Burns management in ICU: Quality of the evidence: A systematic review

When Palliative Care May Be the Only Option in the Management of Severe Burns: A Case Report Written With the Help of ChatGPT

We present a case of 100% third-degree burns. The patient received full resuscitative measures, but the family was prepared for a poor outcome based on the severe extent of the injuries. After several days of treatment, it became apparent that the patient indeed could not survive the injuries and palliative care was instituted, including mechanical ventilation, fluid therapy, and analgesia. Surgery was not possible without causing major disfigurement, including enucleation of both eyes and amputation of all limbs.

Comparison Among Bone Marrow and Wheat Flour's Mixture and Standard Treatment on Healing Second-Degree Burn Wound in Rats

The treatment of extensive skin burns remains as a challenge for health care personnel. This study aimed to compare the combination of bone marrow and wheat flour with standard treatment on animal models. In this experimental study, 45 male rats were randomly assigned into three groups as follows: The first group was control (no treatment), the second group received bone marrow and wheat flour combination topically, and the third group received standard treatment (1% silver sulfadiazine). The treatment lasted for up to 21 days. On the 22nd day, the rats were killed. The number of blood vessels and hair follicles was measured in the burn wound bed. The area and depth of the wound were also measured. Data were analyzed using SPSS software version 16. The results showed that, complete closure of the wound was better in the bone marrow treated group compared with the group receiving the silver sulfadiazine and the control group. Furthermore, the wound healing was better in the silver sulfadiazine group compared with the control group. Microscopic examination revealed a significant increase in the number of hair follicles and blood vessels in the bone marrow and silver groups compared with the control group. The results showed that, the group treated with bone marrow, because of the presence of mesenchymal and stem cells can cause stimulating angiogenesis and producing vegetative tissue, hence it improved maturation, shrinkage, and contraction of the wound in comparison with the silver sulfadiazine and control groups.

A study comparing the effect of premedication with intravenous midazolam or dexmedetomidine on ketamine-fentanyl sedoanalgesia in burn patients: A randomized clinical trial

INTRODUCTION

Dressing changes and wound care-debridement procedures often cause fear and anxiety in burn patients, as these processes are quite painful. In order to determine the best method for alleviating pain during these procedures, the current study compared the efficacy and safety of intravenous dexmedetomidine and midazolam for premedication prior to these painful burn care procedures.

METHODS

This comparative and randomized study included patients who had a burn size of 1563%, were aged 1870 years, were diagnosed with the American Society of Anesthesiologists physical status (ASA I-II), and who underwent painful burn care procedures. Patients were intravenously administered either 1 mcg/kg dexmedetomidine (Group 1) or 0.03 mg/kg midazolam (Group 2) prior to the burn care procedure. Recorded at predetermined time points for each patient were heart rhythm (HR), mean arterial pressure (MAP), peripheral oxygen saturation (SpO₂₎, standard bispectral index (BIS), and Ramsay Sedation Scale (RSS).

RESULTS

In the dexmedetomidine group, HR and MAP measurements of patients ​​at the 3rd, 5th, and 10th mins during sedation were significantly lower than the baseline values (p < 0.05). A significant decrease in SpO2 was observed in both groups at the 10th min during sedation, but the decline was higher in the midazolam group (p < 0.05). BIS measurements of the patients in both groups were significantly lower at 10 min. during sedation and at 15th and 60th mins during the procedure (p < 0.05). However, there was no significant difference between the group (p > 0.05). The RSS scales of both groups in during the sedation were higher in the 3rd, 5th and 10th mins than the baseline values (p < 0.05), but there was no significant difference between the groups (p > 0.05). The RSS scales of groups in during the burn procedure were significantly higher at 15 th min than the 0 th values, while the RSS scales of both groups were significantly lower in the 45th and 60th mins (p < 0.05).

CONCLUSION

Results of this study indicate that dexmedetomidine causes hemodynamic alterations while midazolam causes respiratory depression. However, these effects are not severe, and we conclude that both agents are safe and effective to ensure sedation prior to painful burn-care procedures.

There is no fire without smoke! Pathophysiology and treatment of inhalational injury in burns: A narrative review

Smoke inhalation resulting in acute lung injury is a common challenge facing critical care practitioners caring for patients with severe burns, contributing significantly to morbidity and mortality. The intention of this review is to critically evaluate the published literature and trends in the diagnosis, management, implications and novel therapies in caring for patients with inhalation injury.

Volume-outcome relationship on survival and cost benefits in severe burn injury: a retrospective analysis of a Japanese nationwide administrative database

Background

Although it has been reported that high hospital patient volume results in survival and cost benefits for several diseases, it is uncertain whether this association is applicable in burn care.

Methods

We conducted a retrospective observational study on severe burn patients, defined by a burn index ≥ 10, using 2010–2015 data from a Japanese national administrative claim database. A generalized additive mixed-effect model (GAMM) was used to evaluate the nonlinear associations between patient volume and the outcomes (in-hospital mortality, healthcare costs per admission, and hospital-free days at 90 days). Generalized linear mixed-effect regression models (GLMMs) in which patient volume was incorporated as a continuous or categorical variable (≤ 5 or > 5) were also performed. Patient severity was adjusted using the prognostic burn index (PBI) or the risk adjustment model developed in this study, simultaneously controlling for hospital-level clustering. Sensitivity analyses evaluating patients who were directly transported, those with PBI ≤ 120 and those excluding patients who died within 2 days of admission, were also performed.

