Controlling intraoperative hemorrhage during burn surgery: A prospective, randomized trial comparing NuStat® hemostatic dressing to the historic standard of care

Quality indicators for hospital burn care: a scoping review

BACKGROUND

Burn treatments are complex, and for this reason, a specialised multidisciplinary approach is recommended. Evaluating the quality of care provided to acute burn patients through quality indicators makes it possible to develop and implement measures aiming at better results. There is a lack of information on which indicators to evaluate care in burn patients. The purpose of this scoping review was to identify a list of quality indicators used to evaluate the quality of hospital care provided to acute burn patients and indicate possible aspects of care that do not have specific indicators in the literature.

METHOD

A comprehensive scoping review (PRISMA-ScR) was conducted in four databases (PubMed, Cochrane Library, Embase, and Lilacs/VHL) between July 25 and 30, 2022 and redone on October 6, 2022. Potentially relevant articles were evaluated for eligibility. General data and the identified quality indicators were collected for each included article. Each indicator was classified as a structure, process, or outcome indicator.

RESULTS

A total of 1548 studies were identified, 82 were included, and their reference lists were searched, adding 19 more publications. Thus, data were collected from 101 studies. This review identified eight structure quality indicators, 72 process indicators, and 19 outcome indicators listed and subdivided according to their objectives.

CONCLUSION

This study obtained a list of quality indicators already used to monitor and evaluate the hospital care of acute burn patients. These indicators may be useful for further research or implementation in quality improvement programs.

TRIAL REGISTRATION

Protocol was registered on the Open Science Framework platform on June 27, 2022 ( https://doi.org/10.17605/OSF.IO/NAW85 ).

Topical Hemostatic Agents in Burn Surgery: A Systematic Review

Acute burn surgery has long been associated with significant intra-operative bleeding. Several techniques were introduced to limit hemorrhage, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery. A systematic review was performed by two independent reviewers using electronic databases (PubMed, Scopus, Web of Science) from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in burn excision and/or grafting. Data were extracted on the agent(s) used, their dosage, mode of delivery, hemostasis outcomes, and complications. The search identified 1982 nonduplicate citations, of which 134 underwent full-text review, and 49 met inclusion criteria. In total, 32 studies incorporated a vasoconstrictor agent, and 28 studies incorporated a procoagulant agent. Four studies incorporated other agents (hydrogen peroxide, tranexamic acid, collagen sheets, and TT-173). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/ml. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III-V. Determining the optimal topical hemostatic agent is limited by low-quality data and challenges with consistent reporting of intra-operative blood loss. Given the routine use of topical hemostatic agents in burn surgery, high-quality research is essential to determine the optimal agent, dosage, and mode of delivery.

Predicting blood loss in burn excisional surgery

BACKGROUND

Blood loss during burn excisional surgery remains an important factor as it is associated with significant comorbidity, mortality and longer length of stay. Blood loss is, among others, influenced by length of surgery, burn size, excision size and age. Most literature available is aimed at large burns and little research is available for small burns. Therefore, the goal of this study is to investigate blood loss and develop a prediction model to identify patient at risk for blood loss during burn excisional surgery ≤ 10% body surface area.

STUDY DESIGN AND METHODS

This retrospective study included adult patients who underwent burn excisional surgery of ≤ 10% body surface area in the period 2013-2018. Duplicates, patients with missing data and delayed surgeries were excluded. Primary outcome was blood loss. A prediction model for per-operative blood loss (>250 ml) was built using a multivariable logistic regression analysis with stepwise backward elimination. Discriminative ability was assessed by the area under the ROC-curve in conjunction with optimism and calibration.

RESULTS

In total 269 patients were included for analysis. Median blood loss was 50 ml (0-150) / % body surface area (BSA) excised and 0.28 (0-0.81) ml / cm². Median burn size was 4% BSA and median excision size was 2% BSA. Blood loss of> 250 ml was present in 39% of patients. The model can predict blood loss> 250 ml based on %BSA excised, length of surgery and ASA-score with an AUC of 0.922 (95% CI 0.883 - 0.949) and an AUC after optimism correction of 0.915. The calibration curve showed an intercept of 0.0 (95% CI -0.36 to 0.36) with a slope of 1.0 (95% CI 0.78-1.22).

CONCLUSION

Median blood loss during burn excisional surgery of ≤ 10% BSA is 50 ml / % BSA excised and 0.28 ml / cm² excised. However, a substantial part of patients is at risk for higher blood loss. The prediction model can predict P(blood loss>250 ml) with an AUC of 0.922, based on expected length of surgery, ASA-score and size of excision. The model can be used to identify patients at risk for significant blood loss (>250 ml).

