TCYHTH&B s6 1-2014 25
MQT SO DAC DIEM CUA BENH NHAN BONG NANG VA CAC BIEN CHQNG T H U 6 N G GAP 6 CAC BENH NHAN BONG NANG
DIEU TRj TAI KHOA HOI SUfC CAP ClJu - VIEN BONG QUOC GIA
Nguyen Viet Lu>crng Vien Bong Qudc gia
TOM T A T
Li don vi diiu tri bdng tuyin cudi cua ci nwoc nen ty Id benh nhin bong nang. rit ning dwgc diiu tn tgi Vl$n Bdng Qudc gia chiim mot ty Id khi cao Nghien cwu dc dac diim benh ly hdn quan cOng nhw cic biin chdng thudng gap a nhO'ng benh nhan nay se giup chung ta cd ca sd tidn Iwgng vi dwa ra chiin Iwgc diiu tri tdt hon. Nghien cu'u hdi cwu tren 746 benh nhin bdng ning vi rit n$ng tgi khoa Hdi sue cip cwu. Vidn Bdng Qudc gia tw 1/2011 din 12/2012 cho thiy buc tranh khi diy du vi cic d$c diim benh ly d' cic benh nhan bdng nang, rit nang, ding thdi cOng cho chung ta thiy nhO'ng loai bien chwng co thi gap d benh nhin bdng nang, rit n$ng cQng nhw ty' 10 cua cic biin chu'ng dd
SUMMARY
Being a professional hospitals for burns ofthe country, the ratio of patients with severe burns, severe burns treated at the National Institute of Burns occupies a fairly high rate Research the related pathological charactenstics as well as common complications in these patients will provide us with the basis of prognosis and provide better treatment strategies Retrospective study on 746 patients with severe and very severe burns resuscitation in ICU, National Institute of Burns from January 2011 to December 2012 show the pathological characteristics in patients with severe burns, very severe burns, and also shows us what kind of complications can occur in patients with severe burns, severe as well as the rate of such complications.
D A T V A N D £ " '^^^ ^ ' ^ " chu'ng va ty le cac bi§n chting thu'o'ng gap a nhom BN bong nang, r i t MOt trong nhi>ng thach thiec lan nhat nang. Khong nhu'ng t h i viec phan tich m6i hi$n nay trong di^u trj bong 36 1^ vi^c tang ij^n quan giQ'a cac y&u t6 benh ly nhu- lic kha nang cu-u s6ng va giam ty \g ttr vong a nhan gay bong, dien tich bong. 66 sau b$nh nhan (BN) bong n$ng va rat n$ng Ge i^^ng, tuoi BN h\ bong, tinh trang bong ho c6 00- so- cho vi$c ti6n \u-gtng vi dieu trj h a p . . vai cac bien chung thu-i^ng gap a nh6m BN nay c^n phai c6 co- so- va cac so phom BN nay con giup chung ta danh giS li$u cy th§ ve tinh trgng cua cac ^yeu to chinh xac hon va co nhO'ng bien phap du- b$nh ly Ii6n quan, d6ng thd'i cung can phai ph^ng stjm de ngan chSn va han che cac c6 nhu'ng danh gia chinh xie v ^ chung logi bien chu-ng, g6p phan tang kha nang ciru song, giam ty le tCr vong cung nhu' giam chi Phan bi0n khoa hQc TS Chu Anh Tuan P^^ ^a thai gian di6u tn
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Co mot s6 nghien CLFU cung da de cap ve v§n dk nay song tac nhan gay bong, hoan canh b| bong, cong tac s a ciru, cap CU'U da CO nhOng thay doi theo thai gian.
Han nu'a, c6ng tac di^u tri bong cung da co nhOng SLF thay doi do do cung can t h i i t phai cap nhat iai tinh hinh a BN bong nang, rat nSng cung nhu" danh gia lai cac y i u t6 bSnh ly va cac bien chieng hen quan a nhdm BN nay
Xuat phat tu" nhCfng nhan xet tren, chiing toi t i i n hanh nghien ci>u de tai: "Mgt s6 dac diem benh ly a BN bong n^ng, r i t nang va cac b i i n chirng thu'o'ng gap a nhdm BN bong nang, r i t nSng dieu tri tai khoa Hoi sire c i p CU'U, Vien bong Quoc gia tir 1/2011 -12/2012"
vai hai muc tieu sau:
- Nhan xet cac y i u t6 benh ly va cac b i i n chirng thu'ang gap a nhom benh nhan bong nSng, rat nang
- Oanh gia moi lien quan giira cac yeu to b^nh ly vai ty ie va mirc do cac bien chirng thu-b-ng gap a nhom b^nh nhan bong nang, rat nang.
