Cost-effectiveness of adjunctive negative pressure wound therapy in paediatric burn care: evidence from the SONATA in C randomised controlled trial

Barriers and co-designed strategies for the implementation of negative pressure wound therapy in acute pediatric burn care in Australia: A mixed method study

PURPOSE

Pediatric burn injuries are a global clinical issue causing significant morbidity. Early adjunctive negative pressure wound therapy improves re-epithelialization rates in children with burns, yet adoption in acute burn care is inconsistent. This investigation aimed to determine barriers to the implementation of adjunctive negative pressure wound therapy for the acute management of pediatric burns and co-design targeted implementation strategies.

METHODS

A sequential mixed methods design was used explore barriers to adjunctive negative pressure wound therapy implementation in acute pediatric burn care. An online questionnaire was disseminated to healthcare professionals within four major Australian pediatric hospitals, each with a dedicated burns service. Barriers were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews with senior clinicians tailored implementation strategies to local contexts. A stakeholder consensus meeting consolidated implementation strategies and local processes.

RESULTS

Sixty-three healthcare professionals participated in the questionnaire, and semi-structured interviews involved nine senior burn clinicians. We identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change, patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies, intervention complexity, and poor implementation planning.

CONCLUSION

Multiple contextual factors affect negative pressure wound therapy uptake in acute pediatric burn settings. Results will inform a multi-state stepped-wedge cluster randomized controlled trial. Additional resources, education, training, updated policies, and guidelines are required for successful implementation. It is anticipated that adjunctive negative pressure wound therapy, in conjunction with tailored implementation strategies, will enhance adoption and sustainability.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12622000166774. Registered 1 February 2022.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Accelerated Burn Healing in a Mouse Experimental Model Using α-Gal Nanoparticles

Macrophages play a pivotal role in the process of healing burns. One of the major risks in the course of burn healing, in the absence of regenerating epidermis, is infections, which greatly contribute to morbidity and mortality in such patients. Therefore, it is widely agreed that accelerating the recruitment of macrophages into burns may contribute to faster regeneration of the epidermis, thus decreasing the risk of infections. This review describes a unique method for the rapid recruitment of macrophages into burns and the activation of these macrophages to mediate accelerated regrowth of the epidermis and healing of burns. The method is based on the application of bio-degradable "α-gal" nanoparticles to burns. These nanoparticles present multiple α-gal epitopes (Galα1-3Galβ1-4GlcNAc-R), which bind the abundant natural anti-Gal antibody that constitutes ~1% of immunoglobulins in humans. Anti-Gal/α-gal nanoparticle interaction activates the complement system, resulting in localized production of the complement cleavage peptides C5a and C3a, which are highly effective chemotactic factors for monocyte-derived macrophages. The macrophages recruited into the α-gal nanoparticle-treated burns are activated following interaction between the Fc portion of anti-Gal coating the nanoparticles and the multiple Fc receptors on macrophage cell membranes. The activated macrophages secrete a variety of cytokines/growth factors that accelerate the regrowth of the epidermis and regeneration of the injured skin, thereby cutting the healing time by half. Studies on the healing of thermal injuries in the skin of anti-Gal-producing mice demonstrated a much faster recruitment of macrophages into burns treated with α-gal nanoparticles than in control burns treated with saline and healing of the burns within 6 days, whereas healing of control burns took ~12 days. α-Gal nanoparticles are non-toxic and do not cause chronic granulomas. These findings suggest that α-gal nanoparticles treatment may harness anti-Gal for inducing similar accelerated burn healing effects also in humans.

Prophylactic effect of negative‐pressure wound therapy and delayed sutures against incisional‐surgical site infection after emergency laparotomy for colorectal perforation: A multicenter retrospective cohort study

Aim

The prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after highly contaminated laparotomies has not been sufficiently explored. This study aimed to evaluate the prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after emergency surgery for colorectal perforation.

Methods

This nationwide, multicenter, retrospective cohort study analyzed data from the 48 emergency hospitals certificated by the Japanese Society for Abdominal Emergency Medicine. Patients who underwent an emergency laparotomy for colorectal perforation between April 2015 and March 2020 were included in this study. Outcomes, including the incidence of incisional surgical site infection, were compared between patients who were treated with prophylactic negative-pressure wound therapy and delayed sutures (i.e., negative-pressure wound therapy group) and patients who were treated with regular wound management (i.e., control group) using 1:4 propensity score matching analysis.

Results

The negative-pressure wound therapy group comprised 88 patients, whereas the control group consisted of 1535 patients. Of them, 82 propensity score-matched pairs (negative-pressure wound therapy group: 82; control group: 328) were evaluated. The negative-pressure wound therapy group showed a lower incidence of incisional surgical site infection [18 (22.0%) in the negative-pressure wound therapy group and 115 (35.0%) in the control group, odds ratio, 0.52; 95% confidence interval, 0.30 to 0.92; p = 0.026].

Conclusions

The prophylactic use of negative-pressure wound therapy with delayed sutures was associated with a lower incidence of incisional surgical site infection after emergency surgery for colorectal perforation.

