anano20 Surgical veatment and management of the severely bum patient Review and update | Medicina Intensva Inicio Asticles in press Ndmero actual Nuimeros anteriores Suplementos Lo més lelido Apartados SERIES IN INTENSIVE CARE MEDICINE: NEW PERSPECTIVES IN THE MANAGEMENT OF CRITICAL BURN PATIENTS, Abstract Este atieulo ha recibido Keywords 10: 10.2016); medin.2017.07.008, (© Acceso 3 teto completo ; 16198 Resumen Surgical treatment and management of . ° Visitas Palabras clave the severely burn patient: Review and (cts dia de dats) Surgical treatment. update Tratamiento y manejo quirurgico del paciente gran quemado: revisién y puesta al dia . Gacto-Sancher Plastic Surgeon, Plstc and Reconstructive Department, Burns Unit, Vegen del Rocio University Hospital, Sevilla, Spain Informacién del articulo Resumen Texto completo _—Sibliografla Descargar PDF Estadeticas ABSTRACT Since one of the main challenges in treating acute burn injuries is preventing infection, early excising of the eschar and covering of the wound becomes critical. Non-viable tissue is removed by initial aggressive surgical debridement. Many surgical options for covering the wound bed have been described, although split-thickness skin grafts remain the standard for the rapid and permanent closure of full-thickness burns. Significant advances made in the past decades have greatly improved burns patient care, as such that major future improvements in survival rates seem to be more difficult. Research into stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients. Keywords: Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuracién u obtener mds informacién aqui. Aceptar htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 1124anano20 Surgical veatment and management of the severely bum patient Review and update | Medicina Intensva Inicio Articles in press Nimero actual Némeros anteriores FHRLESPE Fetira el tejido He"VAbIE? Se han descrito multiples opciones quirirgicas para cobertura del lecho cuténeo, aunque los injertos de piel parcial continiian siendo el estindar para una cobertura répida y permanente de las quemaduras de espesor total Los grandes avances que han tenido lugar en décadas anteriores han mejorado de forma sustancial los cuidados del paciente quemado de tal forma que parece dificil que pueda haber mejoras importantes en las tasas de supervivencia futuras. Técnicas tales como la investigacién en .cidn contribuirén a células madre, injertos, biomarcadores, control de la inflamacién y rehabi mejorar unos planes de cuidados individualizados y a crear nuevas opciones de tratamiento para estos pacientes. Palabras clave: Quemaduras Tratamiento quirirgico Avances quirirgicos TEXTO COMPLETO Surgical treatment Burns are common injuries with considerable morbidity and mortality. Early excision and grafting has been the standard care for decades. Since mid 70s most studies have shown that excision within 24-48 h after injury is associated with decreased blood loss, infection, length of hospital stay and mortality, and increased graft take,!~ although mortality reductions may only occur in patients without inhalation injury.5¢ The current therapy of the acutely burned patient is based on adequate resuscitation, early wound debridement and closure, support of post burn hypermetabolic response and control of infection. Therefore, since one of the main challenges in treating acute thermal injuries is preventing infection, excising the eschar and covering the wound as early as possible is critical. By early, aggressive surgical debridement, non-viable tissue is removed and hence the wound bed is relatively infection free. Furthermore, the removal of dead tissue has the potential to reduce the Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener mds informacién aqui Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpssiwww.medintonsiva orios-surgical-reatment-managament-soverely-bumn-ariculo-S0210569117301006anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensiva Inicio Asticles in press Ndmero actual Nuimeros anteriores Suplementos Lo més leldo ° In general, partial thickness and second-degree burns are used interchangeably, while full thickness and third degree are synonymous. Complete debridement should proceed at the earliest possible opportunity, even if donor sites are insufficient to provide total wound coverage. In this case, biological dressings (preferably cadaveric donor allograft) should be used to cover the remaining wounds. Excision of burn wounds requires large volumes of blood for transfusion (approximately 1 ce/cm? to be excised).” Another factors leading to blood loss in burn patients are old age, male gender and extensive total body surface areas (TBSA) burnt. Blood loss can be minimized by the use of excision to the level of fascia or tourniquets when performing tangential excisions of the extremities. Moreover adrenaline-lidocaine subcutaneous infiltration solutions can be used in both burned areas and donor sites. Besides, thrombin spray, fibrin glue, alginate dressings and topically applied adrenaline gauzes may also help dealing with bleeding.’* Tangential excision gives a better cosmetic outcome by leaving subcutaneous fat but blood loss is greater. On the contrary, fascial excision presents lower bleeding rates but worse cosmetic results. The latter is indicated in burns comprising extense TBSA and critical patients'-® (Table 1). The depth of excision is judged on the degree of bleeding and on visual inspection of the excised bed, both of which require the technical expertise of an experienced burn surgeon. Equally, to resolve the depth of the injury often relies on clinical examination and experienced judgment. In addition to examining burn wounds directly another potential method to determine the ability of burn wounds to heal is non-i wvasive imaging.” Recently, a number of non-invasive imaging techniques have been investigated for their use in determining burn depth. Such techniques include terahertz imaging, spatial-frequency-domain imaging, near-infrared spectroscopic imaging, and reflectance-mode confocal microscopy, among others.'