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Dobson GP, Morris JL, Letson HL. Pathophysiology of Severe Burn Injuries: New Therapeutic Opportunities From a Systems Perspective. J Burn Care Res 2024; 45:1041-1050. [PMID: 38517382 PMCID: PMC11303127 DOI: 10.1093/jbcr/irae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Indexed: 03/23/2024]
Abstract
Severe burn injury elicits a profound stress response with the potential for high morbidity and mortality. If polytrauma is present, patient outcomes appear to be worse. Sex-based comparisons indicate females have worse outcomes than males. There are few effective drug therapies to treat burn shock and secondary injury progression. The lack of effective drugs appears to arise from the current treat-as-you-go approach rather than a more integrated systems approach. In this review, we present a brief history of burns research and discuss its pathophysiology from a systems' perspective. The severe burn injury phenotype appears to develop from a rapid and relentless barrage of damage-associated molecular patterns, pathogen-associated molecular patterns, and neural afferent signals, which leads to a state of hyperinflammation, immune dysfunction, coagulopathy, hypermetabolism, and intense pain. We propose that if the central nervous system control of cardiovascular function and endothelial-glycocalyx-mitochondrial coupling can be restored early, these secondary injury processes may be minimized. The therapeutic goal is to switch the injury phenotype to a healing phenotype by reducing fluid leak and maintaining tissue O2 perfusion. Currently, no systems-based therapies exist to treat severe burns. We have been developing a small-volume fluid therapy comprising adenosine, lidocaine, and magnesium (ALM) to treat hemorrhagic shock, traumatic brain injury, and sepsis. Our early studies indicate that the ALM therapy holds some promise in supporting cardiovascular and pulmonary functions following severe burns. Future research will investigate the ability of ALM therapy to treat severe burns with polytrauma and sex disparities, and potential translation to humans.
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Affiliation(s)
- Geoffrey P Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia
| | - Jodie L Morris
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia
| | - Hayley L Letson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia
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2
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Buta MR, Donelan MB. Evolution of Burn Care: Past, Present, and Future. Clin Plast Surg 2024; 51:191-204. [PMID: 38429043 DOI: 10.1016/j.cps.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Burn care evolved slowly from primitive treatments depicted in cave drawings 3500 years ago to a vibrant medical specialty which has made remarkable progress over the past 200 years. This evolution involved all areas of burn care including superficial dressings, wound assessment, fluid resuscitation, infection control, pathophysiology, nutritional support, burn surgery, and inhalation injury. Major advances that contributed to current standards of care and improved outcomes are highlighted in this article. New innovations are making possible a future where severe burn injuries will require less morbid interventions for acute care and outcomes will restore patients more closely to their pre-injury condition.
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Affiliation(s)
- Martin R Buta
- Plastic, Reconstructive, and Laser Surgery, Shriners Hospitals for Children, Boston, MA, USA; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA, USA
| | - Matthias B Donelan
- Plastic, Reconstructive, and Laser Surgery, Shriners Hospitals for Children, Boston, MA, USA; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA, USA.
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3
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Resch A, Neumueller A, Christ A, Staud C, Hacker S. Chronic kidney disease and cardiovascular disease reduce survival rates after burn injury: A retrospective study over 20 years. Surgery 2024; 175:1198-1204. [PMID: 38135554 DOI: 10.1016/j.surg.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/31/2023] [Accepted: 11/19/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The Abbreviated Burn Severity Index and comparable scores are used to assess the probability of survival in burned patients. These scores may be useful during the initial management of the patient and in addition to the clinical evaluation. As current models do not include the influence of chronic diseases, we evaluated the impact of comorbidities on survival probability, aiming to improve the existing scoring systems and survival probability accuracy further. METHODS In this retrospective single-center study, patient data from a center for Severe Burn Injury were collected. Over a period of 20 years (2000-2019), a total of 1,193 patients were recorded. The influence of comorbidities (chronic kidney disease, diabetes mellitus type II, and cardiovascular diseases) on the survival probability was analyzed using regression models. These analyses were stratified for sex and period. RESULTS Pre-existing chronic kidney disease, as well as pre-existing cardiovascular disease, had a significant influence on the survival of patients. For chronic kidney disease, the influence was stronger in men than in women. Women were more likely to survive a burn injury with a history of chronic renal insufficiency. An improved Abbreviated Burn Severity Index model, which assigns an additional point for chronic kidney disease, best-described survival probability in our patient cohort. CONCLUSION Cardiovascular disease and chronic kidney disease both have an impact on the survival probability of severely burned patients, but this impact is more severe for chronic kidney disease. An additional Abbreviated Burn Severity Index point for chronic kidney disease would be a proposed adaptation to predict the outcome of burn patients better.
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Affiliation(s)
- Annika Resch
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Albert Neumueller
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Christ
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Clement Staud
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Hacker
- Privatordination Priv. Doz. Dr. Stefan Hacker, Vienna, Austria. https://twitter.com/stefan_hacker_
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4
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Greenhalgh DG, Hill DM, Burmeister DM, Gus EI, Cleland H, Padiglione A, Holden D, Huss F, Chew MS, Kubasiak JC, Burrell A, Manzanares W, Gómez MC, Yoshimura Y, Sjöberg F, Xie WG, Egipto P, Lavrentieva A, Jain A, Miranda-Altamirano A, Raby E, Aramendi I, Sen S, Chung KK, Alvarez RJQ, Han C, Matsushima A, Elmasry M, Liu Y, Donoso CS, Bolgiani A, Johnson LS, Vana LPM, de Romero RVD, Allorto N, Abesamis G, Luna VN, Gragnani A, González CB, Basilico H, Wood F, Jeng J, Li A, Singer M, Luo G, Palmieri T, Kahn S, Joe V, Cartotto R. Surviving Sepsis After Burn Campaign. Burns 2023; 49:1487-1524. [PMID: 37839919 DOI: 10.1016/j.burns.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.