2. D 6 | T U g N G VA PHU'ONG P H A P NGHIEN CU'U
2.1. D6i tu-o-ng n g h i e n CLPU
Gom 746 BN bong nang, du'ac d i i u trj tai khoa Hoi sire cap cifu (HSCC), Vien Bong Quoc gia, trong 2 nam- Tir thang 01 nam 2011 den thang 12 nam 2012
• Tidu chuin Iwa chon bdnh nhan nghien cu'u:
• Benh nhan bong nang, r i t nSng dirac d i i u tn tai khoa HSCC (VBQG) tir thang 01 nam 2011 den thang 12 nam 2012.
BN bong nang dirac xac dinh dira theo phan logi mirc dp bong cua Hpi Bong Hoa Ky(1984)
* Tieu chuan loai trir:
BN dieu tn tai khoa DTTC, nhu'ng khong n i m trong nhdm bong nang theo tifeu chuan ke tren.
- B^nh an kh6ng con d i r a c liru trO' tai thu- vien VBQG.
2.2. PhiFcng phap n g h i e n CIPU 2.2.1. Phwvng phap nghi&n ciiu
Nghien ciru h6i ciru, theo doi doc tren nhUng chi tieu danh gia da xac djnh 2.2.2. Thiet ki nghien cu'u
- Tuy theo muc dich danh gia, BN nghien ciru du'ac chia ra lam cac nhom de so sanh, phan tich riit ra nhSn xet.
- Chan doan dien tich bong. Di?n tich bong du'ac tinh thong qua ap dung mdt trong ba phu-ang phap sau d a y
+ Phu'ang phap con s6 9 cua Pulaski E.J, Tennison C W (1949), Wallace A. (1951)
+ Phirang phap i r a m ban tay BN cua Blokhin N.N, Glumov t.l.
+ Phu'ang phap dira vao cac con so 1 - 3 - 6 - 9 - 1 8 cua Le The Trung (1965),
£)6i vai tre e m , dira vao cac bang tinh s i n di^n tich cac vung giai phau ca the cua BN theo L6 The Trung (1965) hoac Lund, Browder(1944),
- Chan doan dp sau bong; Sir dung each phan loai do sau bong cua Le The Trung (1965), dp sau bong du-g-c chia thanh 5 dO (tir dp I d i n dp V). Chan doan dp sau bong dira vao lam sang
2.3. Xil ly so tieu
S6 lieu thu thap du'ac tinh ra gia trj trung binh hay ty 1$ % (bieu thj b i n g X ± SD, vdi khoang tin cgy 95%), phan tich b i n g chu-ang trinh SPSS version 20.0 theo thuat toan x^
hpac t-student. Gia tn p < 0,05 du'pc coi la c6 y nghTa thong k6.
