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Panayi AC, Heyland DK, Stoppe C, Jeschke MG, Didzun O, Matar D, Tapking C, Palackic A, Bliesener B, Harhaus L, Knoedler S, Haug V, Bigdeli AK, Kneser U, Orgill DP, Hundeshagen G. The long-term intercorrelation between post-burn pain, anxiety, and depression: a post hoc analysis of the "RE-ENERGIZE" double-blind, randomized, multicenter placebo-controlled trial. Crit Care 2024; 28:95. [PMID: 38519972 PMCID: PMC10958907 DOI: 10.1186/s13054-024-04873-8] [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: 01/27/2024] [Accepted: 03/14/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Despite the growing prevalence of burn survivors, a gap persists in our understanding of the correlation between acute burn trauma and the long-term impact on psychosocial health. This study set out to investigate the prevalence of long-term pain and symptoms of anxiety and depression in survivors of extensive burns, comparing this to the general population, and identify injury and demographic-related factors predisposing individuals to psychosocial compromise. METHODS RE-ENERGIZE was an international, double-blinded, randomized-controlled trial that enrolled 1200 patients with partial- or full-thickness burns that required surgical treatment. For the post hoc analysis, we excluded participants who did not complete the Short Form Health Survey (SF-36) questionnaire. Normative data were taken from the 2021 National Health Interview Survey dataset. Propensity score matching was performed using the nearest-neighbor 1-to-1 method, and the two cohorts were compared in terms of chronic pain, and symptoms of anxiety and depression. A multivariable analysis was performed on the burns cohort to identify factors predicting post-discharge pain and symptoms of anxiety and depression. RESULTS A total of 600 burn patients and 26,666 general population adults were included in this study. Following propensity score matching, both groups comprised 478 participants each, who were predominately male, white, overweight and between 20 and 60 years old. Compared to the general population, burn patients were significantly more likely to report the presence of moderate and a lot of pain (p = 0.002). Symptoms of anxiety were significantly higher in the burn population in two of four levels (most of the time; some of the time; p < 0.0001 for both). Responders in the burn population were significantly less likely to report the absence of depressive symptoms (p < 0.0001). Burn patients were also significantly more likely to report that their mental health affects their social life. TBSA, history of depression, and female sex were identified as independently associated factors for pain, anxiety, and depressive symptoms. The presence of chronic pain and anxiety symptoms independently predicted for symptoms of depression. CONCLUSIONS Analyzing the largest multicenter cohort of patients with extensive burns, we find that burn injury is associated with chronic pain, and symptoms of anxiety and depression. In addition, TBSA-burned and history of depression directly correlate with the prevalence of chronic pain, and symptoms of anxiety and depression. Finally, pain, and symptoms of anxiety and depression are interrelated and may have interactive effects on the process of recovery following burn injury. Burn patients would, therefore, benefit from a multidisciplinary team approach with early mobilization of pain and mental health experts, in order to promptly prevent the development of psychosocial challenges and their consequences.
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Affiliation(s)
- Adriana C Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Würzburg, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Marc G Jeschke
- Hamilton Health Sciences Research, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Oliver Didzun
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Dany Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian Tapking
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Alen Palackic
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Björn Bliesener
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Leila Harhaus
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Amir K Bigdeli
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany.
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Ji S, Xiao S, Xia Z. Consensus on the treatment of second-degree burn wounds (2024 edition). BURNS & TRAUMA 2024; 12:tkad061. [PMID: 38343901 PMCID: PMC10858447 DOI: 10.1093/burnst/tkad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/29/2023] [Accepted: 12/08/2023] [Indexed: 02/21/2024]
Abstract
Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.
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Affiliation(s)
- Shizhao Ji
- Correspondence: Shizhao Ji, ; Shichu Xiao, ; Zhaofan Xia,
| | - Shichu Xiao
- Correspondence: Shizhao Ji, ; Shichu Xiao, ; Zhaofan Xia,
| | - Zhaofan Xia
- Correspondence: Shizhao Ji, ; Shichu Xiao, ; Zhaofan Xia,
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Kuvvet Yoldaş T, Atalay A, Demirağ K, Uyar M, Çankayalı İ. Changes in Energy Expenditure Determined by Indirect Calorimetry in Severe Burn Patients During the Acute Phase. Cureus 2023; 15:e46705. [PMID: 37818121 PMCID: PMC10560960 DOI: 10.7759/cureus.46705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Severe burn injuries are a major health problem globally. A profound and prolonged hypermetabolic response develops in severe burn injuries and it is crucial to monitor the patients' energy requirements in order to meet them adequately. The aim of the present study was to examine the energy changes during the acute phase using the indirect calorimetry (IC) method in severe burn patients. METHODS The study included 15 severe burn patients. Patients with FiO2 >60%, tube thoracostomy, closed underwater drain (CUWD) and air leakage were excluded from the study. Patients' demographic data, burn percentages, burn types, duration of stay in intensive care, mortality and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were recorded. Indirect calorimeter measurements were taken once from the patients upon their first arrival and during the following four weeks. Resting energy expenditure (REE), basal metabolic rate (BMR), oxygen consumption (VO₂), carbon dioxide production (VCO₂), body temperatures, presence of sepsis, Sequential Organ Failure Assessment (SOFA) and Modified Nutrition Risk in Critically Ill (mNUTRIC) scores were recorded. The data were analysed using SPSS 24 and p-values <0.05 were considered statistically significant. RESULTS In the study, 13 (86.67%) of the patients were male. Patients' mean age was 45.27±18.16 years, and mean BMI 25.99±4.22 kg/m2. Five patients (33.33%) had chronic diseases. The average burn percentage was 45%, with 7 (46.67%) patients having a burn percentage of ≤40%, while 8 (53.33%) had a burn percentage of >40%. A total of 14 (93.33%) had flame burns; 3 (20.00%) patients deceased, and 12 (80.00%) were discharged. The mean APACHE II score was 11.53±6.83. The measured mean values of REE, VO₂, VCO₂ and fever were seen to be the highest in the first week after admission and decreases were observed in the subsequent weeks. SOFA score averages were the highest at admission, and decreased in the following weeks. CONCLUSION Severe burn patients were observed to go through the hypermetabolic process in the acute phase and their energy requirements were high particularly in the first week. It was concluded that regular IC monitoring can be beneficial to fully meet the energy requirements of severe burn patients due to the prolonged hypermetabolic process.
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Affiliation(s)
- Tuba Kuvvet Yoldaş
- Clinic of Anesthesiology and Reanimation, University of Health Sciences, Tepecik Education and Research Hospital, İzmir, TUR
| | - Alev Atalay
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ege University, İzmir, TUR
| | - Kubilay Demirağ
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ege University, İzmir, TUR
| | - Mehmet Uyar
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ege University, İzmir, TUR
| | - İlkin Çankayalı
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ege University, İzmir, TUR
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Shah NR, Palackic A, Brondeel KC, Walters ET, Wolf SE. The Burn Wound. Surg Clin North Am 2023; 103:453-462. [PMID: 37149381 DOI: 10.1016/j.suc.2023.01.007] [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: 05/08/2023]
Abstract
Skin serves as a protective barrier against infection, prevents excessive fluid and electrolyte losses, performs crucial thermoregulation, and provides tactile feedback of surroundings. The skin also plays an essential role in human perception of body image, personal appearance, and self-confidence. With these many diverse functions, understanding normal anatomic composition of skin is pivotal to evaluating the extent of its disruption from burn injury. This article discusses the pathophysiology, initial evaluation, subsequent progression, and healing of burn wounds. By delineating the various microcellular and macrocellular alterations of burn injury, this review also augments providers' capacity to deliver patient-centered, evidence-based burn care.
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Affiliation(s)
- Nikhil R Shah
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Alen Palackic
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Kimberley C Brondeel
- John Sealy School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Elliot T Walters
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
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Kopel J, Sorensen G, Griswold J. A Reappraisal of Oxandrolone in Burn Management. J Pharm Technol 2022; 38:232-238. [PMID: 35832568 PMCID: PMC9272491 DOI: 10.1177/87551225221091115] [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: 11/16/2022] Open
Abstract
Objective: Burn injuries remain among the most severe traumatic injuries globally. With the discovery of cortisol, the use of steroids has become an essential therapy for the management of inflammatory and metabolic conditions. Several studies have shown the steroid oxandrolone improves burn injuries through stimulating anabolic and reducing catabolic processes. In this review, we examine the efficacy and applications of oxandrolone with regard to burn management and treatment. Data Sources: A literature search was performed using the PubMed database from January 1990 to May 2020 to identify articles on oxandrolone and burn management. A total of 18 studies were included in our review. Study Selection and Criteria: The keywords used in our search strategy for PubMed included "oxandrolone" and "burns." Data Synthesis: The main benefit of oxandrolone is the improved long-term lean body, protein, and bone mineral mass of burn patients. In addition, 3 separate meta-analyses showed oxandrolone shortened length of hospital stay, donor-site healing time, reduced weight loss, and net protein loss. However, oxandrolone therapy did not affect mortality, infection, or liver function. Conclusion: Oxandrolone remains an effective therapy for reducing the hypermetabolic response and comorbidities from burn injuries. Future clinical trials are needed using larger sample sizes and long-term follow-up to determine whether oxandrolone in the context of rehabilitation programs can reduce mortality, lower treatment costs, and improve function outcomes among burn patients.