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Affiliation(s)
- David G Greenhalgh
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA.
| | - David M Hill
- Department of Clinical Pharmacy & Translational Scre have been several studies that have evaluatedience, College of Pharmacy, University of Tennessee, Health Science Center; Memphis, TN, USA
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eduardo I Gus
- Division of Plastic & Reconstructive Surgery, The Hospital for Sick Children; Department of Surgery, University of Toronto, Toronto, Canada
| | - Heather Cleland
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Alex Padiglione
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Dane Holden
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University/Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Aidan Burrell
- Department of Epidemiology and Preventative Medicine, Monash University and Alfred Hospital, Intensive Care Research Center (ANZIC-RC), Melbourne, Australia
| | - William Manzanares
- Department of Critical Care Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - María Chacón Gómez
- Division of Intensive Care and Critical Medicine, Centro Nacional de Investigacion y Atencion de Quemados (CENIAQ), National Rehabilitation Institute, LGII, Mexico
| | - Yuya Yoshimura
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Folke Sjöberg
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wei-Guo Xie
- Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Paula Egipto
- Centro Hospitalar e Universitário São João - Burn Unit, Porto, Portugal
| | | | | | | | - Ed Raby
- Infectious Diseases Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | | | - Soman Sen
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Chunmao Han
- Department of Burn and Wound Repair, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Moustafa Elmasry
- Department of Hand, Plastic Surgery and Burns, Linköping University, Linköping, Sweden
| | - Yan Liu
- Department of Burn, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Carlos Segovia Donoso
- Intensive Care Unit for Major Burns, Mutual Security Clinical Hospital, Santiago, Chile
| | - Alberto Bolgiani
- Department of Surgery, Deutsches Hospital, Buenos Aires, Argentina
| | - Laura S Johnson
- Department of Surgery, Emory University School of Medicine and Grady Health System, Georgia
| | - Luiz Philipe Molina Vana
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Nikki Allorto
- Grey's Hospital Pietermaritzburg Metropolitan Burn Service, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Gerald Abesamis
- Alfredo T. Ramirez Burn Center, Division of Burns, Department of Surgery, University of Philippines Manila - Philippine General Hospital, Manila, Philippines
| | - Virginia Nuñez Luna
- Unidad Michou y Mau Xochimilco for Burnt Children, Secretaria Salud Ciudad de México, Mexico
| | - Alfredo Gragnani
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Carolina Bonilla González
- Department of Pediatrics and Intensive Care, Pediatric Burn Unit, Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Hugo Basilico
- Intensive Care Area - Burn Unit - Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Fiona Wood
- Department of Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James Jeng
- Department of Surgery, University of California, Irvine, CA, USA
| | - Andrew Li
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Mervyn Singer
- Department of Intensive Care Medicine, University College London, London, United Kingdom
| | - Gaoxing Luo
- Institute of Burn Research, Southwest Hospital, Army (Third Military) Medical University, Chongqing, China
| | - Tina Palmieri
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Steven Kahn
- The South Carolina Burn Center, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine, CA, USA
| | - Robert Cartotto
- Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario, Canada
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Mahung C, Wallet SM, Jacobs JE, Zhou LY, Zhou H, Cairns BA, Maile R. Multiplexed Human Gene Expression Analysis Reveals a Central Role of the TLR/mTOR/PPARγ and NFkB Axes in Burn and Inhalation Injury-Induced Changes in Systemic Immunometabolism and Long-Term Patient Outcomes. Int J Mol Sci 2022; 23:9418. [PMID: 36012680 PMCID: PMC9409318 DOI: 10.3390/ijms23169418] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Burn patients are subject to significant acute immune and metabolic dysfunction. Concomitant inhalation injury increases mortality by 20%. In order to identify specific immune and metabolic signaling pathways in burn (B), inhalation (I), and combined burn-inhalation (BI) injury, unbiased nanoString multiplex technology was used to investigate gene expression within peripheral blood mononuclear cells (PBMCs) from burn patients, with and without inhalation injury. PBMCs were collected from 36 injured patients and 12 healthy, non-burned controls within 72 h of injury. mRNA was isolated and hybridized with probes for 1342 genes related to general immunology and cellular metabolism. From these specific gene patterns, specific cellular perturbations and signaling pathways were inferred using robust bioinformatic tools. In both B and BI injuries, elements of mTOR, PPARγ, TLR, and NF-kB signaling pathways were significantly altered within PBMC after injury compared to PBMC from the healthy control group. Using linear regression modeling, (1) DEPTOR, LAMTOR5, PPARγ, and RPTOR significantly correlated with patient BMI; (2) RPTOR significantly correlated with patient length of stay, and (3) MRC1 significantly correlated with the eventual risk of patient mortality. Identification of mediators of this immunometabolic response that can act as biomarkers and/or therapeutic targets could ultimately aid the management of burn patients.
