Burn injuries

Understanding the Drivers of Cost and Length of Stay in a Cohort of 21,875 Patients with Severe Burn

Burn management has significantly advanced in the past 75 years, resulting in improved mortality rates. However, there are still over one million burn victims in the United States each year, with over 3,000 burn-related deaths annually. The impacts of individual patient, hospital, and regional demographics on length of stay (LOS) and total cost have yet to be fully explored in a large nationally representative cohort. Thus, this study aimed to examine various hospital and patient characteristics using a sample of over 20,000 patients. Inpatient data from the National Inpatient Sample from 2008 to 2015 were analyzed, and only patients with an ICD-9 code for second- or third-degree burns were included. In addition, a major operating room procedure must have been indicated on the discharge summary for patients to be included in the final dataset, ensuring that only severe burns requiring complex care were analyzed. Analysis of covariance models was used to evaluate the impact of various patient, hospital, and regional variables on both LOS and cost. The study found that skin grafts and fasciotomy significantly increased the cost of hospitalization. Having burns on the face, neck, and trunk significantly increased costs for patients with second-degree burns, while burns on the trunk resulted in the longest LOS for patients with third-degree burns. Infections in the hospital and additional procedures, such as flaps and skin grafts, also led to longer stays. The study also found that the prevalence of postoperative complications, such as electrolyte imbalance, was high among patients with burn surgery.

Effect of albumin substitution on pharmacokinetics of piperacillin/tazobactam in patients with severe burn injury admitted to the ICU

BACKGROUND

Pathophysiological changes in severely burned patients alter the pharmacokinetics (PK) of anti-infective agents, potentially leading to subtherapeutic concentrations at the target site. Albumin supplementation, to support fluid resuscitation, may affect pharmacokinetic properties by binding drugs. This study aimed to investigate the PK of piperacillin/tazobactam in burn patients admitted to the ICU before and after albumin substitution as total and unbound concentrations in plasma.

PATIENTS AND METHODS

Patients admitted to the ICU and scheduled for 4.5 g piperacillin/tazobactam administration and 200 mL of 20% albumin substitution as part of clinical routine were included. Patients underwent IV microdialysis, and simultaneous arterial plasma sampling, at baseline and multiple timepoints after drug administration. PK analysis of total and unbound drug concentrations under steady-state conditions was performed before and after albumin supplementation.

RESULTS

A total of seven patients with second- to third-degree burns involving 20%-60% of the total body surface were enrolled. Mean (SD) AUC0-8 (h·mg/L) of total piperacillin/tazobactam before and after albumin substitution were 402.1 (242)/53.2 (27) and 521.8 (363)/59.7 (32), respectively. Unbound mean AUC0-8 before and after albumin supplementation were 398.9 (204)/54.5 (25) and 456.4 (439)/64.5 (82), respectively.

CONCLUSIONS

Albumin supplementation had little impact on the PK of piperacillin/tazobactam. After albumin supplementation, there was a numerical increase in mean AUC0-8 of total and unbound piperacillin/tazobactam, whereas similar Cmax values were observed. Future studies may investigate the effect of albumin supplementation on drugs with a higher plasma protein binding.

Application of Phagotherapy in the Treatment of Burn Patients (Review)

Treatment of patients with a burn injury is a complex process involving multicomponent multidirectional intensive therapy of the majority of organs and systems damaged by thermal effects on the skin, alternating with repeated surgical interventions aimed at removing nonviable tissues with subsequent plastic closure of wound defects. After the recovery from the burn shock, local infectious complications are considered to be the leading problem that decelerates the process of recovery and is the main cause of lethal outcomes. Since the skin integrity is broken, microorganisms penetrate readily into the internal environment of the human organism resulting in a septic state with multiple organ failure. A widespread and often uncontrollable use of antibacterial drugs in medical practice has led to the emergence of multiple drug resistance (MDR) in microorganisms. Introduction of drugs made on the basis of bacteriophages into practice is presently becoming increasingly important. This is confirmed by the growing interest in this field of pharmacology, the development of special programs aimed at studying the processes of phage and bacterial cell interaction. This review presents the main types of bacteria pertaining to MDR pathogens, principles of their classification, and the risk factors for infecting patients. The mechanisms of the selective action of phage particles on a bacterial cell and the possibility of using phage therapy in the treatment of burn injury (experimental and clinical data) based on the analysis of foreign literature are demonstrated as well as new positive properties of phages related to the changes in the macroorganism immune status caused by the interaction with bacteriophage particles.

