Clinical review: the critical care management of the burn patient

Selective enzymatic debridement and modified Meek technique in the treatment of extensive burns: Preliminary observations

Background

Selective bromelain-based enzymatic debridement (BED) has emerged as a valid alternative for the treatment of extensive burns, with Total Body Surface Area (TBSA) > 20%. Autologous skin grafting represents the procedure of choice but the scarcity of donor sites remains the main reconstructive challenge. The modified Meek micro-grafting technique may represent a valid strategy to optimize the final outcome.

Methods

A single-cohort retrospective analysis was performed, involving nine burn patients (TBSA > 20%) who underwent both BED and subsequently modified Meek technique. Demographic and clinical data (mechanism of injury, surgical treatment, complications, necessity of re-grafting, further surgery and esthetic outcome) were collected.

Results

All patients had large burns of mixed and deep dermal thickness (first, second, and third degree). All burns were enzymatically debrided postadmission and covered by the modified Meek technique. Local infection due to poor general conditions was the main complication for all patients. All but two patients survived. The selectiveness of the enzymatic debridement and dermal preservation seemed to improve the quality of scars resulting from micro-grafting. Evaluations performed at 12 ± 2 months postburn showed superior scar quality compared to areas treated with traditional (sheet/mesh) grafts.

Conclusion

Combined BED and Meek techniques may provide an effective synergic combination for the treatment of extensive burns.

Anti factor Xa monitoring for venous thromboprophylaxis in severely burn-injured patients: A systematic review

INTRODUCTION

Patients with severe burn injuries are at risk of venous thromboembolism (VTE) and associated sequelae. Burn-injured patients may require larger doses of VTE prophylaxis so underdosing may occur with standard regimens. Monitoring anti-factor Xa (AFXa) levels may allow tailoring of dosage but is currently uncommon. The purpose of this systematic review was to methodically review the available literature with respect to AFXa in severe burn-injured patients, and thereby assess its efficacy.

METHODS

Using PRISMA guidelines, "Xa" and "burns" were used to systematically review MEDLINE (1946 - present) and EMBASE (1974 - present) databases for publications regarding the monitoring of AFXa levels for thromboprophylaxis in burn-injured patients.

RESULTS

Eight studies (432 patients) met inclusion. Peak AFXa level at initial measurement was reported in all studies and was within the range for prophylaxis in 184 of 432 cases (42.6%), below range in 246 of 432 cases (56.9%) and above range for 2/432 (0.5%). Complications were reported in 7 studies (412 patients), with a total of 30 (7.3%) complications, comprising of 16 (53.3%) VTE events and 14 (46.7%) mortalities. Three studies comprising 270 patients compared complications between patients who were within the reference range with patients who were below the range. There were 164 patients from the 'within the reference range' groups that had a total of 6 (3.7%) complications, comprised of 4 (66.7%) VTE events and 2 (33.3%) mortalities. There were 106 patients from the 'below reference range group' that had a total of 11 (10.4%) complications, comprised of 9 (81.8%) VTE events and 2 (18.2%) mortalities.

CONCLUSION

Our findings suggest standard prophylactic anticoagulation dosing risks underdosing and therefore, an increased risk in the development of VTE. AFXa monitoring allows individually tailored dose adjustment to reach therapeutic levels, which may be efficacious in reducing VTE events and is therefore recommended where possible.

The incidence of cancer following hospitalisation for a burn injury in Scotland 2009-2019: A retrospective cohort study

BACKGROUND

Studies suggest increased occurrence of cancer in persons who have experienced a burn injury with hospital admission.

OBJECTIVE

To determine the incidence of cancer among those hospitalised for burn injuries in Scotland compared with a similar group without a history of burn injury hospitalisation.

METHOD

A retrospective cohort design was used to compare cancer (ICD10 C00-97, excluding C44) incidence in two groups: 6805 burn injury patients discharged from Scottish hospitals between 2009 and 2019, and 25,946 subjects from the general population who were matched to burn patients by sex, year of birth, and degree of social deprivation. Cancer incidence was identified from the Scottish cancer registry. Cox proportional hazard regression was used to model time to cancer incidence adjusting for age, sex, degree of deprivation and presence of a comorbidity. Cancer risk was presented as standardised incidence ratios (SIRs) and hazard ratios (HR).

RESULTS

We found a higher prevalence of pre-existing conditions, particularly alcohol abuse among patients with burns. Pre-existing cancers were more common in the burn cohort (3.5%) than the comparison group (1.7%) and were excluded from further analysis. Over a median follow-up of 4-5 years, a total of 236 (3.5%) burn patients and 969 (3.7%) persons in the comparison group were diagnosed with cancer. At 0-6 months the cancer SIR for burn patients was 1.88 95% CI (1.40-2.52). After excluding the first six months of follow-up, the overall incidence of cancer was marginally elevated in burn patients (SIR 1.04, 95% CI 0.90-1.19, p = 0.62) and not statistically different from the incidence in comparison subjects (adjusted HR 1.03, 95% CI 0.88-1.21, p = 0.71).

CONCLUSIONS

Patients that suffer burn injury have a higher incidence of cancer than the general population and a group matched by age, sex and degree of deprivation. A higher incidence of adverse health-related behaviours such as smoking, alcohol use and pre-existing health conditions among many patients that suffer a burn most likely explain this observed increase. Any persisting inflammatory or immune dysfunction following burn injury is unlikely to account for the increase in cancers in this study.

Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care

Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.

Coenzyme Q10 supplementation in burn patients: a double-blind placebo-controlled randomized clinical trial

BACKGROUND

Burn injuries are important medical problems that, aside from skin damage, cause a systemic response including inflammation, oxidative stress, endocrine disorders, immune response, and hypermetabolic and catabolic responses which affect all the organs in the body. The aim of this study was to determine the effect of coenzyme Q10 (CoQ10) supplementation on inflammation, oxidative stress, and clinical outcomes in burn patients.

METHODS

In a double-blind placebo-controlled randomized clinical trial, 60 burn patients were randomly assigned to receive 100 mg CoQ10 three times a day (total 300 mg/day) or a placebo for 10 days. Inflammatory markers including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), oxidative stress markers including total antioxidant capacity (TAC), malondialdehyde (MDA) and superoxide dismutase (SOD) activity, fasting blood glucose (FBG), blood urea nitrogen (BUN), creatinine, white blood cells (WBC), and body temperature were assessed as primary outcomes and albumin, prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), other hematological parameters, blood pressure, O2 saturation, ICU duration, and 28-mortality rate were assessed as secondary outcomes.

RESULTS

Fifty-two participants completed the trial. CRP and ESR levels were not significantly different between CoQ10 and placebo groups at the end of the study (P = 0.550 and P = 0.306, respectively). No significant differences between groups were observed for TAC (P = 0.865), MDA (P = 0.692), and SOD activity (P = 0.633) as well. Administration of CoQ10 resulted in a significant increase in albumin levels compared to placebo (P = 0.031). There was no statistically significant difference between the two groups in other measured outcomes (P > 0.05).

CONCLUSION

Results showed that in patients with burn injury, CoQ10 administration had no effect on inflammatory markers and oxidative stress, although serum albumin levels were improved after supplementation. Further studies with albumin as the primary outcome are needed to confirm this finding.

Multidisciplinary staff perceived barriers and enablers to early mobilization of patients with burns in the ICU

BACKGROUND

Complex challenges face clinicians managing critically ill patients with burns, particularly in the context of enhancing outcomes after a stay in ICU. Compounding this, a dearth of research explores the specific and modifiable factors that impact early mobilization in the ICU environment.

AIM

To explore the barriers and enablers of early functional mobilization for patients with burns in the ICU from a multidisciplinary perspective.

DESIGN

A qualitative phenomenological study.

METHODS

Semi-structured interviews supplemented by online questionnaires conducted with 12 multidisciplinary clinicians (four doctors, three nurses and five physical therapists) who previously managed burn patients at a quaternary level ICU. Data were thematically analysed.

RESULTS

Four main themes: patient, ICU clinicians, the workplace and the physical therapist were identified as impacting on early mobilization. Subthemes identified barriers or enablers to mobilization but all were strongly influenced by overarching theme of the clinician's "emotional filter." Barriers included high levels of pain, heavy sedation and low levels of clinician exposure to treating patients with burns. Enablers included higher levels of clinician's experience and knowledge about burn management and benefits of early mobilization; increased coordinated staff resources when undertaking mobilization; and, open communication and positive culture towards early mobilization across the multidisciplinary team.

