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India is one of the few places in the world where burn victims, predominantly young married women and children, are a result of domestic accidents. Suicidal burns are also very high, making up almost 90 percent of cases.
Treating these patients, who are emotionally broken and have little will to live, is a big challenge for Indian doctors, who have to combine counseling skills with their medical proficiency to bring about the best results.
Yet we can hope for positive changes in future thanks to the experiments of an enthusiastic plastic surgeon, Dr. K. Sudhakar of Osmania General Hospital in Hyderabad, India, who recently demonstrated that including a fluid called Voluven to replace fluid loss can prevent deaths in burn patients, while decreasing complications associated with infusing fluids.
Thirty-two patients were randomly divided into two groups. One, the control group, received regular fluids while the other, the test group, received Voluven in addition to regular fluids. The study lasted for 48 hours after hospitalization as this is the most critical period for a patient with burns.
Nearly all burn cases in India get admitted to government hospitals which lack modern treatment modalities and sophisticated monitoring facilities, are underfunded and overcrowded and therefore show high rates of morbidity and mortality. The majority of patients cannot afford private hospitals which are better equipped to treat such cases.
The mechanism of injury due to burns is quite complex. The extremely high temperature damages the skin and underlying tissues and disrupts protective layers. As a result, an array of toxic chemicals is released into the blood that perpetuates the damage. The walls of all blood vessels, which are like a tight fabric in health, get converted into a loose mesh and all the fluid, along with protein particles, oozes out and accumulates within tissues and broken skin.
This fluid, rich in nutrients, is an invitation for all sorts of microbes which thrive on it. Normally, these bacteria cannot enter the blood as the skin acts like a barricade. But now that it is damaged, bacteria can easily enter and give rise to a life-threatening condition, sepsis.
The continuous ooze out of veins and capillaries, causing immense loss of the circulating blood fluid, affects the normal functioning of vital organs like the brain, heart, lungs and kidneys. Such a malfunction occurring due to decreased blood supply leads to a condition called shock which is fatal if not diagnosed and treated in time.
A burn patient has a high risk of going into sepsis and shock, leading to death, and so timely therapy within the first 48 hours after injury largely determines his survival.
The primary line of treatment is infusing large amounts of fluids, like saline, to make up for the loss and prevent shock. However, harmful chemicals that damage blood vessel walls don't withdraw for at least 48 hours and until then, most of the infused fluids leak out into tissues and under the skin, producing massive swelling of the body.
That is why a burn patient receiving treatment resembles a bloated balloon as his weight increases by at least 5-6 kilograms. This accumulated fluid delays healing of wounds and causes breathlessness if it gathers around the lungs.
The world over, experts are trying to figure out better ways to treat a burn patient in the first two days so as to minimize these problems.
Voluven is a fluid that contains small particles of starch suspended in it. The particles do not seep out of the injured blood vessels and have a property to retain fluid inside the vessels. Voluven also decreases the release of toxic chemicals and hastens healing of vessel walls and in turn, promotes early arrest of fluid leakage. Thus, patients need fewer fluids to restore the balance and many complications arising due to fluid overload are bypassed.
When Dr. Sudhakar learned of Voluven he felt it was tailor-made for burn patients. Since there were no previous studies of such an application, he decided to undertake the study himself, with a completely open mind.
The results were very encouraging. As compared to the control group, the Voluven group needed just half the volume of fluids, resulting in less body swelling and less than four kilograms of weight gain. The deaths were also almost half in number.
In fact, the favorable results were so starkly evident in the Voluven group that after recruiting the first 20 patients, Sudhakar was no longer comfortable in depriving any burn patient of Voluven. So all the remaining patients were included in the test group!
This study, though small, is ground breaking. It should inspire more surgeons to conduct larger clinical trials, so that there is more evidence to justify the use of Voluven routinely in burn patients.
A serious health concern like burns, involving the young population in a growing country like India, deserves that every ray of hope be explored as aggressively as possible because it can mean life for thousands of burn victims.
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(Dr. Pradnya Kulkarni is a clinical pathologist from India. She worked as a consultant pathologist in a private laboratory in Pune before moving to Hong Kong with her husband and young daughter. She is also a freelance writer, focusing on medical issues of public concern. ©Copyright Pradnya Kulkarni.)