TCYHTH&B so 1 - 2014 27
3. K ^ QUA NGHIEN c i r u 3.1. Die diem b f n h n h a n nghien cipu
Bang 3.1. Dac diem b^nh nhan nghien ciju O9C diem
Thcri gian vao vien (h) TUOI (nam) Dien tich bong (%) Dien bong sau (%) Bong ho hap {n,%}
Bong 6uong tieu hoa Ty le nam/nO
Gia tri trung binti 24.67 24.61 41.03 17.27
Min - Max 1 -154 0.5 • 98 12-98
0-90 326 (43,70)
11 (1.47) 510/236
Nh$n xdt- Di$n tich bong chung va bong sau trung binh a mirc kha cao BN co bong hd hap chiem ty 1$ cao (43,70%) BN nam gap n h i i u han BN nir trong nghien ciru cua chiing toi
Bang 3.2. D^c diem b^nh nhan nghien CLFU theo givi tinh, lira tuoi
Nhom tuoi
<16 16-60
>60 C«ng
G Nam S6BN
168 310 32 510
%
60.2 75.1 59.3
Ul
ua
SoBN 111 103 22 236
%
39.8 24.9 40.7
C9ng S6BN
279 413 54 746
%
37,4 55,4 7,2 100%
Nh$n xit: Ty ]g BN nam n h i i u han BN nCr a t i t ca mpi lira tuoi Benh nhan lira tuoi lao dOng (16 - 60 tuoi) chiem ty \€ cao n h i t (55,4%)
"'^~~~--.„„^^^ Tuoi Tic nhan --~„„^^^
Nhiel kho Nhi$t u-ot Di$n cao the Hoa chat
Cdng
Bang 3.3. Tac nhan gay bong
<16 n (%|
61 (18.28) 219(78.49) 7(2,51) 02 (0.72) 279(100)
16-60 n (%l 288 (69,73)
35 (8.47) 85 (20,58) 05(1.22) 413(100)
>60 n (%) 50 (92,59)
4(7,41) 0 0 54 (100)
Cong n (•/.) 389(52,15) 258(34,58) 92(12,33) 07 (0,94) 745(100) Nhit} xil. Tre em, nhi#t irM la tac nhan gay bong chu yeu (78.49%) Nguai l*n va ngi^tn giS. nhi$t kh6 li tSc nhSn gay bong hang dau (69.73% va 92,59%) Bong do ijien cao the chiem mdt ty l§ dSng ke (12.33%) trong d6 chij yeu ii li>a tuoi lao dpng
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3.2. Cac b i l n c h i f n g s a u b o n g va m d i lien q u a n giCpa cac bidn c h i r n g d o v o i cac lofii b o n g , mipc d o b o n g
Bang 3.4. Cac b i l n chu'ng gap a nhom b f n h nhan nghien CLFU Bien chu'ng
S6c bong Suy da tang Suy than cap ARDS Soc nhiim khuan Nhiem khuan huyet Xuat huygt tieu hoa
S6 lipcng 640/746 181/746 162/746 141/746 128/746 40/746 11/746
Ty If % 85.79 24,26 21.72 18.90 17,16 5,36 1.47 Nhin xet Gap kha nhieu bien chirng nang trong nhdm BN nghien ciru, bien chirng g^p nhiiu n h i t la soc bong ( c h i i m 85.79%) trong tong s6 BN bong du'pc nghien ciru
Bang 3.5. Bien chLrng 6 benh nhan bong ho hap (n = 326)
Bi4n chu'ng
Soc bong ARDS Soc nhigm khuan Nhiem khuan huyel Suy than Suy da tang
S6BN Co Khong
Co Khong
Co Khong
Co Khong
Co Khong
Co Khong
C6(n = n 305
21 107 219 91 235 23 303 125 201 140 186
Bong h 326)
93,56
%
6,44 32,82 67,18 27,91 72,09 7,06 92,94 38,34 61,66 42,94 57,06
0 hap Khong(n
n 335 85 34 386 37 383 17 403 37 381 46 374
= 420) 79,76
%
20,24 8,10 91,90 8,81 91,19 4,05 95.95 8,81 90,71 10,96 89,05
P
<0,05
<0.05
<0.05
<0.05
<0.05
<0.05
Nhin xet - & nhO'ng BN co bong ho h i p , ty le s i c bong gap rat cao (93,56%) cao han so vai ty le s i c bong a cac BN khong co bong hd h i p (79,76%) sir khac biet cd y nghia (p<0,05).
- & nhu'ng BN co bong ho h i p , ty IS c^c b i i n chirng khac gap cung kha cao va cao hon h i n nhom BN khdng cd bong hd hap, si/
khac biet cd y nghia (p<0,05), Noi each khac bong ho h i p da lam tang nguy c a cua cac b i i n chirng sau bong.
Bang 3.S. K§t qua c i y khuan mau {n =746) Ketqua ciy mau
Khong mpc P aeruginosa S aureus Khac
Tong so
So lipcng 706
16 19 5 746
Ty If % 94.64
2.14 2.55 0.67 100
TCYHTH&B s6 1-2014 29
Nhin xit: S6 lu-Q-ng BN cay khuan mau co mgc vi khuan c h i i m ty ie thap (5,36%) so vdi t i n g so BN du-g^c cay mau Hai logi vi khuan gay n h i i m khuan huyet gap nhieu la tru'c khuan mu xanh va ty cau vang.