The Effect of Burn Resuscitation Volumes on the Gut Microbiome in a Swine Model

INTRODUCTION

While recent reports underscore the significance of the gut microbiome (GM) in health and disease, its importance in burn outcomes remains unclear. Moreover, aggressive intravenous (IV) fluid resuscitation of patients may alter intestinal flora. Herein, we describe GM changes following a large burn in swine randomized to different volumes of IV Lactated Ringers' (LR).

METHODS

Anesthetized Yorkshire swine sustained 40% total body surface area full-thickness burns and were randomized to different volumes of IV LR: none (n = 5), 15 mL/kg/d (low; n = 6), or 80 mL/kg/d (high; n = 6). At baseline and days 1 and 2, fecal swabs were collected for 16s rDNA sequencing. Proximal jejunum was collected immediately after euthanasia (day 2) for western blot, histopathology, and cytokine analyses.

RESULTS

Burns produced significant shifts in β-diversity and non-significant reductions in α-diversity that did not recover regardless of treatment group. Burn-induced increases in Proteobacteria and decreases in Firmicutes were attenuated by IV fluids in a dose-dependent manner, and also correlated with α-diversity. IV fluids caused a dose-dependent increase in Bacteroides and prevented a transient increase in the opportunistic pathogen Haemophilus parainfluenzae. While high volumes of IV fluids increased intestinal Hsp70 levels (P = 0.0464), they reduced SGLT1 (P = 0.0213) and caspase3 (P = 0.0139) levels. IV fluids elicited a non-specific cytokine response; however, Bacteroidetes levels correlated with intestinal IL18 levels (P = 0.0166, R = 0.4201).

CONCLUSIONS

We present the first report on the gut microbiome in a porcine burn model, and present data to suggest that IV fluids may influence GM and gut functional proteins following a burn. Overall, burn-induced GM diversity shifts may expose diagnostic and/or therapeutic targets to improve outcomes.

The Bactericidal Tandem Drug, AB569: How to Eradicate Antibiotic-Resistant Biofilm Pseudomonas aeruginosa in Multiple Disease Settings Including Cystic Fibrosis, Burns/Wounds and Urinary Tract Infections

The life-threatening pandemic concerning multi-drug resistant (MDR) bacteria is an evolving problem involving increased hospitalizations, billions of dollars in medical costs and a remarkably high number of deaths. Bacterial pathogens have demonstrated the capacity for spontaneous or acquired antibiotic resistance and there is virtually no pool of organisms that have not evolved such potentially clinically catastrophic properties. Although many diseases are linked to such organisms, three include cystic fibrosis (CF), burn/blast wounds and urinary tract infections (UTIs), respectively. Thus, there is a critical need to develop novel, effective antimicrobials for the prevention and treatment of such problematic infections. One of the most formidable, naturally MDR bacterial pathogens is Pseudomonas aeruginosa (PA) that is particularly susceptible to nitric oxide (NO), a component of our innate immune response. This susceptibility sets the translational stage for the use of NO-based therapeutics during the aforementioned human infections. First, we discuss how such NO therapeutics may be able to target problematic infections in each of the aforementioned infectious scenarios. Second, we describe a recent discovery based on years of foundational information, a novel drug known as AB569. AB569 is capable of forming a "time release" of NO from S-nitrosothiols (RSNO). AB569, a bactericidal tandem consisting of acidified NaNO₂ (A-NO₂ ^-) and Na₂-EDTA, is capable of killing all pathogens that are associated with the aforementioned disorders. Third, we described each disease state in brief, the known or predicted effects of AB569 on the viability of PA, its potential toxicity and highly remote possibility for resistance to develop. Finally, we conclude that AB569 can be a viable alternative or addition to conventional antibiotic regimens to treat such highly problematic MDR bacterial infections for civilian and military populations, as well as the economical burden that such organisms pose.

Sepsis Definitions in Burns

Background: Sepsis is the leading cause of death in burns. Despite its importance, sepsis lacks a proper definition. An established definition will lead to early and accurate diagnosis, prompt treatment, and a reduced mortality rate. The aim of this work is to discuss current definitions and to look ahead at novel definitions with clinical implications. Method: A review of the current understanding of sepsis definitions in burns. Results: Adaptation of sepsis definitions in the general population and specific burn definitions have gotten better but still need improvements and, potentially, incorporation of molecular, laboratory, patient-specific, and clinical factors. This work includes the history, evolution, and predictive value of current definitions of sepsis in burns. A review of current and future markers of sepsis and potentially useful definitions are presented. Conclusions: Sepsis definitions have evolved over the last decades and will continue to do so. We believe the best definition in burn patients is the Sepsis-3 that was developed originally for critically ill patients. However, there are several studies investigating more specific definitions with better sensitivity and specificity.