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Affiliation(s)
- Jonathan Kopel
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
| | - Grant Sorensen
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
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Nutritional Support with Omega-3 Fatty Acids in Burn Patients: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Nutrients 2022; 14:nu14142874. [PMID: 35889830 PMCID: PMC9320673 DOI: 10.3390/nu14142874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022] Open
Abstract
Background: In burn patients, the profound effect of nutritional support on improved wound healing and a reduced rate of hospitalization and mortality has been documented. Fish oil as a primary source of omega-3 fatty acids in nutritional support may attenuate the inflammatory response and enhance immune function; however, unclear effects on the improvement of clinical outcomes in burn patients remain. Methods: The systematic literature review was conducted by searching the electronic databases: Cochrane Library, PubMed, ScienceDirect, and Scopus to assess the randomized controlled trials of nutritional support with omega-3 fatty acids compared to control diets in patients that presented with burns from any causes. Results: Seven trials were included in this meta-analysis. We found no significant differences in length of stay (LOS) (p = 0.59), mortality (p = 0.86), ventilation days (p = 0.16), gastrointestinal complications—e.g., constipation and diarrhea (p = 0.73)—or infectious complications—e.g., pneumonia and sepsis (p = 0.22)—between the omega-3-fatty-acid-receiving group and the control/other diets group. Conclusions: We did not find a benefit of omega-3 support in reducing the various complications, mortality and LOS in burn patients. Further studies are necessary to find the effect of nutritional support with omega-3 fatty acids over low-fat diets in this population.
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7
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Calum H, Trøstrup H, Laulund AS, Thomsen K, Christophersen L, Høiby N, Moser C. Murine burn lesion model for studying acute and chronic wound infections. APMIS 2022; 130:477-490. [PMID: 35441434 DOI: 10.1111/apm.13228] [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] [Received: 03/05/2021] [Accepted: 04/13/2022] [Indexed: 02/05/2023]
Abstract
Acute wounds, such as thermal injury, and chronic wounds are challenging for patients and the healthcare system around the world. Thermal injury of considerable size induces immunosuppression, which renders the patient susceptible to wound infections, but also in other foci like the airways and urinary tract. Infected thermal lesions can progress to chronic wounds with biofilm making them more difficult to treat. While animal models have their limitations, murine wound models are still the best tool at the moment to identify strategies to overcome these challenges. Here, we present a murine burn model, which has been developed to study biofilm formation, the significance of wound healing, and for identifying novel treatment candidates. Investigating the effect of a thermal injury in mice, we observed that 48 h after introduction of the injury, the mice showed a reduction in polymorphonuclear neutrophil granulocytes (PMNs) and a reduced capacity for phagocytosis and oxidative burst. Regarding the chronic wound, Pseudomonas aeruginosa biofilm arrested wound healing and kept the wound in an inflammatory state, but suppressing PMN function by means of the PMN factor S100A8/A9, corresponding to observations in human venous leg ulcers. Monotherapy and dual treatment with S100A8/A9 and ciprofloxacin on P. aeruginosa biofilm-infected murine wounds have been investigated. In combination, S100A8/A9 and ciprofloxacin reduced the bacterial quantity, lowered the proinflammatory response, and increased anti-inflammatory cytokines after 4 days of treatment. When the treatment was prolonged, an additional prevention of resistance development was detected in all the dual-treated mice. In the present review, we provide data on using the murine model for research with the aim of better understanding pathophysiology of wounds and for identifying novel treatments for humans suffering from these lesions.
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Affiliation(s)
- Henrik Calum
- Department of Clinical Microbiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hannah Trøstrup
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Sofie Laulund
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kim Thomsen
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Christophersen
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Immunology and Microbiology (ISIM), University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
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Lagziel T, Akhavan AA, Yoon JS, Martinez SL, Cox CA, Duraes EFR, Hultman CS, Caffrey J. Carry That Weight! The Challenge of Managing Weight Changes During Inpatient Admission for Patients With Burn Injuries ≥20% TBSA. J Burn Care Res 2022; 43:781-786. [DOI: 10.1093/jbcr/irac054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
The hypermetabolic state of patients with ≥20% total body surface area (TBSA) causes loss of muscle mass and compromised immune function with delayed wound healing. Weight loss is most severe in patients with ≥20% TBSA with initial weight gain due to fluid resuscitation. The American Burn Association (ABA) proposed quality measures for burn injury admissions, including weight loss from admission to discharge. We assessed how our outcomes adhere to these measures and if they correlate with previously described results. We retrospectively reviewed adult admissions with ≥20% TBSA burn injuries from 2016 to 2021. Four groups were established based on %TBSA: 20% to 29% (Group 1), 30% to 39% (Group 2), 40% to 59% (Group 3), and ≥60% (Group 4). We assessed weight changes from admission to discharge and performed multivariate analyses to account for age, sex, total surgeries, and length of stay. Data from 123 patients revealed 40 with 20% to 29% TBSA, 29 with 30% to 39% TBSA, 33 with 40% to 59% TBSA, 21 with ≥60% TBSA. A significant difference in weight loss was observed when comparing Groups 1 and 2 and Groups 3 and 4 (Group 1: −3.63%, Group 2: −2%, Group 3: −9.28%, Group 4: −13.85%; P-value ≤ .05). Groups 3 and 4 had significantly longer lengths of stay compared to Groups 1 and 2 (Group 1: 32.16, Group 2: 37.5, Group 3: 71.13, Group 4: 87.18; P-value ≤ .01). Most patients that experienced weight loss during their admission had <15% weight loss. We found no significant difference in outcomes for patients receiving oxandrolone vs not. The mean weight change was −11% for patients with an overall weight loss and +5% for patients with an overall weight gain. The significant difference between the two groups was admission body mass index (BMI; loss: 30.4 kg/m2, gain: 26.0 kg/m2; P-value ≤ .05). Patients with ≥20% TBSA suffer weight changes, likely due to metabolic disturbances. Increased length of stay and higher %TBSA may be associated with greater weight loss. Patients experiencing weight gain had lower admission BMI suggesting that patients with higher BMI are more prone to weight loss. Our findings support that patients with %TBSA ≥40 are unique, requiring specialized nutritional protocols and metabolic analysis.
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Affiliation(s)
- Tomer Lagziel
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arya A Akhavan
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua S Yoon
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of General Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Stephanie L Martinez
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carrie A Cox
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eliana F R Duraes
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles Scott Hultman
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julie Caffrey
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Review of History of Basic Principles of Burn Wound Management. Medicina (B Aires) 2022; 58:medicina58030400. [PMID: 35334576 PMCID: PMC8954035 DOI: 10.3390/medicina58030400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 01/09/2023] Open
Abstract
Thermal energy is an essential and useful resource to humans in modern society. However, a consequence of using heat carelessly is burns. Burn injuries have various causes, such as exposure to flame, radiation, electrical, and chemical sources. In this study, we reviewed the history of burn wound care while focusing on the basic principles of burn management. Through this review, we highlight the need for careful monitoring and customization when treating burn victims at each step of wound care, as their individual needs may differ. We also propose that future research should focus on nanotechnology-based skin grafts, as this is a promising area for further improvement in wound care.
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10
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Glucose Metabolism in Burns-What Happens? Int J Mol Sci 2021; 22:ijms22105159. [PMID: 34068151 PMCID: PMC8153015 DOI: 10.3390/ijms22105159] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 11/16/2022] Open
Abstract
Severe burns represent an important challenge for patients and medical teams. They lead to profound metabolic alterations, trigger a systemic inflammatory response, crush the immune defense, impair the function of the heart, lungs, kidneys, liver, etc. The metabolism is shifted towards a hypermetabolic state, and this situation might persist for years after the burn, having deleterious consequences for the patient's health. Severely burned patients lack energy substrates and react in order to produce and maintain augmented levels of glucose, which is the fuel "ready to use" by cells. In this paper, we discuss biological substances that induce a hyperglycemic response, concur to insulin resistance, and determine cell disturbance after a severe burn. We also focus on the most effective agents that provide pharmacological modulations of the changes in glucose metabolism.
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Burmeister DM, Chu GCY, Chao T, Heard TC, Gómez BI, Sousse LE, Natesan S, Christy RJ. ASCs derived from burn patients are more prone to increased oxidative metabolism and reactive oxygen species upon passaging. Stem Cell Res Ther 2021; 12:270. [PMID: 33957963 PMCID: PMC8100366 DOI: 10.1186/s13287-021-02327-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/07/2021] [Indexed: 11/16/2022] Open
Abstract
Background Patients with severe burn injury (over 20% of the total body surface area) experience profound hypermetabolism which significantly prolongs wound healing. Adipose-derived stem cells (ASCs) have been proposed as an attractive solution for treating burn wounds, including the potential for autologous ASC expansion. While subcutaneous adipocytes display an altered metabolic profile post-burn, it is not known if this is the case with the stem cells associated with the adipose tissue. Methods ASCs were isolated from discarded burn skin of severely injured human subjects (BH, n = 6) and unburned subcutaneous adipose tissue of patients undergoing elective abdominoplasty (UH, n = 6) and were analyzed at passages 2, 4, and 6. Flow cytometry was used to quantify ASC cell surface markers CD90, CD105, and CD73. Mitochondrial abundance and reactive oxygen species (ROS) production were determined with MitoTracker Green and MitoSOX Red, respectively, while JC-10 Mitochondrial Membrane Potential Assays were also performed. Mitochondrial respiration and glycolysis were analyzed with a high-resolution respirometer (Seahorse XFe24 Analyzer). Results There was no difference in age between BH and UH (34 ± 6 and 41 ± 4 years, respectively, P = 0.49). While passage 2 ASCs had lower ASC marker expression than subsequent passages, there were no significant differences in the expression between BH and UH ASCs. Similarly, no differences in mitochondrial abundance or membrane potential were found amongst passages or groups. Two-way ANOVA showed a significant effect (P < 0.01) of passaging on mitochondrial ROS production, with increased ROS in BH ASCs at later passages. Oxidative phosphorylation capacities (leak and maximal respiration) increased significantly in BH ASCs (P = 0.035) but not UH ASCs. On the contrary, basal glycolysis significantly decreased in BH ASCs (P = 0.011) with subsequent passaging, but not UH ASCs. Conclusions In conclusion, ASCs from burned individuals become increasingly oxidative and less glycolytic upon passaging when compared to ASCs from unburned patients. This increase in oxidative capacities was associated with ROS production in later passages. While the autologous expansion of ASCs holds great promise for treating burned patients with limited donor sites, the potential negative consequences of using them require further investigation.