™!” Many of these techniques have not been yet refined sufficiently for clinical application. Nowadays, laser Doppler imaging provides the most evidence for accurately assessing burn severity,!? but it has been shown to be superior to. visual assessment only 48 h after thermal injury.!? Table 1 Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpssiwww.medintonsiva orios-surgical-reatment-managament-soverely-bumn-ariculo-S0210569117301006anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensiva Inicio Articles in press Nimero actual Nimeros anteriores Suplerientos plane for grafting leido outcome burn injuries Lower bleeding rates The Versajet hydrosurgery system (Smith & Nephew, London, UK) is a device based on the Venturi effect, able to cut and aspirate debris contemporarily.!* While in full thickness burns the sharp debridement is advisable, the Versajet shows its benefits in the treatment of partial thickness burns. Especially for debridement of difficult to treat areas such as the face, neck, lips, fingers, interdigital spaces, convex and concave areas. With the Versajet System, tissue excision is precise; moreover it helps to avoid the damage of viable tissue and its vascular supply. Is suggested by some to have facilitated a paradigm shift in wound management by allowing debridement of undesirable tissue while accurately preserving viable structures.*° Enzymatic debridement Enzymatic debridement is considered one promising alternative to surgical excision and has driven motivated clinicians and researchers for half a century to investigate the potential of various non-surgical debriding agents and enzymatic debridement means for burns, even with slow and inefficient enzymes. Therefore, until recently, results proved to be highly variable.2° Hand burns have a special place in the field of burn care, demanding special attention and treatment. Hands are involved in 30-60% of all burn patients. Due to the anatomy of the hand (important and delicate structures crowded in a small limited space without subdermal soft tissue), surgical debridement of the burned tissue is technically difficult and may cause considerable complications” (Fig. 1). Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008anano20 Surgical reatment and management of the severely bun patient Review and update | Medicina Intensiva Inicio Asticles in press Niimero actual Niimeros anteriores Suplementos Figure 1 (A) Female 44 years. Flame burn in left hand. (8) Nexobrid being applied 24 h post burn. (C) Four hours after enzymatic debridement. No surgical procedure was needed. (0.31M8), Lately, enzymatic debridement studies have been reported with promising results.’®? Application is possible outside the operation room as long as sufficient analgesia is ensured during this otherwise painful debridement procedure. In a subgroup of hand burns, additional benefits were seen as these patients exhibited earlier time to wound closure and better long-term results.!® Similar findings had previously been reported in a retrospective data analysis of 69 hand burns.” Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el anilisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta su uso, Puede cambiar la configuracién u obtener més informacién aqui. Aceptar htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 5128anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Ndimero actual Nuimeros anteriores YRS exacerbated bp tM B8ema developed during the acute phase of burn resuscitation in the first 48h after injury. As the interstitial pressure rises there is initially impairment of venous outflow followed by diminution of arterial inflow. This condition will cause dysfunction, ischemia, or necrosis within or distal to that body structure, often within hours. In the limbs, nerve and muscle death may occur causing permanent functional impairment or even the need for amputation. In the abdomen, the impaired blood supply to the bowels, kidneys and other internal organs results in the rapid onset of hepatic and renal failure, intestinal ischemia, and restriction of diaphragmatic excursion. Escharotomy releases the constricting tissue allowing the body tissues and organs to maintain their normal perfusion and function. In most cases a single incision is inadequate to provide release of the constricting burn eschar. Escharotomy incisions are routinely performed on both sides of the torso or the medial and lateral sides of each affected limb. For the abdomen and chest, transverse incisions are often required to permit restoration of respiratory movement. Delayed primary closure of escharotomy incisions may produce better functional and cosmetic results than those achieved if the escharotomies are allowed to close by secondary intention.