Self-inflicted Burn Injury Is Independently Associated With Increased Mortality in a More Economically Developed Country: A Propensity Score Matching Analysis

Self-inflicted burn accounts for considerable morbidity and mortality in more economically developed countries, and there is a substantial debate regarding the pathophysiological relevance between self-inflicted burns and unfavorable outcomes. To validate whether self-inflicted injury is an independent predictor of high mortality regardless of the severity of burn, they conducted a retrospective observational study using the Japan Trauma Data Bank, a nationwide database including over 200 major tertiary care centers. Among 2006 patients with burn who had arrived at collaborating centers between 2004 and 2016, they included patients aged ≥15 years, those who did not present with cardiopulmonary arrest upon arrival, and those who had ≥10 percent total body surface area burns. Patients with missing survival data or unknown mechanism of injury were excluded. In total, 1094 patients were eligible, of whom 222 (20.3 percent) had self-inflicted burns. The patients were divided into the self-inflicted and non-self-inflicted groups, and propensity score was calculated using the demographic information of the patients, injury variables, time from injury to hospital arrival, and other survival predictors. Via a propensity score matching, 98 pairs were selected, and the self-inflicted group had a higher mortality than the non-self-inflicted group (43.9 vs 28.6 percent, hazard ratio = 1.77; 95% confidence interval = 1.10-2.86; P = .02). Inverse probability weighting and multivariate logistic regression were performed as sensitivity analyses, and results validated that self-inflicted burn was independently associated with increased in-hospital mortality. Therefore, patients with self-inflicted burns should receive judicious management, regardless of burn injury severity.

Five Years Experience With Meek Grafting in the Management of Extensive Burns in an Adult Burn Center

Background

In extensive burn injuries with lack of donor sites for skin grafting, the Meek technique of skin expansion can be an efficient and effective method in covering extensive wounds. The aim of this retrospective study was to present our experience with the Meek technique of grafting.

Methods

We performed a retrospective analysis of patients from our burn center who underwent Meek grafting between 2012 and 2016. Demographics, burn details, clinical course, operative management, and outcomes were collected and analyzed from patient records and operative notes. Outcome measures, including graft take rate, complications and need for further surgery, were recorded.

Results

Twelve patients had Meek grafting. The average age was 38 years (range: 15-66). The average percent total body surface area burned was 54.3% (range: 31%-77%). Eighty-three percent of grafted areas healed well, and no regrafting was necessary. In the remaining 17%, infection and hematoma were the leading cause of graft failure.

Conclusions

Meek grafting constitutes a rapid and efficient surgical approach for the skin coverage of extensive full-thickness burn injuries with limited autograft donor sites.

Enteral resuscitation with oral rehydration solution to reduce acute kidney injury in burn victims: Evidence from a porcine model

Intravenous (IV) resuscitation of burn patients has greatly improved outcomes and become a cornerstone of modern burn care. However, the heavy fluids and vascular access required may not be feasible in austere environments, mass casualty, or delayed transport scenarios. Enteral resuscitation has been proposed for these situations; we sought to examine the effectiveness of this strategy on improving burn-induced kidney injury. Anesthetized Yorkshire swine sustaining 40% TBSA full-thickness contact burns were randomized to three groups (n = 6/group): fluid deprivation, ad libitum water access, or 70 mL/kg/d Oral Rehydration Salt solution (ORS). Urine and blood were collected at baseline (BL), 6, 12, 24, 32, and 48h post-burn, at which point tissue was harvested and CT angiography performed. Although fluid consumption by ad libitum and ORS groups were matched (132±54mL/kg versus 120±24mL/kg, respectively), ORS intake increased urine output compared with water and no water (47.3±9.0 mL/kg versus 16.1±2.5 mL/kg, and 24.5±1.7 mL/kg respectively). Plasma creatinine peaked 6h following burn (1.67±0.07mg/dL) in all animals, but at 48h was comparable to BL in animals receiving water (1.23±0.06mg/dL) and ORS (1.30±0.09mg/dL), but not fluid deprived animals (1.56±0.05mg/dL) (P<0.05). Circulating levels of blood urea nitrogen steadily increased, but also decreased by 48h in animals receiving enteral fluids (P<0.05). Water deprivation reduced renal artery diameter (-1.4±0.17mm), whereas resuscitation with water (-0.44±0.14 mm) or ORS maintained it (-0.63±0.20 mm;P< 0.02). Circulating cytokines IL-1β, IL-6, IFNγ, and GM-CSF were moderately elevated in the fluid-deprived group. Taken together, the data suggest that enteral resuscitation with ORS rescues kidney function following burn injury. Incorporating enteral fluids may improve outcomes in resource-poor environments and possibly reduce IV fluid requirements to prevent co-morbidities associated with over-resuscitation. Studies into different volumes/types of enteral fluids are warranted. While ORS has saved many lives in cholera-associated dehydration, it should be investigated further for use in burn patients.