CONCLUSION

Patient, clinician and workplace barriers and enablers were identified to influencing the likelihood of achieving early mobilization of patients with burns in the ICU. Emotional support for staff through multidisciplinary collaboration and development of structured burns training program were key recommendations to address barriers and strengthen enablers to early mobilization of patients with burns in the ICU.

Pharmacological YAP activation promotes regenerative repair of cutaneous wounds

Chronic cutaneous wounds remain a persistent unmet medical need that decreases life expectancy and quality of life. Here, we report that topical application of PY-60, a small-molecule activator of the transcriptional coactivator Yes-associated protein (YAP), promotes regenerative repair of cutaneous wounds in pig and human models. Pharmacological YAP activation enacts a reversible pro-proliferative transcriptional program in keratinocytes and dermal cells that results in accelerated re-epithelization and regranulation of the wound bed. These results demonstrate that transient topical administration of a YAP activating agent may represent a generalizable therapeutic approach to treating cutaneous wounds.

Aberrant inflammatory responses in intoxicated burn-injured patients parallel impaired cognitive function

Burn-injured patients with alcohol use disorder (AUD) have increased morbidity and mortality compared to alcohol-abstaining individuals with similar injuries. It is hypothesized that this is due, in part, to alcohol-induced dysregulation of the systemic inflammatory response, leading to worsened clinical outcomes, including increased susceptibility to infection, and heightened cognitive impairment. To examine the effects of alcohol on inflammatory markers after burn injury, we used multiplex assays to measure a panel of 48 cytokines, chemokines, and growth factors in the plasma of burn patents within 24 h of admission to the University of Colorado Burn Center. Thirty patients were enrolled between July 2018 to February 2020 and were stratified based on presence of AUD and total body surface area (TBSA) burn of ≥20% into four groups: [AUD-, TBSA <20%, N = 12], [AUD+, TBSA <20%, N = 3], [AUD-, TBSA ≥20%, N = 8], [AUD+, TBSA ≥20%, N = 7]. In addition, Confusion Assessment Method (CAM) scores were collected to evaluate patient delirium during the course of hospitalization. Multivariate statistical analysis demonstrated a number of cytokines and other factors that were significantly different between the groups. For example, the anti-inflammatory cytokine interleukin 1 receptor antagonist (IL-1ra) was dampened in the AUD+, TBSA ≥20% cohort with a 75.2% decrease compared to AUD-, TBSA ≥20%, and an 83.9% decrease compared to AUD-, TBSA <20% (p = 0.008). Additionally, plasma levels of the pro-inflammatory mediator CXCL12 (C-X-C motif chemokine ligand 12, also known as stromal cell-derived factor 1, SDF-1) was higher in the AUD + groups (p = 0.03) and similarly, IL-18 levels were greater in AUD+, TBSA ≥20% (p = 0.009). Eotaxin (also known as cytokine CC motif ligand 11, CCL11) was markedly elevated in the AUD+, TBSA ≥20% cohort with a 2.4-fold increase over the AUD-, TBSA ≥20%, and a 1.7-fold rise compared to the AUD-, TBSA <20% cohorts (p = 0.04). Interestingly, there was also a marked rise in CAM + delirium scores (85.7%) among the AUD + patients with TBSA ≥20% (p = 0.02). Not surprisingly, we found that hospital stays increased with AUD+ and larger burns (p = 0.0009). Our findings reveal that burn patients who misuse alcohol have aberrant inflammatory responses that may lead to greater immune dysregulation and worse clinical outcomes.

ARAG, an Antioxidant-Rich Gel, Shows Superiority to Mepilex Ag in the Treatment of Deep Partial Thickness Burns without Sacrificing Antimicrobial Efficiency

Current treatments for deep tissue burns are limited, and most serve only to enhance hydration or prevent bacterial growth. This leaves burn healing dependent on slow natural processes to debride the wound and reestablish the epidermal and dermal layers of the skin. Infections are well known to destabilize this process through a variety of mechanisms, most notably through increased inflammation and the resulting oxidative stress. In this study, we show that ARAG (an antioxidant-rich antimicrobial gel) can suppress the growth of multiple bacteria commonly found to infect burns (Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa, and Staphylococcus aureus). This inhibition is comparable to that conferred by silver ion release from burn dressings such as Mepilex-Ag. We further show, using a porcine model for deep partial-thickness burns, that ARAG allows for enhanced wound healing over Mepilex-Ag, the current standard of care. Histological findings indicate this is likely due to increased wound debridement and dampening of late inflammatory processes, leading to more balanced physiologic healing. Taken together, these findings show promise for ARAG as a superior alternative to the current standard of care.

Reducing Blood Loss in a Burn Care Unit: A Review of Its Key Determinants

Patients with a major burn injury differ considerably from the typical critical ill and trauma population. Very often, burn patients suffer from anemia throughout their hospital stay. This is caused both by combination of persistent blood loss with decreased erythropoiesis. Therefore, burn patients do have major transfusion requirements. However, transfusion is not devoid of risks or costs. We hereby review the best surgical techniques and medical approaches, aiming to reduce blood loss in a burn patient and optimize red cell production, so that we can reduce the need of RBC transfusion. The implementation of a combination of surgical techniques aiming to reduce blood loss and medical care approaches to prevent anemia, rather than single attitudes, should be adopted in burn care. There is an urgent need for clear guidelines that can easily be accepted, applied, and spread across different burn units to methodically implement measures to reduce blood loss and transfusion needs, and ultimately improve burn patients' outcome and the health care financial status.

Burns: Classification, Pathophysiology, and Treatment: A Review

Burns and their treatment are a significant medical problem. The loss of the physical barrier function of the skin opens the door to microbial invasion and can lead to infection. The repair process of the damage caused by the burn is impaired due to the enhanced loss of fluids and minerals through the burn wound, the onset of hypermetabolism with the concomitant disruption of nutrient supply, and derangements in the endocrine system. In addition, the initiated inflammatory and free radical processes drive the progression of oxidative stress, the inhibition of which largely depends on an adequate supply of antioxidants and minerals. Clinical experience and research provide more and more data to make the treatment of patients with thermal injury increasingly effective. The publication discusses disorders occurring in patients after thermal injury and the methods used at various stages of treatment.

Does early excision or skin grafting of severe burns improve prognosis? A retrospective cohort study

The present study aimed to investigate the appropriate timing of excision or skin grafting of burn wounds in patients with severe burns. We retrospectively analyzed data from the Diagnosis Procedure Combination Database, a nationwide inpatient database in Japan. Patients with severe burns (burn index ≥10) who underwent excision or skin grafting within 7 days from September 2010 to March 2019 were included. We defined the early surgery group as patients who underwent excision or skin grafting within 2 days of admission and the delayed surgery group as those who underwent surgery within 3-7 days of admission. Propensity score matching was used to compare the in-hospital mortality between the two groups, yielding a cohort of 389 pairs. A total of 2362 eligible patients were categorized into the early surgery group (n = 626) and delayed surgery group (n = 1736). The overall in-hospital mortality was 19.6%. In-hospital mortality did not differ significantly between the early surgery (15.9%) and the delayed surgery groups (17.2%; p = 0.70). These results suggest that excision or skin grafting within 2 days of admission was not associated with improved in-hospital mortality compared with surgery thereafter for patients with severe burns.

Prospective study and validation of early warning marker discovery based on integrating multi-omics analysis in severe burn patients with sepsis

Background

Early detection, timely diagnosis and rapid response are essential for case management and precautions of burn-associated sepsis. However, studies on indicators for early warning and intervention have rarely been conducted. This study was performed to better understand the pathophysiological changes and targets for prevention of severe burn injuries.

Methods

We conducted a multi-center, prospective multi-omics study, including genomics, microRNAomics, proteomics and single-cell transcriptomics, in 60 patients with severe burn injuries. A mouse model of severe burn injuries was also constructed to verify the early warning ability and therapeutic effects of potential markers.

Results

Through genomic analysis, we identified seven important susceptibility genes (DNAH11, LAMA2, ABCA2, ZFAND4, CEP290, MUC20 and ENTPD1) in patients with severe burn injuries complicated with sepsis. Through plasma miRNAomics studies, we identified four miRNAs (hsa-miR-16-5p, hsa-miR-185-5p, hsa-miR-451a and hsa-miR-423-5p) that may serve as early warning markers of burn-associated sepsis. A proteomic study indicated the changes in abundance of major proteins at different time points after severe burn injury and revealed the candidate early warning markers S100A8 and SERPINA10. In addition, the proteomic analysis indicated that neutrophils play an important role in the pathogenesis of severe burn injuries, as also supported by findings from single-cell transcriptome sequencing of neutrophils. Through further studies on severely burned mice, we determined that S100A8 is also a potential early therapeutic target for severe burn injuries, beyond being an early warning indicator.