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Affiliation(s)
- Cressida Mahung
- North Carolina Jaycee Burn Center, Department of Surgery, Chapel Hill, NC 27514, USA
| | - Shannon M. Wallet
- Division of Oral and Craniofacial Health Sciences Adams School of Dentistry, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Jordan E. Jacobs
- North Carolina Jaycee Burn Center, Department of Surgery, Chapel Hill, NC 27514, USA
| | - Laura Y. Zhou
- Department of Biostatistics, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Haibo Zhou
- Department of Biostatistics, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Bruce A. Cairns
- North Carolina Jaycee Burn Center, Department of Surgery, Chapel Hill, NC 27514, USA
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina School of Medicine, 8031 Burnett Womack, Chapel Hill, NC 27599, USA
| | - Robert Maile
- North Carolina Jaycee Burn Center, Department of Surgery, Chapel Hill, NC 27514, USA
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina School of Medicine, 8031 Burnett Womack, Chapel Hill, NC 27599, USA
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6
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O'Neil AM, Rush C, Griffard L, Roggy D, Boyd A, Hartman B. 5 -Year Retrospective Analysis of a Vented Mobility Algorithm in the Burn ICU. J Burn Care Res 2022; 43:1129-1134. [PMID: 34978322 DOI: 10.1093/jbcr/irab248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Early mobilization with mechanically ventilated patients has received significant attention within recent literature, however limited research has focused specifically on the burn population. The purpose of this single center, retrospective analysis was to review the use of a burn critical care mobility algorithm, to determine safety and feasibility of a burn vented mobility program, share limitations preventing mobility progression at our facility, and discuss unique challenges to vented mobility with intubated burn patients. A retrospective review was completed for all intubated burn center admissions between January 2015 to December 2019. Burn Therapy notes were then reviewed for data collection, during the intubation period, using stages of the mobility algorithm. In 5 years following initial implementation, the vented mobility algorithm was utilized on 127 patients with an average total body surface area of 22.8%. No adverse events occurred. Stage 1 (Range of motion) was completed with 100% of patients (n=127). Chair mode of bed, stage 2a, was utilized in 39.4%(n=50) of patients, while 15.8% (n=20) of patients were dependently transferred to the cardiac chair in stage 2b. Stage 3 (sitting on the edge-of-bed) was completed with 25% (n=32) of patients, with 11% (n=14) progressing to stage 5 (standing), and 3.9% (n=5) actively transferring to a chair. In 5 years, only 4.7% (n=6) reached stage 6 (ambulation). The most common treatment limitations were medical complications (33%) and line placement (21%). Early mobilization during mechanical ventilation is safe and feasible within the burn population, despite challenges including airway stability, sedation, and line limitations.
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Affiliation(s)
| | | | | | - David Roggy
- Richard M Fairbanks Burn Center, Indianapolis, IN
| | - Allison Boyd
- Richard M Fairbanks Burn Center, Indianapolis, IN
| | - Brett Hartman
- Indiana University School of Medicine, Indianapolis, IN
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7
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Luca-Pozner V, Nischwitz SP, Conti E, Lipa G, Ghezal S, Luze H, Funk M, Remy H, Qassemyar Q. The use of a novel burn dressing out of bacterial nanocellulose compared to the French standard of care in paediatric 2nd degree burns - A retrospective analysis. Burns 2021; 48:1472-1480. [PMID: 34924226 DOI: 10.1016/j.burns.2021.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/18/2021] [Accepted: 11/23/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE Paediatric burn care is a delicate discipline which benefits from special attention. Despite being highly effective, the current standard of care for second degree burns in the largest paediatric burn center in France - exposure to infrared light - involves long hospital stays, straining economic and professional resources, especially in times of a pandemic. The present study investigated this standard of care and compared it to the use of a bacterial nanocellulose dressing. MATERIALS AND METHODS A retrospective analysis of two groups has been performed: the control group assessed thirty consecutive children treated with the standard of care, and the intervention group assessed thirty consecutive children treated with the bacterial nanocellulose dressing. Parameters evaluated were: healed wounds, additional treatments, rate of infections, hospital length of stay, pain experience and overall satisfaction. RESULTS The two groups did not differ significantly in terms of age and TBSA. A significant reduction in hospital length of stay (p < .001) and pain experience (p < .001) could be observed. In terms of healed wounds, additional treatments and infections, the two groups were equally matched (p > .05) with satisfactory results in both groups. Tendencies towards better results could be seen in the intervention group. CONCLUSION The use of bacterial nanocellulose wound dressings is an important tool in the armamentarium of today's burn surgeons. Satisfying results were achieved, ameliorating burn care for children. Future studies are indicated to further support its value and assess the economic impact.
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Affiliation(s)
- V Luca-Pozner
- Armand Trousseau Hospital, Department of Plastic and Reconstructive Surgery, 28 Av du Dr Arnold Netter, Paris, France; Sorbonne University, 91-105 Boulevard de l'Hopital, Paris, France
| | - S P Nischwitz
- COREMED - Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, Graz, Austria; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.