Bang 3.7. Cac y i u td li§n quan d i n sdc nhilm khuan (n = 128) Cac ydu td lien quan
TUOI (nam) Dien tich bong (%) Dipn tich bong sau (%}
Bong ho hap (n.%) Glucose vao vien (mmol/1)
Soc nhilm khuan 06
31.39 ±23,20 52,84 ± 24,94 29.00 ± 20.76 78/128(60,94) 8,39 ± 4,02
Khong 23,21 ± 20,22 38,59*21,20 14,84 ±8,31 50/618(8,09) 7,79 ± 3,92
P
< 0,001
< 0,001
< 0,001
< 0.001 0.103 Nhin xit: - Chi s i trung binh cua tuoi,
di$n tich bdng chung; dien tich bdng sau a nhdm BN c6 soc nhidm khuan cao han so voi nhdm BN khdng c6 soc nhiem khuan, khac biet c d y nghTa (p< 0,001)
- 0 nhdm BN co sdc n h i i m khuan ty le
bong ho hap (60,94%) cao han han so vdi nhdm khdng cd s i c n h i i m khuan (8,09%), s y khac biet cd y nghTa thong kd (p<0,001), N6i each khac a nhom BN bj bong hd hap, ty le gap bien ehirng s i c n h i i m khuan eao han n h i i u so vdi nhdm BN khdng bj bdng hd hap Being 3.8. Cac yeu td lien quan den b i l n chii'ng suy than cap (n = 162) Cac y l u t d lien quan
Tuoi (nam) Dipn tich bong (%) Di^n tich bong sau C^o) Bong ho hap (n,%) Glucose vao vien (mmol/1)
Suy t h i n c i p (n=162) Co
41,46 ±21,68 50,40 ± 25,41 34,77 1 22,70 126/162 (77,16)
9,15±3,56
Khong 1994 ±931 35.66 ±18.14 12.42 ±4,14 201/584 (34,42)
7,54 ± 3,85
P
< 0,001
< 0,001
< 0,001
< 0,001
< 0,001 Nh$n xdt: - Chi so trung binh cua tuoi,
di^n tieh bong chung; di^n tich bong sau d nhdm BN cd suy thgn c i p cao han h i n so vdl nhdm BN khdng cd b i i n chiKng suy than c i p , s y khac bi$t cd y nghTa (P<0,001).
- 0* nhdm BN cd suy than cap, ty \g cd bdng hd hap (77,16%) cao han nhieu so vdi nhdm BN khdng cd suy thgn cap (34,42%),
s y khac biet cd y nghTa (p<0,001) Noi each khac, d nhdm BN bi bdng hd hap ty !e b i i n chirng suy than cap eao han so vdi nhdm BN khdng bj bdng hd hap,
Nhdm BN ed suy than c i p , chi so glucose mau trung binh eao han so vdi nhdm BN khdng cd suy than cap, su' khae biet ed y nghTa (p<0.001)
Bang 3.9. Cac y i u td lien quan den hpi chijng ARDS (n = 141) Cic y i u td lien quan
Tu6i (nam) Di$n tich bong (%) Di$n tich bong siu {%) Bong hd hip (n, %) Glucose vio vi$n (mmol/1)
ARDS Co 36,92 ± 20,65 61,28 ±26,58 36,42 ± 22,96 107/141(75,89) 9,30 ± 3,41
Khong 21,75 ±20,07 36,32 ±18,34 12,81 ±4,40 219/505(36.20)
7.56 ± 3.87
P
< 0.001
< 0.001
< 0.001
< 0.001
< 0,001
TCYHTH&B so 1-2U14
Nhin xdt: - Chi sd trung binh cua: tuoi;
dien tieh bdng chung; dien tich bdng sau d nhdm BN cd ARDS cao han h i n so vdi nhdm BN khdng ed ARDS, su' khac biet cd y nghTa (P<0,001).
- 0 nhdm BN cd ARDS. ty le cd bdng hd h i p (75,89%) cao han n h i i u so vdi nhdm BN khdng cd ARDS (36,20%), s y khae bidt cd y nghTa (p<0,001) Ndi each khae, a nhdm BN bj bdng hd h i p ty le b i i n chirng ARDS cao han n h i i u so vdi nhdm BN khdng bi bong hd h i p .
