Major burn is considered the most severe type of injury, with high mortality risk and poor quality of life prognosis for survivors. Appropriate burn wound management may require multiple treatment modalities, with specifi c sequencing particular to each patient, addressing every injured area depending on burn surface and depth, patient's general status and also available infrastructure and burn center resources. Early excision of burn eschar and grafting with autologous split-thickness skin grafts remains the universal standard of surgical burn care in acute phase. Ongoing research is conducted for developing new skin substitutes that meet the ethical, safety effi ciency and economical criteria in order to obtain adequate wound coverage when autologous skin grafts are not available. Each severe burned patient represents a complex case, requiring long-term multiple-stage and interdisciplinary treatment, adequate rehabilitation and follow-up program to obtain optimal functional results and socio-professional reinsertion. RezumatArsurile majore reprezintä cel mai grav tip de traumatism, cu risc mare de deces și prognostic rezervat în ceea ce privește calitatea vieţii supravieţuitorilor. Abordarea terapeuticä a leziunilor postcombustionale implicä un tratament multimodal, specifi c fi ecărui pacient, în funcţie de suprafaţa și profunzimea leziunilor, starea generală a pacientului cât și infrastructura și resursele existente în cadrul unităţii de îngrijire a pacientului ars. Excizia grefară precoce cu autogrefe de piele liberă despicată reprezintă standardul universal de tratament chirurgical în faza acută a arsurii. În prezent, continuă cercetările pentru dezvoltarea unor noi substituenţi de piele pentru acoperirea suprafeţelor arse excizate, când autogrefele nu sunt disponibile sau starea pacientului nu permite utilizarea acestora. Substituenţii tegumentari trebuie să întrunească criterii etice, de siguranţă, efi cienţă cât și economice pentru a putea fi utilizaţi pe scară largă pentru acoperirea defectelor postcombustionale. Fiecare pacient ars reprezintă un caz complex ce necesită tratament îndelungat, multistadial, impunând cooperare interdisciplinară. Urmărirea atentă a pacientului, reevaluarea periodică, efectuarea corecţiilor chirurgicale stadiale și încadrarea sa într-un program susţinut de recuperare medicală sunt elemente esenţiale pentru obţinerea unor rezultate optime funcţionale și estetice pentru o cât mai bună reinserţie socio-profesională. Cuvinte cheie: arsuri majore, faza acută, tratament chirurgical, grefe de piele, substituenţi tegumentari
Since 1998, when the first successful hand transplant was performed in France, at Lyon, an unpredicted development of reconstructive transplant surgery (transplant of VCA: vascularized composite allografts) occurred. Those procedures represents the only option for patients having extensive, complex tissue defects, involving multiple anatomical layers, impossible to approach using conventional reconstructive techniques. More than two hundred VCA procedures were reported worldwide, including: upper and lower limbs, face, larynx, trachea, abdominal wall, penis, uterus, knee allotransplant. Important aspects arise in the study of immunological mechanisms of acceptance and rejection of the allograft, the mode of action of immunosuppressive agents and protocols currently used in transplant programs for vascularized composite allografts. Immunosuppressive regimens that are used for solid organ transplantation (kidney, heart) are also effective for VCA transplants with good results regarding survival and functionality of the allografts. Current goal is the minimization of immunosuppression, composite tissue allotransplantation procedures being addressed for functional recovery (are not life-saving interventions like solid organ transplants). The ideal situation, which would allow a large scale utilization of VCA procedures, is the possibility of induction the donor-specific tolerance, allowing allograft acceptance without the need of immunosuppressive therapy. Currently this circumstance is difficult to achieve in clinical practice, resulting in large transplant centers ongoing research focusing on immunological difficult aspects.
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