Pre-operative Blood Loss Prediction Formulas in Burn Surgeries: A Review

Extensive burn surgeries lead to a considerable amount of blood loss. Predicting pre-operative blood loss is essential for blood ordering and crossmatching. Accurate amount of ordered blood units ensures patients' safety and minimizes cost. However, blood loss estimation is complicated due to a variety of factors influencing blood loss, including patient and operative-related variables. Currently, no standard method to predict blood loss exists prior to surgery. Our goal is to review factors influencing blood loss and formulas that can predict blood loss. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE databases for studies investigating blood loss in burn surgeries with a clear quantitative outcome. Fifteen studies were included, comprising 1613 subjects. All studies calculated blood loss and assessed possible related factors, and four studies proposed preoperative blood loss prediction formulas. Larger areas of tissue excised and grafted, younger age, and delayed surgery were correlated with increased blood loss. Varying decrease in blood loss was observed with tumescent usage and other bleeding control methods. Other variables produced inconsistent results. From four prediction formulas, only one formula, Dye's Formula, had been applied and proven effective in reducing unused blood units clinically by up to 40% of cross-matched blood. Various confounding factors and dissimilarities between studies make reliable prediction method construction challenging. With consideration of diverse patient characteristics, some study develops formulas to achieve optimal patient care and avoid unnecessary hospital expenditure. Further research with consistent variables should be done to construct a standardized blood loss estimation formula.

Adipose stromal vascular fraction: a promising treatment for severe burn injury

Thermal skin burn injury affects both adults and children globally. Severe burn injury affects a patient's life psychologically, cosmetically, and socially. The pathophysiology of burn injury is well known. Due to the complexity of burn pathophysiology, the development of specific treatment aiding in tissue regeneration is required. Treatment of burn injury depends on burn severity, size of the burn and availability of donor site. Burn healing requires biochemical and cellular events to ensure better cell response to biochemical signals of the healing process. This led to the consideration of using cell therapy for severe burn injury. Adult mesenchymal stem cells have become a therapeutic option because of their ability for self-renewal and differentiation. Adipose stromal vascular fraction (SVF), isolated from adipose tissues, is a heterogeneous cell population that contains adipose-derived stromal/stem cells (ADSC), stromal, endothelial, hematopoietic and pericytic lineages. SVF isolation has advantages over other types of cells; such as heterogeneity of cells, lower invasive extraction procedure, high yield of cells, and fast and easy isolation. Therefore, SVF has many characteristics that enable them to be a therapeutic option for burn treatment. Studies have been conducted mostly in animal models to investigate their therapeutic potential for burn injury. They can be used alone or in combination with other treatment options. Treatment with both ADSCs and/or SVF enhances burn healing through increasing re-epithelization, angiogenesis and decreasing inflammation and scar formation. Research needs to be conducted for a better understanding of the SVF mechanism in burn healing and to optimize current techniques for enhanced treatment outcomes.

The impact of initial surgical management on outcome in patients with severe burns: a 9-year retrospective analysis

PURPOSE

To investigate the prognostic value of the factors related to the initial surgical management of burn wounds in severely burned patients.

METHODS

A total of 189 severely burned adult patients who were admitted to our institute between January 2012 and December 2020 and met the inclusion criteria were recruited. Patients were divided into survival and nonsurvival groups. The patient data included sex, age, total burn surface area (TBSA), burn index (BI), inhalation injury, mechanical ventilation, initial surgical management of the burn wound (including post-injury time before surgery, surgical duration, surgical area, intraoperative fluid replenishment, intraoperative blood loss, and intraoperative urine output), and duration in the burn intensive care unit (BICU). Independent samples t tests, Mann-Whitney U tests, and χ 2 tests were performed on these data. those of which with statistically significant differences were subjected to univariate and multivariate Cox regression analyses to identify independent risk factors affecting the prognosis of severely burned patients. Receiver operating characteristic (ROC) curves were plotted, and the area under the curve (AUC), optimal cut-off value were calculated. Patients were divided into two groups, according to the optimal cut-off value of the independent risk factors. The TBSA, surgical area and survival rates of the two groups during hospitalization were analysed.

RESULTS

The survival group (146 patients) and the nonsurvival group (43 patients) differed significantly in TBSA, burn index, inhalation injury, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, intraoperative blood loss, and duration in the BICU (P<0.05). Univariate Cox regression analysis showed that TBSA, burn index, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, and intraoperative blood loss were risk factors for death in severely burned patients (P<0.05). Multivariate Cox regression analysis showed that the burn index and intraoperative blood loss were independent risk factors for death in severely burned patients (P<0.05). When the intraoperative blood loss during the initial surgical management of burn wounds was used to predict death in 189 severely burned patients, the AUC was 0.637 (95% confidence interval (CI): 0.545-0.730, P=0.006), and the optimal cut-off for intraoperative blood loss was 750 ml. Kaplan-Meier survival analysis showed that the prognosis of the group with intraoperative blood loss ≤750 ml was better than that of the group with intraoperative blood loss >750 ml (P=0.008). Meanwhile, the TBSA and surgical area in the group with intraoperative blood loss ≤750 ml were significantly lower than that of the group with intraoperative blood loss >750 ml (P<0.05).