| | - E Conti
- Armand Trousseau Hospital, Department of Plastic and Reconstructive Surgery, 28 Av du Dr Arnold Netter, Paris, France
| | - G Lipa
- Armand Trousseau Hospital, Department of Plastic and Reconstructive Surgery, 28 Av du Dr Arnold Netter, Paris, France
| | - S Ghezal
- Armand Trousseau Hospital, Department of Plastic and Reconstructive Surgery, 28 Av du Dr Arnold Netter, Paris, France
| | - H Luze
- COREMED - Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, Graz, Austria; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - M Funk
- EVOMEDIS GmbH, Graz, Austria
| | - H Remy
- Armand Trousseau Hospital, Department of Plastic and Reconstructive Surgery, 28 Av du Dr Arnold Netter, Paris, France
| | - Q Qassemyar
- Armand Trousseau Hospital, Department of Plastic and Reconstructive Surgery, 28 Av du Dr Arnold Netter, Paris, France; Sorbonne University, 91-105 Boulevard de l'Hopital, Paris, France
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8
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Maile R, Willis ML, Herring LE, Prevatte A, Mahung C, Cairns B, Wallet S, Coleman LG. Burn Injury Induces Proinflammatory Plasma Extracellular Vesicles That Associate with Length of Hospital Stay in Women: CRP and SAA1 as Potential Prognostic Indicators. Int J Mol Sci 2021; 22:ijms221810083. [PMID: 34576246 PMCID: PMC8468249 DOI: 10.3390/ijms221810083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 12/19/2022] Open
Abstract
Severe burn injury is a devastating form of trauma that results in persistent immune dysfunction with associated morbidity and mortality. The underlying drivers of this immune dysfunction remain elusive, and there are no prognostic markers to identify at-risk patients. Extracellular vesicles (EVs) are emerging as drivers of immune dysfunction as well as biomarkers. We investigated if EVs after burn injury promote macrophage activation and assessed if EV contents can predict length of hospital stay. EVs isolated early from mice that received a 20% total body surface area (TBSA) burn promoted proinflammatory responses in cultured splenic macrophages. Unbiased LC-MS/MS proteomic analysis of early EVs (<72 h post-injury) from mice and humans showed some similarities including enrichment of acute phase response proteins such as CRP and SAA1. Semi-unbiased assessment of early human burn patient EVs found alterations consistent with increased proinflammatory signaling and loss of inhibition of CRP expression. In a sample of 50 patients with large burn injury, EV SAA1 and CRP were correlated with TBSA injury in both sexes and were correlated with length of hospital stay in women. These findings suggest that EVs are drivers of immune responses after burn injury and their content may predict hospital course.
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Affiliation(s)
- Robert Maile
- Curriculum in Toxicology and Environmental Medicine, North Carolina Jaycee Burn Center, Department of Surgery, Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (R.M.); (B.C.)
| | - Micah L. Willis
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Laura E. Herring
- Department of Pharmacology, School of Medicine, UNC Proteomics Core Facility, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (L.E.H.); (A.P.)
| | - Alex Prevatte
- Department of Pharmacology, School of Medicine, UNC Proteomics Core Facility, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (L.E.H.); (A.P.)
| | - Cressida Mahung
- North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Bruce Cairns
- Curriculum in Toxicology and Environmental Medicine, North Carolina Jaycee Burn Center, Department of Surgery, Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (R.M.); (B.C.)
| | - Shannon Wallet
- Department of Microbiology and Immunology, Division of Oral and Craniofacial Health Sciences, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Leon G. Coleman
- Bowles Center for Alcohol Studies, Department of Pharmacology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Correspondence:
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9
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Willis ML, Mahung C, Wallet SM, Barnett A, Cairns BA, Coleman LG, Maile R. Plasma extracellular vesicles released after severe burn injury modulate macrophage phenotype and function. J Leukoc Biol 2021; 111:33-49. [PMID: 34342045 DOI: 10.1002/jlb.3mia0321-150rr] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Extracellular vesicles (EVs) have emerged as key regulators of immune function across multiple diseases. Severe burn injury is a devastating trauma with significant immune dysfunction that results in an ∼12% mortality rate due to sepsis-induced organ failure, pneumonia, and other infections. Severe burn causes a biphasic immune response: an early (0-72 h) hyper-inflammatory state, with release of damage-associated molecular pattern molecules, such as high-mobility group protein 1 (HMGB1), and proinflammatory cytokines (e.g., IL-1β), followed by an immunosuppressive state (1-2+ wk post injury), associated with increased susceptibility to life-threatening infections. We have reported that early after severe burn injury HMGB1 and IL-1β are enriched in plasma EVs. Here we tested the impact of EVs isolated after burn injury on phenotypic and functional consequences in vivo and in vitro using adoptive transfers of EV. EVs isolated early from mice that underwent a 20% total body surface area burn injury (burn EVs) caused similar hallmark cytokine responses in naïve mice to those seen in burned mice. Burn EVs transferred to RAW264.7 macrophages caused similar functional (i.e., cytokine secretion) and immune gene expression changes seen with their associated phase of post-burn immune dysfunction. Burn EVs isolated early (24 h) induced MCP-1, IL-12p70, and IFNγ, whereas EVs isolated later blunted RAW proinflammatory responses to bacterial endotoxin (LPS). We also describe significantly increased HMGB1 cargo in burn EVs purified days 1 to 7 after injury. Thus, burn EVs cause immune outcomes in naïve mice and macrophages similar to findings after severe burn injury, suggesting EVs promote post-burn immune dysfunction.
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Affiliation(s)
- Micah L Willis
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cressida Mahung
- North Carolina Jaycee Burn Center Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shannon M Wallet
- Adams School of Dentistry, Division of Oral and Craniofacial Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alexandra Barnett
- Department of Pharmacology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Bruce A Cairns
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,North Carolina Jaycee Burn Center Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Leon G Coleman
- Department of Pharmacology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert Maile
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,North Carolina Jaycee Burn Center Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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10
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Won P, Bello MS, Stoycos SA, Carrera BT, Kurakazu DM, Briere J, Garner WL, Gillenwater J, Yenikomshian HA. The Impact of Peer Support Group Programs on Psychosocial Outcomes for Burn Survivors and Caregivers: A Review of the Literature. J Burn Care Res 2021; 42:600-609. [PMID: 33677491 DOI: 10.1093/jbcr/irab042] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Peer support group programs are often recommended for burn survivors as a way to facilitate their psychosocial recovery and reintegration into the community. Such programs provide opportunities for burn patients and their caretakers to access emotional and informational support from healthcare providers and other survivors in inpatient or outpatient settings. Despite their popularity, however, there is little information currently available on the efficacy of these groups. In response, we reviewed the existing literature on peer support group programs and their impacts on psychosocial outcomes for burn survivors and their caregivers. A systematic review of the literature utilizing PubMed, PsycINFO, and Medline databases was conducted for articles published between 1990 and 2018. Twenty-five articles including inpatient, outpatient, integrative peer support groups, and burn camps met our inclusion criteria. All inpatient peer support group program articles (n = 4) reported associations with psychosocial improvements. Integrative peer support group program articles (n = 2) reported associations with social integration and reduction in post-traumatic stress and anxiety. All outpatient peer support group program articles (n = 8) demonstrated associations with psychosocial outcomes involving life satisfaction, acceptance of self, and reduced levels of isolation. Findings were less consistent for burn camps: eight articles suggested improvements in psychological outcomes while three articles reported no significant psychosocial effects. Although these results are encouraging, further study is indicated both to replicate these findings, and to determine the optimal implementation of inpatient and outpatient peer support programs.