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Affiliation(s)
- David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA. .,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, 3698 Chambers Pass, San Antonio, TX, USA.
| | - Grace Chu-Yuan Chu
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, 3698 Chambers Pass, San Antonio, TX, USA
| | - Tony Chao
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Tiffany C Heard
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, 3698 Chambers Pass, San Antonio, TX, USA
| | - Belinda I Gómez
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, 3698 Chambers Pass, San Antonio, TX, USA
| | - Linda E Sousse
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, 3698 Chambers Pass, San Antonio, TX, USA
| | - Shanmugasundaram Natesan
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, 3698 Chambers Pass, San Antonio, TX, USA
| | - Robert J Christy
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, 3698 Chambers Pass, San Antonio, TX, USA
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12
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Osborne T, Edgar D, Gittings P, Wood F, Le Huray T, Allan B, Scott BR, Wall B. A prospective pilot study of the energy balance profiles in acute non-severe burn patients. Burns 2021; 48:184-190. [PMID: 33785242 DOI: 10.1016/j.burns.2021.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/07/2021] [Accepted: 03/05/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Major burn patients have been shown to exhibit a hyper-metabolic state of activity which can persist for up to two years after burn. The relationship between total body surface area (TBSA) and resting metabolic rate (RMR) has been investigated in larger burns (≥20% TBSA), however not in non-severe burns (≤15% TBSA). The primary aim of this observational study was to examine the association between the acute effects of burns <15% TBSA with RMR in patients using indirect calorimetry, as well as any potential covariates. The secondary aim was to determine 24-h energy balance. METHODS The study included data from 39 participants (82% male), all admitted to the State Adult Burn Unit at Fiona Stanley Hospital. Each patient was recruited upon admission and RMR data was collected on day four (± one day) after burn. RESULTS The pooled data bivariate correlation showed a significant relationship between RMR and TBSA (r=0.435, p=0.009). A stronger relationship was also found between RMR and TBSA in males (r=0.634, p=0.001). Patients recorded a caloric deficit of 116kcal/day. CONCLUSION This study demonstrated that a moderately strong linear association exists between RMR and TBSA in males for burns of ≤15% TBSA. The energy balance data indicated that supplementation of calorific intake for non-severe burns suggests careful consideration.
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Affiliation(s)
- Tyler Osborne
- Disciple of Exercise Science, College of Science, Health Engineering and Education, Murdoch University, Perth, Western Australia, Australia; Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Western Australia, Australia
| | - Dale Edgar
- State Adult Burns Unit, Government of Western Australia South Metropolitan Health Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Fiona Wood Foundation, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Burn Injury Research Node, Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia; Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia
| | - Paul Gittings
- State Adult Burns Unit, Government of Western Australia South Metropolitan Health Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Fiona Wood Foundation, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Fiona Wood
- State Adult Burns Unit, Government of Western Australia South Metropolitan Health Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Fiona Wood Foundation, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia.
| | - Thomas Le Huray
- Disciple of Exercise Science, College of Science, Health Engineering and Education, Murdoch University, Perth, Western Australia, Australia
| | - Brodie Allan
- Disciple of Exercise Science, College of Science, Health Engineering and Education, Murdoch University, Perth, Western Australia, Australia
| | - Brendan R Scott
- Disciple of Exercise Science, College of Science, Health Engineering and Education, Murdoch University, Perth, Western Australia, Australia; Murdoch Applied Sports Science Laboratory, Murdoch University, Perth, Western Australia, Australia; Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Western Australia, Australia
| | - Bradley Wall
- Disciple of Exercise Science, College of Science, Health Engineering and Education, Murdoch University, Perth, Western Australia, Australia; Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Western Australia, Australia.
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13
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Zhang C, Chang M, Zhou Z, Yi L, Huang X, Gao C, Guo F, Huan J. Factors Influencing Length of Hospital Stay and Predictors Affecting Probability of Requiring Surgery in Severely Pediatric Burn Patients. J Burn Care Res 2020; 41:1165-1171. [PMID: 32163568 DOI: 10.1093/jbcr/irz202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Although many researches have explored the prognostic factors associated with length of hospital stay (LOS) of adult burn patients, fewer reports concerning pediatric burn patients have been conducted. The present study employed pediatric burn data to identify factors related to LOS and developed a novel model to assess the possibility of requiring surgery. A total of 750 children admitted for burns met the criteria for enrollment. We have analyzed the medical records using multivariable linear regression and logistic regression. The pediatric patients were stratified into medical (nonsurgical) and surgical groups, respectively. The median LOS was 27.11 ± 17.91 days (range: 6-107 days). Following multiple linear regression, surgery (P < .001; 95% confidence interval [CI]: 6.485, 11.918), percent total BSA (%TBSA) (P < .001; 95% CI: 0.271, 0.459), days to surgery (P < .001; 95% CI: 0.349, 0.648), etiology (P < .001; 95% CI: -15.801, -9.422), infection (P < .001; 95% CI: 4.163, 8.329), and erythrocyte loss (P < .001; 95% CI: 1.923, 4.017) were significantly associated with LOS. After logistic regression, the percent full thickness (%FT) (P < .001; odds ratio [OR]: 2.358; 95% CI: 1.680, 3.311), infection (P < .001; OR: 2.935; 95% CI: 2.014, 4.278), and erythrocyte loss (P < .001; OR: 0.572; 95% CI: 0.470, 0.696) within 5 days postadmission were independently related to the probability of requiring surgery. In conclusion, in pediatric patients admitted with burn size of TBSA ≥20%, factors independently influencing LOS were surgery, %TBSA, days to surgery, etiology, erythrocyte loss, and infection. Furthermore, the pivotal predictors of probability requiring surgery were %FT, infection, and erythrocyte loss.
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Affiliation(s)
- Chuankai Zhang
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Mengling Chang
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Zengding Zhou
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Lei Yi
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Xiaoqin Huang
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Chengjin Gao
- Emergency Department, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, China
| | - Feng Guo
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China.,Department of Plastic Surgery, Affiliated Sixth People's Hospital of Shanghai, Shanghai jiaotong University, China
| | - Jingning Huan
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
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14
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Sierp EL, Kurmis R, Lange K, Yandell R, Chapman M, Greenwood J, Chapple LAS. Nutrition and Gastrointestinal Dysmotility in Critically Ill Burn Patients: A Retrospective Observational Study. JPEN J Parenter Enteral Nutr 2020; 45:1052-1060. [PMID: 32767430 DOI: 10.1002/jpen.1979] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/27/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Gastrointestinal (GI) dysmotility impedes nutrient delivery in critically ill patients with major burns. We aimed to quantify the incidence, timing, and factors associated with GI dysmotility and subsequent nutrition delivery. METHODS A 10-year retrospective observational study included mechanically ventilated, adult, critically ill patients with ≥15% total body surface area (TBSA) burns receiving nutrition support. Patients with a single gastric residual volume ≥250 mL were categorized as having GI dysmotility. Daily medical and nutrition data were extracted for ≤14 days in the intensive care unit (ICU). Data are mean (SD) or median (interquartile range). Factors associated with GI dysmotility and the effect on nutrition and clinical outcomes were assessed. RESULTS Fifty-nine patients were eligible; 51% (n = 30) with GI dysmotility and 49% (n = 29) without. Baseline characteristics (dysmotility vs no dysmotility) were age (48 [33-60] vs 34 [26-46] years); Acute Physiology and Chronic Health Evaluation II score (16 [12-17] vs 13 [10-16]); sex ([men] 80% vs 86%); and TBSA (49% [35%-59%] vs 38% [26%-55%]). Older age was associated with increased probability of dysmotility (P = .049). GI dysmotility occurred 32 (19-63) hours after ICU admission but was not associated with reduced nutrient delivery. Postpyloric tube insertions were attempted in 83% (n = 25) of patients, with 72% (n = 18) being successful. Postpyloric feeding achieved higher nutrition adequacy than gastric feeding (energy: 82% [95% CI, 70-94] vs 68% [95% CI, 63-74], P = .036; protein: 75% [95% CI, 65-86] vs 61% [95% CI, 56-65], P = .009). CONCLUSION GI dysmotility occurs early in critically ill burn patients, and postpyloric feeding improves nutrition delivery.