Digestive decontamination in burn patients: A systematic review of randomized clinical trials and observational studies

OBJECTIVE

The objective of this systematic review is to assess the effect of selective digestive decontamination (SDD) or non-absorbable enteral antibiotics (EA) on mortality, the incidence of infection and its adverse effects in burn patients.

MATERIAL AND METHODS

Systematic review of randomized clinical trials (RCT) or observational studies enrolling burn patients, and comparing SDD or EA prophylaxis with placebo or no treatment. The search includes Pubmed/Medline, EMBASE, WOS, Cochrane Library (1970-2015). Bibliographic references were also reviewed, as well as communications presented at conferences (2012-2015), without language restrictions. Two reviewers inspected each reference identified by the search independently; the risk of bias was assessed with the Cochrane Collaboration method for RCT and the Newcastle Ottawa Scale for observational studies.

RESULTS

Five RCT and 5 observational studies were identified enrolling a total of 1680 patients. The overall methodological quality of the studies was poor. The pooled effect of RCT using EA was OR: 0.62 (95% CI: 0.20-1.94). The only RCT using SDD reported OR 0.20 (95% CI: 0.09-0.81). The incidence of Enterobacteriaceae bloodstream was lower in cases treated with SDD or EA. The incidence of pneumonia was only reduced in the studies using SDD. None of the studies reported an increase in antibiotic resistance but in one RCT SDD was associated to an increase in methicillin-resistant Staphylococcus aureus infections, that was controlled with enteral vancomycin.

CONCLUSIONS

SDD and EA have shown a beneficial effect in burn patients. Both practices are safe. Higher quality RCTs should be conducted to properly assess the efficacy and safety of SDD in this population.

Timeline of health care-associated infections and pathogens after burn injuries

BACKGROUND

Infections are an important cause of morbidity and mortality after burn injuries. Here, we describe the time line of infections and pathogens after burns.

METHODS

A retrospective study was performed in a large tertiary care burn center from 2004-2013. Analyses were performed on health care-associated infections (HAIs) meeting Centers for Disease Control and Prevention criteria and on all positive cultures. Incidence rates per 1,000 days were calculated for specific HAI categories and pathogens and across hospitalization time (week 1, weeks 2-3, and week ≥4).

RESULTS

Among 5,524 patients, the median burn size was 4% of total body surface area (interquartile range, 2%-10%). Of the patients, 7% developed an HAI, of whom 33% had >1 HAI episode. Gram-positive bacteria were isolated earlier, and gram-negative bacteria were isolated later during hospitalization. Of 1,788 bacterial isolates, 44% met criteria for multidrug resistance, and 23% met criteria for extensive drug resistance. Bacteria tended to become increasingly resistant to antibiotics as time from admission increased.

CONCLUSIONS

We observed differences in infection type, pathogen, and antibiotic-resistant bacterium risk across time of hospitalization. These results may guide infection prevention in various stages of the postburn admission.

Extra-large negative pressure wound therapy dressings for burns - Initial experience with technique, fluid management, and outcomes

OBJECTIVE

The use of negative-pressure-wound-therapy (NPWT) is associated with improved outcomes in smaller burns. We report our experience using extra-large (XL) NPWT dressings to treat ≥15% total body surface area (TBSA) burned and describe our technique and early outcomes. We also provide NPWT exudate volume for predictive fluid resuscitation in these critically ill patients.

METHODS

We retrospectively reviewed patients treated with XL-NPWT from 2012 to 2014. Following excision/grafting, graft and donor sites were sealed with a layered NPWT dressing. We documented wound size, dressing size, NPWT outputs, graft take, wound infections, and length of stay (LOS). Mean NPWT exudate volume per %TBSA per day was calculated.

RESULTS

Twelve burn patients (mean TBSA burned 30%, range 15-60%) were treated with XL-NPWT (dressing TBSA burned and skin graft donor sites range 17-44%). Average graft take was 97%. No wound infections occurred. Two patients had burns ≥50% TBSA and their LOS was reduced compared to ABA averages. XL-NPWT outputs peaked at day 1 after grafting followed by a steady decline until dressings were removed. Average XL-NPWT dressing output during the first 5 days was 101±66mL/%BSA covered per day. 2 patients developed acute kidney injury.

