The Frequency and Reason For Amputations in Electrically Burned Pediatric Patients

Electrical injuries induce substantial morbidity and mortality. Amputations are often necessary to enable survival and based on tissue nonviability, development of life-threatening infection, or expected nonfunctional outcome. They analyzed occurrence and type of amputations in their institution for electrical and nonelectrical pediatric burns and the number of reconstructive operations. Patients who underwent any amputation between 1999 and 2017 were identified. Patients with electrical burns (EB) were matched regarding age, sex, and percent total body surface area (%TBSA) burned to patients with nonelectrical burns (NEB). Both groups (n = 35 EB, n = 70 NEB) were comparable regarding age (EB, 11.6 ± 4.5 years; NEB, 11.1 ± 4.5 years, P = .550) and %TBSA (36.7 ± 15.4% and 37.7 ± 12.9%, P = .738). Major amputations (above wrist or ankle) were performed in 77% of EB vs 31% of NEB (P < .001). Amputations above knee or elbow were performed in 13 (37.1%) vs two patients (2.9%, P < .001). Eight (22.9%) vs six patients (8.6%) underwent combination of two or more major amputations (P = .042). In both groups, most amputations were performed for functional reasons. Length of stay was shorter in EB group (33 ± 27 vs 47 ± 38 days, P = .040). EB patients underwent 9.9 ± 7.1 total operations compared with 14.4 ± 5.1 operations (P < .001). Of these, 6.5 ± 3.6 and 7.9 ± 3.3 (P = .023) were performed during acute stay and 3.3 ± 4.8 and 6.5 ± 3.5 after acute stay (P < .001), respectively. Mortality was comparable. EB were associated with larger extent of limb loss and more major amputations than NEB with amputations. They furthermore required a smaller number of reconstructive procedures. EB require extra attention of caregivers, because of their extensive tissue damage.

Estimated versus achieved maximal oxygen consumption in severely burned children maximal oxygen consumption in burned children

PURPOSE

In burned children, exercise training increases maximal oxygen consumption (VO2 max) and can be combined with the nonspecific beta-blocker propranolol to decrease cardiac work. VO2 max is estimated if indirect calorimetry is not available. We compared measured and estimated VO2 max in severely burned children treated with or without propranolol to determine the suitability of commonly used formulas in these populations.

METHODS

Patients received propranolol or placebo (control) during acute hospitalization. VO2 max was measured during a modified Bruce treadmill test at discharge and compared to values obtained using the Cooper, Bruce, American College of Sports Medicine, and Porro formulas. Pearson correlations and Bland-Altman analyses were used to compare measured and estimated values.

RESULTS

Ninety-nine children (propranolol n=46,control n=53) admitted at our facility between 2003 and 2016 were analyzed. Age at burn (propranolol 12±4years, control 12±3years,p=0.893) and total body surface area burned (propranolol 44±15%,control 49±14%,p=0.090) were comparable between groups. Measured VO2 max was higher in the propranolol group (25.5±6.0mL/min/kg vs. 22.0±4.7mL/min/kg,p=0.002) and was generally lower than estimated values. Age, sex, inhalation injury, body mass index, exercise time, and maximal speed were predictive of measured VO2 max in the control group. Age, sex, and maximal speed were predictive in the propranolol group. Backward selection yielded the formula [7.63+ 2.16×sex(females=0,males=1)+0.41×age(years)+0.15×maximal speed(m/min)] (R2=0.6525).

CONCLUSIONS

Propranolol seems to have beneficial effects on cardiorespiratory capacity in burned children. However, estimated VO2 max with common formulas were too high. The VO2 max formula reported here is suitable for propranolol-treated children and the Porro formula for non-propranolol-treated children.

Bone metabolism in pediatric burned patients: A review

Severe burns in children can lead to growth delays, bone loss, and wasting of lean body mass and muscle with subsequent long-term effects such as osteoporosis. The following review examines 11 randomized, placebo-controlled, prospective clinical trials in pediatric burns between 1995 and 2017. These studies included approximately 250 burned children, and they were conducted to evaluate the impact of severe burn on markers of bone formation and bone metabolism. Some trials also analyzed current therapy regimens such as pamidronate and vitamin D. The clinical utility of these outlined biomarkers is uncertain with regard to acute burn care, as the current literature remains unclear. This review thus serves to address the impact of severe burn on markers of bone formation and bone metabolism in pediatric patients but will not focus on the clinical utility of the markers. The aim of this review is to summarize the findings of the trials to guide the future care of burned patients to maximize bone recovery.