Conclusions

Our multi-omics study identified seven susceptibility genes, four miRNAs and two proteins as early warning markers for severe burn-associated sepsis. In severe burn-associated sepsis, the protein S100A8 has both warning and therapeutic effects.

Identification of ferroptosis-related genes and predicted overall survival in patients with burns

Introduction

Burns are a common trauma associated with considerable mortality and morbidity. Although a lot is known regarding burns' pathogenesis, the involvement of ferroptosis is uncertain. Here, we aimed to explore vital ferroptosis-related genes and molecules in burns, through bioinformatics analysis, to uncover new effective therapeutic targets.

Methods

The FerrDb database was used to acquire ferroptosis-related genes and GSE19743 was downloaded from Gene Expression Omnibus (GEO), a dataset with analysis of control and burned individuals. Hub genes were selected with Cytoscape software, and Gene Ontology (GO), and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were conducted. Cox proportional hazard function and Kaplan-Meier survival analyses were implemented to screen prognosis-related genes. Additionally, the miRWalk database was used to acquire the miRNAs relevant to our hub genes function and analyzed for enrichment.

Result

We identified 64 differentially expressed genes and through the intersection with ferroptosis-related genes, 10 were selected as hub genes. GO analysis revealed that the hub genes' most enriched activities were response to oxidative stress, pyridine-containing compound metabolic processes, and reactive oxygen species metabolic processes. KEGG pathways' analysis showed that these overlapped genes were enriched in several pathways, namely, in VEGF signaling. Furthermore, the molecular miRNA functions significantly enriched were signal transduction and cell communication, namely, the biological pathways of the glypican pathway and the ErbB receptor signaling network. SLC40A1 and GPT2 genes were found to be associated with overall survival, suggesting an important role in burn prognosis.

Discussion

This study may improve our understanding of the underlying burn mechanisms and provide a new direction for the prevention of poor outcomes, advances in burns treatment, and drug development.

Adherence to Burn Resuscitation Guidelines Reduces Resuscitation Fluids and Mortality

In our province, regional recommendations for optimal fluid resuscitation were published in 2011 to improve the management of acute burn patients prior to transfer to a specialized burn center. The purpose of this study was to determine compliance with these provincial burn resuscitation guidelines and their subsequent impact on patient outcomes. A retrospective review of patients transferred to the provincial burn center after being initially managed at peripheral sites was performed from 2011 to 2019. Patients were included if their burn injury was greater than 20% TBSA and they were transferred within 24 hours postburn injury. Charts were reviewed for the amount of fluid patients received and resuscitation associated outcomes. A total of 72 patients met the inclusion criteria, 37 of which were treated in accordance with the 2011 guidelines. For patients that followed the 2011 provincial guidelines, they received on average 3.2 cc/kg/TBSA of fluid during the first 24 hours postburn injury. Significantly more fluids were given when guidelines were not followed with an average of 4.4 cc/kg/TBSA (P = .03). Mortality rates were found to be significantly lower during the primary admission with guidelines compliance (16.2% vs 2.7%, P = .04). No significant differences were found between the remaining evaluated complications including abdominal compartment syndrome (8.1% vs 2.7%) and need for escharotomy (35.2% vs 21.6%). The use of clinical practice guidelines decreased excess IV fluid administration in additional to decreasing mortality rates for patients initially assessed in peripheral low volume centers.

A practical formula for fluid resuscitation in acute paediatric burns in a low resource setting: A pilot study

BACKGROUND

Appropriate fluid resuscitation of acute burn injury is critical and there are recognized challenges with fluid resuscitation, including those with relevance to low resource settings. We developed a practical protocol that guides burn resuscitation and sought to evaluate the safety of our modified resuscitation formula through a small pilot study that particularly addresses the problems we have experienced in a low resource setting.

METHODS

Children with burns more than 15% total body surface area admitted within 24 h of injury to Edendale Hospital between 1 June 2021 and 31 August 2021 were included. The resuscitation formula used was 2 mls of Ringers Lactate per bodyweight in kilograms per% total body surface area (TBSA) given over 24 h and adjusted according to urine output. Data analysed included age, weight, mechanism, TBSA, hours post burn at presentation to hospital, total fluid given in the first 24 h of admission, total urine output in the first 24 h of admission, number of fluid adjustments made during the first 24 h and complications related to fluid resuscitation.

RESULTS

Ten children were included. The median age was 3 (IQR 2-5) years old, with a mean weight of 14.9 (SD 5.07) kilograms, a median TBSA of 17.4 (IQR 16-26)%, presenting at a median of 12 (6.5-18) hours post burn injury. Mechanism of burn was scald in all cases, with 9 being hot water and hot food in one. In the first 24 h a mean of 2.05 (SD 0.58) mls/kg of fluid was received with a mean urine output of 1.66 (SD 0.57) mls/kg/hr.

CONCLUSION

The results of this pilot study to evaluate the safety of our protocol seem reasonable. It is limited by the lack of larger injuries as well as adult patients and a larger prospective study is pertinent.

Early expression of IL-10, IL-12, ARG1, and NOS2 genes in peripheral blood mononuclear cells synergistically correlate with patient outcome after burn injury

BACKGROUND

No methods exist to rapidly and accurately quantify the immune insult created by burn injuries. The development of a rapid, noninvasive clinical biomarker assay that evaluates a burn patient's underlying immune dysfunction and predicts clinical outcomes could transform burn care. We aimed to determine a set of peripheral biomarkers that correlates with clinical outcomes of burn patients.

METHODS

This prospective observational study enrolled two patient cohorts within a single burn center into an institutionally approved institutional review board study. Blood draws were performed <48 hours after injury. Initial unbiased immune gene expression analysis compared 23 burn patients and 6 healthy controls using multiplex immune gene expression analysis of RNA from peripheral blood mononuclear cells. We then performed confirmatory outcomes analysis in 109 burn patients and 19 healthy controls using a targeted rapid quantitative polymerase chain reaction. Findings were validated and modeled associations with clinical outcomes using a regression model.

RESULTS

A total of 149 genes with a significant difference in expression from burn patients compared with controls were identified. Pathway analysis identified pathways related to interleukin (IL)-10 and inducible nitric oxide synthase signaling to have significant z scores. quantitative polymerase chain reaction analysis of IL-10, IL-12, arginase 1 (ARG1), and inducible nitric oxide synthase demonstrated that burn injury was associated with increased expression of ARG1 and IL-10, and decreased expression of nitric oxide synthase 2 (NOS2) and IL-12. Burn severity, acute lung injury, development of infection, failure of skin autograft, and mortality significantly correlated with expression of one or more of these genes. Ratios of IL-10/IL-12, ARG1/NOS2, and (ARG1-IL-10)/(NOS2-IL-12) transcript levels further improved the correlation with outcomes. Using a multivariate regression model, adjusting for patient confounders demonstrated that (ARG1-IL-10)/(NOS2-IL-12) significantly correlated with burn severity and development of acute lung injury.

CONCLUSION

We present a means to predict patient outcomes early after burn injury using peripheral blood, allowing early identification of underlying immune dysfunction.

LEVEL OF EVIDENCE

Prognostic/Epidemiological; Level II.

miR-181c, a potential mediator for acute kidney injury in a burn rat model with following sepsis

BACKGROUND

The miRNA profile is changed after burn or sepsis and is involved in regulating inflammatory reactions. However, the function and molecular mechanism of miRNAs in regulating burn sepsis-induced acute kidney injury (AKI) are still unclear.

METHODS

In this study, animal and cell sepsis models were established after burned rats were injected with lipopolysaccharide (LPS) or NRK-52E cells treated with LPS, respectively. Cytokine expression, inflammatory cell infiltration, serum creatinine (Scr) and kidney injury molecule-1 (KIM-1) levels were analysed after the indicated treatments.