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Affiliation(s)
| | | | - Kylie Lange
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, Australia
| | | | - Marianne Chapman
- Royal Adelaide Hospital, Port Road, Adelaide, Australia.,Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, Australia
| | | | - Lee-Anne S Chapple
- Royal Adelaide Hospital, Port Road, Adelaide, Australia.,Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, Australia
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15
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Abstract
PURPOSE OF REVIEW Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management. This review critically discusses current practices and recently published data regarding the evaluation and management of severe burn injury. RECENT FINDINGS Burn patients have long, complex ICU stays with accompanying multiorgan dysfunction. Recent advances in burn intensive care have focused on acute respiratory distress syndrome from inhalation injury, acute kidney injury (AKI), and transfusion, resulting in new strategies for organ failure, including renal replacement therapy and extracorporeal life support. SUMMARY Initial evaluation and treatment of acute severe burn injury remains an ongoing area of study. This manuscript reviews current practices and considerations in the acute management of the severely burn injured patient.
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16
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Polychronopoulou E, Herndon DN, Porter C. The Long-Term Impact of Severe Burn Trauma on Musculoskeletal Health. J Burn Care Res 2020; 39:869-880. [PMID: 30010999 DOI: 10.1093/jbcr/iry035] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/15/2018] [Indexed: 12/13/2022]
Abstract
Severe burn injury causes a profound stress response that leads to muscle and bone cachexia. Evidence suggests that these deficits persist for several months or even years after injury and are associated with growth delay, increased incidence of fractures, and increased hospital admissions for musculoskeletal disorders. Thus, there is an overwhelming need to determine the optimal acute and rehabilitative strategies to mitigate these deficits and improve quality of life for burn survivors. To date, there is limited research on the long-term impact of cachexia on functional performance and overall health, as well as on the lasting impact of pharmacological, nutritional, and exercise interventions. The aim of this review is to emphasize the long-term consequences of musculoskeletal cachexia and determine the best evidence-based strategies to attenuate it. We also underline important knowledge gaps that need to be addressed in order to improve care of burn survivors.
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Affiliation(s)
- Efstathia Polychronopoulou
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas.,Shriners Hospitals for Children - Galveston, Galveston, Texas
| | - David N Herndon
- Shriners Hospitals for Children - Galveston, Galveston, Texas.,Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Craig Porter
- Shriners Hospitals for Children - Galveston, Galveston, Texas.,Department of Surgery, University of Texas Medical Branch, Galveston, Texas
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17
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Clayton RP, Herndon DN, Abate N, Porter C. The Effect of Burn Trauma on Lipid and Glucose Metabolism: Implications for Insulin Sensitivity. J Burn Care Res 2020; 39:713-723. [PMID: 29931151 DOI: 10.1093/jbcr/irx047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Severe burns represent a unique form of trauma in terms of the magnitude and persistence of the stress response they incur. Given advances in acute burn care in the last quarter of a century and the resultant reduction in mortality rates, even for those with massive burns, greater emphasis is now placed on understanding the metabolic stress response to severe burn trauma in order to devise strategies that promote recovery and reduce morbidity. Derangements in metabolism including protein and lipid redistribution and altered glucose handling are hallmarks of the pathophysiological response to burn trauma. In this review article, we aim to distill and discuss the c urrent literature concerning the effect of burn trauma on lipid and glucose metabolism. Furthermore, we will discuss the implications of altered lipid metabolism with regards to insulin sensitivity and glucose control, while discussing the utility of agents and strategies aimed at restoring normal lipid and glucose metabolism in burned patients.
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Affiliation(s)
- Robert P Clayton
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston
| | - David N Herndon
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston.,Department of Surgery, University of Texas Medical Branch, Galveston
| | - Nicola Abate
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston.,Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Craig Porter
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston
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18
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Chang CK, Bartkova J, Liao YS, Tzeng YS. Successful Treatment of Lower Limb Burn Wounds With Long-Term Survived Human Skin Allograft in an Immunosuppressed Patient: A Case Report. INT J LOW EXTR WOUND 2020; 20:167-171. [PMID: 32037916 DOI: 10.1177/1534734620904566] [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: 11/16/2022]
Abstract
Early excision and autografting have been the principles in managing acute burn wounds. Despite the known benefits of early autografting, there are situations in which the placement of autograft is unsafe or even unavailable. In these clinical situations, skin substitutes like artificial dressings and human skin allografts are considered as useful for temporary wound coverage. We present an immunosuppressed patient with deep lower limb burn wound who received human skin allograft for wound management. The applied human skin allograft persisted for a longer period without infection or rejection and successfully improved her wound healing. Large and well-designed prospective studies are needed to confirm the encouraging results of the present case report.
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Affiliation(s)
- Chun-Kai Chang
- Zouying Branch of Kaohsiung Armed Forces General Hospital, Kaohsiung.,Tri-Service General Hospital, National Defense Medical Center, Taipei
| | | | - Yi-Shu Liao
- Taichung Armed Forces General Hospital, Taichung
| | - Yuan-Sheng Tzeng
- Tri-Service General Hospital, National Defense Medical Center, Taipei
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19
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Sommerhalder C, Blears E, Murton AJ, Porter C, Finnerty C, Herndon DN. Current problems in burn hypermetabolism. Curr Probl Surg 2020; 57:100709. [PMID: 32033707 PMCID: PMC7822219 DOI: 10.1016/j.cpsurg.2019.100709] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/08/2019] [Indexed: 12/29/2022]
Affiliation(s)
| | | | | | - Craig Porter
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
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20
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Valentini M, Seganfredo FB, Fernandes SA. Pediatric enteral nutrition therapy for burn victims: when should it be initiated? Rev Bras Ter Intensiva 2019; 31:393-402. [PMID: 31618360 PMCID: PMC7005954 DOI: 10.5935/0103-507x.20190062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 12/04/2018] [Indexed: 11/20/2022] Open
Abstract
Objective To review the scientific evidence regarding the initiation of enteral nutrition in the pediatric burn population. Methods This study was a systematic review and meta-analysis of randomized clinical trials comparing early enteral nutrition and late enteral nutrition in individuals aged 1 month to 18 years with burns. The MEDLINE/PubMed, Embase and Cochrane Library databases were searched using the terms "burns", "fires", "child nutrition disorders", "nutritional support" and related terms. Results Three articles that included a total of 781 patients were identified. There was no significant difference in the mortality rate between the early and late groups (OR = 0.72, 95%CI = 0.46 - 1.15, p = 0.17). Patients who received early enteral nutrition had a 3.69-day reduction in the length of hospital stay (mean difference = -3.69, 95%CI = -4.11 - -3.27, p < 0.00001). There was a higher incidence of diarrhea and vomiting and decreased intestinal permeability in the early group. This group also presented higher a serum insulin concentration and insulin/glucagon ratio as well as lower caloric deficit and weight loss when compared to the control group. Conclusion Analysis of the different intragroup variables suggests the importance of starting nutritional support early. Considering the number of pediatric burn patients, there is a need for robust studies with greater scientific impact.
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Affiliation(s)
- Mariéle Valentini
- Hospital de Pronto Socorro de Porto Alegre - Porto Alegre (RS), Brasil
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21
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The Role of Mitochondrial Stress in Muscle Wasting Following Severe Burn Trauma. J Burn Care Res 2019; 39:100-108. [PMID: 28448295 DOI: 10.1097/bcr.0000000000000553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/26/2018] [Indexed: 11/26/2022]
Abstract
Increased resting metabolic rate and skeletal muscle wasting are hallmarks of the pathophysiological stress response to severe burn trauma. However, whether these two responses occur independently in burn patients or are in fact related remains unclear. In light of recent evidence demonstrating that increased proteolysis in skeletal muscle of burned patients is accompanied by mitochondrial hypermetabolism, oxidative stress, and protein damage; in this article, we discuss the evidence for a role for the mitochondrion in skeletal muscle wasting following severe burn trauma. In particular, we focus on the role of mitochondrial superoxide production in oxidative stress and subsequent proteolysis, and discuss the role of the mitochondrion as a signaling organelle resulting in protein catabolism in other cellular compartments following severe burn trauma.
