires
雑誌名: Ann N Y Acad Sci. 1968 Aug 14;150(3):874-94.
Abstract/Text
PMID 4973463  Ann N Y Acad Sci. 1968 Aug 14;150(3):874-94.
著者: C R Baxter
雑誌名: Surg Clin North Am. 1978 Dec;58(6):1313-22.
Abstract/Text The problems and complications of the fluid resuscitation phase of the treatment of major thermal burns are many and varied. Emphasis has been placed on the most important organ system responses commonly observed in the first week after injury. The efficacy of treatment and the lack of available treatment are outlined. The mechanical complications occurring from poorly selected and monitored fluid administration sites, complications of monitoring, problems of constrictive edema (usually in the extremities), airway problems, respiratory care, and innumerable other technical aspects were purposely omitted. While these problems and complications are extremely important and occur commonly in our experience, they are in the realm of technical performance of good emergency and intensive care medicine and their optimal management does not affect the problems and complications of the residual organ systems.

PMID 734611  Surg Clin North Am. 1978 Dec;58(6):1313-22.
著者: C Holm, M Mayr, J Tegeler, F Hörbrand, G Henckel von Donnersmarck, W Mühlbauer, U J Pfeiffer
雑誌名: Burns. 2004 Dec;30(8):798-807. doi: 10.1016/j.burns.2004.06.016.
Abstract/Text BACKGROUND: Ever since Charles Baxter's recommendations the standard regime for burn shock resuscitation remains crystalloid infusion at a rate of 4 ml/kg/% burn in the first 24h following the thermal injury. A growing number of studies on invasive monitoring in burn shock, however, have raised a debate regarding the adequacy of this regime. The purpose of this prospective, randomised study was to compare goal-directed therapy guided by invasive monitoring with standard care (Baxter formula) in patients with burn shock.
PATIENTS AND METHODS: Fifty consecutive patients with burns involving more than 20% body surface area were randomly assigned to one of two treatment groups. The control group was resuscitated according to the Baxter formula (4 ml/kg BW/% BSA burn), the thermodilution (TDD) group was treated according to a volumetric preload endpoint (intrathoracic blood volume) obtained by invasive haemodynamic monitoring.
RESULTS: The baseline characteristics of the two treatment groups were similar. Fluid administration in the initial 24h after burn was significantly higher in the TDD treatment group than in the control group (P = 0.0001). The results of haemodynamic monitoring showed no significant difference in preload or cardiac output parameters. Signs of significant intravasal hypovolemia as indicated by subnormal values of intrathoracic and total blood volumes were present in both treatment groups. Mortality and morbidity were independent on randomisation.
CONCLUSION: Burn shock resuscitation due to the Baxter formula leads to significant hypovolemia during the first 48 h following burn. Haemodynamic monitoring results in more aggressive therapeutic strategies and is associated with a significant increase in fluid administration. Increased crystalloid infusion does not improve preload or cardiac output parameters. This may be due to the fact that a pure crystalloid resuscitation is incapable of restoring cardiac preload during the period of burn shock.

PMID 15555792  Burns. 2004 Dec;30(8):798-807. doi: 10.1016/j.burns.200・・・
著者: Jason Wasiak, Heather Cleland, Fiona Campbell
雑誌名: Cochrane Database Syst Rev. 2008 Oct 8;(4):CD002106. doi: 10.1002/14651858.CD002106.pub3. Epub 2008 Oct 8.
Abstract/Text BACKGROUND: An acute burn wound is a complex and evolving injury. Extensive burns produce, in addition to local tissue damage, systemic consequences. Treatment of partial thickness burn wounds is directed towards promoting healing, and a wide variety of dressings is currently available. Improvements in technology and advances in understanding of wound healing have driven the development of new dressings. Dressing selection should be based on their effects of healing, but ease of application and removal, dressing change requirements, cost and patient comfort should also be considered.
OBJECTIVES: To assess the effects of burn wound dressings for superficial and partial thickness burns.
SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (Searched 29/5/08); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 2 2008; Ovid MEDLINE - 1950 to May Week 3 2008; Ovid EMBASE - 1980 to 2008 Week 21 and Ovid CINAHL - 1982 to May Week 4 2008.
SELECTION CRITERIA: All randomised controlled trials (RCTs) that evaluated the effects of burn wound dressings for superficial and partial thickness burns.
DATA COLLECTION AND ANALYSIS: Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion.
MAIN RESULTS: A total of 26 RCTs are included in this review and most were methodologically poor. A number of dressings appear to have some benefit over other products in the management of superficial and partial thickness burns. This benefit relates to time to wound healing, the number of dressing changes and the level of pain experienced. The use of biosynthetic dressings is associated with a decrease in time to healing and reduction in pain during dressing changes. The use of silver sulphadiazine (SSD) as a comparator on burn wounds for the full duration of treatment needs to be reconsidered, as a number of studies showed delays in time to wound healing and increased number of dressing applications in patients treated with SSD dressings.
AUTHORS' CONCLUSIONS: There is a paucity of high quality RCTs on dressings for superficial and partial thickness burn injury. The studies summarised in this review evaluated a variety of interventions, comparators and clinical endpoints. Despite some potentially positive findings, the evidence, which largely derives from trials with methodological shortcomings, is of limited usefulness in aiding clinicians in choosing suitable treatments.