® Skin grafts The standard for rapid and permanent closure of full-thickness burns is a split-thickness skin graft from an uninjured donor site on the same patient. Two types of autografts used for permanent wound coverage have been used: ~ Sheet graft is a piece of donor skin harvested from an unburned area of the body. Size of the donor skin is about the same as the burn wounds. This occurs because the donor skin used in sheet grafts does not usually stretch. When the TBSA burned is large, sheet grafts are usually saved for the face, neck and hands, making the most visible parts of the body appear less scarred. When a burn is small and there is plenty of donor skin available, a sheet graft can be used to cover the entire burned area. The disadvantages of sheet grafts comprise both higher rates of postoperative hematoma and larger donor site than meshed skin. Sheet grafts are usually more durable and scars less. = Meshed skin orafis As th f injury there i stionately less di te fe Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensiva Inicio Articles in press Niimero actual Némeros anteriores Suplementos Lani dp ° . motion and the graft site healng rate resulting in less satisfactory functional and cosmetic result. Moreover, donor sites can be very painful and add more wound-healing areas to the patient.2? Various dressings have been used to cover donor sites during healing, with variable results. In 1958 a remarkable technique for expanding autografts was described by the American surgeon CP, Meek. With a so-called ‘MEEK-WALL’ dermatome postage stamp autografts were obtained and expanded with a ratio 1:9 using double pleated gauzes. The method however required too much skill and it became eclipsed by the introduction of mesh skin grafts by Tanner in 1964. However, lack of autograft donorsites is still encountered as a limiting factor in achieving wound closure in case of extensive burns. The meshgraft technique requires donorsites of suitable size and shape and epithelialization may be delayed in case of expansion ratios greater than 1:4. Encouraging results are reported in combinations of the new MEEK technique with other methods for wound healing in burns, like dermal generating templates and cell spraying methods.4? Skin grafts will not take on an infected wound, over a hematoma, or on a wound with necrotic material. Adequate debridement and recipient-site preparation are essential for skin graft take. Skin graft procedures performed early after the burn injury with meticulous technique and postoperative splinting will often prevent subsequent contractures. Temporary wound coverage Patients with more extensive burns often require temporary coverage with an allograft, xenograft, skin substitute, or dermal analog due to insufficient or unavailable donor sites. Besides, temporary skin substitutes are used when the patient is too ill to undergo the creation of another ‘wound that results when skin is harvested from a donor site, in cases regarding the viability of the recipient bed, or when there is a concern regarding potential infectious complications. Allografts, or tissue taken from a living or deceased human donor, and xenografts, taken from a different species, promote re-epithelialization and prepare the wound bed for autograft, increasing the healing rate when compared with traditional dressings.”® Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpssiwww.medintonsiva orios-surgical-reatment-managament-soverely-bumn-ariculo-S0210569117301006 128anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Niimero actual Némeros anteriores fuplerentos jhe mis leldo .” . . . os ger long abandoned.”” However in developing countries, synthetic skin options are either not available or are very expensive and would be a huge burden of cost to the health system. Besides, the use of cadaveric donor skin in those countries is not acceptable due to religious and cultural beliefs, and relatives would not consent to skin harvesting from cadavers. They also lack the facilities for storage and screening of cadaveric skin, hence the option of live siblings’ allograft is considered as a viable option despite the limited literature available.?®° A variety of different skin substitutes and dermal analogs are available in different regions of the world? (Table 2). They can be broadly divided into those which replace the epidermis or replace the dermis.®! Epidermal substitutes are normally only a few cell layers thick and lack normal dermal components. Collagen-based dermal substitutes are porous matrices that act as templates for dermal regeneration. Like skin grafts, these products become revascularized over time and then can be covered with a thin epidermal graft to complete the coverage. Among the advantages of these products are decreased donor-site morbidity and elasticity and skin feeling patient satisfaction when compared with conventional meshed split-thickness skin grafts.” Small areas of bone, joint capsule, and tendon can also be covered. Disadvantages include cost and an increased susceptibility to infection compared with split-thickness skin grafts. These products have also been successful in treating reconstructive problems such as hypertrophic scarring and joint contractures.®* Commercially available dermal substitutes include acellular matrices, commonly from human or other sources.# Table 2. Skin substtut and coverage options. Product Classification Characteristics EpiDex Autologous Keratinocyte-based Dermagraft Cellular _Bioabsorbable polyglactin mesh scaffold with human fibroblasts (neonatal origin) Epicel Cellular —_Keratinocyte-based cultured epidermal autograft Recell Cellular Autologous cell suspension of keratinocytes, fibroblasts, Langerhans cells and Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpssiwww.medintonsiva orios-surgical-reatment-managament-soverely-bumn-ariculo-S0210569117301006anano20 Surgical reatment and management of the severely bun patient Review and update | Medicina Intensiva Inicio Articles in press Ndimero actual Nuimeros anteriores FybeE wth has been chat@é Veith porcine dermal collagen. It is considered a dressing used for temporary closure of superficial burns and donor sites.*"* Nowadays there are different products under development that integrate the concept of dermal scaffolds actively promoting revascularization by incorporating stem cells and growth factors to recreate a favorable cellular microenvironment.