Results

We analyzed 5250 eligible severe burn patients from 737 hospitals. The PBI and the developed risk adjustment model had good discriminative ability with areas under the receiver operating characteristic curves of 0.86 and 0.89, respectively. The GAMM plots showed that in-hospital mortality and healthcare costs increased according to the increase in patient volumes; then, they reached a plateau. Fewer hospital-free days were observed in the higher volume hospitals. The GLMM model showed that patient volume (incorporated as a continuous variable) was significantly associated with increased in-hospital mortality (adjusted odds ratio [95% confidence interval (CI)] = 1.14 [1.09–1.19]), high healthcare costs (adjusted difference [95% CI] = $4876 [4436–5316]), and few hospital-free days (adjusted difference [95% CI] = − 3.1 days [− 3.4 to − 2.8]). Similar trends were observed in the analyses in which patient volume was incorporated as a categorical variable. The results of sensitivity analyses showed comparable results.

Conclusions

Analysis of Japanese nationwide administrative database demonstrated that high burn patient volume was significantly associated with increased in-hospital mortality, high healthcare costs, and few hospital-free days. Further studies are needed to validate our results.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0363-7) contains supplementary material, which is available to authorized users.

Investigating the interrater reliability of a novel functional outcome measure for use in the burns intensive care unit: The Functional Assessment for Burns - Critical Care (FAB-CC)

INTRODUCTION

Intensive Care Unit Acquired Weakness challenges the clinical care of critically ill patients. Despite a surge in validated ICU functional outcome measures following the publication of Clinical Guideline 83 'Rehabilitation After Critical Illness' by the National Institute for Health and Care Excellence (2009), there are none composed specifically for use in the Burns ICU. We therefore developed and tested the inter-rater reliability of a burn specific novel functional outcome measure; The Functional Assessment for Burns-Critical Care (FAB-CC).

OBJECTIVES

This research aimed to investigate the interrater reliability of the FAB-CC.

METHODS

A quantitative reliability study assessed the ability of the FAB-CC to obtain accurate data when utilised by three separate raters (m=3) scoring the same clinical episodes (n=24).

RESULTS

The Intraclass Correlation Coefficient (ICC) for the FAB-CC as a complete tool revealed excellent agreement (ICC 0.998; P<0.001, 95% confidence interval 0.996-0.999), with Cronbach's Alpha (α 0.999). Individual components of the FAB-CC displayed excellent agreement (ICC>0.983; P<0.001) with narrow 95% confidence intervals.

CONCLUSIONS

The FAB-CC is a novel functional outcome measure that is reliable for use with critically ill burn patients. It has demonstrated real clinical utility in the identification and management of ICU-AW in this unique patient group.

Clinical Practice Variation in Acute Severe Burn Injury

The New South Wales (NSW) Statewide Burn Injury Service Database was reviewed to identify variations in clinical practice with respect to care of severely burn-injured patients in intensive care. We compared differences in practice relating to duration of endotracheal intubation and surgical grafting. In this retrospective observational study, we reviewed all intensive care unit (ICU) admissions to the two NSW adult burns centres, ICU A and ICU B, between January 2008 and December 2015. Data were analysed for association between duration of intubation and outcome. There were 855 admissions to adult ICU, with a significant difference in the percentage total body surface area (% TBSA) of burn and inhalation injury between patients in the two units. There was a significant difference in duration of intubation and ICU length of stay (LOS) between the units, which persisted when adjusted for age, % TBSA and inhalational injury. When analysing patients with more severe burns (>20% TBSA or intubated), the difference in duration of intubation remained significant (median of three days [interquartile range, IQR, 1–11 days] in A and 2 days [IQR 1–6 days] in B, P=0.003) as did ICU LOS (median 3 days [IQR 2–11 days] for A and 2 days [IQR 1–6 days] for B, P <0.0005). There was no significant difference in mortality between the two units for the severe or the more severe subgroup of burns when adjusted for age, % TBSA and inhalational injury (adjusted odds ratio, OR, for mortality 1.17 [95% confidence intervals 0.6 to 2.3, P=0.65]). There were significant differences in clinical practice, including duration of intubation, between the two ICUs. Longer intubation was associated with a longer ICU LOS, but was not associated with a difference in mortality. Large collaborative, prospective multicentre studies in severe burns are needed to identify best practice and variations in practice to determine if they are associated with increased mortality and/or cost.

Resuscitation using less fluid has no negative impact on hydration status in children with moderate sized scalds: a prospective single-centre UK study

BACKGROUND

After a burn, optimal fluid resuscitation is critical for positive patient outcome. Although national guidelines advocate using resuscitation fluids of 4mL per kg body weight and percent body surface area (%BSA) for paediatric burns of >10% BSA, evidence in adults suggest that such volumes lead to over-resuscitation and related complications. Our aim was to investigate whether children managed with biosynthetic dressings (Biobrane™) and reduced fluid volumes remain well hydrated, as determined by clinical and laboratory parameters.

METHODS

At a single UK Burn Centre, children with scalds of 10-19%BSA managed with Biobrane were given 80% maintenance fluids and no formal burn resuscitation (permissive hypovolaemia [PH] group). Urine output (UO), serum sodium, urea, and creatinine were used as 24h markers of hydration and concentrations compared to those in a patient cohort treated within the same centre when traditional resuscitation was used (TR group).

RESULTS

Serum sodium concentrations and UO in the PH group were similar to those in the TR group (median sodium: PH=136, TR=136, P=1.00; median UO: PH=1.5, TR=1.8, P=0.25). Urea concentrations were lower and creatinine concentrations higher in the TR group compared to the PH group (median urea: PH=3.2, TR=2.3, P=0.04; median creatinine: PH=21, TR=30, P<0.001). A higher proportion of TR patients than PH patients fell outside the reference ranges for urea (61% vs. 23%; P=0.04) and creatinine (44% vs. 8%; P=0.03).

CONCLUSION

Based on markers of hydration, children with moderate-sized scalds managed with Biobrane can be safely managed with less fluid.