PMID 18843629  Cochrane Database Syst Rev. 2008 Oct 8;(4):CD002106. do・・・
著者: Sadanori Akita, Kozo Akino, Toshifumi Imaizumi, Akiyoshi Hirano
雑誌名: Wound Repair Regen. 2008 Sep-Oct;16(5):635-41. doi: 10.1111/j.1524-475X.2008.00414.x.
Abstract/Text Second-degree burns are sometimes a concern for shortening patient suffering time as well as the therapeutic choice. Thus, adult second-degree burn patients (average 57.8 +/- 13.9 years old), mainly with deep dermal burns, were included. Patients receiving topical basic fibroblast growth factor (bFGF) or no bFGF were compared for clinical scar extent, passive scar hardness and elasticity using a Cutometer, direct scar hardness using a durometer, and moisture analysis of the stratum corneum at 1 year after complete wound healing. There was significantly faster wound healing with bFGF, as early as 2.2 +/- 0.9 days from the burn injury, compared with non-bFGF use (12.0 +/- 2.2 vs. 15.0 +/- 2.7 days, p<0.01). Clinical evaluation of Vancouver scale scores showed significant differences between bFGF-treated and non-bFGF-treated scars (p<0.01). Both maximal scar extension and the ratio of scar retraction to maximal scar extension, elasticity, by Cutometer were significantly greater in bFGF-treated scars than non-bFGF-treated scars (0.23 +/- 0.10 vs. 0.14 +/- 0.06 mm, 0.59 +/- 0.20 vs. 0.49 +/- 0.15 mm: scar extension, scar elasticity, bFGF vs. non-bFGF, p<0.01). The durometer reading was significantly lower in bFGF-treated scars than in non-bFGF-treated scars (16.2 +/- 3.8 vs. 29.3 +/- 5.1, p<0.01). Transepidermal water loss, water content, and corneal thickness were significantly less in bFGF-treated than in non-bFGF-treated scars (p<0.01).

PMID 19128258  Wound Repair Regen. 2008 Sep-Oct;16(5):635-41. doi: 10.・・・
著者: S P Pegg, K Ramsay, L Meldrum, M Laundy
雑誌名: Scand J Plast Reconstr Surg. 1979;13(1):95-101.
Abstract/Text A series of 645 consecutive burn injuries are analysed. There were 175 patients in the control group, 156 in the Maphenide (Sulfamylon) group and 314 in the Silver Sulphadiazine (S. S. D.) group. The Maphenide group and S.S.D. group are compared statistically with the control group. S.S.D. proved superior in relation to clinical infection rate and culture rate in reduction of Pseudomonas and Staphylococcus. Other culture rates were analysed. There were significant reductions in both groups for E. coli and Candida albicans. Pneumonias were significantly increased in both groups and the mortality rate reduced with S.S.D. Overall S.S.D. gave better results than Maphenide.

PMID 451487  Scand J Plast Reconstr Surg. 1979;13(1):95-101.
著者: X Z Li, H Nikaido, K E Williams
雑誌名: J Bacteriol. 1997 Oct;179(19):6127-32.
Abstract/Text Silver-resistant mutants were selected by stepwise exposure of silver-susceptible clinical strains of Escherichia coli, two of which did not contain any plasmids, to either silver nitrate or silver sulfadiazine. These mutants showed complete cross-resistance to both compounds. They showed low-level cross-resistance to cephalosporins and HgCl2 but not to other heavy metals. The Ag-resistant mutants had decreased outer membrane (OM) permeability to cephalosporins, and all five resistant mutants tested were deficient in major porins, either OmpF or OmpF plus OmpC. However, the well-studied OmpF- and/or OmpC-deficient mutants of laboratory strains K-12 and B/r were not resistant to either silver compound. Resistant strains accumulated up to fourfold less (110m)AgNO3 than the parental strains. The treatment of cells with carbonyl cyanide m-chlorophenylhydrazone increased Ag accumulation in Ag-susceptible and -resistant strains, suggesting that even the wild-type Ag-susceptible strains had an endogenous Ag efflux activity, which occurred at higher levels in Ag-resistant mutants. The addition of glucose as an energy source to starved cells activated the efflux of Ag. The results suggest that active efflux, presumably coded by a chromosomal gene(s), may play a major role in silver resistance, which is likely to be enhanced synergistically by decreases in OM permeability.