RESULTS

Burn sepsis increased the expression of inflammatory factors (TNF-α and IL-1β) and chemokines (MIP-1α, MIP-2 and MCP-1). Moreover, burn sepsis promoted macrophage and neutrophil infiltration into the kidney and upregulated the levels of Scr and KIM-1 in the kidney and urine. Ectopic expression of miR-181c significantly reduced LPS-induced TLR4 protein expression, suppressed KIM-1 mRNA levels and subsequently inhibited the activation of inflammatory genes (TNF-α and IL-1β) and chemokine genes (MIP-1α, MIP-2 and MCP-1).

CONCLUSIONS

Our results demonstrated that miR-181c could suppress TLR4 expression, reduce inflammatory factor and chemokine secretion, mitigate inflammatory cell infiltration into the kidney and downregulate KIM-1 expression, which might ultimately attenuate burn sepsis-induced AKI.

Characterization of the Basal and mTOR-Dependent Acute Pulmonary and Systemic Immune Response in a Murine Model of Combined Burn and Inhalation Injury

Severe burn injury leads to a cascade of local and systemic immune responses that trigger an extreme state of immune dysfunction, leaving the patient highly susceptible to acute and chronic infection. When combined with inhalation injury, burn patients have higher mortality and a greater chance of developing secondary respiratory complications including infection. No animal model of combined burn and inhalation injury (B+I) exists that accurately mirrors the human clinical picture, nor are there any effective immunotherapies or predictive models of the risk of immune dysfunction. Our earlier work showed that the mechanistic/mammalian target of rapamycin (mTOR) pathway is activated early after burn injury, and its chemical blockade at injury reduced subsequent chronic bacterial susceptibility. It is unclear if mTOR plays a role in the exacerbated immune dysfunction seen after B+I injury. We aimed to: (1) characterize a novel murine model of B+I injury, and (2) investigate the role of mTOR in the immune response after B+I injury. Pulmonary and systemic immune responses to B+I were characterized in the absence or presence of mTOR inhibition at the time of injury. Data describe a murine model of B+I with inhalation-specific immune phenotypes and implicate mTOR in the acute immune dysfunction observed.

Music therapy and music medicine interventions with adult burn patients: A systematic review and meta-analysis

BACKGROUND

Pain is one of the most common and most difficult symptoms to manage in adult burn patients in the Intensive Care Unit (ICU). Insufficient or unsuccessful pain management can negatively affect physiological, psychological, and social health in burn patients, both during and after hospitalization. Music therapy and music medicine interventions have been shown to positively affect pain and mental health in this population. This systematic review and meta-analysis provide an update of Randomized Controlled Trials (RCTs) using music therapy or music medicine interventions in adult burn patients.

METHODS

A variety of databases were searched from their beginning to June 2020, including PsycINFO and PsycArticles (via APAsycNET), PubMed and MEDLINE (via OvidSP), Scopus, Web of Science, and the Cochrane Library. Data of all articles meeting the inclusion criteria were extracted, organized, and processed according to the PRISMA guidelines. Statistical analysis was performed using Q-test and I2 statistics.

RESULTS

10 RCTs with a total of 1061 participants were included. The results of the meta-analysis showed a statistically significant reduction of pain (I² = 96.03%, P < 0.001), anxiety (I² = 98.85%, P < 0.002), and improved relaxation (I² = 87.19%, P < 0.001) favoring music interventions compared to control groups.

CONCLUSIONS

This review provides preliminary evidence for the effectiveness of music interventions for adult burn patients. However, more high-quality RCTs are needed to safely establish guidelines for music therapists and other health care professionals in using music for health purposes with this population.

Patient-centred outcomes are under-reported in the critical care burns literature: a systematic review

BACKGROUND

Developments in the care of critically ill patients with severe burns have led to improved hospital survival, but long-term recovery may be impaired. The extent to which patient-centred outcomes are assessed and reported in studies in this population is unclear.

METHODS

We conducted a systematic review to assess the outcomes reported in studies involving critically ill burns patients. Randomised controlled trials (RCTs) and cohort studies on the topics of fluid resuscitation, analgesia, haemodynamic monitoring, ventilation strategies, transfusion targets, enteral nutrition and timing of surgery were included. We assessed the outcomes reported and then classified these according to two suggested core outcome sets.

RESULTS

A comprehensive search returned 6154 studies; 98 papers met inclusion criteria. There were 66 RCTs, 19 clinical studies with concurrent controls and 13 interventional studies without concurrent controls. Outcome reporting was inconsistent across studies. Pain, reported using the visual analogue scale, fluid volume administered and mortality were the only outcomes measured in more than three studies. Sixty-six studies (67%) had surrogate primary outcomes. Follow-up was poor, with median longest follow-up across all studies 5 days (IQR 3-28). When compared to the suggested OMERACT core outcome set, 53% of papers reported on mortality, 28% reported on life impact, 30% reported resource/economic outcomes and 95% reported on pathophysiological manifestations. Burns-specific Falder outcome reporting was globally poor, with only 4.3% of outcomes being reported across the 98 papers.

CONCLUSION

There are deficiencies in the reporting of outcomes in the literature pertaining to the intensive care management of patients with severe burns, both with regard to the consistency of outcomes as well as a lack of focus on patient-centred outcomes. Long-term outcomes are infrequently reported. The development and validation of a core outcome dataset for severe burns would improve the quality of reporting.

Usefulness of lactate albumin ratio at admission to predict 28-day mortality in critically ill severely burned patients: A retrospective cohort study

INTRODUCTION

Lactate albumin ratio (LAR) has been used as a prognostic marker associated with organ failure in critically ill septic patients. LAR and its association with outcomes has never been studied in burned patients. The aim of this study was to evaluate the ability of LAR to predict 28-day mortality.

METHODS

A retrospective cohort study including all burn patients hospitalized in intensive care unit. The primary endpoint was the 28-day mortality.

RESULTS

One thousand three hundred thirty four patients were screened, and 471 were included between June 2012 and December 2018. Briefly, the population study was mainly composed by men (249, 59.1%), the median age, TBSA burned, full thickness, ABSI and IGS2 were 52 [34-68], 20 [10-40], 8 [1-23], 7 [5-9] and 25 [15-40] respectively. Fifty-two patients (12.4%) died at day 28 after admission. At admission, the LAR level was lower in 28-day survivors compared non-survivors (0.05 [0.04, 0.08] vs 0.12 [0.07, 0.26], p < 0.001 respectively). In multivariate analysis accounting for ABSI, LAR levels at admission> 0.13 was independently associated with 28-day mortality (adjusted OR = 3.98 (IC95 1.88-8.35)). The ability of LAR at admission to discriminate 28-day mortality showed an AUC identical when compared to SOFA and ABSI scores (0.81 (IC95 0.74-0.88), 0.80 (IC95 0.72-0.85) and (0.85 (IC95 0.80-0.90), p < 0.05, respectively). Patients with LAR levels ≥ 0.13 at admission had higher 28-day mortality (40.6% vs 6.8%, p < 0.001, HR 7.39 (IC95 4.28-12.76)).

CONCLUSION

At admission, LAR is an easy and reliable marker independently associated to 28-day mortality in patients with severe burn injury, but prediction by LAR does not perform better than lactate level alone.

3D Printing: Advancement in Biogenerative Engineering to Combat Shortage of Organs and Bioapplicable Materials

Abstract

Organ or cell transplantation is medically evaluated for end-stage failure saving or extending the lives of thousands of patients who are suffering from organ failure disorders. The unavailability of adequate organs for transplantation to meet the existing demand is a major challenge in the medical field. This led to day-day-increase in the number of patients on transplant waiting lists as well as in the number of patients dying while on the queue. Recently, technological advancements in the field of biogenerative engineering have the potential to regenerate tissues and, in some cases, create new tissues and organs. In this context, major advances and innovations are being made in the fields of tissue engineering and regenerative medicine which have a huge impact on the scientific community is three-dimensional bioprinting (3D bioprinting) of tissues and organs. Besides this, the decellularization of organs and using this as a scaffold for generating new organs through the recellularization process shows promising results. This review discussed about current approaches for tissue and organ engineering including methods of scaffold designing, recent advances in 3D bioprinting, organs regenerated successfully using 3D printing, and extended application of 3D bioprinting technique in the field of medicine. Besides this, information about commercially available 3D printers has also been included in this article.