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22
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Sunderman CA, Gottschlich MM, Allgeier C, Warden G. Safety and Tolerance of Intraoperative Enteral Nutrition Support in Pediatric Burn Patients. Nutr Clin Pract 2019; 34:728-734. [DOI: 10.1002/ncp.10399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | | | - Chris Allgeier
- Shriner's Hospitals for Children-Cincinnati; Cincinnati Ohio USA
| | - Glenn Warden
- Shriner's Hospitals for Children-Cincinnati; Cincinnati Ohio USA
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23
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Affiliation(s)
- David G Greenhalgh
- From the Shriners Hospitals for Children-Northern California, and the Firefighters Burn Institute Regional Burn Center and the Department of Surgery, University of California, Davis - all in Sacramento
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24
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Anti-IL-6 eluting immunomodulatory biomaterials prolong skin allograft survival. Sci Rep 2019; 9:6535. [PMID: 31024011 PMCID: PMC6484015 DOI: 10.1038/s41598-019-42349-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/26/2019] [Indexed: 12/26/2022] Open
Abstract
A primary goal in the management of burn wounds is early wound closure. The use of skin allografts represents a lifesaving strategy for severe burn patients, but their ultimate rejection limits their potential efficacy and utility. IL-6 is a major pleiotropic cytokine which critically links innate and adaptive immune responses. Here, we devised anti-IL-6 receptor eluting gelatin methacryloyl (GelMA) biomaterials (GelMA/anti-IL-6), which were implanted at the interface between the wound beds and skin allografts. Our visible light crosslinked GelMA/anti-IL-6 immunomodulatory biomaterial (IMB) demonstrated a stable kinetic release profile of anti-IL-6. In addition, the incorporation of anti-IL-6 within the GelMA hydrogel had no effect on the mechanical properties of the hydrogels. Using a highly stringent skin transplant model, the GelMA/anti-IL-6 IMB almost doubled the survival of skin allografts. The use of GelMA/anti-IL-6 IMB was far superior to systemic anti-IL-6 receptor treatment in prolonging skin allograft survival. As compared to the untreated control group, skin from the GelMA/anti-IL-6 IMB group contained significantly fewer alloreactive T cells and macrophages. Interestingly, the environmental milieu of the draining lymph nodes (DLNs) of the mice implanted with the GelMA/anti-IL-6 IMB was also considerably less pro-inflammatory. The percentage of CD4+ IFNγ+ cells was much lower in the DLNs of the GelMA/anti-IL-6 IMB group in comparison to the GelMA group. These data highlight the importance of localized immune delivery in prolonging skin allograft survival and its potential utility in treating patients with severe burns.
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25
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Leung J, Ridley EJ, Cleland H, Ihle JF, Paul E, King SJ. Predictive energy equations are inaccurate for determining energy expenditure in adult burn injury: a retrospective observational study. ANZ J Surg 2019; 89:578-583. [DOI: 10.1111/ans.15119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/16/2019] [Accepted: 01/28/2019] [Indexed: 12/24/2022]
Affiliation(s)
- James Leung
- Victorian Adult Burns ServiceThe Alfred Hospital Melbourne Victoria Australia
| | - Emma J. Ridley
- Nutrition DepartmentThe Alfred Hospital Melbourne Victoria Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Heather Cleland
- Victorian Adult Burns ServiceThe Alfred Hospital Melbourne Victoria Australia
- Department of Surgery, Central Clinical SchoolMonash University Melbourne Victoria Australia
| | - Joshua F. Ihle
- Department of Intensive Care MedicineThe Alfred Hospital Melbourne Victoria Australia
- School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Eldho Paul
- School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Susannah J. King
- Victorian Adult Burns ServiceThe Alfred Hospital Melbourne Victoria Australia
- Nutrition DepartmentThe Alfred Hospital Melbourne Victoria Australia
- Department of Dietetics, Human Nutrition and SportLa Trobe University Melbourne Victoria Australia
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26
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Zhao F, Liu W, Yu Y, Liu X, Yin H, Liu L, Yi G. Effect of small molecular weight soybean protein-derived peptide supplementation on attenuating burn injury-induced inflammation and accelerating wound healing in a rat model. RSC Adv 2019; 9:1247-1259. [PMID: 35518054 PMCID: PMC9059567 DOI: 10.1039/c8ra09036j] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/19/2018] [Indexed: 12/18/2022] Open
Abstract
The populations most afflicted by burn injuries have limited abilities to support the significant specialized requirements and costs for acute and long-term burn injury care. This article describes the results of optimizing the use of readily absorbed small molecular weight soybean protein enzymolysis-derived peptide to attenuate rat burn injury-induced inflammation and accelerate wound healing. A major full-thickness 30% total body surface area burn-injury rat model was utilized and the systemic white blood cell (WBC) counts, the relative level of stimulation index of respiratory burst, and the inflammatory markers procalcitonin (PCT), tumor necrosis factor-α (TNF-α), chemokine (C–C motif) ligand 3 (CCL-3), chemokine (C–C motif) ligand 11 (CCL-11) and interleukin-10 (IL-10) were assessed. The burn injury-induced neutrophil and macrophage immune cell infiltration of the cutaneous tissues was detected by immunohistochemical analysis of the protein markers myeloperoxidase (MPO) and cluster of differentiation 68 (CD-68). The local induction of the burn injury-induced toll-like receptor 4/nuclear factor kappa-light-chain-enhancer of activated B (TLR4/NF-κB) signaling pathway in the effected cutaneous tissues was determined by the quantification of the protein expression of TLR4 and phosphorylated NF-κB/p65 using Western blots. In addition, burn wound size and healing rate were assessed biweekly for 8 weeks by imaging and measuring the burn wound surface area, and the angiogenesis protein marker of cluster of differentiation 31 (CD-31) expression in cutaneous tissues was also detected by immunohistochemical analysis. The results showed that nutrient supplementation with optimized readily absorbed small molecular weight soybean protein-derived peptide resulted in a dramatic anti-inflammatory effect as evidenced by the significant increase in the burn injury-induced systemic white blood cell counts and their relative level of stimulation index of respiratory burst, reduction in the burn injury-induced activation of NF-κB transcriptional signaling pathways, significant reduction in the local burn injury-induced cutaneous infiltration of neutrophils and macrophages at all measured time points, reduction in wound size and improved rate of burn injury wound healing with increased CD-31 protein expression. These results indicated that dietary supplementation with small molecular weight soybean-derived peptides could be used as an adjunct therapy in burn injury management to reduce inflammation and improve overall patient outcomes. The populations most afflicted by burn injuries have limited abilities to support the significant specialized requirements and costs for acute and long-term burn injury care.![]()
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Affiliation(s)
- Fen Zhao
- Beijing Advanced Innovation Center for Food Nutrition and Human Health
- Beijing Engineering and Technology Research Center of Food Additives
- Beijing Technology and Business University
- Beijing 100048
- China
| | - Wei Liu
- Burn Institute
- The First Affiliated Hospital of PLA General Hospital
- Beijing 100048
- China
| | - Yonghui Yu
- Beijing Advanced Innovation Center for Food Nutrition and Human Health
- Beijing Engineering and Technology Research Center of Food Additives
- Beijing Technology and Business University
- Beijing 100048
- China
| | - Xinqi Liu
- Beijing Advanced Innovation Center for Food Nutrition and Human Health
- Beijing Engineering and Technology Research Center of Food Additives
- Beijing Technology and Business University
- Beijing 100048
- China
| | - Huinan Yin
- Burn Institute
- The First Affiliated Hospital of PLA General Hospital
- Beijing 100048
- China
| | - Lingying Liu
- Burn Institute
- The First Affiliated Hospital of PLA General Hospital
- Beijing 100048
- China
| | - Guofu Yi
- Beijing Advanced Innovation Center for Food Nutrition and Human Health
- Beijing Engineering and Technology Research Center of Food Additives
- Beijing Technology and Business University
- Beijing 100048
- China
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27
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Mendez-Romero D, Clark AT, Christie A, Wolf SE. Weight changes and patterns of weight measurements in hospitalized burn patients: a contemporary analysis. BURNS & TRAUMA 2018; 6:30. [PMID: 30349824 PMCID: PMC6192117 DOI: 10.1186/s41038-018-0131-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/19/2018] [Indexed: 11/17/2022]
Abstract
Background Severe burn is associated with significant changes in body weight due to resuscitation volumes, fluid shifts, a hypermetabolic state, prolonged bed rest, and caloric intake. Our goal was to quantify and describe trends in weight change in patients with burns of all severities under modern treatment conditions and to identify the time points at which these changes occur. Methods An institutional review board-approved chart review was conducted of acute burn patients treated at an American Burn Association-verified regional burn center from February 2016 to November 2016. Patients were then divided into three groups based on percent of total burn surface area (%TBSA) burn: 1–19%, 20–39%, and ≥ 40%. Weight was expressed as percent change of weight from baseline. Regression analysis was conducted on percent weight changes for each TBSA group. Results We identified 197 burn patients with a length of stay (LOS) of ≥ 7 days. Of the study cohort, 149 had TBSA burn of 1–19%, 27 had TBSA burn of 20–39%, and 21 had TBSA burn of ≥ 40%. All groups had a majority of White male, non-Hispanic patients with mean ages between 40 and 42 years. Burn patients with > 20% TBSA burn had a median increase in weight above baseline of approximately 5 to 8% likely due to resuscitation fluids within the first week of hospitalization. Weight loss below baseline often did not exceed 10% and was more pronounced as LOS increased, mostly in patients with > 20% TBSA burn. Whereas patients with 1–19% TBSA burn on average returned to baseline weight at last measurement, patients with 20–39% TBSA and ≥ 40% TBSA burn continued a decline in weight at 4 weeks (r2 = 0.57 and 0.55, respectively) on the same trajectory. Conclusions Burn patients with > 20% TBSA burn had an increase in weight above baseline of up to 8%, likely due to resuscitation fluids within the first week of hospitalization. Weight loss below baseline often did not exceed 10% and was more pronounced as LOS increased, mostly in patients with > 20% TBSA burn. Therefore, our patients on average, lost body weight to a lesser extent than the maximum mean loss of 22% of pre-burn weight reported prior to modern treatment conditions.
