Survey on Current Hydrotherapy Use Among North American Burn Centers:

Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Assessment of the Clinical Effects of Aquatic-based Exercises in the Treatment of Children With Juvenile Dermatomyositis: A 2x2 Controlled-Crossover Trial

Objectives

This study aims to compare the effect of aquatic-based exercises (AQBEs) and land-based exercises (LBEs) on muscle strength, fatigue and quality of life (QoL), and skin disease activity in children with juvenile dermatomyositis (JDM).

Patients and methods

The design of the study was an assessor-blinded, controlled 2x2 crossover trial. Fourteen children (4 boys, 10 girls; mean age 11.7±2.2 years; range, 10 to 16 years) were evaluated. AQBEs and LBEs were applied through two treatment sequences as half of the children received AQBEs first while the second half received LBEs first. Isometric muscle strength, fatigue level and QoL (Pediatric Quality of Life Inventory Multidimensional Fatigue Scale [PedsQL-MFS]), and skin disease activity score (DASskin) were measured at four occasions for each treatment sequence.

Results

The AQBEs had significant superiority over LBEs with improved hip flexors' strength (p=0.007) and hip abductors' strength (p=0.001), while both types of treatment had the same effect in increasing strength of shoulder flexors and abductors (p<0.05). AQBEs improved PedsQL-MFS, and DASskin significantly more than LBEs (p<0.001). For all outcome measures, there was no significant difference in the treatment sequence the children received first.

Conclusion

Supervised AQBEs are more effective in improving muscle strength, fatigue and QoL, and skin disease activity than LBEs in children with JDM. Furthermore, the treatment sequence had no significant effect on measured variables.

Successful Eradication of Multidrug Resistant Acinetobacter in the Helsinki Burn Centre

Multidrug-resistant (MDR) Acinetobacter is an important pathogen implicated in nosocomial infections in healthcare environments. Virulence factors, resistance mechanisms, and limited therapeutic options make this pathogen a major problem currently facing burn intensive care units (ICUs) worldwide. The purpose of this study was to assess the effect of infection control measures taken in Helsinki Burn Centre in 2001 on MDR Acinetobacter prevalence in ICU burn patients. Data were retrospectively collected from patient files from 1998 to 2012. ICU burn patients were defined as those with either over 30% of total body surface area burnt or requiring mechanical ventilation. Inclusion criteria consisted of patients who tested positive for Acinetobacter sp. in routine bacterial cultures or cultures taken because of a clinically suspected infection. Infection control interventions performed in 2001 consisted of various shower room renovations and changes in hospital hygiene and burn treatment regimes. Between 1998 and 2012, 75 patients were diagnosed with Acinetobacter sp. colonization. Following the infection control interventions the incidence of Acinetobacter sp. radically declined. Between 1998 and 2001, there were 31 cases of MDR Acinetobacter colonizations diagnosed, but from 2002 to 2012 no MDR strains were found. Changes to hospital hygiene and wound treatment protocols as well as structural changes to the hospital environment can have a major impact on preventing and treating Acinetobacter outbreaks in burn centers.

Seeking the source of Pseudomonas aeruginosa infections in a recently opened hospital: an observational study using whole-genome sequencing

OBJECTIVES

Pseudomonas aeruginosa is a common nosocomial pathogen responsible for significant morbidity and mortality internationally. Patients may become colonised or infected with P. aeruginosa after exposure to contaminated sources within the hospital environment. The aim of this study was to determine whether whole-genome sequencing (WGS) can be used to determine the source in a cohort of burns patients at high risk of P. aeruginosa acquisition.

STUDY DESIGN

An observational prospective cohort study.

SETTING

Burns care ward and critical care ward in the UK.

PARTICIPANTS

Patients with >7% total burns by surface area were recruited into the study.

METHODS

All patients were screened for P. aeruginosa on admission and samples taken from their immediate environment, including water. Screening patients who subsequently developed a positive P. aeruginosa microbiology result were subject to enhanced environmental surveillance. All isolates of P. aeruginosa were genome sequenced. Sequence analysis looked at similarity and relatedness between isolates.

RESULTS

WGS for 141 P. aeruginosa isolates were obtained from patients, hospital water and the ward environment. Phylogenetic analysis revealed eight distinct clades, with a single clade representing the majority of environmental isolates in the burns unit. Isolates from three patients had identical genotypes compared with water isolates from the same room. There was clear clustering of water isolates by room and outlet, allowing the source of acquisitions to be unambiguously identified. Whole-genome shotgun sequencing of biofilm DNA extracted from a thermostatic mixer valve revealed this was the source of a P. aeruginosa subpopulation previously detected in water. In the remaining two cases there was no clear link to the hospital environment.