Negative Pressure Wound Therapy with Instillation and Dwell for the Management of a Complex Burn: A Case Report and Review of the Literature

Research over the last 50 years has led to significant improvements in outcomes for burn victims. Advances in infection control, attenuation of the hypermetabolic response, and new improved surgical approaches have led to decreased morbidity and mortality. Early wound excision eliminates the devitalized tissue, which is the main reservoir for pathogen propagation. Immediate autografting reestablishes the natural barrier of the skin, which blocks pathogen access to the host. Advances in burn care have increased treatment options for patients with devastating injuries presenting with multiple comorbidities. Over the last 20 years, negative pressure assisted wound therapy (NPWT) has shown to improve wound management and healing as well as decrease the length of recovery in burn patients. As NPWT applications evolve, the development of negative pressure wound therapy with instillation and dwell time (NPWTi-d) for the management of complex and infected wounds has proven vital for patient care. We present the case of a 68-year-old male patient presenting with a three-day-old third-degree burn wound spanning 46% of the total body surface area (TBSA). After the infected wound was treated unsuccessfully with the standard of care (excision, debridement, and grafting), the team utilized NPWTi-d in order to mitigate the infection and promote the formation of granulation tissue, leading to the successful grafting of the burn wound. NPWTi-d was a useful adjunct in treating and stimulating wound healing in a complex patient. This is the first case report of its kind, utilizing a whole-body vacuum assisted closure (VAC) with NPWTi-d, with successful results showing a decreased bacterial burden, decreased morbidity and mortality, and patient wound closure.

Relationship between lean body mass and isokinetic peak torque of knee extensors and flexors in severely burned children

OBJECTIVE

Severe burns cause hypermetabolic responses and prolonged hospitalization, resulting in loss of body mass and muscle strength. This study aimed to determine whether long-term gains in lean body mass (LBM) after structured exercise programs are functionally meaningful and related to greater muscle strength in severely burned children.

STUDY DESIGN

LBM and muscle strength were measured at discharge and at 6, 12, 24, and 36 months after burn in 349 children. Body composition, including LBM, was measured via dual-emission X-ray-absorptiometry. Peak torque was measured using Biodex dynamometer at varying angular velocities (90, 120, 150, 180°/s). Pearson correlation analysis evaluated the association between LBM and peak torque.

RESULTS

LBM progressively increased from discharge (32.5±11.5kg) to 36 months following injury (40.2±12.3kg). Peak torque and peak torque/LBM increased from discharge (56.4±34.0Nm and 1.7±34.0Nmkg^-1) to 36 months after burn (102.3±43.8Nm and 2.5±0.7Nmkg^-1, p<0.01 for both). LBM and peak torque at all angular velocities showed moderate/strong correlations, with 120°/s being the strongest (all time-points: R²≥0.57).

CONCLUSION

In severely burned children participating in a rehabilitative exercise program, gains in LBM over time are related to increases in muscle strength, suggesting that gained muscle mass is functional. Measurement of muscle strength at an angular velocity of 120°/s best reflects gains in LBM and should be considered for reliable measure of strength in future studies.

Correlation between invasive and noninvasive blood pressure measurements in severely burned children

INTRODUCTION

Accurate blood pressure monitoring is essential for burn management, with the intra-arterial line method being the gold standard. Here we evaluated agreement between cuff and intra-arterial line methods.

METHODS

Data from burned children admitted from 1997 to 2016 were retrospectively reviewed. Simultaneously collected intra-arterial and cuff measurements were cross-matched and linear regression performed to assess agreement for systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP).

RESULTS

We identified 9969 matches for SBP, DBP, and MAP in 872 patients (579 male) aged 8±5years with burns covering 52±20% of the total body surface area and a hospitalization lasting 33±31 days. Intra-arterial lines had a complication rate of 1%. The mean bias (95% CI) between methods was 1.3 (0.5, 2.1) mm Hg for SBP, -6.4 (-7.0, -5.7) mmHg for DBP, and -5.8 (-6.4, -5.3) mmHg for MAP. The standard deviation of the bias (95% limit of agreement) was 12.1 (-22.5, 25.1) mmHg for SBP, 9.9 (-25.8, 13.0) mmHg for DBP, and 8.7 (-22.8, 11.1) mmHg for MAP.