CONCLUSION

The use of XL-NPWT to treat extensive burns is feasible with attention to application technique. NPWT dressings appear to improve graft take, and to decrease risk of infection, LOS, and pain and anxiety associated with wound care. Measured fluid losses can improve patient care in future applications of NPWT to large burn wounds.

The characteristics and correlation between the ischemia-reperfusion and changes of redox status in the early stage of severe burns

OBJECTIVE

Both the ischemia-reperfusion injury and the abnormal changes of redox status are the important pathologic changes in the burn shock stage for severe burns. The study of clinical dynamic, quantitative relevance about them was performed.

METHODS

In this study, blood redox potential (ORP) values (ΔORP value was adopted, as the quantitative index to reflect the overall redox status), plasma uric acid levels (important antioxidant, as antioxidant index), and the burn shock state-related indicators (lactic acid and hematocrit) of 48 burn patients were dynamically, quantitatively monitored during the early stage after injury.

RESULTS

The results revealed that the duration of abnormal fluctuation of redox status in the early stage of severe burns was longer than that of the traditional clinical shock stage (2-3 days). The changes of overreduction soon after injury were closely related to the hypovolemia-related hypoxia, and the following overoxidation status was consistent with the pathophysiological changes related to the reperfusion, and the degrees of variation were closely related to the severity of burn injury and prognosis. Moreover, early surgery (3 days after injury) had no significant influence on the changing trend of abnormal redox status in the early stage of severe burns.

CONCLUSION

The ischemia-reperfusion injury caused by burn shock appears the main factor contributing to the abnormal biphasic changes of redox status in the early stage of severe burns. Our findings provide useful information for the redox regulation treatment for burn shock.

Burn plus lipopolysaccharide augments endoplasmic reticulum stress and NLRP3 inflammasome activation and reduces PGC-1α in liver

Extensively burned patients often suffer from sepsis (especially caused by Pseudomonas aeruginosa), which may prolong metabolic derangement, contribute to multiple organ failure, and increase mortality. The molecular and cellular mechanisms of such infection-related metabolic derangement and organ dysfunction are unclear. We have previously shown that severely burned patients have significant and persisting hepatic endoplasmic reticulum (ER) stress. We hypothesized that ER stress and the unfolded protein response correlate with NOD-like receptor, pyrin domain containing 3 (NLRP3) inflammasome activation in burn. These may trigger profound metabolic changes in the liver, which form the pathological basis of liver damage and liver dysfunction after burn injury. A two-hit rat model was established by a 60% total body surface area scald burn and intraperitoneal injection of P. aeruginosa-derived lipopolysaccharide (LPS) 3 days after burn. One day later, animals were killed, and liver tissue samples were collected for gene expression and protein analysis of NLRP3 inflammasome activation, ER stress, and glucose and lipid metabolism. Liver damage was assessed by plasma markers (alanine aminotransferase and aspartate aminotransferase) and liver immunohistochemical analysis. Our results showed that burn injury and LPS injection induced inflammasome activation in liver and augmented hepatic ER stress and liver damage. Although there was an increased metabolic demand after burn, hepatic NLRP3 inflammasome activation corresponded to inhibition of PGC-1α (peroxisome proliferator-activated receptor γ-coactivator 1α) and its upstream regulators protein kinase A catalyst unit, AMP-activated protein kinase α, and sirtuin-1 may provide a mechanism for the enhanced metabolic derangement after major burn injury plus sepsis. In conclusion, burn + LPS augments inflammasome activation and ER stress in liver, which in turn contribute to postburn metabolic derangement.

Topical application of ALK5 inhibitor A-83-01 reduces burn wound contraction in rats by suppressing myofibroblast population

Burn scar contracture that follows the healing of deep dermal burns causes severe deformation and functional impairment. However, its current therapeutic interventions are limited with unsatisfactory outcomes. When we treated deep second-degree burns in rat skin with activin-like kinase 5 (ALK5) inhibitor A-83-01, it reduced wound contraction and enhanced the area of re-epithelialization so that the overall time for wound closing was not altered. In addition, it reduced myofibroblast population in the dermis of burn scar with a diminished deposition of its biomarker proteins such as α-SMA and collagen. Treatment of rat dermal fibroblast with A-83-01 inhibited transforming growth factor-β1 (TGF-β1)-dependent induction of α-SMA and collagen type I. Taken together, these results suggest that topical application of ALK5 inhibitor A-83-01 could be effective in preventing the contraction of burn wound without delaying the wound closure by virtue of its inhibitory activity against the TGF-β-induced increase of myofibroblast population.