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Affiliation(s)
- Paul Won
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mariel S Bello
- LAC+USC Hospital, University of Southern California, Los Angeles, CA, USA.,Department of Psychology, University of Southern California, Los Angeles, CA, USA
| | - Sarah A Stoycos
- LAC+USC Hospital, University of Southern California, Los Angeles, CA, USA.,Department of Psychology, University of Southern California, Los Angeles, CA, USA
| | - Brenda T Carrera
- LAC+USC Hospital, University of Southern California, Los Angeles, CA, USA
| | - Dawn M Kurakazu
- LAC+USC Hospital, University of Southern California, Los Angeles, CA, USA
| | - John Briere
- Department of Psychiatry and Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
| | - Warren L Garner
- Division of Plastic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Justin Gillenwater
- Division of Plastic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Haig A Yenikomshian
- Division of Plastic Surgery, University of Southern California, Los Angeles, CA, USA
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11
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Burmeister DM, Smith SL, Muthumalaiappan K, Hill DM, Moffatt LT, Carlson DL, Kubasiak JC, Chung KK, Wade CE, Cancio LC, Shupp JW. An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation. J Burn Care Res 2020; 42:113-125. [PMID: 33306095 DOI: 10.1093/jbcr/iraa214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.
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Affiliation(s)
- David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Susan L Smith
- The Warden Burn Center, Orlando Regional Medical Center, Orlando, Florida
| | | | - David M Hill
- Firefighters' Burn Center, Regional One Health, Memphis, Tennessee
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Deborah L Carlson
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C Kubasiak
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Charles E Wade
- Center for Translational Injury Research, and Department of Surgery, McGovern School of Medicine and The John S. Dunn Burn Center, Memorial Herman Hospital, Houston, Texas
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
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12
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A non-inferiority study comparing efficacy of preoperative prophylactic antibiotics for preventing infectious complications in patients with less severe burns. Burns 2020; 47:67-71. [PMID: 33288331 DOI: 10.1016/j.burns.2020.10.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/28/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022]
Abstract
While international burn injury guidelines discourage prophylactic antibiotics on admission, current surgery guidelines focusing on antimicrobial prophylaxis place thermal injury under a general plastics procedure umbrella, and require significant evidential extrapolation. The purpose of this study was to determine if withholding systemic antibiotics in patients with <20% total body surface area (TBSA) burns without invasive wound infections and undergo wound excision is non-inferior to patients that receive preoperative antibiotics. Success was defined as lack of graft loss, bacteremia, or surgical site infection. One-thousand and eighty-three patients were screened and 100 patients undergoing 133 operations remained after exclusions. Seventy-four percent were male. Median age and %TBSA was 41 years (30, 55) and 5 (1.5, 8.3), respectively. We found no differences in demographics between patients that did and did not receive preoperative antibiotics. The success rates were 81.7% and 84.3%, respectively. There was one clinically significant bacteremia in each group. Withholding preoperative antibiotics was non-inferior with a percent difference of 2.6 (95% CI; -10.4, 15.6). Patients that did not receive antibiotics were no more likely to incur infection-related complications. In patients with <20% TBSA burns and without active wound infections, withholding preoperative systemic antibiotics will preserve unneeded antimicrobial exposure without increasing risk of infection-related complications.
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13
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Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T, Lefort H, Louvet N, Losser MR, Lucas C, Pantet O, Roquilly A, Rousseau AF, Soussi S, Wiramus S, Gayat E, Blet A. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med 2020; 39:253-267. [PMID: 32147581 DOI: 10.1016/j.accpm.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children. DESIGN A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion. RESULTS The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations. CONCLUSION Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, San Francisco, United States.