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Affiliation(s)
- Denisse Mendez-Romero
- Department of Surgery, Division of Burn, Trauma, and Critical Care, University of Texas Southwestern Medical Center, E05514B, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Audra T Clark
- Department of Surgery, Division of Burn, Trauma, and Critical Care, University of Texas Southwestern Medical Center, E05514B, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Alana Christie
- Department of Surgery, Division of Burn, Trauma, and Critical Care, University of Texas Southwestern Medical Center, E05514B, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Steven E Wolf
- Department of Surgery, Division of Burn, Trauma, and Critical Care, University of Texas Southwestern Medical Center, E05514B, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
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Grammatikopoulou MG, Theodoridis X, Gkiouras K, Stamouli EM, Mavrantoni ME, Dardavessis T, Bogdanos DP. AGREEing on Guidelines for Nutrition Management of Adult Severe Burn Patients. JPEN J Parenter Enteral Nutr 2018; 43:490-496. [PMID: 30320409 DOI: 10.1002/jpen.1452] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/11/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Severe burns are associated with a plethora of profound metabolic, immunologic, and physiologic responses, demanding prompt and adequate management. The objective of the present study was to review, compare, and critically appraise medical nutrition therapy guidelines for adult patients with severe burns, and produce salient points for the future update of relevant guidelines. METHODS A total of 8 clinical practice guidelines developed by the American Burn Association (ABA), the European Burn Association (EBA), the European Society for Parenteral and Enteral Nutrition (ESPEN), the Midlands National Health Service, the Society for Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the Spanish Society of Intensive Care Medicine and Coronary Units and Spanish Society of Parenteral and Enteral Nutrition, the Indian Association for Parenteral and Enteral Nutrition (IAPEN), and the International Society for Burn Injury regarding medical nutrition therapy in burn patients was independently reviewed by a team of 4 multidisciplinary researchers using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. RESULTS From the appraised guidelines, the SCCM/ASPEN guidelines received the greatest scoring in the majority of AGREE domains compared with ABA, EBA, and IAPEN, which obtained the lowest scores. On the other hand, the ESPEN guidelines provided the majority of information concerning nutrition support and medical nutrition therapy. CONCLUSION Our study identified gaps in most nutrition guidelines and emphasized methodologic issues that could improve the quality of future guidelines concerning nutrition support among adult severe burn patients.
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Affiliation(s)
- Maria G Grammatikopoulou
- Department of Nutrition and Dietetics, Alexander Technological Educational Institute, Thessaloniki, Greece.,Department of Medicine, Faculty of Health Sciences, University of Thessaly, Larissa, Greece.,Department of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Xenophon Theodoridis
- Department of Medicine, Faculty of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Gkiouras
- Department of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni-Maria Stamouli
- Department of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Myrsini-Eleni Mavrantoni
- Department of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Dardavessis
- Department of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.,Division of Transplantation, Immunology and Mucosal Biology, MRC Centre for Transplantation, King's College London Medical School, London, UK
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Dolp R, Rehou S, McCann MR, Jeschke MG. Contributors to the length-of-stay trajectory in burn-injured patients. Burns 2018; 44:2011-2017. [PMID: 30104050 DOI: 10.1016/j.burns.2018.07.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/16/2018] [Accepted: 07/20/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Burn patients have a highly variable length-of-stay (LOS) due to the complexity of the injury itself. The LOS for burn patients is estimated as one day per percent total body surface area (TBSA) burn. To focus care expectation and prognosis we aimed to identify key factors that contribute to prolonged LOS. METHODS This was a retrospective cohort-study (2006-2016) in an adult burn-centre that included patients with ≥10% TBSA burn. Patients were stratified into expected-LOS (<2 days LOS/%TBSA) and longer-than-expected-LOS (≥2 days LOS/%TBSA). We assessed demographics, comorbidities, and in-hospital complications. Logistic regression and propensity matching was utilized. RESULTS Of the 583 total patients, 477 had an expected-LOS whereas 106 a longer-than-expected-LOS. Non-modifiable factors such as age, 3rd degree TBSA%, inhalation injuries and comorbidities were greater in the exceeded LOS patients. Subsequent matched analysis revealed factors like number of procedures performed, days ventilated and in-hospital complications (bacteremia, pneumonia, sepsis, graft loss, and respiratory failure) were significantly increased in the longer-than-expected-LOS group. CONCLUSIONS Progress has been made to update the conventional one day/%TBSA to better aid health care providers in giving appropriate outcomes for patients and their families and to supply intensive care units with valuable data to assess quality of care and to improve patient prognosis.
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Affiliation(s)
- Reinhard Dolp
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Rehou
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Determinants of skeletal muscle protein turnover following severe burn trauma in children. Clin Nutr 2018; 38:1348-1354. [PMID: 29907353 DOI: 10.1016/j.clnu.2018.05.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 02/17/2018] [Accepted: 05/29/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Burns remain the fifth cause of non-fatal pediatric injuries globally, with muscle cachexia being a hallmark of the stress response to burns. Burn-induced muscle wasting is associated with morbidity, yet the determinants of muscle protein catabolism in response to burn trauma remains unclear. Our objective was to determine the effect of patient and injury characteristics on muscle protein kinetics in burn patients. METHODS This retrospective, observational study was performed using protein kinetic data from pediatric patients who had severe burns (>30% of the total body surface area burned) and underwent cross-limb stable isotope infusions between 1999 and 2008 as part of prospective clinical trials. Mixed multiple regression models were used to assess associations between patient/injury characteristics and muscle protein fractional synthesis rate (FSR), net balance (NB), and rates of phenylalanine appearance (Ra; index of protein breakdown) and disappearance (Rd; index of protein synthesis) across the leg. RESULTS A total of 268 patients who underwent 499 studies were analyzed. Increasing time post injury was associated with greater FSR (p < 0.001) and NB (p = 0.01). Males were more catabolic than females (as indicated by lower NB, p = 0.04 and greater Ra, p = 0.008), a consequence of higher protein breakdown rather than lower synthesis. Increasing burn size was associated with higher protein synthesis rate (as indicated by higher FSR, p = 0.019) and higher protein breakdown rates (as indicated by greater Ra, p = 0.001). FSR was negatively associated with age (p < 0.001). CONCLUSIONS Data from this large patient cohort show that injury severity, sex, and time post injury influence skeletal muscle wasting in burned children. These findings suggest that individual patient characteristics should be considered when devising therapies to improve the acute care and rehabilitation of burn survivors.
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Imeokparia F, Johnson M, Thakkar RK, Giles S, Capello T, Fabia R. Safety and efficacy of uninterrupted perioperative enteral feeding in pediatric burn patients. Burns 2018; 44:344-349. [DOI: 10.1016/j.burns.2017.07.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 05/25/2017] [Accepted: 07/12/2017] [Indexed: 12/15/2022]
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Calum H, Høiby N, Moser C. Mouse Model of Burn Wound and Infection: Thermal (Hot Air) Lesion-Induced Immunosuppression. ACTA ACUST UNITED AC 2017. [DOI: 10.1002/cpmo.25] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Henrik Calum
- Department of Clinical Microbiology, Hvidovre Hospital; Copenhagen Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, Rigshospitalet; Copenhagen Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet; Copenhagen Denmark
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Clark A, Imran J, Madni T, Wolf SE. Nutrition and metabolism in burn patients. BURNS & TRAUMA 2017; 5:11. [PMID: 28428966 PMCID: PMC5393025 DOI: 10.1186/s41038-017-0076-x] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022]
Abstract
Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas. Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.
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Affiliation(s)
- Audra Clark
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Jonathan Imran
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Tarik Madni
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Steven E Wolf
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
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Collier ZJ, Gottlieb LJ, Alverdy JC. Stochasticity among Antibiotic-Resistance Profiles of Common Burn-Related Pathogens over a Six-Year Period. Surg Infect (Larchmt) 2017; 18:327-335. [DOI: 10.1089/sur.2016.191] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
| | - Lawrence J. Gottlieb
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - John C. Alverdy
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
- Department of Surgery, University of Chicago, Chicago, Illinois
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35
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Manzano-Nunez R, García-Perdomo HA, Ferrada P, Ordoñez Delgado CA, Gomez DA, Foianini JE. Safety and effectiveness of propranolol in severely burned patients: systematic review and meta-analysis. World J Emerg Surg 2017; 12:11. [PMID: 28265298 PMCID: PMC5335497 DOI: 10.1186/s13017-017-0124-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this systematic review was to determine the effectiveness and safety of propranolol compared to placebo or usual care for improving clinical relevant outcomes in severely burned patients (TBSA >20%). METHODS Relevant articles from randomized controlled trials were identified by a literature search in MEDLINE, EMBASE, and CENTRAL. We included trials involving patients with a severe burn (>20% of total body surface area affected). Trials were eligible if they evaluated propranolol and compared to usual care or placebo. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for the final analysis. We conducted a meta-analysis using a random-effects model. RESULTS We included ten studies in our systematic review. These studies randomized a total of 1236 participants. There were no significant differences between propranolol and placebo with respect to mortality (RD -0.02 [95% CI -0.06 to 0.02]), sepsis (RD -0.03 [95% CI -0.09 to 0.04]), and the overall hospital stay (MD -0.37 [-4.52 to 3.78]). Propranolol-treated adults had a decrease in requirements of blood transfusions (MD -185.64 [95% CI -331.06 to -40.43]) and a decreased heart rate (MD -26.85 [95% CI -39.95 to -13.75]). CONCLUSIONS Our analysis indicates that there were no differences in mortality or sepsis in severely burned patients treated with propranolol compared with those who had usual care or placebo. However, the use of propranolol in these patients resulted in lower requirements of blood transfusion and lower values of heart rate. The evidence synthesized in this systematic review is limited to conclude that propranolol reduces the length of hospital stay among severely burned patients. Future trials should assess the impact of propranolol on clinically relevant outcomes such as mortality and adverse events.