CONCLUSION

The burn index and intraoperative blood loss during the initial surgical management of burn wounds are independent risk factors affecting the outcome of severely burned patients with good predictive values. During surgery, haemostatic and anaesthetic strategies should be adopted to reduce bleeding, and the bleeding volume should be controlled within 750 ml to improve the outcome.

Efficacy of Hemostatic Gauzes in a Swine Model of Prolonged Field Care with Limb Movement

INTRODUCTION

Prolonged field care for junctional wounds is challenging and involves limb movement to facilitate transport. No studies to date have explored the efficacy of gauze products to limit rebleeding in these scenarios.

MATERIALS AND METHODS

We randomly assigned 48 swine to QuikClot Combat Gauze, ChitoGauze, NuStat Tactical, or Kerlix treatment groups (12 each) and then inflicted a severe groin injury by utilizing a modified Kheirabadi model of a 6-mm femoral artery punch followed by unrestricted bleeding for 60 seconds. We reassessed rebleed following limb movement at 30 minutes of stabilization and 4 hours after stabilization.

RESULTS

Swine treated with Combat Gauze proved to have the lowest incidence of rebleeding, and conversely, NuStat Tactical had the highest incidence of rebleeding at wounds after limb movement. Importantly, rebleeds occurred at a rate of 25%-58% across all swine treatment groups at 30 minutes postinjury and 0%-42% at 270 minutes postinjury demonstrating that limb movements universally challenge hemostatic junctional wounds.

CONCLUSIONS

Our findings highlight the difficulty of controlling hemorrhage from junctional wounds with hemostatic gauze in the context of prolonged field care and casualty transport. Our research can guide selection of hemorrhage control gauze when patients have prolonged field extraction or difficult transport. Our data demonstrates the frequency of junctional wound rebleeding after movement and thus the importance of frequent patient reassessment.

Cell salvage in burn excisional surgery

BACKGROUND

Hemostasis during burn surgery is difficult to achieve, and high blood loss commonly occurs. Bleeding control measures are limited, and many patients require allogeneic blood transfusions. Cell salvage is a well-known method used to reduce transfusions. However, its evidence in burns is limited. Therefore, this study aimed to examine the feasibility of cell salvage during burn surgery.

STUDY DESIGN AND METHODS

A prospective, observational study was conducted with 16 patients (20 measurements) scheduled for major burn surgery. Blood was recovered by washing saturated gauze pads with heparinized saline, which was then processed using the Cell Saver. Erythrocyte concentrate quality was analyzed by measuring hemoglobin, hematocrit, potassium, and free hemoglobin concentration. Microbial contamination was assessed based on cultures at every step of the process. Differences in blood samples were tested using the Student's t-test.

RESULTS

The red blood cell mass recovered was 29 ± 11% of the mass lost. Patients' preoperative hemoglobin and hematocrit levels were 10.5 ± 1.8 g/dL and 0.33 ± 0.05 L/L, respectively. The erythrocyte concentrate showed hemoglobin and hematocrit levels of 13.2 ± 3.9 g/dL and 0.40 ± 0.11 L/L thus showing a concentration effect. The potassium level was lower in the erythrocyte concentrate (2.5 ± 1.5 vs. 4.1 ± 0.4 mmol/L, p < 0.05). The free hemoglobin level was low (0.16 ± 0.21 μmol/L). All cultures of the erythrocyte concentrate showed bacterial growth compared to 21% of wound cultures.

CONCLUSION

Recovering erythrocytes during burn excisional surgery using cell salvage is possible. Despite strict sterile handling, erythrocyte concentrates of all patients showed bacterial contamination. The consequence of this contamination remains unclear and should be investigated in future studies.

Advancements in Regenerative Strategies Through the Continuum of Burn Care

Burns are caused by several mechanisms including flame, scald, chemical, electrical, and ionizing and non-ionizing radiation. Approximately half a million burn cases are registered annually, of which 40 thousand patients are hospitalized and receive definitive treatment. Burn care is very resource intensive as the treatment regimens and length of hospitalization are substantial. Burn wounds are classified based on depth as superficial (first degree), partial-thickness (second degree), or full-thickness (third degree), which determines the treatment necessary for successful healing. The goal of burn wound care is to fully restore the barrier function of the tissue as quickly as possible while minimizing infection, scarring, and contracture. The aim of this review is to highlight how tissue engineering and regenerative medicine strategies are being used to address the unique challenges of burn wound healing and define the current gaps in care for both partial- and full-thickness burn injuries. This review will present the current standard of care (SOC) and provide information on various treatment options that have been tested pre-clinically or are currently in clinical trials. Due to the complexity of burn wound healing compared to other skin injuries, burn specific treatment regimens must be developed. Recently, tissue engineering and regenerative medicine strategies have been developed to improve skin regeneration that can restore normal skin physiology and limit adverse outcomes, such as infection, delayed re-epithelialization, and scarring. Our emphasis will be centered on how current clinical and pre-clinical research of pharmacological agents, biomaterials, and cellular-based therapies can be applied throughout the continuum of burn care by targeting the stages of wound healing: hemostasis, inflammation, cell proliferation, and matrix remodeling.