| | - Damien Barraud
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France
| | - Isabelle Constant
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | | | - Nicolas Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Mathieu Fontaine
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Laetitia Goffinet
- Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | | | - Mathieu Jeanne
- CHU Lille, Anaesthesia and Critical Care, Burn Centre, 59000 Lille, France; University of Lille, Inserm, CHU Lille, CIC 1403, 59000 Lille, France; University of Lille, EA 7365 - GRITA, 59000 Lille, France
| | - Jeanne Jonqueres
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Hugues Lefort
- Department of emergency medicine, Legouest Military Teaching Hospital, Metz, France
| | - Nicolas Louvet
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Marie-Reine Losser
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France; Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France; Inserm UMR 1116, Team 2, 54000 Nancy, France; University of Lorraine, 54000 Nancy, France
| | - Célia Lucas
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), BH 08-651, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Antoine Roquilly
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University of Nantes, Nantes, France
| | | | - Sabri Soussi
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Interdepartmental Division of Critical Care, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sandrine Wiramus
- Department of Anaesthesia and Intensive Care Medicine and Burn Centre, University Hospital of Marseille, La Timone Hospital, Marseille, France
| | - Etienne Gayat
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alice Blet
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France; Department of Research, University of Ottawa Heart Institute, Ottawa, ON, Canada
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14
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McInnes JA, Cleland HJ, Cameron PA, Darton A, Tracy LM, Wood FM, Singer Y, Gabbe BJ. Epidemiology of burn-related fatalities in Australia and New Zealand, 2009–2015. Burns 2019; 45:1553-1561. [DOI: 10.1016/j.burns.2019.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/03/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
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15
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Two Students' Summary of Basil A. Pruitt's Impact on Surgical Care, Teaching and Education. J Trauma Acute Care Surg 2019. [DOI: 10.1097/01.ta.0000577300.72696.8f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Lang TC, Zhao R, Kim A, Wijewardena A, Vandervord J, McGrath R, Fitzpatrick S, Fulcher G, Jackson CJ. Plasma protein C levels are directly associated with better outcomes in patients with severe burns. Burns 2019; 45:1659-1672. [PMID: 31221425 DOI: 10.1016/j.burns.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/20/2019] [Accepted: 05/01/2019] [Indexed: 11/30/2022]
Abstract
Protein C circulates in human plasma to regulate inflammation and coagulation. It has shown a crucial role in wound healing in animals, and low plasma levels predict the presence of a wound in diabetic patients. However, no detailed study has measured protein C levels in patients with severe burns over the course of a hospital admission. A severe burn is associated with dysfunction of inflammation and coagulation as well as a significant risk of morbidity and mortality. The current methods of burn assessment have shortcomings in reliability and have limited prognostic value. The discovery of a biomarker that estimates burn severity and predicts clinical events with greater accuracy than current methods may improve management, resource allocation and patient counseling. This is the first study to assess the potential role of protein C as a biomarker of burn severity. We measured the plasma protein C levels of 86 patients immediately following a severe burn, then every three days over the first three weeks of a hospital admission. We also analysed the relationships between burn characteristics, blood test results including plasma protein C levels and clinical events. We used a primary composite outcome of increased support utilisation defined as: a mean intravenous fluid administration volume of five litres or more per day over the first 72 h of admission, a length of stay in the intensive care unit of more than four days, or greater than four surgical procedures during admission. The hypothesis was that low protein C levels would be negatively associated with increased support utilisation. At presentation to hospital after a severe burn, the mean plasma protein C level was 76 ± 20% with a range of 34-130% compared to the normal range of 70-180%. The initial low can be plausibly explained by impaired synthesis, increased degradation and excessive consumption of protein C following a burn. Levels increased gradually over six days then remained at a steady-state until the end of the inpatient study period, day 21. A multivariable regression model (Nagelkerke's R2 = 0.83) showed that the plasma protein C level on admission contributed the most to the ability of the model to predict increased support utilisation (OR = 0.825 (95% CI = 0.698-0.977), P = 0.025), followed by burn size (OR = 1.252 (95% CI = 1.025-1.530), P = 0.027), burn depth (partial thickness was used as the reference, full thickness OR = 80.499 (1.569-4129.248), P = 0.029), and neutrophil count on admission (OR = 1.532 (95% CI = 0.950-2.473), P = 0.08). Together, these four variables predicted increased support utilisation with 93.2% accuracy, 83.3% sensitivity and 97.6% specificity. However if protein C values were disregarded, only 49.5% of the variance was explained, with 82% accuracy, 63% sensitivity and 91.5% specificity. Thus, protein C may be a useful biomarker of burn severity and study replication will enable validation of these novel findings.
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Affiliation(s)
- Thomas Charles Lang
- Sutton Laboratories Level 10, The Kolling Institute, The University of Sydney, Northern Clinical School, Royal North Shore Hospital, Reserve Rd, St. Leonards, 2065, NSW, Australia; Department of Anaesthesia, Prince of Wales and Sydney Children's Hospitals, Barker St, Randwick, 2031, NSW, Australia.
| | - Ruilong Zhao
- Sutton Laboratories Level 10, The Kolling Institute, The University of Sydney, Northern Clinical School, Royal North Shore Hospital, Reserve Rd, St. Leonards, 2065, NSW, Australia
| | - Albert Kim
- Royal North Shore Hospital, Reserve Rd St., Leonards, 2065, NSW, Australia
| | - Aruna Wijewardena
- Royal North Shore Hospital, Reserve Rd St., Leonards, 2065, NSW, Australia
| | - John Vandervord
- Royal North Shore Hospital, Reserve Rd St., Leonards, 2065, NSW, Australia
| | - Rachel McGrath
- Royal North Shore Hospital, Reserve Rd St., Leonards, 2065, NSW, Australia
| | | | - Gregory Fulcher
- Royal North Shore Hospital, Reserve Rd St., Leonards, 2065, NSW, Australia
| | - Christopher John Jackson
- Sutton Laboratories Level 10, The Kolling Institute, The University of Sydney, Northern Clinical School, Royal North Shore Hospital, Reserve Rd, St. Leonards, 2065, NSW, Australia
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17
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Badulak JH, Schurr M, Sauaia A, Ivashchenko A, Peltz E. Defining the criteria for intubation of the patient with thermal burns. Burns 2018; 44:531-538. [PMID: 29548862 DOI: 10.1016/j.burns.2018.02.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Recent studies demonstrate that burn patients are undergoing unnecessary intubations. We sought to determine the clinical criteria that predict intubations with benefit. METHODS This was a retrospective review of intubated adults admitted to our center with thermal burns 2008-2013. Criteria for intubation were defined as traditional criteria (suspected smoke inhalation, oropharynx soot, hoarseness, dysphagia, singed facial hair, oral edema, oral burn, non-full thickness facial burns), or ABA criteria as defined by the 2011 ABA guidelines (full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper airway trauma, altered mentation, hypoxia/hypercarbia, hemodynamic instability). Patients with <26days free from mechanical ventilation (ventilator-free days (VFD)) out of 28, were deemed indicated long-term intubations. Those with ≥26 VFD were deemed unnecessary short-term intubations. RESULTS Of 218 patients, 151 had long-term and 67 had short-term intubations. Long-term intubation was strongly associated with ABA criteria (77.5%) compared to traditional criteria (22.5%) (p<0.001). Sensitivity of ABA criteria for long-term intubation was 77% and specificity 46%. Traditional criteria associated with long-term intubation included suspected smoke inhalation (OR 2.45 [95% CI, 1.18-5.11]), and singed facial hair (OR 2.53 [95% CI, 1.25-5.09]). The addition of these to ABA criteria created the Denver criteria, which exhibited an increased sensitivity for long-term intubations (95%), but decreased specificity (24%). CONCLUSIONS Intubation should be considered for patients displaying the Denver criteria, which includes full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper airway trauma, altered mentation, hypoxia/hypercarbia, hemodynamic instability, suspected smoke inhalation, and singed facial hair. Patients lacking these criteria should not be intubated.