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Affiliation(s)
- Ramiro Manzano-Nunez
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
- UROGIV Research Group, Universidad Del Valle, Cali, Colombia
| | | | - Paula Ferrada
- Surgical Critical Care, Virginia Commonwealth University, Richmond, VA USA
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Abstract
Thyroid crisis is an exacerbation of hyperthyroidism that results in severe systemic disturbances and could be fatal. Similarly, severe burn injury also has a hypermetabolic response as part of its presentation. When these two conditions are present concurrently, one must be cognizant that the patient requires urgent optimization of their hyperthyroid status before surgery, and continuous monitoring in an intensive care unit setting. We offer a systematic approach to managing these patients.
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37
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Holdy KE. Monitoring Energy Metabolism with Indirect Calorimetry: Instruments, Interpretation, and Clinical Application. Nutr Clin Pract 2017; 19:447-54. [PMID: 16215138 DOI: 10.1177/0115426504019005447] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Indirect calorimetry is the best measure to guide calorie administration during nutrition support. This article presents an update of the types of currently available indirect calorimeters and reviews the recent advances that guide the clinical application of indirect calorimetry. The emphasis of this report is placed on issues that the practicing clinician can use to evaluate, interpret, and apply measurements of energy expenditure.
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Affiliation(s)
- Kalman E Holdy
- Nutrition and Metabolic Support Service, Sharp Memorial Hospital, San Diego, California, USA.
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38
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Clark A, Imran J, Madni T, Wolf SE. Nutrition and metabolism in burn patients. BURNS & TRAUMA 2017. [PMID: 28428966 DOI: 10.1186/s41038-017-0076-xh] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas. Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.
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Affiliation(s)
- Audra Clark
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Jonathan Imran
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Tarik Madni
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Steven E Wolf
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
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39
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Porter C, Tompkins RG, Finnerty CC, Sidossis LS, Suman OE, Herndon DN. The metabolic stress response to burn trauma: current understanding and therapies. Lancet 2016; 388:1417-1426. [PMID: 27707498 PMCID: PMC5753602 DOI: 10.1016/s0140-6736(16)31469-6] [Citation(s) in RCA: 203] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/11/2016] [Accepted: 07/21/2016] [Indexed: 12/18/2022]
Abstract
Major burns provoke a profound stress response, which is unrivalled in terms of its magnitude and duration. Evidence suggests that the pathophysiological stress response to severe burn trauma persists for several years after injury. Thus, there is a pressing need for novel strategies that mitigate this response and restore normal metabolic function in patients with burns. This is the first in a Series of three papers about the care of people with burns. In this paper, we review the current knowledge of the stress response to burn trauma, with a focus on hypermetabolism, muscle wasting, and stress-induced diabetes. We highlight recent developments and important knowledge gaps that need to be pursued to develop novel therapeutic strategies to improve outcomes in burn survivors.
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Affiliation(s)
- Craig Porter
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA.
| | - Ronald G Tompkins
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
| | - Labros S Sidossis
- Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ, USA; Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
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40
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Prelack K, Yu YM, Dylewski M, Lydon M, Keaney TJ, Sheridan RL. Measures of Total Energy Expenditure and Its Components Using the Doubly Labeled Water Method in Rehabilitating Burn Children. JPEN J Parenter Enteral Nutr 2016; 41:470-480. [DOI: 10.1177/0148607115597665] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kathy Prelack
- Shriners Hospitals for Children, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yong Ming Yu
- Shriners Hospitals for Children, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martha Lydon
- Shriners Hospitals for Children, Boston, Massachusetts, USA
| | - Timothy J. Keaney
- Shriners Hospitals for Children, Boston, Massachusetts, USA
- Lawrence General Hospital, Lawrence, Massachusetts, USA
| | - Robert L. Sheridan
- Shriners Hospitals for Children, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
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Chao T, Herndon DN, Porter C, Chondronikola M, Chaidemenou A, Abdelrahman DR, Bohanon FJ, Andersen C, Sidossis LS. Skeletal Muscle Protein Breakdown Remains Elevated in Pediatric Burn Survivors up to One-Year Post-Injury. Shock 2015; 44:397-401. [PMID: 26263438 PMCID: PMC4615533 DOI: 10.1097/shk.0000000000000454] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Acute alterations in skeletal muscle protein metabolism are a well-established event associated with the stress response to burns. Nevertheless, the long-lasting effects of burn injury on skeletal muscle protein turnover are incompletely understood. This study was undertaken to investigate fractional synthesis (FSR) and breakdown (FBR) rates of protein in skeletal muscle of pediatric burn patients (n = 42, >30% total body surface area burns) for up to 1 year after injury. Skeletal muscle protein kinetics were measured in the post-prandial state following bolus injections of C6 and N phenylalanine stable isotopes. Plasma and muscle phenylalanine enrichments were quantified using gas chromatography-mass spectrometry. We found that the FSR in burn patients was 2- to 3-fold higher than values from healthy men previously reported in the literature (P ≤ 0.05). The FBR was 4- to 6-fold higher than healthy values (P < 0.01). Therefore, net protein balance was lower in burn patients compared with healthy men from 2 weeks to 12 months post-injury (P < 0.05). These findings show that skeletal muscle protein turnover stays elevated for up to 1 year after burn, an effect attributable to simultaneous increases in FBR and FSR. Muscle FBR exceeds FSR during this time, producing a persistent negative net protein balance, even in the post-prandial state, which likely contributes to the prolonged cachexia seen in burned victims.
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Affiliation(s)
- Tony Chao
- Metabolism Unit, Shriners Hospitals for Children, Galveston, TX
- Division of Rehabilitation Sciences, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - David N. Herndon
- Metabolism Unit, Shriners Hospitals for Children, Galveston, TX
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Craig Porter
- Metabolism Unit, Shriners Hospitals for Children, Galveston, TX
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Maria Chondronikola
- Metabolism Unit, Shriners Hospitals for Children, Galveston, TX
- Division of Rehabilitation Sciences, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
- Department of Nutrition and Dietetics, Harokopio University of Athens, Greece
| | | | - Doaa Reda Abdelrahman
- Metabolism Unit, Shriners Hospitals for Children, Galveston, TX
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Clark Andersen
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Labros S. Sidossis
- Metabolism Unit, Shriners Hospitals for Children, Galveston, TX
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
- Department of Nutrition and Dietetics, Harokopio University of Athens, Greece
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
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Giuliani S, McArthur A, Greenwood J. Preoperative fasting among burns patients in an acute care setting: a best practice implementation project. ACTA ACUST UNITED AC 2015; 13:235-53. [DOI: 10.11124/jbisrir-2015-2208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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43
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Rowan MP, Cancio LC, Elster EA, Burmeister DM, Rose LF, Natesan S, Chan RK, Christy RJ, Chung KK. Burn wound healing and treatment: review and advancements. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:243. [PMID: 26067660 PMCID: PMC4464872 DOI: 10.1186/s13054-015-0961-2] [Citation(s) in RCA: 468] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Burns are a prevalent and burdensome critical care problem. The priorities of specialized facilities focus on stabilizing the patient, preventing infection, and optimizing functional recovery. Research on burns has generated sustained interest over the past few decades, and several important advancements have resulted in more effective patient stabilization and decreased mortality, especially among young patients and those with burns of intermediate extent. However, for the intensivist, challenges often exist that complicate patient support and stabilization. Furthermore, burn wounds are complex and can present unique difficulties that require late intervention or life-long rehabilitation. In addition to improvements in patient stabilization and care, research in burn wound care has yielded advancements that will continue to improve functional recovery. This article reviews recent advancements in the care of burn patients with a focus on the pathophysiology and treatment of burn wounds.
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Affiliation(s)
- Matthew P Rowan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.
| | - Leopoldo C Cancio
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Eric A Elster
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - David M Burmeister
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Lloyd F Rose
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Shanmugasundaram Natesan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Rodney K Chan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.,Brooke Army Medical Center, 3551 Roger Brook Dr, Fort Sam Houston, TX, 78234, USA
| | - Robert J Christy
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Kevin K Chung
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
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Revisión sistemática del efecto del propranolol sobre el hipermetabolismo del quemado. Med Intensiva 2015; 39:101-13. [DOI: 10.1016/j.medin.2014.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/30/2014] [Accepted: 08/01/2014] [Indexed: 02/05/2023]
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Weijs PJM, Cynober L, DeLegge M, Kreymann G, Wernerman J, Wolfe RR. Proteins and amino acids are fundamental to optimal nutrition support in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:591. [PMID: 25565377 PMCID: PMC4520087 DOI: 10.1186/s13054-014-0591-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Proteins and amino acids are widely considered to be subcomponents in nutritional support. However, proteins and amino acids are fundamental to recovery and survival, not only for their ability to preserve active tissue (protein) mass but also for a variety of other functions. Understanding the optimal amount of protein intake during nutritional support is therefore fundamental to appropriate clinical care. Although the body adapts in some ways to starvation, metabolic stress in patients causes increased protein turnover and loss of lean body mass. In this review, we present the growing scientific evidence showing the importance of protein and amino acid provision in nutritional support and their impact on preservation of muscle mass and patient outcomes. Studies identifying optimal dosing for proteins and amino acids are not currently available. We discuss the challenges physicians face in administering the optimal amount of protein and amino acids. We present protein-related nutrition concepts, including adaptation to starvation and stress, anabolic resistance, and potential adverse effects of amino acid provision. We describe the methods for assessment of protein status, and outcomes related to protein nutritional support for critically ill patients. The identification of a protein target for individual critically ill patients is crucial for outcomes, particularly for specific subpopulations, such as obese and older patients. Additional research is urgently needed to address these issues.