Lay Summary

Today's need for organs for the transplantation process in order to save a patient's life or to enhance the survival rate of diseased one is the prime concern among the scientific community. Recent, advances in the field of biogenerative engineering have the potential to regenerate tissues and create organs compatible with the patient's body. In this context, major advances and innovations are being made in the fields of tissue engineering and regenerative medicine which have a huge impact on the scientific community is three-dimensional bioprinting (3D bioprinting) of tissues and organs. Besides this, the decellularization of organs and using this as a scaffold for generating new organs through the recellularization process shows promising results. This review dealt with the current approaches for tissue and organ engineering including methods of scaffold designing, recent advances in 3D bioprinting, organs regenerated successfully using 3D printing, and extended application of 3D bioprinting technique in the field of medicine. Furthermore, information about commercially available 3D printers has also been included in this article.

Glutamine relieves the hypermetabolic response and reduces organ damage in severe burn patients: A multicenter, randomized controlled clinical trial

BACKGROUND

Severe burns can cause a hypermetabolic response and organ damage. Glutamine is a conditionally essential amino acid with various pharmacological effects. In this study, whether glutamine could alleviate the hypermetabolic response and maintain organ function after burn injury was analyzed.

METHODS

A multicenter, randomized, single-blind, parallel controlled trial was conducted to evaluate the efficacy of glutamine in decreasing hypermetabolism after burn injury. Physiological and biochemical indexes, such as vital signs, metabolic hormones, metabolic rate, and organ damage, were recorded on the 7th and 14th days after treatment.

RESULTS

In total, 55 adult burn patients with a total burn surface area (TBSA) of 30-70% were included in this study and randomly divided into the burn control (B, 28 patients) and burn+glutamine (B+G, 27 patients) groups. Except for the glutamine administration, the groups did not differ in the other treatments and nutrition supplements. The levels of diamine oxidase (DAO), lactulose/mannitol (L/M), β₂-microglobulin, lactate dehydrogenase (LDH), hydroxybutyrate dehydrogenase (HBD) and cardiac troponin l (cTnl) in the B+G group were significantly lower than those in the B group (p < 0.05 or 0.01). The levels of resting energy expenditure (REE), serum catecholamines, glucagon, lactate and Homeostasis model assessment (HOMA) in the B+G group were significantly lower than those in the B group (p < 0.05 or 0.01). No significant difference was found in the length of hospitalization or the mortality rate between the two groups (p > 0.05).

CONCLUSIONS

Glutamine moderately alleviates the hypermetabolic response and reduces organ damage after severe burns. Therefore, the early application of glutamine, which is effective and safe, should be used as an active intervention as early as possible.

Cross-sectional analysis of national electronic injury surveillance system for burn injuries presenting to United States emergency departments 2000-2018

Patients with burns commonly present to Emergency Departments (EDs), in addition to burn centers. Patients at burn centers typically have more severe burns than those at EDs, and previous studies have analyzed burn center databases. To update the overall burn epidemiology in the United States (US), we analyzed burn injury trends and sources across all age groups using the National Electronic Injury Surveillance System (NEISS), which collects all injuries reported to US EDs. A total of 97,986 burn injuries were recorded in NEISS, 2000-2018. We found a downward trend in the pediatric burn rate and an upward trend in the adult burn rate. Almost half of burns were in children (48.41%), especially in those under 5 (29.79%), and slightly more common in men (53.93%). Most were treatable in the ED (87.83%) and hot water was the most common source overall (20.88%), followed by hair curlers for children less than 2 years old, ranges/ovens for 2 to <5 years, microwaves for 5 to <10 years, and cookware for 10 to <18 years and adults ≥18 years. The most common injured region was the hand for all age groups (34.44%). Although most burn injuries were potentially preventable, the overall burn rate did not decrease 2000-2018. Therefore, we offer guidance on prevention strategies for high-risk sources and age groups.

The Effect of Music Therapy on Perceived Pain, Mental Health, Vital Signs, and Medication Usage of Burn Patients Hospitalized in the Intensive Care Unit: A Randomized Controlled Feasibility Study Protocol

Background: Burn patients experience major physiological and psychological stressors during treatment and rehabilitation, including elevated levels of pain, anxiety, stress, or depression. Music interventions inclusive of music therapy (MT) have been shown to improve such symptoms, but rigorous clinical trials investigating specific music therapy methods in adult burn patients are scarce. Methods: This is a single center Randomized Controlled Trial (RCT) protocol with two parallel arms. Participants are 81 adult burn patients admitted to the Intensive Care Unit (ICU) of the University Hospital Fundación Santa Fe de Bogotá in Colombia. The intervention consists of a Music Assisted Relaxation (MAR) protocol, a music therapy technique composed of entrained live music combined with a guided relaxation and/or the use of imagery. The effects of the MAR will be compared to a control group (treatment as usual) over a period of maximum 2 weeks or six interventions. The primary outcome measure is perceived background pain, as measured with a Visual Analog Scale (VAS) before and after each intervention. Secondary outcomes are anxiety and depression levels; vital signs; and the use of pain medication. Additionally, some patients in the intervention group will be invited to participate in electroencephalography, electromyography, and electrocardiography recordings during the MAR. Discussion: This study protocol follows the SPIRIT guidelines for defining items of clinical trials and is the first study in Colombia to evaluate the effects of music therapy for adult burn patients. With this RCT it is hoped to gather new knowledge about the potential of music therapy to help critical care patients cope and recover from their injuries during the hospitalization in the ICU. Trial registration: www.clinicaltrials.gov, Identifier: NCT04571255. Protocol version: V1.0, May 24th 2021.

Quantification of the negative impact of sedation and inotropic support on achieving early mobility in burn patients in ICU: A single center observational study

INTRODUCTION

Early rehabilitation for burns survivors in the intensive care unit (ICU) is arguably more challenging than the general population. Early achievement of functional verticality milestones (FVMs) has the potential to ameliorate the detrimental effects of bed rest and immobility observed in ICU patients and reduce healthcare costs. However, the time to achieving FVMs after burn injury is influenced by factors such as sedation practices, cardiovascular stability, mechanical ventilation, acute skin reconstruction and length of stay (LOS) during the acute intensive care period.

OBJECTIVES/AIMS

The aims of this study were to identify the association between early achievement of FVMs and factors influencing cessation of bedrest in adult patients with burns receiving ICU care, and to explore barriers to achievement of FVMs as recorded by clinicians.

METHODS

A 5-year retrospective observational cohort study was conducted. The digital medical records were reviewed for each case to explore episodes of FVMs and patient factors which may contribute to persistent bed rest, such as use of infused sedative and/or inotropic medication, mechanical ventilation, burn surgery, total body surface area (TBSA), ICU length of stay and pre-ICU practices. Logistic regression was used to examine the association between FVM achievement and treatment and injury factors in ICU survivors.

RESULTS

The total sample available for analysis included 64 patients. When sedation/agitation score was within recommended limits, odds of achieving FVMs was 21 times greater than periods outside those limits. When deep sedatives were infused, the odds of achieving FVMs decreased by 87% compared to periods when there was no infusion of these medications. In addition, the odds of achieving FVMs was reduced by 13% for each increase of 1 mL/h in the daily maximum noradrenaline dose.

DISCUSSION AND CONCLUSION

Maintaining sedation and agitation scores within the optimal range, and minimising sedative infusion and inotropic support enhances the likelihood of early and frequent mobilization in patients with burns admitted to ICU. Additional barriers identified were mechanical ventilation, burns surgery, pre-ICU practices and ICU length of stay. The challenge for clinicians moving forward is to determine how these factors may be modified to increase early mobilization of burn patients in ICU.

Plasma extracellular vesicles released after severe burn injury modulate macrophage phenotype and function

Extracellular vesicles (EVs) have emerged as key regulators of immune function across multiple diseases. Severe burn injury is a devastating trauma with significant immune dysfunction that results in an ∼12% mortality rate due to sepsis-induced organ failure, pneumonia, and other infections. Severe burn causes a biphasic immune response: an early (0-72 h) hyper-inflammatory state, with release of damage-associated molecular pattern molecules, such as high-mobility group protein 1 (HMGB1), and proinflammatory cytokines (e.g., IL-1β), followed by an immunosuppressive state (1-2+ wk post injury), associated with increased susceptibility to life-threatening infections. We have reported that early after severe burn injury HMGB1 and IL-1β are enriched in plasma EVs. Here we tested the impact of EVs isolated after burn injury on phenotypic and functional consequences in vivo and in vitro using adoptive transfers of EV. EVs isolated early from mice that underwent a 20% total body surface area burn injury (burn EVs) caused similar hallmark cytokine responses in naïve mice to those seen in burned mice. Burn EVs transferred to RAW264.7 macrophages caused similar functional (i.e., cytokine secretion) and immune gene expression changes seen with their associated phase of post-burn immune dysfunction. Burn EVs isolated early (24 h) induced MCP-1, IL-12p70, and IFNγ, whereas EVs isolated later blunted RAW proinflammatory responses to bacterial endotoxin (LPS). We also describe significantly increased HMGB1 cargo in burn EVs purified days 1 to 7 after injury. Thus, burn EVs cause immune outcomes in naïve mice and macrophages similar to findings after severe burn injury, suggesting EVs promote post-burn immune dysfunction.