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Affiliation(s)
- Jenelle H Badulak
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Michael Schurr
- Mountain Area Health Education Center, Division of General Surgery, 121 Hendersonville Road, Asheville, NC 28803, United States.
| | - Angela Sauaia
- University of Colorado, Department of Surgery, 12631 E. 17th Avenue, C-305, Aurora, CO 80045, United States.
| | - Anna Ivashchenko
- University of Colorado, Department of Surgery, 12631 E. 17th Avenue, C-305, Aurora, CO 80045, United States.
| | - Erik Peltz
- University of Colorado, Department of Surgery, 12631 E. 17th Avenue, C-305, Aurora, CO 80045, United States.
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18
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Comparative Analysis of Early Excision and Grafting vs Delayed Grafting in Burn Patients in a Developing Country. J Burn Care Res 2018; 37:278-82. [PMID: 23816999 DOI: 10.1097/bcr.0b013e31827e4ed6] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The present study attempts to compare how the patients who undergo early excision and grafting behave as compared with patients who are treated along usual conservative lines of management in centers where the resources are less than optimal. The data of 20 female patients were analyzed. Age of the patients ranged between 20 and 30 years, percentage area burn ranged between 20 and 40%, and percentage area resurfaced by skin grafting 5 to 10%. The patients were divided into two groups of 10 patients each. Group I included those patients who underwent early excision and grafting within 5 days of burn injury. Group II included those patients who were treated conservatively and the residual raw area was grafted 3 weeks or more after sustaining the burn. The two groups were compared for the amount of blood loss, transfusion requirement, graft take, and the total hospital stay. Statistical significance was tested by the application of Mann-Whitney U test. The mean percentage area burn was 29.1 ± 5.6% in group I and 24.7 ± 4.9% in group II. Mean percentage area resurfaced by skin grafting in group I was 9.4 ± 2.3% and 8.1 ± 1.6% in group II. Graft take in group I was 90 ± 7.8%, whereas that in group II was 95 ± 6.7%. Mean blood loss in group I and group II was 346 ± 17.6 ml and 241 ± 14.7 ml respectively. (P = .001). Mean transfusion requirement in the perioperative period was 1.6 pints in group I and 1.1 pints in group II. The mean hospital stay in the patients who underwent early excision and grafting was 15.1 ± 4.1 days, whereas that in the patients who underwent delayed grafting was 36.2 ± 6.3 days (P = .001). Early excision and grafting decreases the hospital stay of burn patients. The present study suggests that it has a definite applicability even in places where the resources might be less than optimal.
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19
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Hill DM, Sinclair SE, Hickerson WL. Rational Selection and Use of Antimicrobials in Patients with Burn Injuries. Clin Plast Surg 2017; 44:521-534. [DOI: 10.1016/j.cps.2017.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Hodgman EI, Subramanian M, Arnoldo BD, Phelan HA, Wolf SE. Future Therapies in Burn Resuscitation. Crit Care Clin 2017; 32:611-9. [PMID: 27600132 DOI: 10.1016/j.ccc.2016.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Since the 1940s, the resuscitation of burn patients has evolved with dramatic improvements in mortality. The most significant achievement remains the creation and adoption of formulae to calculate estimated fluid requirements to guide resuscitation. Modalities to attenuate the hypermetabolic phase of injury include pharmacologic agents, early enteral nutrition, and the aggressive approach of early excision of large injuries. Recent investigations into the genomic response to severe burns and the application of computer-based decision support tools will likely guide future resuscitation, with the goal of further reducing mortality and morbidity, and improving functional and quality of life outcomes.
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Affiliation(s)
- Erica I Hodgman
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA
| | - Madhu Subramanian
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA
| | - Brett D Arnoldo
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA
| | - Herb A Phelan
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA
| | - Steven E Wolf
- Division of Burns, Trauma, and Critical Care, Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9158, USA.