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Affiliation(s)
- Peter J M Weijs
- Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. .,Department of Intensive Care Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. .,Department of Nutrition and Dietetics, Amsterdam University of Applied Sciences, Wibautstraat 2-4 1091 GM, Amsterdam, the Netherlands. .,EMGO+ Institute of Health and Care Research, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Luc Cynober
- Clinical Chemistry Department, Cochin and Hôtel-Dieu Hospitals, APHP, 1 place du Parvis Notre-Dame 75004, Paris, France. .,Nutrition Lab, EA 4466, Department of Experimental, Metabolic and Clinical Biology, Faculty of Pharmacy, Paris Descartes University, 12 rue de l'Ecole de Médicine 75270, Paris, France.
| | - Mark DeLegge
- Baxter Healthcare, Deerfield, IL, 60015-4625, USA.
| | - Georg Kreymann
- Baxter Healthcare SA Europe, CH-8010, Zürich, Switzerland.
| | - Jan Wernerman
- Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Karolinska Institutet, 141 86, Stockholm, Sweden.
| | - Robert R Wolfe
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, 4243 Ireland St #336, College Station, TX, 77843, USA.
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Austin RE, Merchant N, Shahrokhi S, Jeschke MG. A comparison of Biobrane™ and cadaveric allograft for temporizing the acute burn wound: Cost and procedural time. Burns 2014; 41:749-53. [PMID: 25458501 DOI: 10.1016/j.burns.2014.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/19/2014] [Accepted: 10/03/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In many circumstances early burn excision and autografting is unsafe or even impossible. In these situations, skin substitute dressings can be utilized for temporary wound coverage. Two commonly used dressings for this purpose are cadaveric allograft and Biobrane™. MATERIALS AND METHODS Five year retrospective cohort study evaluating upper extremity burns treated with temporary wound coverage (Biobrane™ or allograft). The primary outcome was to determine the impact choice of wound coverage had on operative time and cost. The secondary outcome was the need for revision of upper extremity debridement prior to definitive autografting. RESULTS 45 patients were included in this study: 15 treated with cadaveric allograft and 30 treated with Biobrane™ skin substitute. Biobrane™ had a significantly lower procedure time (21.12 vs. 54.78 min per %TBSA excised, p=0.02) and cost (1.30 vs. 2.35 dollars per minute per %TBSA excised, p=0.002). Both techniques resulted in 2 revisions due to complications. CONCLUSION Biobrane™ is superior to cadaveric allograft as a temporizing skin substitute in the acute burn wound, both in terms of procedure time and associated cost. We believe that this is largely due to the relative ease of application of Biobrane™. Furthermore, given its unique characteristics, Biobrane™ may serve as a triage and transport option for severe burns in the military and mass casualty settings.
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Affiliation(s)
- Ryan E Austin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, 149 College St, Stewart Building, 5th Floor, Toronto, ON M5T 1P5, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, D704, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
| | - Nishant Merchant
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, D704, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
| | - Shahriar Shahrokhi
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, 149 College St, Stewart Building, 5th Floor, Toronto, ON M5T 1P5, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, D704, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
| | - Marc G Jeschke
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, 149 College St, Stewart Building, 5th Floor, Toronto, ON M5T 1P5, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, D704, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
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Auxenfans C, Menet V, Catherine Z, Shipkov H, Lacroix P, Bertin-Maghit M, Damour O, Braye F. Cultured autologous keratinocytes in the treatment of large and deep burns: a retrospective study over 15 years. Burns 2014; 41:71-9. [PMID: 24996248 DOI: 10.1016/j.burns.2014.05.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 04/07/2014] [Accepted: 05/28/2014] [Indexed: 11/29/2022]
Abstract
AIM The aim was to review the use and indications of cultured autologous epidermis (CAE) in extensive burns and to evaluate the efficiency of our strategy of burn treatment. MATERIALS AND METHODS This retrospective study comprised 15 years (1997-2012). INCLUSION CRITERIA all patients who received CAE. EXCLUSION CRITERIA patients who died before complete healing and patients who received exclusively cultured allogeneic keratinocytes. Evaluation criteria were clinical. Time and success of wound healing after CAE graft were evaluated. RESULTS A total of 63 patients were included with severity Baux score of 107 (from 70 to 140) and mean percentage of TBSA of 71% (from 40% to 97%). The CAE were used as Cuono method, in STSG donor sites and deep 2nd degree burns and in combination with large-meshed STSG (1:6-1:12) in extensively burned patients. Cuono method was used in 6 patients. The final take was 16% (0-30) because of the great fragility of the obtained epidermis. Nine patients with deep 2nd degree burns (mean TBSA 81%, from 60 to 97%) were successfully treated with only CAE without skin grafting. Combined technique (STSG meshed at 1:6-1:12 covered with CAE) was used in 27 patients (mean TBSA 69%, from 49% to 96%) with 85% success rate. Finally, donor sites treated with CAE in 49 patients could be harvested several times thanks to rapid epithelialization (time of wound healing was 7 days (from 5 to 10 days)). CONCLUSION The CAE allow rapid healing of STSG donor sites and deep 2nd second degree burns in extensively burned patients.
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Affiliation(s)
| | - Veronique Menet
- Tissues and Cells Bank, Edouard Herriot Hospital, Lyon, France
| | | | | | | | | | - Odile Damour
- Tissues and Cells Bank, Edouard Herriot Hospital, Lyon, France
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Przkora R, Fram RY, Herndon DN, Suman OE, Mlcak RP. Influence of inhalation injury on energy expenditure in severely burned children. Burns 2014; 40:1487-91. [PMID: 24893760 DOI: 10.1016/j.burns.2014.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 04/12/2014] [Accepted: 04/16/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Determine the effect of inhalation injury on burn-induced hypermetabolism in children. DESIGN Prospective study comparing hypermetabolism (i.e., resting energy expenditure and oxygen consumption) in burned children with and without inhalation injury during acute hospitalization. SETTING Single pediatric burn center. PATIENTS Eighty-six children (1-18 years) with ≥40% total body surface area burns were stratified to two groups: no inhalation injury and inhalation injury. INTERVENTIONS None. MAIN MEASUREMENTS AND RESULTS Inhalation injury was diagnosed based on bronchoscopic evaluation. At admission, PaO2:FiO2 ratios (an index of respiratory distress) were significantly higher in patients with no inhalation injury than in patients with inhalation injury. No differences were detected in resting energy expenditure or percent of the predicted basal metabolic rate between groups. Additionally, oxygen consumption did not significantly differ between groups. CONCLUSIONS Inhalation injury does not augment the burn-induced hypermetabolic stress response in children, as reflected by resting energy expenditure and oxygen consumption.
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Affiliation(s)
- Rene Przkora
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States; Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, United States.
| | - Ricki Y Fram
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States
| | - Ronald P Mlcak
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States.
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Mehta Y, Gupta A, Todi S, Myatra SN, Samaddar DP, Patil V, Bhattacharya PK, Ramasubban S. Guidelines for prevention of hospital acquired infections. Indian J Crit Care Med 2014; 18:149-63. [PMID: 24701065 PMCID: PMC3963198 DOI: 10.4103/0972-5229.128705] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These guidelines, written for clinicians, contains evidence-based recommendations for the prevention of hospital acquired infections Hospital acquired infections are a major cause of mortality and morbidity and provide challenge to clinicians. Measures of infection control include identifying patients at risk of nosocomial infections, observing hand hygiene, following standard precautions to reduce transmission and strategies to reduce VAP, CR-BSI, CAUTI. Environmental factors and architectural lay out also need to be emphasized upon. Infection prevention in special subsets of patients - burns patients, include identifying sources of organism, identification of organisms, isolation if required, antibiotic prophylaxis to be used selectively, early removal of necrotic tissue, prevention of tetanus, early nutrition and surveillance. Immunodeficient and Transplant recipients are at a higher risk of opportunistic infections. The post tranplant timetable is divided into three time periods for determining risk of infections. Room ventilation, cleaning and decontamination, protective clothing with care regarding food requires special consideration. Monitoring and Surveillance are prioritized depending upon the needs. Designated infection control teams should supervise the process and help in collection and compilation of data. Antibiotic Stewardship Recommendations include constituting a team, close coordination between teams, audit, formulary restriction, de-escalation, optimizing dosing, active use of information technology among other measure. The recommendations in these guidelines are intended to support, and not replace, good clinical judgment. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments.
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Affiliation(s)
- Yatin Mehta
- From: Institute of Critical Care and Anesthesiology, Medanta- The Medicity, Gurgaon, India
| | - Abhinav Gupta
- Critical Care, Medanta – The Medicity, Gurgaon, India
| | | | - SN Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Dr. E Borges Road, Parel, Mumbai, India
| | - D. P. Samaddar
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Tata Steel Limited, Jamshedpur, Jharkhand, India
| | - Vijaya Patil
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Dr. E Borges Road, Parel, India
| | | | - Suresh Ramasubban
- Critical Care, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
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