CONCLUSIONS

Cuff measurements vary widely from those of intra-arterial lines, which have a low complication rate. Intra-arterial lines are advisable when tight control of the hemodynamic response is essential.

Multi-institutional analysis of independent predictors for burn mortality in the United States

Background

Previous reports individually identified different factors that predict death after burns. The authors employed the multi-center American Burn Association's (ABA) National Burn Repository (NBR) to elucidate which parameters have the highest negative impact on burn mortality.

Methods

We audited data from the NBR v8.0 for the years 2002-2011 and included 137,061 patients in our study. The cases were stratified into two cohorts based on the primary outcome of death/survival and then evaluated for demographic data, intraoperative details, and their morbidity after admission. A multivariable regression analysis aimed to identify independent risk factors associated with mortality.

Results

A total of 3.3% of patients in this analysis did not survive their burn injuries. Of those, 52.0% expired within 7 days after admission. Patients in the mortality cohort were of older age (p < 0.001), more frequently female (p < 0.001), and had more pre-existing comorbidities (p < 0.001). Total body surface area (TBSA), inhalation injury, hospitalization time, and occurrence of complications were higher compared to survivors (p < 0.001). Lack of insurance (odds ratio (OR) = 1.84, confidence interval (CI) 1.38-2.46), diabetes (OR = 1.24, CI 1.01-1.53), any complication (OR = 4.09, CI 3.27-5.12), inhalation injury (OR = 3.84, CI 3.38-4.36), and the need for operative procedures (OR = 2.60, CI 2.20-3.08) were the strongest independent contributors to mortality after burns (p < 0.001). Age (OR = 1.07, CI 1.06-1.07) and TBSA (OR = 1.09, CI 1.09-1.09) were significant on a continuous scale (p < 0.001) while overall comorbidities were not a statistical risk factor.

Conclusion

Uninsured status, inhalation injury, in-hospital complications, and operative procedures were the strongest mortality predictors after burns. Since most fatal outcomes (52.0%) occur within 7 days after injury, physicians and medical staff need to be aware of these risk factors upon patient admission to a burn center.

Role of Wnt signaling during inflammation and sepsis: A review of the literature

Despite the development of modern intensive care and new antimicrobial agents, the mortality of patients with severe sepsis and septic shock remains high. Systemic inflammation is a consequence of activation of the innate immune system. It is characterized by the intravascular release of proinflammatory cytokines and other vasoactive mediators, with concurrent activation of innate immune cells. The Wnt signaling pathway plays a critical role in the development of multicellular organisms. Abnormal Wnt signaling has been associated with many human diseases, ranging from inflammation and degenerative diseases to cancer. This article reviews the accumulating evidence that the Wnt signaling pathway plays a distinct role in inflammation and sepsis.

A Prospective, Randomized, Controlled Trial Comparing the Outpatient Treatment of Pediatric and Adult Partial-Thickness Burns with Suprathel or Mepilex Ag

Modern treatment of partial-thickness burns follows the paradigm of less frequent dressing changes to allow for undisturbed reepithelialization of the burn wound. We compared Mepilex Ag (M), a silver-impregnated foam dressing, and Suprathel (S), a DL-lactid acid polymer, in the outpatient treatment of partial-thickness burns in pediatric and adult patients. Patients were enrolled in a randomized, controlled, prospective clinical trial. We monitored time to reepithelialization, wound pain, discomfort during dressing changes, and treatment cost. Objective scar characteristics (elasticity, transepidermal water loss, hydration, and pigmentation) and subjective assessments (Patient and Observer Scar Assessment Scale) were measured at 1 month post burn. Data are presented as mean ± SEM, and significance was accepted at P < 0.05. Sixty-two patients (S n = 32; M n = 30) were enrolled; age, sex, and burn size were comparable between the groups. Time to reepithelialization was not different between the groups (12 days; P = 0.75). Pain ratings were significantly reduced during the first 5 days after burn in the Suprathel group in all patients (P = 0.03) and a pediatric subgroup (P < 0.001). Viscolelasticity of burned skin was elevated compared with unburned skin in the Mepilex Ag group at 1 month post burn. Patients treated with Suprathel reported better overall scar quality (S: 2; M: 4.5; P < 0.001). The cost of treatment per square centimeter for Mepilex Ag was considerably lower than that of Suprathel. Both dressings are feasible and efficacious for the outpatient treatment of minor and selected moderate partial-thickness burns. Reduced pain, especially in a pediatric patient population, may be advantageous, despite increased treatment cost.

