Initial General Management and Surgery of Six Extensively Burned Children Treated With Cultured Epidermal Autografts By Martin Chalumeau, Jean-Pascal Saulnier, Pierre Ainaud, Her& Lebever, Jean Stephanazzi, Anne Lecoadou, and Herv6 Carsin Cedex, France Purpose:The aim of this study was to document the surgical and intensive care methods used in six extensively burned children (EBC), ie, total body surface area (TBSA) burned over 70% or TBSAwith deep burns over 60%. treated with cultured epidermal autografts (CEA). Methods:Six EBC, with a mean age of 7.5 years (range, 2.5 to 12) received CEA. Their mean TBSA burned was 82% (range, 70-94) with 74% (range, 60-90) of TBSA with deep burns. All sustained flame burns and inhalation injuries. Results: The survival rate was six of six. The average initial and final engraftment rates of CEA were, respectively, 79% (range, 70 to 95) and 84% (range, 72 to 100). CEA definitively covered 45% (range, 18 to 57) of TBSA for a mean cost per child of $80,000 (range, 55,000 to 110,000). Conclusion: Even if CEA are expensive, such engraftment rates and survival ratio results make them an excellent alternative wound covering method for EBC when donor sites for widely meshed autografts are exhausted. J Pediatr Surg 34:602-605. Copyright o 7999 by W.B. Saun- ders Company. INDEX WORDS: Cultured skin, burns. E XTENSIVELY BURNED CHILDREN (EBC), ie, total body surface area (TBSA) burned over 70% or TBSA with deep bums over 60% are rare1,2 but until recently they suffered from a high mortality ratio.3 The availability of cultured epidermal autografts (CEA)4 and its application to children5 might transform the prognosis. To our knowledge, there are no published data concem- ing a homogenous series of EBC treated by CEA with a high engraftment rate. We report the surgical and the intensive care methods used for six EBC, all sustaining inhalation injuries, treated in our center with a survival rate of 100%. MATERIALS AND METHODS From 1990 to 1995, CEA have been used for the treatment of 27 extensively burned patients (as previously defined) in our center. We analyzed in a retrospective and descriptive fashion the major data concerning all patients younger than 15 years of age. Data are expressed as arithmatical means plus range in brackets. Patient Population Data concerning the patient population are summarized in Table I. Mean age was 7.5 years (2.5 years to 12 years). None had major prior disease. All sustained skin burns by flames. The TBSA burned was 82% (70% to 94%) with 74% (60% to 90%) of the TBSA with deep bums (according to initial clinical evaluation). Inhalation injuries were From the Bum Center; Percy Military Hospital, Cedex, France. The CEA program was supported by a special grant from the French Ministry of Defense. Address reprint requests to Herve’ Carsin, MD, Bum Center; Percy Military Hospital, BP406, 92141 Clamart Cedex, France. Copyright o 1999 by WB. Saunders Company 0022-3468/99/3404-0019$03.00/0 602 constant. Anuric acute renal failure was present at admission in cases 1 and5. Keratinocyte Culture Method The culture of keratinocyte followed Rheinwald and Green’s meth- od.6 On the sixth (1st to 18th) day postadmission, a full-thickness biopsy specimen (2 to 3 cm2) was removed from hairy skin and sent to a commercial laboratory (BioSurface Technology Inc, Cambridge, MA). A coculture of autologous keratinocytes with lethaly irradiated 3T3 murin fibroblasts led in 10 days to a pluristratified epithelium. Depending on the wound surface to be covered, a part of this “primary culture” was started again after proteolytic treatement to obtain in another 10 days a “secondary culture.” Then it was stapled on Vaseline gauze and sent back for immediate clinical use or cryopreserved. Local Treatments Deep burns were excised early to the fascia in three separate procedures. The first and last excision occurred on the second (first to third) and the 14th (6th to 26th) day postadmission, respectively. Excised areas were covered either temporarily by allografts (cryopre- served cadaver homografts), or definitively by widely meshed auto- grafts overlaid by allografts according to the technique described by Alexander and McMillan.’ Autografts were preferred for coverage of articular areas or the back. Dressings were renewed every day with cerium-silversulfadiazine on unexcised areas, and every 2 to 3 days with polyvinylpyrholidone-iodine plus Vaseline gauze on excised areas. On the 28th (23th to 44th) day postadmission, secondary cultures were available. Receiving areas were prepared by allograft dermabrasion according to the technique described by Cuono et a.ks and CEA were laid down, stapled, and wrapped by a bridal veil and dry gauze. Dressings were changed every day as deep as the bridal veil with polyvidone-iodine plus Corticotulle (triamcinolon-neomycin-poly- mixin B) or polyvidone-iodine plus Vaseline gauze. The withdrawal of the stapled Vaseline gauze, called take-down, occured on the eighth (7th to 10th) day. During this critical period, close bacteriologic monitoring was maintained, and systematic intravenous antibiotherapy was admin- istered. This antibiotherapy always used teicoplanin as an antistaphylo- Journal of Pediatric Surgery, Vol34, No 4 (April), 1999: pp 602-605