** Cultured epithelial cells Alternatively, cell-based techniques for more permanent coverage have made progress. Both widely expanded meshed autograft and cultured epithelial cells have particular advantages and disadvantages (Table 3). Table 3. Expanded meshed autograft versus cultured epithelial autograft. Advantage Disadvantage Meshed autograft Low costfcomplexity Limited donor site Durable Muhtple surgeries Cultured epithelium Cover large wounds High cost Useful in limited donor areas Long term fragility Lack of dermis Increased scar contracture Research on cultured epithelial cells has made advancements, especially with respect to culture time. Culture-based options use a small biopsy of the patient's skin to provide keratinocytes, which are expanded over 2-3 weeks. Some commercial products are available for this goal such as, Epicel o ReCell.25” These techniques may reduce the amount of donor skin needed for large burns treatment, significantly reducing the healing time of both the donor and the burn sites, and increasing overall graft success and scar quality.** However, it shows some limitations including sensitivity to infection and the lack of a dermis, which leads to fragility of the healed skin and severe scarring. Therefore its use in our clinical environment is usually restricted to large d astients with no other theraneutical anti Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuracién u obtener mds informacién aqui. Aceptar htpssiwww.medintonsiva orios-surgical-reatment-managament-soverely-bumn-ariculo-S0210569117301006anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensiva Inicio Asticles in press Ndmero actual Nuimeros anteriores BURERBBEPEtive physiothepYdFplintage and grow with age, especially in children. These local flaps can be classified as advancement flaps, rotation flaps, and transposition flaps. Harvesting a tissue from the burnt area is possible, but there are increased chances of flap failure. For cases where traditional flaps are not easily designed because of extensive burn injury, propeller flaps may be an excellent choice.** The original propeller flap uses intact skin in the fossa of the elbow or axilla elevated on a central subcutaneous pedicle. More recently, these flaps have been designed as perforator flaps..® Other advances include multilobed propeller flaps, keystone flaps and square flaps. Traditionally, free flaps were used in burn reconstruction when there was exposed bone, tendon, or cartilage present and local or regional flaps were inadequate. To reduce donor-site morbidity, perforator flaps such as anterolateral thigh flaps or conventional flaps such as groin flaps and scapular flaps are useful? (Fig. 2). Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus hébitos de navegacién. Si continua navegando, consideramios que acepta su uso, Puede cambiar la configuracién u obtener més informacién aqui. Aceptar htpssiwww.medintonsiva orios-surgical-reatment-managament-soverely-bumn-ariculo-S0210569117301006 10128anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Ndimero actual Nuimeros anteriores ‘Swalagrenah@Ested based on thbPabdefblSlACartery via the subscapular artery. (C) The important scalp defect was covered and grafted. (Photos courtesy of Dra, Lagares Borrego}. (0,38M8), Composite tissue allotransplantation (CTA) For very significant deformities that result from injuries to extremities and the face, CTA offers a solution that can restore significant esthetic and functional units in a single surgical procedure. Hand and face allotransplantation are demanding and challenging operations. To our knowledge only three of the 19 face CTA accomplished have been performed in burn patients, and one of them died.4*-4 The potential high risk of lifetime immunosuppression remains a significant barrier to the widespread use of this technology.” Another particular concern specific to the burn patient population regarding CTA is the high prevalence of psychiatric comorbidity and drug abuse, as well as high risk of septic complications. Therefore, CTA is sti regarded as an experimental procedure. Due to the complexity involved, its indications appear to be currently limited to only severely disfiguring facial defects in burns (involving the peri-orbital and/or peri-oral regions) and bilateral hand amputation, with severe functional and cosmetic impairment.4” Future research Wound healing is a complex process centered on cellular proliferation, matrix deposition, and ing. Studies have attempted to delineate the influence of fat grafts on wound area and volume reduction. The current literature reports significant functional and esthetic tissue remod improvements after fat grafting in the setting of burn and radiation injuries. In vivo studies demonstrating the regenerative capacities of adipose derived stem cells have proven to be generalizable to a clinical setting, given the extent of improvement in tissue quality noted after fat grafting in numerous patient population.* In porcine models the speed and quality of wound healing was statistically better in the models that received an adipose graft when compared to those receiving only growth factors.“? Moreover, Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 1126anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Niimero actual Némeros anteriores euugenun vr euiuivguus mLisunueyee Hay BLA WUUNY HeMNB, asuunee Creru@ung wus fuplementos Lomfe leldo , eratinocytes expansion On human fibroblasts following trypsin extraction, and engineered skin with keratinocytes on a fibrin matrix, have demonstrated improvements in wound healing.