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21
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Tay KSV, Chong SJ, Tan BK. Impact of a Newly Implemented Burn Protocol on Surgically Managed Partial Thickness Burns at a Specialized Burns Center in Singapore. Ann Plast Surg 2016; 76:276-9. [DOI: 10.1097/sap.0000000000000682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Hardwicke J. The influence of outcomes on the provision and practice of burn care. Burns 2016; 42:307-15. [DOI: 10.1016/j.burns.2015.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/06/2015] [Indexed: 01/10/2023]
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23
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Duke JM, Boyd JH, Randall SM, Wood FM. Long term mortality in a population-based cohort of adolescents, and young and middle-aged adults with burn injury in Western Australia: A 33-year study. ACCIDENT; ANALYSIS AND PREVENTION 2015; 85:118-124. [PMID: 26432064 DOI: 10.1016/j.aap.2015.09.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 06/03/2015] [Accepted: 09/13/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Advances in the treatment and management of burn patients over the past decades have resulted in a decline of in-hospital mortality rates. Current estimates of burn-related mortality are usually in the context of deaths occurring during the admission or within a short time period after the incident burn. Limited data are available that examine long term mortality after burn injury. This study aimed to assess the impact of burn injury on long-term mortality and quantify any increased risk of death attributable to burn injury. METHODS A population-based cohort study of persons 15-44 years of age hospitalised for burn injury (n=14,559) in Western Australia (1980-2012) and a matched non-injured comparison group (n=56,822) using linked health administrative data was used. Hospital morbidity and death data were obtained from the Western Australian Hospital Morbidity Data System and Death Register. De-identified extraction of all linked hospital morbidity and death records for the period 1980-2012 were provided by the Western Australian Data Linkage System. Survival analysis was conducted using the Kaplan-Meier method and Cox proportional hazards modelling. RESULTS The adjusted all-cause Mortality Rate Ratio (MRR) for burn injury was 1.8 (95%CI: 1.7-2.0); those with burn injury had a 1.8 times greater rate of mortality than those with no injury. The index burn injury was estimated to account for 44% of all recorded deaths in the burn injury cohort during the study period after discharge. Increased risk of mortality was observed for both severe (MRR, 95%CI: 1.9, 1.3-2.9) and minor (MRR, 95%CI: 2.5, 2.2-3.0) burns. CONCLUSIONS An increased risk of long-term all-cause mortality is associated with both minor and severe burn injury. Estimates of total mortality burden based on the early in-patient period alone, significantly underestimates the true burden of burn injury in adolescents, and young and middle aged adults. These results have significant implications for burn injury prevention.
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Affiliation(s)
- Janine M Duke
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Western Australia, Perth, Australia.
| | - James H Boyd
- Population Health Research Network, Centre for Data Linkage, Curtin University, Western Australia, Perth, Australia
| | - Sean M Randall
- Population Health Research Network, Centre for Data Linkage, Curtin University, Western Australia, Perth, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Western Australia, Perth, Australia; Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Western Australia, Perth, Australia
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Abstract
Marked expansion of physiologic understanding and the improvement of burn patient outcomes have resulted from multidisciplinary clinical/laboratory research programs at burn centers in the United States and elsewhere.
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Affiliation(s)
- Basil A Pruitt
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Building 3611, JBSA, Fort Sam Houston, TX 78234-6315, USA.
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25
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Wolf SE, Tompkins RG, Herndon DN. On the horizon: research priorities in burns for the next decade. Surg Clin North Am 2014; 94:917-30. [PMID: 25085097 DOI: 10.1016/j.suc.2014.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This review demonstrates that many advances have been made in burn care that have made dramatic differences in mortality, clinical outcomes, and quality of life in burn survivors; however, much work remains. In reality, the current standard of care is insufficient and we cannot be satisfied with the status quo. We must strive for the following goals: no deaths due to burn, no scarring, and no pain. These particular goals have only begun to be confronted.
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Affiliation(s)
- Steven E Wolf
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines, Dallas, TX 75390-9158, USA.
| | - Ronald G Tompkins
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, 301 University, Galveston, TX 77550, USA
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26
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Hussain A, Choukairi F, Dunn K. Predicting survival in thermal injury: A systematic review of methodology of composite prediction models. Burns 2013; 39:835-50. [DOI: 10.1016/j.burns.2012.12.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 11/13/2012] [Accepted: 12/06/2012] [Indexed: 12/26/2022]
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27
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Cohen MJ. Towards hemostatic resuscitation: the changing understanding of acute traumatic biology, massive bleeding, and damage-control resuscitation. Surg Clin North Am 2012; 92:877-91, viii. [PMID: 22850152 DOI: 10.1016/j.suc.2012.06.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
During the past decade there has been a profound change in the understanding of postinjury coagulation. Concurrently, new data suggest that a resuscitative strategy to minimize large volumes of crystalloid while recreating whole is associated with reduced morbidity and mortality. This article outlines the history of resuscitation and transfusion practices in trauma, the changing understanding of coagulation and inflammation, and clinical data driving changes in resuscitative conduct. Finally, the current state of the science suggests future basic science and clinical investigation that will drive changes in transfusion and resuscitation in severely injured military personnel and civilian patients.
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Affiliation(s)
- Mitchell Jay Cohen
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA.
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28
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Forster NA, Zingg M, Haile SR, Künzi W, Giovanoli P, Guggenheim M. 30 years later—Does the ABSI need revision? Burns 2011; 37:958-63. [DOI: 10.1016/j.burns.2011.03.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 03/10/2011] [Accepted: 03/18/2011] [Indexed: 10/18/2022]
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29
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Kamolz LP. Burns: learning from the past in order to be fit for the future. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:106. [PMID: 20236479 PMCID: PMC2875484 DOI: 10.1186/cc8192] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Many advances have been made in the understanding and treatment of burns. Advances in burn surgery and critical care have decreased mortality and morbidity. Survival from severe burns is no longer the exception, but unfortunately death still occurs. Williams and colleagues have determined in their recent paper the predominant causes of death in order to develop new treatment avenues and future trajectories suitable to increase survival and overall outcome. A lot of burn deaths may be preventable with better airway management and a more precise and adequate volume management, but the leading cause of death in patients suffering from severe burns, which has to be faced, is sepsis. Sepsis due to multidrug-resistant organisms will continue to impede efforts to increase survival, and new strategies that go beyond the surgical and clinical techniques, which are already implemented, have to be developed in order to fight these organisms and their related complications.
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