Recent perspectives of nanotechnology in burn wounds management: a review

OBJECTIVE

The burden of the management of problematic skin wounds characterised by a compromised skin barrier is growing rapidly. Almost six million patients are affected in the US alone, with an estimated market of $25 billion annually. There is an urgent requirement for efficient mechanism-based treatments and more efficacious drug delivery systems. Novel strategies are needed for faster healing by reducing infection, moisturising the wound, stimulating the healing mechanisms, speeding up wound closure and reducing scar formation.

METHODS

A systematic review of qualitative studies was conducted on the recent perspectives of nanotechnology in burn wounds management. Pubmed, Scopus, EMBASE, CINAHL and PsychINFO databases were all systematically searched. Authors independently rated the reporting of the qualitative studies included. A comprehensive literature search was conducted covering various resources up to 2018-2019. Traditional techniques aim to simply cover the wound without playing any active role in wound healing. However, nanotechnology-based solutions are being used to create multipurpose biomaterials, not only for regeneration and repair, but also for on-demand delivery of specific molecules. The chronic nature and associated complications of nonhealing wounds have led to the emergence of nanotechnology-based therapies that aim at facilitating the healing process and ultimately repairing the injured tissue.

CONCLUSION

Nanotechnology-based therapy is in the forefront of next-generation therapy that is able to advance wound healing of hard-to-heal wounds. In this review, we will highlight the developed nanotechnology-based therapeutic agents and assess the viability and efficacy of each treatment. Herein we will explore the unmet needs and future directions of current technologies, while discussing promising strategies that can advance the wound-healing field.

Combined Complex Skin Repair in Patient With Extensive Burns: A Case Report

Auto-skin grafting is the current treatment of choice for extensive burns. Nevertheless, the lack of donor sites for skin grafting remains one of the greatest limiting factors for the treatment of extensively burned patients. We present the case of a 53-year-old male patient with deep and full thickness burns on 91% of the total body surface area. We used the Meek technique for split-thickness skin graft expansion to treat this patient. In order to obtain sufficient skin for grafting, we repeatedly harvested the same anatomical areas. Acceleration of burn wounds, recipient, and donor site healing was achieved by systemic treatment with recombinant human growth hormone and topical recombinant human epidermal growth factors. This combined, complex treatment modality contributed to the successful skin repair in this patient.

Recommendations for influenza vaccination in burns patients based on a systematic review of the evidence

Severe burn injury is a serious systemic insult that can lead to life threatening secondary infections. Immunosuppression, inhalation injury and prolonged length of hospital stay are factors which predispose patients to severe respiratory tract infections. Furthermore, evidence shows that burns can put one at risk of infection long after the original injury. Currently in the United Kingdom, the annual National Flu Immunisation programme outlines guidance for groups who are deemed high risk and therefore eligible for the influenza vaccine. At present, no guidance exists for administration of the influenza vaccine in burn injured patients, despite knowledge of immunosuppression. The aim of this literature review is to examine the evidence for associations between burn injury and influenza and where available, evaluate efficacy of influenza vaccines in this cohort. In addition, literature was searched for the effectiveness of the influenza vaccine in patients 65 years and above, and in patients admitted to the intensive care unit (ICU); two domains common to patients with severe burns. Three papers were found to suggest increased susceptibility to influenza following burn injury, however no papers studying the effectiveness of the influenza vaccine in this group were found. Several studies demonstrated improved outcomes in patients over 65 years and patients admitted to ICU. Following evaluation of the evidence, this review advocates for the consideration of hospitalized burn patients for the influenza vaccine. We suggest avoidance of vaccine administration in the acute burn phase. Further prospective clinical trials would be required to validate these findings.

Investigation and assessment of neutrophil dysfunction early after severe burn injury

BACKGROUND

Extensive burn injury results in a complex immune response that is associated with mortality and prognosis. Studies on acquired immune and the development of sepsis in burn patients have been reported. However, one of the main cells in innate immune, neutrophil dysfunction in the burn shock stage has not been thoroughly characterized.

METHODS

Neutrophil chemotaxis, expression of neutrophil surface markers (P2X1 receptor, [P2RX1]), degranulation (myeloperoxidase [MPO], heparin-binding protein [HBP], matrix metalloproteinase-9 [MMP-9] and neutrophil elastase [NE]), oxidative burst capacity, neutrophil extracellular trap (NET) generation, phagocytosis and apoptosis were measured in 18 patients with major burns (≥30% total body surface area [TBSA]) within 48 h after burn injury. In addition, circulating neutrophils and vascular permeability in mice model with 30% TBSA third-degree burns were also observed and investigated.

RESULTS

Neutrophil functions were reduced considerably in burn shock stage, which was characterized by decreased chemotaxis, phagocytosis and abnormal bactericidal function. Increased release of heparin-binding protein (HBP) and the expression of P2RX1 on the neutrophil surface are related to fluid leakage and decreased chemotaxis during burn shock stage, respectively. The combination of HBP concentration in plasma and P2RX1 expression on neutrophils gives a better prediction of neutrophil dysfunction in burn-injured patients.

CONCLUSION

Neutrophil dysfunction plays a key role in the development of burn injury. Targeting the restoration of neutrophil function may be a feasible therapeutic intervention to help reduce fluid loss during shock and the severity of subsequent infection.

Pseudomonal Meningoencephalitis With Ventriculitis Secondary to Bacteremia in a Burn Patient: A Novel Case

Burn patients with large burn surface area involvement are at increased risk of infection due to the presence of large wounds, multiple surgeries, prolonged intensive care unit admission, and immunosuppression. Pseudomonas aeruginosa is the most commonly isolated organism in this population. Even with frequent infections in the burn population, meningitis and encephalitis are rare, and ventriculitis is exceptional. We report the case of a 66-year-old woman who developed P. aeruginosa bacteremia during her hospital course, causing secondary meningoencephalitis with ventriculitis. She was admitted for partial- and full-thickness burns affecting the neck, chest, abdomen, upper medial arms, and bilateral anteromedial thighs for an estimated 20% total body surface area burn. She met sepsis criteria and broad-spectrum antimicrobial coverage was initiated. Magnetic resonance imaging of the brain, performed for altered mental status, revealed meningitis and ventriculitis. Cerebrospinal fluid analysis demonstrated findings consistent with bacterial meningitis, with cultures positive for P. aeruginosa. Serial neuroimaging with computerized tomography revealed new areas of ischemia concerning for septic emboli. In the presence of altered mental status and fever of unknown origin, workup should remain broad. Even in the presence of another source, it is important to keep an open mind for the rarer intracerebral infection as it requires different management, including urgent evaluation of antibiotic selection and dosing to ensure central nervous system penetration, and neurosurgical evaluation.

Venous thromboembolism in burns patients: Are we underestimating the risk and underdosing our prophylaxis?

BACKGROUND

Burns patients exhibit all factors of Virchow's triad and are thus at high theoretical risk of venous thromboembolism (VTE). At our tertiary referral burns unit, a standard dose of low molecular weight heparin, which acts primarily by inhibiting Factor Xa, is given for thromboprophylaxis. However, the pharmacokinetics of enoxaparin are altered following a burn injury, and thus burns patients are likely underdosed on their thromboprophylaxis. The objectives of this study were to determine the incidence and risk factors for VTE among burns patients at the Victorian Adult Burns Service (VABS) and to determine the adequacy of the current enoxaparin thromboprophylaxis regimen through measurement of anti-factor Xa (AFXa) levels and comparison with established reference ranges.

METHODS

This study consisted of two parts. In part 1, the Burns Registry of Australia and New Zealand (BRANZ) was reviewed for cases of VTE in burns patients admitted to the VABS from 2013 - 2018. Part 2 was a prospective study that determined peak and trough AFXa levels in patients admitted to the VABS with >10% total body surface area (TBSA) burns.