Topical Antimicrobials in Burn Care: Part 1-Topical Antiseptics

Burn wounds disrupt the body's primary defense against invasion and colonization by microorganisms. Topical antimicrobials are one component in burn wound care. These agents suppress microbial growth to advantage skin cells and wound healing. Topical antimicrobials can be divided into 2 superclasses: antiseptics and antibiotics. We review the 4 main classes of topical antiseptics (emulsifiers, acids, oxidizers, and heavy metals) and antiseptic-impregnated dressings in current clinical use and address the mechanisms, as well as the advantages and disadvantages of each antiseptic for burn wound management.

Co-administration of vancomycin and piperacillin-tazobactam is associated with increased renal dysfunction in adult and pediatric burn patients

Background

Burn patients are prone to infections which often necessitate broad antibiotic coverage. Vancomycin is a common antibiotic after burn injury and is administered alone (V), or in combination with imipenem-cilastin (V/IC) or piperacillin-tazobactam (V/PT). Sparse reports indicate that the combination V/PT is associated with increased renal dysfunction. The purpose of this study was to evaluate the short-term impact of the three antibiotic administration types on renal dysfunction.

Methods

All pediatric and adult patients admitted to our centers between 2004 and 2016 with a burn injury were included in this retrospective review if they met the criteria of exposition to either V, V/IC, or V/PT for at least 48 h, had normal baseline creatinine, and no pre-existing renal dysfunction. Creatinine was monitored for 7 days after initial exposure; the absolute and relative increase was calculated, and patient renal outcomes were classified according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria depending on creatinine increases and estimated creatinine clearance. Secondary endpoints (demographic and clinical data, incidences of septicemia, and renal replacement therapy) were analyzed. Antibiotic doses were modeled in logistic and linear multivariable regression models to predict categorical KDIGO events and relative creatinine increase.

Results

Out of 1449 patients who were screened, 718 met the inclusion criteria, 246 were adults, and 472 were children. Between the study cohorts V, V/IC, and V/PT, patient characteristics at admission were comparable. V/PT administration was associated with a statistically higher serum creatinine, and lower creatinine clearance compared to patients receiving V alone or V/IC in adults and children after burn injury. The incidence of KDIGO stages 1, 2, and 3 was higher after V/PT treatment. In children, the incidence of KDIGO stage 3 following administration of V/PT was greater than after V/IC. In adults, the incidence of renal replacement therapy was higher after V/PT compared with V or V/IC. Multivariate modeling demonstrated that V/PT is an independent predictor of renal dysfunction.

Conclusion

Co-administration of vancomycin and piperacillin-tazobactam is associated with increased renal dysfunction in pediatric and adult burn patients when compared to vancomycin alone or vancomycin plus imipenem-cilastin. The mechanism of this increased nephrotoxicity remains elusive and warrants further scientific evaluation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1899-3) contains supplementary material, which is available to authorized users.

Predicting and managing sepsis in burn patients: current perspectives

Modern burn care has led to unprecedented survival rates in burn patients whose injuries were fatal a few decades ago. Along with improved survival, new challenges have emerged in the management of burn patients. Infections top the list of the most common complication after burns, and sepsis is the leading cause of death in both adult and pediatric burn patients. The diagnosis and management of sepsis in burns is complex as a tremendous hypermetabolic response secondary to burn injury can be superimposed on systemic infection, leading to organ dysfunction. The management of a septic burn patient represents a challenging scenario that is commonly encountered by providers caring for burn patients despite preventive efforts. Here, we discuss the current perspectives in the diagnosis and treatment of sepsis and septic shock in burn patients.

Rehabilitation in the Acute Versus Outpatient Setting

Rehabilitation of patients with burn injuries aims to restore strength, coordination, and mobility as closely to normal as possible and should begin immediately after initial admission. In the acute phase, baseline assessments are made against which all subsequent rehabilitation success is held. In the intermediate phase, active, full range-of-motion movement, ambulation of steadily increasing distances, and resistive exercise and stretching aid in the prevention of muscle and bone atrophy and preserve muscle memory and coordination. In the long-term outpatient rehabilitation phase, individualized patient-centered exercise programs can be advantageous in achieving measurable and lasting positive rehabilitation outcomes.