CONCLUSIONS

This study reveals that WGS can be used for source tracking of P. aeruginosa in a hospital setting, and that acquisitions can be traced to a specific source within a hospital ward.

Hydrotherapy in burn care: a survey of hydrotherapy practices in the UK and Ireland and literature review

INTRODUCTION

Hydrotherapy is widely used in burns management however there are risks associated with its use, in particular cross-infection. Data regarding indications and techniques in common use is deficient. This study aimed to investigate hydrotherapy practices in the UK and Ireland.

METHODS

A survey of the hydrotherapy practice of major burn care providers was performed by e mail and where necessary, follow up telephone contact.

RESULTS

The survey included 28 burn care providers. 27 reported using hydrotherapy. Only 11 (41%) had defined indication criteria with 4 (15%) implementing a specific protocol. Variations in hydrotherapy practice were seen.

CONCLUSION

Hydrotherapy is used nationwide, however considerable variation in practice exists. One area worthy of further consideration is the need for appropriate standards of infection control.

Intermediate-level disinfection with accelerated hydrogen peroxide prevents accumulation of bacteria in Versajet™ tubing during repeated daily debridement using simulated-use testing with an inoculated pork hock

OBJECTIVE

This study assesses the feasibility of using the Versajet™ system (VJS) on an inoculated pork hock (PH) skin surface sequentially for 8 days with daily cleaning and intermediate-level disinfection (ILD).

METHODS

Daily, PHs were inoculated with bacteria suspended in artificial test soil (ATS). An ILD protocol with accelerated hydrogen peroxide (AHP, OxivirTB(®)) was employed to clean and disinfect the VJS between debridements.

RESULTS

PH skin contains 6.1-6.8×10(6)cfu/cm(2) bacteria. Bacterial counts in the handpiece and discharge hoses immediately after debridement of the PHs, and before cleaning, increased throughout the study period (5.19-6.43log10cfu/mL). Cleaning with the ILD protocol was reduced bacterial counts on the VJS by 6-log. Protein, a surrogate marker of organic contamination, was also reduced post-cleaning and ILD. Compared to a maximum post-debridement level of protein (57.9 μg/mL) obtained before ILD, VJS protein levels dropped to 9.8 (handpiece) and 13.8 μg/mL (discharge hose).

CONCLUSIONS

Disinfection of the handpiece and discharge hose after debridement with AHP resulted in a 6-log reduction in bacterial count and 4.2 fold reduction in protein. An ILD protocol with an AHP may be a feasible method for serial skin surface debridements with the VJS for up to eight days.

Evolving changes in the management of burns and environmental injuries

Burns and environmental injuries are common as primary or secondary problems in survivors of natural disasters, terrorist incidents, and combat operations. In recent years, intensive military medical experience has resulted in substantial progress in treatment of these important problems. This article reviews practical applications of this new knowledge.

A mechanistic study on the effect of ethanol and importance of water on permeation of drugs through human third-degree burn eschar

Ethanol that affects hydration of skin and used in wound treatment formulations was studied here for its effect on permeation of drugs through burn eschar and to investigate the presence of a porous pathway in this barrier. In this study, permeations of clindamycin phosphate (CP, hydrophilic) and diazepam (lipophilic) through human burn eschar were investigated in the presence and absence of ethanol. Permeability coefficients (K(p) ) of CP and diazepam through hydrated eschar were calculated to be 13·1 × 10(-3) and 17·4 × 10(-3) cm/h respectively. These K(p) values were decreased by about 1·5-5·3 and 2-10·7 times respectively upon the addition of 20-70% ethanol. Increased amount of ethanol decreased permeation flux of CP (2-20 times) and increased that of diazepam (3-80 times) from saturated solutions. Thermal analysis showed that ethanol dehydrates eschar and also changes its internal proteineous structure. Such changes were concluded to be the main reasons behind decreased K(p) of both drugs. Comparison of K(p) data suggests the possibility and importance of a pore pathway in permeation of both drugs through the hydrated burn eschar. Present results show that ethanol, and possibly other dehydrating agents, can decrease the permeability of eschar and that this effect should be considered in formulation developments.