RESULTS

Part 1. Totally, 1,475 patients were admitted to the VABS between 2013 - 2018. There were 20 cases of VTE (1.36%). Percent TBSA of burn (OR = 1.04, 95% CI: 1.03 - 1.06), full thickness burns (OR = 2.78, 95% CI: 1.15 - 6.73), ICU admission (OR = 15.08, 95% CI: 5.01 - 45.44), mechanical ventilation (OR = 10.62, 95% CI: 4.05 - 27.91), operative procedures (OR = 1.43, 95% CI: 1.29 - 1.59), and a longer hospital stay (OR = 1.05, 95% CI: 1.04 - 1.07) were all associated with an increased VTE risk. Part 2. A total of 20 participants with >10% TBSA burns were recruited to the prospective study. Peak anti Factor Xa (AFXa) levels were measured for all 20 participants with 15% recording an initial prophylactic peak AFXa level within reference range. Upon subsequent measurements, 50% of participants reached a prophylactic peak AFXa level. Trough AFXa levels were measured for 17 participants with no participant recording an initial or subsequent trough AFXa level at or above the prophylactic threshold.

CONCLUSION

Our study demonstrates a high incidence of VTE among burns patients at the VABS, especially among the major burns patients, and a thromboprophylaxis protocol that is ineffective in achieving prophylactic levels of AFXa level. The evidence suggests a need to evaluate different dosing protocols among burns patients in order to improve AFXa levels, with the aim of decreasing incidence of VTE in high-risk patients.

Adult Cranioplasty and Perioperative Patient Safety: Does Plastic Surgery Facility Volume Matter?

ABSTRACT

Cranioplasty lies at the intersection of neurosurgery and plastic surgery, though little is known about the impact of plastic surgery involvement. The authors hypothesized that adult cranioplasty patients at higher volume plastic surgery facilities would have improved inpatient outcomes. Adult cranioplasty encounters were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Regression models included the following variables: age, gender, race/ethnicity, Elixhauser Comorbidity Index, payer, hospital size, region, and urban/teaching status. Outcomes included odds of receiving a flap, perioperative patient safety indicators, and mortality. The weighted sample included 49,305 encounters with diagnoses of neoplasm (31.2%), trauma (56.4%), infection (5.2%), a combination of these diagnoses (3.9%), or other diagnoses (3.2%). There were 1375 inpatient mortalities, of which 10 (0.7%) underwent a flap procedure. On multivariable regression, higher volume plastic surgery facilities and all diagnoses except uncertain neoplasm were associated with an increased likelihood of a flap procedure during the admission for cranioplasty, using benign neoplasm as a reference (P < 0.001). Plastic surgery facility volume was not significantly associated with likelihood of a patient safety indicator event. The highest volume plastic surgery quartile was associated with lower likelihood of inpatient mortality (P = 0.008). These findings support plastic surgery involvement in adult cranioplasty and suggest that these patients are best served at high volume plastic surgery facilities.

Burn Unit admission and management protocol during COVID-19 pandemic

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COVID-19 is an adjunctive risk factor for burn injured patients.

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Isolation of suspected cases and development of management procedures are essential preventive measures to reduce viral spread.

•

We developed an admission protocol to our Burn Unit which proved itself effective in minimizing the contagion between patients and healthcare workers.

Background

The actual epidemic outbreak is the third time in the last two decades in which a coronavirus results in a major global spread with serious consequences in terms of vastity of affected patients, life losses, health system organization efforts and socio-economic implications. Lacking effective therapies and vaccinations, during viral outbreak the major and most incisive mean for viral spread control is spread prevention, especially for the fragile burn-injured patients we are called to care for in Burn Units.

Methods

We developed an admission and inpatient management protocol to preserve burn patients from SARS-CoV-2 contagion, in order to avoid additional morbidity and mortality in patients with already compromised health conditions.

Data from burn-injured patients admitted to our Unit following this new protocol were retrospectively analyzed in order to verify its effectiveness in prevention of viral spread.

Results

From the 8th of March to the 8th of June, we admitted 18 patients in the Burn Unit ICU and semi-ICU and 17 patients in the Burn Ward. Two of them resulted positive to COVID-19 nasopharyngeal swab and bronchoalveolar lavage collected immediately on admission, for both the extension of burns and their general clinical conditions implied ICU admission. Moreover, a caregiver of an admitted child resulted positive to the nasopharyngeal swab. No other cases of SARS-CoV-2 positivity have been reported neither between hospitalized patients nor between healthcare workers.

Conclusion

The evidence of high ICU admission rate and high mortality in patients affected by SARS-CoV-2 combined with the fragile clinical conditions of burn patients required the development of an admission and hospitalization management protocol.

Feasibility and impact of the implementation of a clinical scale-based sedation-analgesia protocol in severe burn patients undergoing mechanical ventilation. A before-after bi-center study

BACKGROUND

Severe burn patients undergo prolonged administration of sedatives and analgesics for burn care. There are currently no guidelines for the dose adaptation of sedation-analgesia in severe burn patients.

METHODS

We performed a before-after 2-center study to demonstrate the feasibility and efficacy of a sedation-analgesia scale-based protocol in severely burned patients receiving ≥24h of invasive mechanical ventilation. Before the intervention, continuous infusion of hypnotic and morphine derivatives was continued. During the Intervention phase, general anesthesia was relayed from day 1 by RASS/BPS-titrated continuous infusion of hypnotic and morphine derivatives and with short half-life drugs adminstered for daily burn dressings. The primary outcome was the duration of invasive mechanical ventilation in the ICU.

RESULTS

Eighty-seven (46.2%) patients were included in the Control phase and 101 (53.7%) in the Intervention phase. The median burned cutaneous surface was 20% [11%-38%] and median ABSI was 7 [5-9]. The durations of hypnotic and opioid infusions were not statistically different between the 2 phases (8 days [2-24] vs. 6 days [2-17] (P=0.3) and 17 days [4-32] vs. 8 days [3-23] (P=0.06), respectively). The duration of mechanical ventilation was 14 days [3-29] in the Control phase and 7 days [2-24] in the Intervention phase (P=0.7). When taking into account the competition between mortality and weaning from mechanical ventilation, we found no significant difference between the 2 phases (Gray test, P=0.4). The time-series analysis showed no difference for the duration of mechanical ventilation in the Intervention phase (P=0.6). Eighteen (20.7%) patients died in the Control phase, and 18 (18%) in the Intervention phase (P=0.6).

CONCLUSION

Scale-based lightening of continuous sedation-analgesia with repeated short general anesthesia for dressing is feasible in severe burn patients but failed to demonstrate a decrease in the duration of invasive mechanical ventilation.

Changes in total body surface area and the distribution of skin surfaces in relation to body mass index

BACKGROUND

A correct estimation of total burn surface area is important since it is used for determining fluid resuscitation volumes, nutritional estimates and hospital admission criteria. Wallace's rule of nines is the most commonly used methods for this purpose. However, fat distribution is non-uniform and the total body surface area changes with obesity. The aim of this study was to determine if the rule of nines applies to all body mass index groups.

METHODS

A total of 217 individuals were included in the study. The patients were divided into 4 groups according to their BMI (18.5-25kg/m² (60 persons)), 25-29.9kg/m² (61 individuals)), 30-34.9kg/m² (55 persons)), >35kg/m² (41 persons)). Each patient underwent a complete duel-energy X-ray absorptiometry body scan to determine the surface area (cm²) of the various regions of the body.

RESULTS

We found no statistically significant variations between the Wallace body percentage distributions and our results in the men for all BMI ranges (head p=0.331, arms p=0.861, legs p=0.282, trunk p=0.696). In contrast, among women we found a statistically significant change in body surface area percentage distribution between the BMI groups and specific body regions (head p=0.000, legs p=0.000 and trunk p=0.001).

CONCLUSION

The Wallace rule of nines is a quick and acceptable method for estimating the total burn surface area percentage in men of all BMI ranges. However, for women, a more accurate method of burn area estimation is required as proposed by our BMI adjusted charts.

Goal-Directed Fluid Resuscitation Protocol Based on Arterial Waveform Analysis of Major Burn Patients in a Mass Burn Casualty

BACKGROUND

Adequate fluid titration during the initial resuscitation period of major burn patients is crucial. This study aimed to evaluate the feasibility and efficacy of a goal-directed fluid resuscitation protocol that used hourly urine output plus the arterial waveform analysis FloTrac (Edwards LifeSciences, Irvine, Calif) system for major burns to avoid fluid overload.