*? Taken together, the future impact of keratinocyte-mediated cell coverage options is promising. Nevertheless more research is needed before broad conclusions can be made. Pain management Pain is the most frequent complaint of burn-injured patients. It is known that persistent pain of a peripheral origin may induce pathological changes on a spinal and supraspinal level, leading to central sensitization, mechanical and thermal skin hyperalgesia and pain maintenance.** These patients usually present a hyperaroused state that augments the probability of defence programs activation.55 Recent publications report unacceptably high pain ratings for procedural and chronic pain 4 months after injury.%®°7 Clinical observations in different burn units may confirm that these reports are not unusual. The discrepancy between patients and staff assessments of pain severity is constant in burn patient's literature.*® Those who specialize in these patients care may become accustomed to the expectation that pain will not be controlled, particularly during procedures. Burn Unit personal may rationalize that it will only hurt for a brief period of time therefore underestimating procedural pain. Usually pain-relieving protocols include the systematic use of opioids, with the dispensable use of nonsteroidal anti-inflammatory analgesics and anxiolytics as adjuvant drugs. All of them administered either by oral or intravenous access. Patient-controlled analgesia (PCA) is used for patients upon hospital admission and after surgical procedures. Moreover, sedation with propofol or midazolam is used very frequently for extensive burn-dressing changes. The use of fentanyl administered during treatments and procedures has shown a significant difference in pain reduction post-procedure, with minimal presence of adverse events arising from sedo-analgesia. Therefore fentanyl offers a potentially significant improvement showing it is a safe and effective way to control procedural pain.®? r -comnetitive antagonist af NMDA tors and he used for can: Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 1228anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Nimero actual Némeros anteriores Iespunanre 6 Upise 91oy appears Ge PILES Surin BUUH HE HOMULIng Hnpuranpeoras Suplementos Tomas'eido eee Additionally, a number of non-pharmacological therapies have been described. Qualitative research has shown humor as a coping approach during their injuries acceptance process. Additionally, other non-pharmacological interventions such as relaxation techniques, music therapy, or more recently techniques using virtual reality devices‘ have been tested in experimental studies. All of them resulting in heterogeneous effects on pain reduction before and after wound care. Although burn injury pain has been well-described as a major clinical problem during the last two decades** researchers continue to report that burn pain remains undertreated.°$*”* Thus it becomes difficult to understand why is burn injury pain still a major problem after 20 years of research. This should be a matter of concern because unrelieved pain may be contributing to long-term sensory problems, including chronic pain, paresthesias, and dysesthesias®”° as well as debilitating psychological conditions.” Perhaps, the main problem is that we are focusing on the fact that burn pain is a very difficult type of pain to treat and not querying if we are doing our best to treat it. For example, reabsobable staples have been well described in literature’””? but, to our knowledge, clinical application in burn injuries has not been mentioned again for the last 15 years. Taking into account that absorbable tacks show the advantages of metal staples for skin grafts without the associated problems in burns grafting (procedural pain during removal)’ one could think that their more widespread use should be considered. Besides, different classes of medications in combination with non pharmacologic methods (multimodal analgesia) are rarely used in Burn Units even though they appear to be very useful for pain management in the burn- injured. Therefore more research and real application of evidences is needed to be able to target specific mechanisms that contribute to the variable intensity making this type of pain such a difficult management problem. Pressure garments and physiotherapy After burn wounds and grafts have acutely healed, burn patients present hypertrophic scarring risk. Custom-fit pressure garments have been used in burn patients in order to prevent or correct hypertrophic scarring. To our knowledge little scientific documentation of the effectiveness of Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpssiwww.medintonsiva orios-surgical-reatment-managament-soverely-bumn-ariculo-S0210569117301006 19128anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Nimero actual Némeros anteriores Suplémentos Lo mas leldo r & Increased survival rates in patients with severe burns bring into focus the rehabilitative challenges and recovery that these patients must face. Physiotherapy rehabilitation is an integral component of burn care in order to maintain the range of motion, prevent contracture development, maximize function and promote psychological wellbeing and social integration.’° In recent years, the use of interactive video games for rehabilitation of burns has become established.’