- Nhdm BN cd ARDS, chi sd glucose mau trung binh eao han so vdl nhdm BN khdng ed ARDS, su' khac biet cd y nghTa (P<0,001),
- Cd rdi loan ddng mdu vdi mire y nghTa p < 0 , 0 5
4. BAN LUAN
4.1. Dac d i l m cua cac BN b o n g nang va cac bien chipng thu'o'ng gap
Tren 746 BN bdng nang dirge nghien ciru, chiing tdi t h i y cd mdt sd dac d i i m nhu- sau Lira tuoi gap nhieu n h i t la lica tuoi tir 16 - 60 tuoi (chiem tdi 55,4%), day la lira tuoi dang lao ddng. D i i u nay ed t h i du'ac ly giai vJ hau h i t cac bdng nang va r i t nang thirdng gap nhiiu trong cac vu tai nan, tham hoa trong lao dpng san x u i t , giao thdng (chay no trong ham id, chay h i m tau, nha may ed hda ehat, bdng do dien eao t h i , ehay xe , ) ma nan nhan h i u h i t la ngirdi dang dp tuoJ lao dpng, Mot dae diem nu'a cung cho t h i y vdi nhirng edng viec ed tinh c h i t nang nhoc, de chay no, d i bi bdng nang, . thi p h i n ldn do nam gidi dam nhan, cho nen trong nghien cii'u cua ehiing tdi ty le BN nam cung gap nhiiu han BN nu' (510/236), k i t qua nay eung phii hap vdi nhieu nghien eiru trong nu'dc va cac nghien eiru d eac trung tam bdng tren t h i gidi [1], [2], [7], [8]; (9). Ngoai ra mpt d$c diem ma chung tdi cung nhan t h i y d nhdm BN nghien ciru nay dd la ty le bdng hd hap k i t hp'p eao (326 BN cd bong da va bdng
hd h i p k i t hp'p trong s6 746 BN bdng nang du'ac nghien ciru, chiem 43,70%). K i t qua nay cao han k i t qua cua cac nghien ciJu trong n y d c t r i f d c day cung nhu" cac nghign CLi-u khac tren t h i gidi [2]; [5J; [6]; [10]. Hoan canh bl bdng ( h i m Id, ham tau, trong nha kin, chay no...); tac nhan gay bdng (lOa con, lOa xang, vat lieu de chay, khi metal..) la nhOng tac nhan thu'dng gap cung nhu- tinh trang tir thieu e h i i m mdt ty le ddng ke d nhdm BN nay cd le la nguyen nhan lam cho ty le bdng hd h i p cao trong nghien ciru cua chiing tdi.
Chiing tdi gap ty le b i i n chirng cao trong nhdm BN nghien ciJu, hau het cac bien chirng dien hinh trong bdng deu gap d nhdm BN nay nhu": sdc bdng; suy da tang; suy than c i p ; ARDS; soc n h i i m khuan; n h i i m khuan h u y i t va x u i t huyet tieu hda Trong dd c6 mdt sd b i i n chirng gap vdi ty le r i t cao vi du nhu-: sdc bdng (85,79%), suy da tang (24,26%), suy than c i p (21,72%).
4.2. M d i lien q u a n giO>a cac y d u t d benh ly va cac b i l n c h i i ' n g t h i p o r g g a p a cac benh nhan b o n g n a n g , r i t n a n g
Qua nghien ciru chung tdi t h i y ring d nhdm benh nhan cd bdng hd hap thi ty le gap sdc bdng r i t cao (93,56%), eao han nhiiu so vdi nhdm benh nhan khdng ed bdng hd h i p (79,76%). N h i i u nghien eiru cung da cho t h i y , ngoai nhO'ng y i u to anh hu'dng den soc bdng du'ac ghi nhan nhu' dien tieh bdng chung, dien tich bdng sau, tuoi, cac b$nh ly k i t hap thi bdng hd h i p du'p'c xem la y i u td quan trpng anh hirdng d i n sdc bdng [1];
[2], [3] Ben canh b i i n chirng sdc bdng thi ty le eac b i i n chirng khac d nhdm cd bdng ho h i p eung cao han nhdm khdng ed bdng ho h i p , vdi su- khac biet ed y nghTa thong ke.
K i t qua nay cung phii hp'p vdi k i t qua nghien ciru eua n h i i u tac gia khac [1], [2], [3].