METHODS

We conducted a retrospective cohort study of 43 major burn patients at the Tri-Service General Hospital after the Formosa Fun Coast Dust Explosion on June 27, 2015. Because of the limited capacity of intensive care units (ICUs), 23 intubated patients were transferred from the burn wards or emergency department to the ICU within 24 hours. Fluid administration was adjusted to achieve a urine output of 30 to 50 mL/h, cardiac index greater than 2.5 L/min/m, and stroke volume variation (SVV) less than 12%. The hourly crystalloid fluid infusion rate was titrated based on SVV and hourly urine output.

RESULTS

Of the 23 critically burned patients admitted to the ICU, 13 patients who followed the goal-directed fluid resuscitation protocol within 12 hours postburn were included in the analysis. The mean age (years) was 21.8, and the mean total body surface area (TBSA) burned (%) was 68.0. The mean Revised Baux score was 106.8. All patients sustained inhalation injury. The fluid volumes administered to patients in the first 24 hours and the second 24 hours (mL/kg/% total body surface area) were 3.62 ± 1.23 and 2.89 ± 0.79, respectively. The urine outputs in the first 24 hours and the second 24 hours (mL/kg/h) were 1.13 ± 0.66 and 1.53 ± 0.87, respectively. All patients achieved the established goals within 32 hours postburn. In-hospital mortality rate was 0%.

CONCLUSIONS

The SVV-based goal-directed fluid resuscitation protocol leads to less unnecessary fluid administration during the early resuscitation phase. Clinicians can efficaciously manage the dynamic body fluid changes in major burn patients under the guidance of the protocol.

Respiratory and coagulation dysfunctions on admission as independent predictors of in-hospital mortality in critically ill burn patients

Mortality rate for burns patients in developing countries is approximately 34%. Data show that most patients in burn units will likely experience organ dysfunction. Sequential Organ Failure Assessment (SOFA) score assesses organ dysfunction and is frequently used in the ICU, but there are no previous studies regarding SOFA score in burn units in Indonesia specifically. This study was a retrospective study, conducted to assess the validity of the SOFA score in predicting mortality of critically ill burn patients in the Burn HDU and ICU of Cipto Mangunkusumo General Hospital between January 2012 to December 2017. This study included 169 subjects who met the inclusion and exclusion criteria. Medical records were used to identify the subjects' characteristics, SOFA score within 24 hours, and outcome (deceased or survived) at day 30. SOFA score validity was assessed using Area Under Curve (AUC), Hosmer-Lemeshow goodness of fit and multivariate logistic regression. The mortality rate for burn patients was 32.5%. SOFA score had very good discrimination (AUC 96.4%, CI 95% 0.933 - 0.995) and good calibration (Hosmer-Lemeshow p = 0.561). SOFA variables which had a statistically significant effect on 30-day mortality in the Burn Unit were PaO2/FiO2 ratio < 400, PaO2/FiO2 ratio < 300, PaO2/FiO2 ratio < 200 with mechanical ventilation and platelet count < 150,000/mm3. SOFA score was a valid instrument for predicting 30 day mortality of critically ill burn patients in the Burn HDU and ICU of Cipto Mangunkusumo General Hospital, especially respiration and coagulation variables.

Fractional CO2 Laser Treatment Outcomes for Pediatric Hypertrophic Burn Scars

Carbon dioxide ablative fractional laser (CO2-AFL) therapy has not been widely adopted in pediatric burn care given limited outcomes literature and no established guidelines on laser treatment protocols. We present our experience to further elucidate the clinical role of CO2-AFL therapy for pediatric hypertrophic burn scars. We conducted a prospective cohort study of pediatric burn patients undergoing CO2-AFL treatment of hypertrophic, symptomatic burn scars at a tertiary care regional burn center during a 2-year period. Scars were assessed before each treatment using the Patient and Observer Scar Assessment Scale (POSAS), a validated, subjective, comprehensive scar assessment tool. We treated 49 pediatric patients for a total of 180 laser sessions. Burn severity was full thickness (63.6%) or deep partial thickness (47.7%). Observer-rated POSAS scores revealed statistically significant improvements in pigment, thickness, relief, pliability, and surface area after one treatment with continued improvement until the last laser session. Patient-rated POSAS revealed statistically significant improvements in color, stiffness, thickness, and irregularity after laser treatments. Total POSAS improved from 89.6 ± 17.5 to 76.6 ± 16.8 (P < .0001) after one treatment with further improvement to 69.2 ± 14.9 (P < .0001) at the final laser session. We found convincing evidence that CO2-AFL therapy improves hypertrophic burn scars on both patient- and observer-rated scales confirming statistical and clinical significance to both providers and families. These findings demonstrate that CO2-AFL can improve hypertrophic burn scars in pediatric patients providing a lower risk alternative to invasive therapies and a more immediate, efficacious alternative to more conservative scar treatments.

Burn intensive care treatment over the last 30 years: Improved survival and shift in case-mix

PURPOSE

Mortality in burn intensive care unit (ICU) has been decreasing and treatment appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix.

METHODS

Retrospective study in patients admitted to ICU (1987-2016). Four groups were specified: major burns (≥15% TBSA), inhalation injury with small injury (<15% TBSA, inhalation injury), watchful waiting (<15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the relation between case-mix and outcome.

RESULTS

Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group.

CONCLUSIONS

After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation.

Skin bioprinting: the future of burn wound reconstruction?

Burns are a significant cause of trauma, and over the years, the focus of patient care has shifted from just survival to facilitation of improved functional outcomes. Typically, burn treatment, especially in the case of extensive burn injuries, involves surgical excision of injured skin and reconstruction of the burn injury with the aid of skin substitutes. Conventional skin substitutes do not contain all skin cell types and do not facilitate recapitulation of native skin physiology. Three-dimensional (3D) bioprinting for reconstruction of burn injuries involves layer-by-layer deposition of cells along with scaffolding materials over the injured areas. Skin bioprinting can be done either in situ or in vitro. Both these approaches are similar except for the site of printing and tissue maturation. There are technological and regulatory challenges that need to be overcome for clinical translation of bioprinted skin for burn reconstruction. However, the use of bioprinting for skin reconstruction following burns is promising; bioprinting will enable accurate placement of cell types and precise and reproducible fabrication of constructs to replace the injured or damaged sites. Overall, 3D bioprinting is a very transformative technology, and its use for wound reconstruction will lead to a paradigm shift in patient outcomes. In this review, we aim to introduce bioprinting, the different stages involved, in vitro and in vivo skin bioprinting, and the various clinical and regulatory challenges in adoption of this technology.

Investigating the interrater reliability of a novel functional outcome measure for use in the burns intensive care unit: The Functional Assessment for Burns - Critical Care (FAB-CC)

INTRODUCTION

Intensive Care Unit Acquired Weakness challenges the clinical care of critically ill patients. Despite a surge in validated ICU functional outcome measures following the publication of Clinical Guideline 83 'Rehabilitation After Critical Illness' by the National Institute for Health and Care Excellence (2009), there are none composed specifically for use in the Burns ICU. We therefore developed and tested the inter-rater reliability of a burn specific novel functional outcome measure; The Functional Assessment for Burns-Critical Care (FAB-CC).

OBJECTIVES

This research aimed to investigate the interrater reliability of the FAB-CC.

METHODS

A quantitative reliability study assessed the ability of the FAB-CC to obtain accurate data when utilised by three separate raters (m=3) scoring the same clinical episodes (n=24).

RESULTS

The Intraclass Correlation Coefficient (ICC) for the FAB-CC as a complete tool revealed excellent agreement (ICC 0.998; P<0.001, 95% confidence interval 0.996-0.999), with Cronbach's Alpha (α 0.999). Individual components of the FAB-CC displayed excellent agreement (ICC>0.983; P<0.001) with narrow 95% confidence intervals.

CONCLUSIONS

The FAB-CC is a novel functional outcome measure that is reliable for use with critically ill burn patients. It has demonstrated real clinical utility in the identification and management of ICU-AW in this unique patient group.

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.

New technologies in global burn care - a review of recent advances

There have been truly incredible strides in the standard of burn care. The mortality from burn injuries has more than halved since the 1950s, making it hugely unique among major diseases of the developed world. There can be no doubt technology and technological advances have driven this process, dramatically improved every aspect of burn care, from the intensive care management, the surgical management, management of the healing wound to the post burn sequelae, specifically scar management. This review aims to identify key technological advances in burns, in both the developed and developing world, and evaluate their influence in the continued strategy to improve the standards of global burn care.