® Their ease of use, increasing affordability, interactive functionality and physically rigorous gameplay makes interactive video games ideal to motivate patients unmotivated when undergoing repetitive exercises.”5”” Recent studies utilizing the PlayStationTM EyeToy and Nintendol WiiTM have demonstrated that interactive video games are safe and effective in providing pain relief* as well as improving joint movement and functional ability among burn patients.”5”9 Conclusion Significant advancements made in the past decades have improved burn patient's care in such a way that major future improvements in survival rates seem to be much more difficult. The remarkable advances achieved by plastic and reconstructive surgery over the past century allowed a large number of techniques to substantially improve the outlook of these patients. Despite these advances, we still do not have the ability to perfectly restore patients to their preinjury state. Therefore, improvements are needed to accelerate wound closure and healing as well as upgrade psychological care to promote successful reintegration. Research in stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients. Conflict of interests The author declares no conflict of interests. REFERENCE! Politica de cookies es | en su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 14128anano20 Surgical reatment and management of the severely bun patient Review and update | Medicina Intensva Inicio Articles in press Ndimero actual Nuimeros anteriores Suplesesting Lo mis leido [3]. Sasa, 5. 2sib, 8. Ahmad Early excision and grafting versus delayed excision and grafting of deep thermal burns up to 40% total body surface area: a comparison of outeome. ‘Ann Burns Fire Disasters, 26 (2012), pp. 43-147 Medline [4] P. Vinita, NLA. Khare, M.V.Chandramouli N. Shende,S. Barada Comparative analysis of early excision and grafing ws delayed grafting in burn patents in a developing county. 4 Burn Care Res, 372016), pp. 278-282 hitplddoi.org0.1097/8CR.06013e51827e4ed6 | Medline [5] _¥S.Ong,M. Samuel, ©. Song. ‘Meta-analysis of early excision of burns Burns, 32 (2006) pp. 145-150 htpidedoiorg/l0.1016j.burns.2005.09.005 | Medline [6] &.Curiel-Babe Epidemiology, intial management and analysis of morbidity-mortaliy Med Intesiva, 30 (2006), pp, 363-369 Medline MA Prieto lomino, 5. Fernéndezjiménez, iF, Ferdndes-Ortege, J. Mora-Ordoner, M, Delgado-Amaya, of severe burn patient. [7] MH. Desai, DIN. Herndon, LO. Bromeling, RE. Barrow, Fy: Nichols, RL. Rutan Early burn wound excision significantly reduces blood los. ‘Ann Surg, 211 (1990), pp. 753-762 Medline [8] Pact, F Miles, ). Pereyra, A. Perez, E, Martinez Haemostatic effets ofadrenline-docaine subcutaneous infiltration at donor sits Burns, 35 2009), pp. 343-347 hitplddoi.org0.1016f;bums.2008.06.019 | Medline [9] M.ksser, A Yaf M. Cina, 8. Cho, AJ. Duin Noninvasive assessment of burn wound severity using optical technology review of current ad future modalities Burns, 37 (2011), pp. 377-386 hitpldxdoiorg0.1016f;bumns.2010.11.012 | Medline [10] KM. Cross L. Leonard M. Gomez, JR resen, MA, Levasseur, BJ. Schalth, eta Noninvasive measurement of edema in pata thickness burn wounds ‘J Burn Care Res, 302008), pp. 807-817 hitoyfddo.org/10.1097/8CR.00013e31810485e9 | Medline Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus hébitos de navegacién. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar htpssiwww.medintonsiva orios-surgical-reatment-managament-soverely-bumn-ariculo-S0210569117301006 19128anano20 Surgical reatment and management of the severely bun patient Review and update | Medicina Intensiva Inicio Articles in press Ndimero actual Nuimeros anteriores Suplesesting Lo mis leido [13] H. Hoeksema, K Vande Sipe. Tondu, M. Hamel, K. Van Landuyt, P. Blondel, ea: ‘Accuracy of early burn depth assessment by aser Doppler imaging on diferent days post bur. Burns, 35 (2009), pp. 36-45, hitplddoiorg(l0.1016f;bums.2008.08.011 | Medline [14] M8 Kein, 5, Hunter, 01M. Heimbach, LH. Engray 5, Honari E, Galley ea “The Versaet water dssecor: a new tol for tangential excision. J Burn Care Rehabil 26 2005), pp. 483-487 Medline [15] Ed Fylnd,R.b'Cruz, 5. Menon, Q, Chan, jG, Hawey Ts Lawrence eta Prospective randomised controlled trial eomparing Vrsiet™ hydrosurgery and conventional debridement of patil thickness paediatric burs Burns, 41 (2015), pp. 700-707 htpidedoirg/l0.1016j.burns.2015.02.001 | Medine [16]. Klasen ‘review onthe nonoperative remaval of necrotic tissue from burn wounds Burns, 26 2000), pp. 207-222 Medline [17] PPM. Van Zullen,& Kreis, FAM. Vloemans Groene LP Mackie ‘The prognostic f Burns, 25 (1999), pp. 708-714 Medline regarding long-term functional outcome of full-thickness hand burns [18] Rosenberg. ¥. Krieger, A. Bogdanov-erezovshyE, Silberstein, ¥. Shoham, AJ Singer. ‘Anovel rapid and selective encymatic debridement agent for burn wound management: » multi-center RC. Burns, 40 (2014) pp. 466-474 hitplddoiorg0.1016f;bums.2013.08.013 | Medline [19] 7 Cords.) Hortesj Vogelpohl T. Kremer U Knese,F Hermekamp. Enzymatic debridement forthe treatment of severely burned upper extremities ~ eal single center experiences. {BMC Dermatol, 16 2016), pp. 8 hitpld.do.org20.1186/s12895-016-0045-2 | Medline Published online 2016 Jun 26, doi: 10.1186/s12895-016-0045-2 [20]_. Krieger. A Bogdanow-erezosiy, R Gufinkl E.Sbersten, A. Sl L Rosenberg Eicay of enaymaic debridement of deeply burned hands urs, 382012) po. 108-112 Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus hébitos de navegacién. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 16128anano20 Surgical reatment and management of the severely bun patient Review and update | Medicina Intensiva Inicio Articles in press Ndimero actual Nuimeros anteriores SuplePeneBeconstuct Surg, 11 Ro Re RS3-2269 [23]. SiH. Voineskos, A Ani, L MeKnight, A. Thoma Systematic review of skin Plast Reconstruct Surg, 124 (2008), pp. 298-306 fe donor-site dressings. [24] ROW. Kreis, DLP, Mackie, BR. Hermans, AR, Vloemans. Expansion techniques for skin grafts: comparison between mesh and Meck islnd (sandwich) grat Burns, 20(1994) pp. 539-542 Medline [25] 0.8. Lumenta, LP. Kamole, M. Fey ‘Adult burn patients with more than 60% tsa involved ~ meek and other techniques to overcome restricted skin harvest avllbility — the Viennese concept 1 Burn Care Res, 30 (2009), pp. 231-242 http:fdxdo\.org/10.1097/8CR.06013e31819832d6 | Medline [26] MH. Hermans Preservation methods of allografts and ther (lack of) influence on clnial results in partial thickness burns. Burns, 37 (2011), pp. 873-881 hitplddoi.org0.1016f;bums.2011.01,007 | Medline [27] &.Lineen, N. Namias Biologie dressings in burns. J Craniofac Surg, 19 (2008), pp. 923-928, htp/dxdo\.org10.1097/SCS.06013¢318175bSab | Medline [28] JM. Coenen, Hy. Klasen, E:W. Sauer Successful homografting in an elderly patient with extensive burns using his identical twin brather as skin donor. Burns, 16 (1990), pp. 225-226 Medline [29] 8. Leodoro, A. Chang, Cama Live sibling skin allograts fr severe burns in a paediatric patient: avable option in developing counties, | Paedia Surg Case Reports, 2(2014), pp. 498-500 [30] F.Grocber, M. Holeitr, M. Hampel, 5. Hinderer, K.Schenke-Laylind, Skin tissue engineering in viv and in vitro applications. Clin Plast Surg, 392012), pp. 33-58 http:fdxdol.org/10.1016f.eps.2011.09.007 | Medline [BI] E.catalano, A. Cochs,E. Vatoni, L. Rimondini 8. Azzimont Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus hébitos de navegacién. Si continua navegando, consideramos que acepta su uso, Puede cambiar la configuracién u obtener més informacién aqui Aceptar htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 11128anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Ndimero actual Nuimeros anteriores SupleWeunsepsi Regen, 1920 ns RISES htptbedosorgl01111).1524-875X201L.00713x | Medne [4]. Shahriar Shahrokhi, Arno Anna MG. Jeschke. he use of dermal substitutes in burn surgery: acute phase Wound Rp hit Regen, 222014 Jan, pp. 14-22 pO.LILwre 12165 | Medline [35] RE. Agustin, N. Merchant, S Shahrokhi, M.G. Jeschke. ‘Acomparison of Biobrane and cadaveric allograft for temporizng the acute burn wound: cost and procedural time. Burn, 41 2015), pp. 749-753, [36] F¥. Wood, ML Kotyoba,P Alen. ‘The use of cultured epithelial autograft in the treatment of major burn wounds: eleven years of clinical experienc. Burns, 32 (2006), pp. $38.54 hitpldxdoi.org(l0.1016f;bums.2006.02.025 | Medline [37] FM. Wood, ML Kotybaba,P Alen. “The use of cultured epithelial autograft inthe treatment of major burn injuries a erical review ofthe iterature Burns, 32 (2006) pp. 395-401 hitplddo.orgl0.1016f;bums.2006.01,008 | Medline [38]. Tenenhaus, H.0. Rennekampf Surgical advances in burn and reconstructive plastic surgery: new and emerging technologies Clin Plast Surg, 39 (2012), pp. 435.443 hutp:fdxdo\.org/0.1016f.eps.2012.07.012 | Medline [39]. Pignat R, Ogawa, G.G. Hallock, M, Mateev, AV. Georgeseu,G. Balakrishnan, eta “The Tolyo consensus on propeller aps Plast Reconstr Surg, 127 (2011), pp. 716-722 http:fdxdo.org/0.1097/°RS.06013e3181fedst2 | Medline [40] #4, Murakami, H. Hyakusoku, 8 Ogawa ‘The mulilobed propeller Nap method: Plast Reconstr Surg, 116 (2008), pp. 599-604 Medline [41] Fc. Behan, “The keystone design perforator island fap in reconstructive surgery ANZ ) Surg, 73 2003), pp. 112-120 Medline Politica de cookies su uso, Puede cambiar la configuracién u obtener més informacién aqui Aceptar es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus hébitos de navegacién. Si continua navegando, consideramios que acepta htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 18128anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensiva Inicio Articles in press Ndimero actual Nuimeros anteriores FHRIEBRederge andi, 98 EAR, Hochnke, G. Brandacher,e a Achievements and challenges in composite tssue allotransplantation ‘Transplant Int, 24 2011), pp. 760-769 [45] L. Lantie, m. Hivelin, v Audstd, M.D. Benjosr, LP. Meningaud,F.Belves, et a Feasibility, reproducibility, sks and benefit of face transplantation: a prospective study of outcomes. ‘Ars Transplant, 11 (2011), pp. 367-378 htofdxdolorg20.1112/.2600-6143,2010.03406% | Medline [46] 8. Pomahac,.Pribaz, E Eriksson, D. Annino, S. Caterson, C. Sampson, eta. Restoration offical form and function after severe disfigurement fom buen injury by 2 composite facial allograft ‘Ars J Tansplant, 11 (2011), pp. 386-393 htofdxdo}org20.1112/.2600-6143,2010.03368% | Medline [47] 8. Pomahac, J. Pribaz E Eriksson, E.M. Bueno, JR, DiazSiso,F. Rybick, et al “Theee patients with ful facial transplantation. IN Engl | Med, 366 (2012), pp. 715-722 hitp:/dxdol.org/10.1056)NEJMoa1111432 | Meéline [48] SM. Sultan). Bat, P, Buta, Fat grafting accelerates revasculvisation and decreases fibrosis following thermal injury J Plast Reconstr Aesthet Surg, 65 (2012), pp. 219-227 htto:fdxdol.org/10.1016f.b)ps.2012.08.046 | Medline [49] %8. Fu, LJ Fang, HHL Ui XK: L, 8 Cheng, 2. Sheng Adipose tisue extract enhances skin wound healing Wound Repair Regen, 152007), p. 540-548 Int doiorg10.1113f.1524-475X.2007.00262% | Medline [50] 5. Natesan, NAL. Wrice, BG. Baer, Rj. Christy Debrided skin a a source of autologous stem cll for wound repair Stem Cells, 29 2011), pp. 1219-1230 hitp:fdxdoi.org/0.1002/stem.677 | Medline [51] RK Chan, 0.0. Zamora, N.L. Wrce,0.G. Baer, EM. Renz, RJ. Christy, etal Development ofa vascularized skin construct using adipose-derived stem cells from debrided burned skin, Stem Cell Int, 2012 (2012), pp. 841203 hupfdxdo'.org0.1155/2012/841203 | Medline [52] c.Auxenfans, V. Menet, Z. Catherine, H. Shipkow, P. Lacroix, M. Bertin-Maghit ta Cultured autologous keratinocytes in the treatment of large and deep burns: a retrospective study over 15 years. Politica de cookies es | en su uso, Puede cambiar la configuracién u obtener més informacién aqui Aceptar Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus hébitos de navegacién. Si continua navegando, consideramios que acepta htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 