PMID 9324262  J Bacteriol. 1997 Oct;179(19):6127-32.
著者: Bishara S Atiyeh, Michel Costagliola, Shady N Hayek, Saad A Dibo
雑誌名: Burns. 2007 Mar;33(2):139-48. doi: 10.1016/j.burns.2006.06.010. Epub 2006 Nov 29.
Abstract/Text Silver compounds have been exploited for their medicinal properties for centuries. At present, silver is reemerging as a viable treatment option for infections encountered in burns, open wounds, and chronic ulcers. The gold standard in topical burn treatment is silver sulfadiazine (Ag-SD), a useful antibacterial agent for burn wound treatment. Recent findings, however, indicate that the compound delays the wound-healing process and that silver may have serious cytotoxic activity on various host cells. The present review aims at examining all available evidence about effects, often contradictory, of silver on wound infection control and on wound healing trying to determine the practical therapeutic balance between antimicrobial activity and cellular toxicity. The ultimate goal remains the choice of a product with a superior profile of infection control over host cell cytotoxicity.

PMID 17137719  Burns. 2007 Mar;33(2):139-48. doi: 10.1016/j.burns.2006・・・
著者: S Hoffmann
雑誌名: Scand J Plast Reconstr Surg. 1984;18(1):119-26.
Abstract/Text Topical antibacterial treatment is of major importance in the burn patient. Silver sulfadiazine is an effective agent with low toxicity and few side effects. Deposition of silver in tissues, and absorption of sulfadiazine are both minimal. Present and future problems are represented by the emergence of resistant Gram negative bacilli, including Pseudomonas aeruginosa. The development of related metal sulfadiazines to be used against resistant bacteria is on an investigational stage, and clinical trials are few. Silver sulfadiazine may be used in a variety of other conditions than burns.

PMID 6377481  Scand J Plast Reconstr Surg. 1984;18(1):119-26.
著者: Curtis J Donskey
雑誌名: Clin Infect Dis. 2004 Jul 15;39(2):219-26. doi: 10.1086/422002. Epub 2004 Jun 25.
Abstract/Text The intestinal tract provides an important reservoir for many nosocomial pathogens, including Enterococcus species, Enterobacteriaciae, Clostridium difficile, and Candida species. These organisms share several common risk factors and often coexist in the intestinal tract. Disruption of normal barriers, such as gastric acidity and the indigenous microflora of the colon, facilitates overgrowth of pathogens. Factors such as fecal incontinence and diarrhea contribute to the subsequent dissemination of pathogens into the health care environment. Selective pressure exerted by antibiotics plays a particularly important role in pathogen colonization, and adverse effects associated with these agents often persist beyond the period of treatment. Infection-control measures that are implemented to control individual pathogens may have a positive or negative impact on efforts to control other pathogens that colonize the intestinal tract.

PMID 15307031  Clin Infect Dis. 2004 Jul 15;39(2):219-26. doi: 10.1086・・・
著者: Anantha Padmanabhan, Mark Stern, Judith Wishin, Mari Mangino, Karen Richey, Mary DeSane, Flexi-Seal Clinical Trial Investigators Group
雑誌名: Am J Crit Care. 2007 Jul;16(4):384-93.
Abstract/Text BACKGROUND: Management of fecal incontinence is a priority in acute and critical care to reduce risk of perineal dermatitis and transmission of nosocomial infections.
OBJECTIVE: To evaluate the safety of the Flexi-Seal Fecal Management System in hospitalized patients with diarrhea and incontinence.
METHODS: A prospective, single-arm clinical study with 42 patients from 7 hospitals in the United States was performed. The fecal management system could be used for up to 29 days. The first 11 patients (all from critical care) underwent endoscopic proctoscopy at baseline; 8 of these had endoscopy again after treatment. The remaining 31 patients (from critical or acute care) did not have endoscopy.
RESULTS: Rectal mucosa was healthy after use of the device in all patients who had baseline and follow-up endoscopy. Physicians and nurses reported that the system was easy to insert, remove, and dispose of; its use improved management of fecal incontinence; and it was practical, caregiver- and patient-friendly, time-efficient, and efficacious. Skin condition improved or was maintained in more than 92% of patients. Patients' reports of discomfort, pain, burning, or irritation were uncommon. Adverse events were reported for 11 patients (26%). Death (considered unrelated to study treatment) occurred in 5 patients, 2 patients had generalized skin breakdown, and 1 patient had gastrointestinal bleeding after 4 days of treatment.
CONCLUSIONS: The fecal management system can be used safely in hospitalized patients with diarrhea and fecal incontinence. Additional well-designed, controlled clinical trials may help to measure clinical and economic outcomes associated with the device.