Tuy nhien. di^n tich bdng ehung va di$n tich bdng sau v i n la nhu'ng y i u to cd li§n quan chgt che d i n nhieu b i i n chtrng nSng sau bdng. Nghien ciru cua chiing tdi dS cho t h i y nhdm b^nh nhan cd di6n tich bdng
TCYHTH&B so 1-2014 31
chung Idn. di$n tich bdng sdu Idn thi ty lp g9p soc bdng va s i c n h i i m khuan cao han nhieu so vdi nhdm benh nhan bong ed dien tich bdng chung va bdng sau it han. Ngoai ra cae bien ehirng nhir suy than cap, h^i chirng ARDS d nhdm cd dt$n tich bdng chung va bdng sSu Idn cOng cao han nhieu so vdi nhdm b§nh nhan cd di^n tich bdng chung va bdng sau bd han Nhgn xet nay cOng triing hp'p vdi cac nhan xet cua n h i i u nghien ciru k h a c [ 3 ] , [ 4 ] , [ 1 1 ] ; [ 1 2 ] .
K^T LUAN
K i t qua nghidn cii'u hdi ciru 746 bSnh an b$nh nhan bdng nang, rat nang dirac dieu tri tai khoa D i i u tn tich cu'c, Vi^n Bdng Qudc gia tir 01/2011 - 12/2012, cho phep riit ra mpt sd nhan xdt bu'de d i u nhu' sau:
1 Bdng do nhiet khd (trong do chu yeu la bdng lu'a, khi ndng, khdi ndng) ehiem ty le cao n h i t (52,15%) va bdng hd h i p c h i i m ty 1$ cao (43,70%) d eae b$nh nhan bdng nSng, r i t n^ng trong nghi§n ciru cua chung tdi.
2 (y cae bdnh nhan bdng n^ng, rat nang ty lp g^p cac b i i n chirng r i t cao, hau h i t la cac b i i n chirng nang (soc bdng, s i c n h i i m khuan; suy da tang, suy thSn cap, ARDS) c a c y i u to b^nh ly cd lien quan ch0t ehe tdi cac b i i n chirng sau bdng la dien tich bdng Chung, di$n tich bdng sau. dac biet la bdng hd hap,
TAI Lieu THAM K H A O
T i i n g Vi#t
1 Nguyin Tiln Dung (2011), "Djcti t l hgc mieu ta bong do tai n^n lao dgng d mien BSc Viet Nam", T^p chl Yhgc tham hQava Bong {M20n).Jt 16-24.
2 NguyAn Tiin DOng (2012), "Nghien ciru mpt so biin chirng 6 b?nti nhan bong tio hap*. Tap ctii Y hpc thim hpa va Bdng (3/2012), Jr. 84-89
3 Nguyin Nhu- Lam va CS (2009), 'Nghien ciru mpl s6 yeu to nguy (xj suy 3a tang it benh nhan bong nang". Tap chi Y hgc thijr: hanh (652+653/2009), Tr 95-99.
4- Nguyin Nhir Lam va CS (2011). 'Nghien CLPU dac diem suy than cip theo tieu chuan RIFLE v benh nhan bong nang". Tap chtYhQC tham hoa va Bong (2/2011), Tr. 95-101
5 Vii Truang SOTI (2007), "Nhan xel ket qua dieu tn benh nhan bong nang tai khoa dieu tn ticfi cue - Vien Bong Qu6c gia trong 2 nam (lir thang 7/2005 din thang 6/2007), LiJ$n van thac sy y hoc. Hpc Vien Quan Y. 2007.
6 Chu Anh Tuin va CS (2008), "Nghien ciru cac yiu to benh ly hen quan k i l qua diiu In benh nhan bong n^ng", T$p ctii Y tiqc tham hga va Bong (4/2008), Tr 59-66,
Tieng Anh
7 Brusselaers N. et al (2013), "Assessment of mortality prediction models in a Ghanaian burn population", Burns 39 (2013) 997-1003, 8. David J.S. et al (2012), "A new algorithm to allow
early prediction of mortality in elderly burn patients", Burns 38 (2012) pp 1114-1118 9 ForsterN.A. etal (2011), "30 years later - Does the
A6SI need revision?", Bums 37 (2011) pp 958-963, 10. Guo F. et al (2009), "Management of burns of over 80% of lotal body surface area A comperative sludy", Bums 35 (2009) pp 210-214 11. Hollingsed T.C. et al (2007). "Etiology and
consequences of respiratory failure in thermally injured patients", Am J Surg. Dec; 166(6): 592-596 12. Sheridan R.L. et al (2007). 'Etiology and
prevention of multisystem organ failure", To(a/ Sum Care, Third Edition. Elsevier Cop (2007) David N Herndon. Chapter 32.