19128anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Ndimero actual Nuimeros anteriores SUPIe BED Rry hyperalgesia to HEA SARL Pain, 76 (2998), pp. 377-384 Medline {fer burm injury in man, [55] K. Koxlowska, P. Walker, L. McLean, Carve Fear and the defense cascade: clinica implications and management, Harv Rev Psychiatry, 23 (2015), pp. 263-287 htofdxdol.org0.1097/HRP.0000000000000085 | Medline [56] G4, Carrougher,)7: Ptacek, 5. Honari, AE. Schmidt, JR Tininenko, NS. Gibran, etal Sel-reports of aniety in butn- injured hospitalized adults during routine wound care J Burn Care Res, 7 (2008), pp. 676-681 htp:/dxdo\.org0.1087/01.8CR.0000238100.11905.A8 | Medline [57] J. Schneider, NA Harris, A. £1 Shami, RL. Sheridan, LT. Schule Il, ML. Bilodeau, eta ‘A descriptive review of neuropathielike pain ater bur injury. J Burn Care Res, 27 (2006), pp. 524-528 htpfdx dol.org0.1097/01.8CR.0000226019.76946.50 | Medline [58] CP. Rae, G. Gallagher, 5. Watson J Kinsella, ‘An audit of patient perception compared with medical and nursing stafestimation of pain during burn dressing changes. ur) Anaesthesiol, 17 (2000), pp. 43-45 Medline [59] EM. Thompson, 0.9. Andres, C.Christtiberin Efcacy and safety of procedural sedation and analgesia for burn wound care. | Burn Care Res, 332012), pp 504509 Int doiorg20.1097/8CR.0b013e818236%e4F | Medline [60] 2 Tosun, A. Esmaoglu, A. Coruh Propofol-ketamine vs propofolfentanyl combination for deep sedation and analgesia in pediatric patients undergoing burn dressing changes. Pediatr Anesth, 18 (2008), pp. 43-47 [61] &. Visser, 5. Schug, ‘The role of ketamine in pain management, Biomed Pharmacother, 60 (2006), pp. 341-348, hupifdxdoi.org/0.1016j.biopha.2006.06.021 | Medline [62] _& Kornhaber, A. Wikon, M.Z. Abu-Qamar, L. McLean, Coming to terms with tall adult burn survivors’ lved experience of acknowledgement and acceptance during rehabltation Politica de cookies su uso, Puede cambiar la configuracién u obtener més informacién aqui Aceptar es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus hébitos de navegacién. Si continua navegando, consideramios que acepta htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008anano20 Surgical reatment and management of the severely bun patient Review and update | Medicina Intensiva Inicio Articles in press Ndimero actual Nuimeros anteriores Suplemengostiv randomized consoyrasilido | Burn Care Res OF Publ Ar Burn Assoc, 31 (2010), p. $90-597 [65] 8.Kipping,S Rodger, K Miler, RM. Kimble Virtua reality for acute pain reduction n adolescents undergoing burn wound care prospective randomized controlled ta Burns, 382012), po. 650-657 bitfdxdoiorg20.1016),burns.2011.1.010 | Medline [66]. S.Pery, 6. Heidich, E Ramos. Assessment of pin in burned patients | Burn Cave Rehabil, 21983), pp. 322-326 [67] Fumes. ‘An exploratory study of pain, coping, and depressed mood following burn injury J Pain Symptom Manage, 13 (997), pp. 148-157 Medline [68] K. Weinberg C Birdsall, Vail M.A. Marano, SJ Petrone, E.H, Mansour, Pain and anviety with burn dressing changes: patient self-report ‘J Burn Care Rehabil, 21 (2000), pp. 155-156 Medline [69] RH. Dworkin ‘An overview of neuropathic pain: syndromes, symptoms, sighs, and several mechanisms. Clin} Pin, 18 2002), pp. 343-349 Medline [70] H. keds J Stark, H. Fischer, M, Wagner, R, Drdla, T. Jager, et al ‘Synaptic amplifier of inflammatory pan in the spinal dorsal horn, Science, 312 (2006), pp. 1659-1662 http:fdxdo.org/0.1126/science.1127233 | Medline [71] 0. Gilbos, m. Friedman, H. Tsu “The burn asa continuous traumatic stress: implications for emotional treatment during hospitalization, | Burn Care Rehabil, 15 (199), pp. 86-91 Medline [72] 5. 0°Broin, O'Donnel, D. O'Donovan, E. Tiernan, Di, Lawlor, PA. Eadie Absorbable skin graft tapes: clinical al using Graftae, Br] Plast Surg, 49(1996), op. 485-487 Medline Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus hébitos de navegacién. Si continua navegando, consideramios que acepta su uso. Puede cambiar la configuracién u obtener més informacién aqui. Aceptar htpsswww.medintonsiva orios-surgical‘reatment-managament-soverely-bumn-ariculo-S0210569117301008 21124anano20 Surgical veatment and management of the severely bum patient: Review and update | Medicina Intensive Inicio Articles in press Ndimero actual Nuimeros anteriores FPSETE Neder, 09 HusgudlB TEEMAER wer. Vitale, Zona Efficacy of inpatient bum rehabilitation prospective pilot study eamining range of mation, hand function and bane. Burns, 382012} pp. 164-171 hitpié.doiorg10.1016f}bu.2011.11.002 | Medline [76] | Parry. L Painting, A. Bagley) Kawada, F. Molitor, S.Sen, et ab ‘A pilot prospective randomized control tral comparing exercises using videogame therapy to standard physical therapy: 6 months followup, ‘Burns Care Res, 36 (2015), pp, 534-544 [7] 15. Par A. Bagley Kawads, Se, D.G, Greenhalgh, TL. Paki Commercially avaiable interactive video gemes in buen rebabiltation: therapeutic potenti Burns, 38 (2012), pp. 493-500, hoiibedovorgl01016f}buns201202010 | Meine [78]. Parker, 8, Delahunt, N. Heberein,N. Devenish, FM. Wood, T.Jackon, et a: Interactive gaming consoles reduced pain during acute minor bur rehabitlation: a randomize, pot ial Burns 42,2016) pp 91-96 http:fdxdo.org/0.1016f.burs.2015.06.022 | Medline [79] 8. Lange, SM. Fhynn, AA. Rizo, Game-based telereabilitation, ur) Phys Rehabil Med, 45 (2009), pp. 143-251 Medline Copyright © 2017. Elsevier Espafia, S.L.U. y SEMICYUC Suscribase a la newsletter Introduzca su email Herramientas Imprimir Politica de cookies es | en Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el andlisis de sus habitos de navegacién. Si continua navegando, consideramos que acepta su uso. 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