Cost-effectiveness of scar management post-burn: a trial-based economic evaluation of three intervention models

Optimal burn scar management has the potential to markedly improve the lives of children, but can require substantial healthcare resources. The study aimed to examine the cost-effectiveness of three scar management interventions: pressure garment; topical silicone gel; combined pressure garment and topical silicone gel therapy, alongside a randomised controlled trial of these interventions. Participants were children (n = 153) referred for burn scar management following grafting, spontaneous healing after acute burn injury, or reconstructive surgery. Healthcare resource use was costed from a health service perspective (6-months post-burn time-horizon). The mean total scar management cost was lowest in the topical silicone gel group ($382.87 (95% CI $337.72, $443.29)) compared to the pressure garment ($1327.02 (95% CI $1081.46, $1659.95)) and combined intervention $1605.97 ($1077.65, $2694.23)) groups. There were no significant between-group differences in Quality Adjusted Life Year estimates. There was a 70% probability that topical silicone gel dominated pressure garment therapy (was cheaper and more effective), a 29% probability that pressure garment therapy dominated combined therapy, and a 63% probability that topical silicone gel dominated combined therapy. In conclusion, topical silicone gel was the cheaper intervention, and may be favoured in the absence of clear clinical effect favouring pressure garment therapy or a combination of these management approaches.Trial registration: ACTRN12616001100482 (prospectively registered).

Ionic complexation improves wound healing in deep second-degree burns and reduces in-vitro ciprofloxacin cytotoxicity in fibroblasts

The development of new treatments capable of controlling infections and pain related to burns continues to be a challenge. Antimicrobials are necessary tools, but these can be cytotoxic for regenerating cells. In this study, antibiotic-anesthetic (AA) smart systems obtained by ionic complexation of polyelectrolytes with ciprofloxacin and lidocaine were obtained as films and hydrogels. Ionic complexation with sodium alginate and hyaluronate decreased cytotoxicity of ciprofloxacin above 70% in a primary culture of isolated fibroblasts (p < 0.05). In addition, the relative levels of the proteins involved in cell migration, integrin β1 and p-FAK, increased above 1.5 times (p < 0.05) with no significant differences in cell mobility. Evaluation of the systems in a deep second-degree burn model revealed that reepithelization rate was AA-films = AA-hydrogels > control films > no treated > reference cream (silver sulfadiazine cream). In addition, appendage conservation and complete dermis organization were achieved in AA-films and AA-hydrogels. Encouragingly, both the films and the hydrogels showed a significantly superior performance compared to the reference treatment. This work highlights the great potential of this smart system as an attractive dressing for burns, which surpasses currently available treatments.

The early association of water irrigation with negative pressure wound therapy does not more efficiently reduce the depth of the alkali infiltration progress into the burn

Water irrigation is an efficacious decontaminating method for dermis exposures to corrosive agents and hence has been widely applied to treat especially alkali burns. Nevertheless, once alkali has infiltrated the deep subcutaneous tissue, washing the tissue surface with water irrigation does not attenuate the damage progress. Therefore, significant efforts have been devoted to promising strategies aimed at removing the deeply infiltrated lye. According to a recent report, the negative pressure wound therapy (NPWT) reduces the pH value of the exudate from alkali-provoked burns thus accelerating wound healing. However, it remains to be ascertained whether or not NPWT coupled with water irrigation, that is, iNPWT, more effectively hinders the alkali injury deepening. In this study, we compared the effectiveness of an early application of water irrigation with or without NPWT in preventing the progressive deepening of the alkali burn in an animal model. Our histological examination results showed no appreciable difference in tissue injury depth, dermal retention, inflammatory cell infiltration, re-epithelization, and cellular function between iNPWT and water irrigation alone treatments. Thus, our results prove that the more expensive NPWT coupled with water irrigation does not more effectively hinder the alkali's injury deepening. Hence, iNPWT use should be more cautious in clinical practice.

Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft

Reported advantages of early excision for larger burn injuries include reduced morbidity, mortality, and hospital length of stay for adult burn patients. However, a paucity of evidence supports the best option for paediatric burns and the advantages of non-excisional (mechanical) debridement. Procedural sedation and analgesia in the emergency department is a popular alternative to debridement in operating theatres under general anaesthesia. This study aims to evaluate the association between early (< 24 h post-injury) non-excisional debridement under general anaesthesia with burn wound re-epithelialisation time and skin graft requirements. Cohort study of children younger than 17 years who presented with burns of five percent total body surface area or greater. Data from January 2013 to December 2019 were extracted from a prospectively collected state-wide paediatric burns' registry. Time to re-epithelialisation was tested using survival analysis, and binary logistic regression for odds of skin graft requirementto analyse effects of early non-excisional debridement in the operating theatre. Overall, 292 children met eligibility (males 55.5%). Early non-excisional debridement under general anaesthesia in the operating theatre, significantly reduced the time to re-epithelialisation (14 days versus 21 days, p = 0.029)) and the odds of requiring a skin graft in comparison to paediatric patients debrided in the emergency department under Ketamine sedation (OR: 6.97 (2.14-22.67), p < 0.001. This study is the first to demonstrate that early non-excisional debridement under general anaesthesia in the operating theatre significantly reduces wound re-epithelialisation time and subsequent need for a skin graft in paediatric burn patients. Analysis suggests that ketamine procedural sedation and analgesia in the emergency department used for burn wound debridement is not an effective substitute for debridement in the operating theatre.

Combination of Three Different Negative Pressure Wound Therapy Applications and Free Flap for Open Elbow Joint Injury With Extensive Burns

Negative pressure wound therapy (NPWT) for treating burns has a variety of therapeutic applications. Here, we present a case of a 53-year-old woman with self-inflicted burn injuries in whom NPWT was applied for three different purposes. The injured sites were the anterior neck, bilateral arms from the wrists upwards to the chest, and back. The left arm was deeply injured, and the elbow joint cavity was opened during treatment. First, NPWT was used for bridge to skin grafting on the entire upper left limb. Second, NPWT was used as a bolster dressing for the autograft after skin grafting was performed on the left arm except the open part of the joint. Third, NPWT over flap was used on the subsequent flap surgical site to address prolonged exudate from the flap margin. The exudate resolved after about a week. Good results were obtained using NPWT during the perioperative period of free flap transplantation for extensive open elbow joint burns. The use of NPWT is an effective option in the treatment of burns.