The occurrence of single and multiple organ dysfunction in pediatric electrical versus other thermal burns

BACKGROUND

Multiple organ failure (MOF) is a major contributor to morbidity and mortality in burned children. While various complications induced by electrical injuries have been described, the incidence and severity of single organ failure (SOF) and MOF associated with this type of injury are unknown. The study was undertaken to compare the incidence and severity of SOF and MOF as well as other complications between electrically and thermally burned children.

PATIENTS AND METHODS

Between 2001 and 2016, 288 pediatric patients with electrical burns (EB; n = 96) or thermal burns (CTR; n = 192) were analyzed in this study. Demographic data; length of hospitalization; and number and type of operations, amputations, and complications were statistically analyzed. Incidence of SOF and MOF was assessed using the DENVER2 classification in an additive mixed model over time. Compound scores and organ-specific scores for lung, heart, kidney, and liver were analyzed. Serum cytokine expression profiles of both groups were also compared over time. Significance was accepted at p < 0.05.

RESULTS

Both groups were comparable in age (CTR, 11 ± 5 years, vs EB, 11 ± 5 years), percent total body surface area burned (CTR, 33% ± 25%, vs EB, 32 ± 25%), and length of hospitalization (CTR, 18 ± 26 days, vs EB, 18 ± 21 days). The percentage of high-voltage injury in the EB group was 64%. The incidence of MOF was lower in the EB group (2 of 96 [2.1%]) than the CTR group (20 of 192 [10.4%]; p < 0.05). The incidence of single organ failure was comparable between groups. Incidence of pulmonary failure was comparable in both groups, but incidence of inhalation injury was significantly higher in the CTR group (p < 0.0001). Patients in the EB group had more amputations (p < 0.001), major amputations (p = 0.001), and combined major amputations (p < 0.01). Mortality was comparable between the groups. Serum cytokine expression profiles were also comparable between the groups.

CONCLUSIONS

In pediatric patients, electrical injury is associated with a lower incidence of MOF than other thermal burns. Early and radical debridement of nonviable tissue is crucial to improve outcomes in the electrical burn patient population.

LEVEL OF EVIDENCE

Retrospective chart review, level III.

Herpesviradae infections in severely burned children

OBJECTIVE

Burn-related immunosuppression can promote human herpesviridae infections. However, the effect of these infections on morbidity and mortality after pediatric burn injuries is unclear.

METHODS

We retrospectively analyzed pediatric patients with burns ≥10% of the total body surface area (TBSA) who were admitted between 2010 and 2015. On clinical suspicion of a viral infection, antiviral therapy was initiated. Viral infection was confirmed via Tzanck smear, viral culture, and/or PCR. Study endpoints were mortality, days of antiviral agent administration, type of viral test used, type of viral infection, and length of hospitalization.

RESULTS

Of the 613 patients were analyzed, 28 presented with clinically diagnosed viral infections. The use of Tzanck smears decreased over the past 5 years, whereas PCR and viral cultures have become standard. Patients with viral infections had significantly larger burns (53±15% vs. 38±18%, p<0.001); however, length of stay per TBSA burn was comparable (0.5±0.4 vs. 0.6±0.2, p=0.211). The most commonly detected herpesviridae was herpes simplex virus 1. Two patients died due to sepsis, which was accompanied by HSV infection. The mortality rate among all patients (2.7%) was comparable to that in the infected group (7.1%, p=0.898). Acyclovir was given systemically for 9±8days (N=76) and/or topically for 9±9days for HSV (N=39, combination of both N=33). Ganciclovir was prescribed in three cases for CMV.

CONCLUSIONS

Viral infections occur more commonly in patients suffering from larger burns, and HSV infections can contribute to mortality.

Recent trends in burn epidemiology worldwide: A systematic review

Burns have been more prevalent among low socioeconomic populations and in less developed regions. Incredible advances in burn care and social development over the recent decades, however, should have placed the incidence and severity of burns in a downwards trend. The aim of this review was to give an overview on current trends in burn epidemiology across the world. Also the socioeconomic development in countries that have published epidemiological data used in this study has been taken into account when comparing the results. There was a worldwide downwards trend of burn incidence, burn severity, length of hospital stay, and mortality rate. These findings were particularly pronounced in very highly developed countries. Data from highly and medium developed countries were more heterogeneous. No studies could be obtained from low and middle income countries. Comparisons between the different studies were compromised by the fact that studies emerged from specialized facilities on one hand and general hospitals on the other. Analyzed studies were also frequently focusing on limited patient populations such as "children" or "elderly". Our findings indicate the need for an international burn database with a minimal data-set in order to obtain objective and comparable results in respect of burn epidemiology.