PMID 17595371  Am J Crit Care. 2007 Jul;16(4):384-93.
著者: Jane Echols, Bruce C Friedman, Robert F Mullins, Zaheed Hassan, Joseph R Shaver, Claus Brandigi, Joan Wilson, Laura Cox
雑誌名: J Wound Ostomy Continence Nurs. 2007 Nov-Dec;34(6):664-70. doi: 10.1097/01.WON.0000300279.82262.07.
Abstract/Text PURPOSE: The primary objective of this study was to compare rates of urinary tract and soft tissue infections in critically ill burn patients before and following introduction of a Bowel Management System (BMS). We also analyzed the economic impact of the BMS as compared to reactive management of fecal soiling via cleansing and dressing changes.
METHODS AND MATERIALS: A retrospective case-matched before-after study was completed. Critically ill burn patients using a BMS were matched with similar patients managed before introduction of the device based on gender, total body surface area burned, burn location, ventilation days, and hospital length of stay.
RESULTS: Reductions in hospital-acquired urinary tract infections and skin and soft tissue infections were observed after introduction of the BMS. Despite its initial cost, it proved more cost effective than a reactive bowel management strategy based on cleansing and dressing changes when fecal soiling occurs.
CONCLUSIONS: Proactive use of a bowel management device appears to reduce some infectious sequelae in a complicated burn care population and proved cost-effective for our facility.

PMID 18030107  J Wound Ostomy Continence Nurs. 2007 Nov-Dec;34(6):664-・・・
著者: Anil Keshava, Andrew Renwick, Peter Stewart, Ann Pilley
雑誌名: Dis Colon Rectum. 2007 Jul;50(7):1017-22. doi: 10.1007/s10350-006-0882-x.
Abstract/Text PURPOSE: Patients with perineal burns and immobile hospitalized patients with severe excoriation from incontinence caused by excessive diarrhea pose difficult management problems, frequently requiring stoma formation. The Zassi Bowel Management System (Zassi Medical Evolutions, Fernandina Beach, Florida) multichannel intrarectal catheter was evaluated for its safety and its ability to divert feces away from perineal skin to allow wound and skin healing.
METHODS: A prospective cohort study was conducted on inpatients from the Burns and Geriatric Units. Patients with previous rectal disease were excluded. Perineal skin and wound healing was measured before and after tube insertion by using the perianal disease activity index score. Data regarding patient comfort, wound contamination, dressing changes, bed linen changes, and adverse events were collected. Proctoscopy was performed before and after tube insertion.
RESULTS: Twenty-two tubes were inserted in 20 patients (7 perineal burns, 13 severe perineal excoriations). Mean perianal disease activity index scores reduced from 14 to 6.4 (P<0.0001) after tube insertion. Mean dressing changes reduced from 3.3 to 1.5 times per day (P<0.01), and mean bed linen changes in the incontinent patients reduced from 9.3 to 1.2 times per day (P<0.0001). Mean duration of rectal intubation was 14 days. Proctoscopy after tube removal was normal in all cases. One patient developed a superficial ulcer on the buttock from retention strapping.
CONCLUSIONS: The Zassi Bowel Management System tube allows diversion of feces away from the perineum for wound healing. It is safe, effective, and may help avoid stoma formation.

PMID 17431722  Dis Colon Rectum. 2007 Jul;50(7):1017-22. doi: 10.1007/・・・
著者: J Bordes, P Goutorbe, Y Asencio, E Meaudre, E Dantzer
雑誌名: Burns. 2008 Sep;34(6):840-4. doi: 10.1016/j.burns.2007.11.009. Epub 2008 Apr 18.
Abstract/Text BACKGROUND: Burns to the perineal, buttock and upper thigh areas are frequently exposed to continual faecal contamination which results in sepsis, graft loss, delayed wound healing and shrinkage of scars. A temporary diverting colostomy may be required. Two specifically designed intrarectal catheters were evaluated for their safety and ability to divert faeces away from the burn and allow wound healing.
METHODS: A prospective study was conducted involving patients at the burns centre. Either the Zassi Bowel Management System or the Flexi-Seal Fecal Management System were used. These differed only in the presence of a specific intraluminal balloon in the Zassi system to facilitate retention of infused irrigates. Data regarding skin graft success, wound contamination and adverse events were collected.
RESULTS: The study included eight participants, five of whom were treated successfully without colostomy. Four participants experienced complications, comprising one bowel occlusion, one anal ulceration and two reversible cases of anal atony.
CONCLUSION: A specifically designed intrarectal catheter can divert faeces to allow wound healing, and may avert colostomy. More studies are necessary to evaluate safety.

PMID 18395989  Burns. 2008 Sep;34(6):840-4. doi: 10.1016/j.burns.2007.・・・

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