Hypertrophic scarring: the greatest unmet challenge after burn injury

Improvements in acute burn care have enabled patients to survive massive burns that would have once been fatal. Now up to 70% of patients develop hypertrophic scars after burns. The functional and psychosocial sequelae remain a major rehabilitative challenge, decreasing quality of life and delaying reintegration into society. Approaches to optimise healing potential of burn wounds use targeted wound care and surgery to minimise the development of hypertrophic scarring. Such approaches often fail, and modulation of the established scar is continued although the optimal indication, timing, and combination of therapies have yet to be established. The need for novel treatments is paramount, and future efforts to improve outcomes and quality of life should include optimisation of wound healing to attenuate or prevent hypertrophic scarring, well-designed trials to confirm treatment efficacy, and further elucidation of molecular mechanisms to allow development of new preventive and therapeutic strategies.

Two-year follow-up of outcomes related to scarring and distress in children with severe burns

PURPOSE

We assessed the perception of scarring and distress by pediatric burn survivors with burns covering more than one-third of total body surface area (TBSA) for up to 2 years post-burn.

METHODS

Children with severe burns were admitted to our hospital between 2004 and 2012, and consented to this IRB-approved-study. Subjects completed at least one Scars Problems and/or Distress questionnaire between discharge and 24 months post burn. Outcomes were modeled with generalized estimating equations or using mixed linear models. Significance was accepted at p < 0.01.

RESULTS

Responses of 167 children with a mean age of 7 ± 5 years and burns covering an average 54 ± 14% of TBSA were analyzed. Significant improvements over the 2-year period were seen in reduction of pain, itching, sleeping disturbance, tightness, range of motion, and strength (p < 0.01). There was a significantly increased persistent desire to hide the scarred body areas over time (p < 0.01). The perception of mouth scarring, inability to portray accurate facial expressions, and skin coloration did not improve over the follow-up period.

CONCLUSIONS

According to self-assessment questionnaires, severely burned children exhibit significant improvements in their overall perception of scarring and distress. However, these patients remain self-conscious with respect to their body image even 2 years after burn injury. Implications for Rehabilitation According to self-assessment questionnaires, severely burned children perceive significant improvements in scarring and distress during the first 2 years post burn. Significant improvements were seen in reduction of pain, itching, sleeping disturbances, tightness, range of motion, and strength (p < 0.01). Burn care providers should improve the treatment of burns surrounding the mouth that with result in scarring, and develop strategies to prevent skin discoloration. Careful evaluation of pain and sleeping disorders during the first year post burn are warranted to improve the patient rehabilitation. Overall, significantly more female patients expressed a persistent desire to hide their scarred body areas. The rehabilitation team should provide access to wigs or other aids to pediatric burn survivors to address these needs.

Human herpes viruses in burn patients: A systematic review

OBJECTIVE

The contribution of human herpes viruses, including herpes simplex virus (HSV), cytomegalovirus (CMV), and varicella zoster virus (VZV) to morbidity and mortality after burns remains controversial. This systematic review was undertaken to assess evidence of herpes virus-related morbidity and mortality in burns.

MATERIALS AND METHODS

PubMed, Ovid, and Web of Science were searched to identify studies of HSV, CMV, or VZV infections in burn patients. Exclusion criteria included: A level of evidence (LoE) of IV or V; nonhuman in vivo studies; and non-English articles. There was no limitation by publication date.

RESULTS

Fifty articles were subjected to full-text analysis. Of these, 18 had LoE between I-III and were included in the final review (2 LoE I, 16 LoE II-III). Eight had a prospective study design, 9 had a retrospective study design, and 1 included both.

CONCLUSIONS

No direct evidence linked CMV and HSV infection with increased morbidity and mortality in burns. Following burn, CMV reactivation was more common than a primary CMV infection. Active HSV infection impaired wound healing but was not directly correlated to mortality. Infections with VZV are rare after burns but when they occur, VZV infections were associated with severe complications including mortality. The therapeutic effect of antiviral agents administered after burns warrants investigation via prospective randomized controlled trials.