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Peters RA, Cancio JM, Glenn K, Cancio LC. Extracorporeal Membrane Oxygenation in a Patient with Severe Inhalation Injury: Multidisciplinary Burn Team Care. J Burn Care Res 2024; 45:796-800. [PMID: 38367208 DOI: 10.1093/jbcr/irae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Indexed: 02/19/2024]
Abstract
INTRODUCTION Inhalation injury is a major risk factor for mortality in burn patients via 3 primary mechanisms: airway edema and obstruction, hypoxemic respiratory failure, and pneumonia. Currently, the mainstay of treatment is supportive care to include early intubation, lung-protective or high-frequency-percussive mechanical ventilation, nebulized heparin, and aggressive pulmonary toilet. Despite these treatments, a subset of these patients progress to severe acute respiratory distress syndrome (ARDS) for which rescue options are limited. CASE PRESENTATION A 31-year-old woman was found down in a house fire. On admission to the burn intensive care unit, she was diagnosed with grade 3 smoke inhalation injury. Cutaneous thermal injury was absent. By hospital day 2, she developed worsening hypoxemia and hypercapnia despite maximal ventilatory support. She was placed on veno-venous extracorporeal membrane oxygenation (ECMO). She received an average of 2.2 hours of direct rehabilitation a day and completed out-of-bed modalities over 90% of total hospital days. After 159 hours, she was decannulated, and by hospital day 18, she was discharged home on supplemental oxygen. CONCLUSION Current literature regarding ECMO in inhalation injury is limited, but a growing body of evidence suggests that treatment of severe smoke inhalation injury should include ECMO for those who fail conventional therapy.
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Affiliation(s)
- Rachael A Peters
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jill M Cancio
- U.S. Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Keith Glenn
- Infectious Disease and Critical Care, San Antonio Military Medical Center, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
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Cancio LC, Pruskowski KA, Kiley JL, Glenn KR, How RA. Letter to the Editor concerning Akhavan AA et al., Invasive non-Candida fungal infections in acute burns-a 13-year review of a single institution and review of the literature. J Burn Care Res 2024:irae034. [PMID: 38426907 DOI: 10.1093/jbcr/irae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Indexed: 03/02/2024]
Affiliation(s)
| | | | - John L Kiley
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Keith R Glenn
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
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Savell SC, Howard JT, VanFosson CA, Medellín KL, Staudt AM, Rizzo JA, Maddry JK, Cancio LC. A Retrospective Cohort Study of Burn Casualties Transported by the US Army Burn Flight Team and US Air Force Critical Care Air Transport Teams. Mil Med 2024; 189:813-819. [PMID: 36165680 DOI: 10.1093/milmed/usac273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/10/2022] [Accepted: 09/02/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The US Army Burn Center, the only burn center in the Department of Defense provides comprehensive burn care. The Burn Flight Team (BFT) provides specialized burn care during transcontinental evacuation. During Operations Iraqi and Enduring Freedom, burn injuries accounted for approximately 5% of all injuries in military personnel. To augment BFT capacity, US Air Force Critical Care Air Transport Teams (CCATTs) mobilized to transport burn patients. The purpose of this study was to describe critically ill, burn injured patients transported to the US Army Burn Center by BFT or CCATT, to compare and contrast characteristics, evacuation procedures, in-flight treatments, patient injuries/illnesses, and outcomes between the two groups. MATERIALS AND METHODS We conducted a retrospective cohort study of CCATT and BFT patients, admitted to the burn ICU between January 1, 2001 and September 30, 2018. Patients with total body surface area burned (TBSA) >30% were evacuated by BFT, while CCATT evacuated patients with ≤ 30% TBSA. RESULTS Ninety-seven patients met inclusion criteria for this study. Of these, 40 (41%) were transported by the BFT and 57 (59%) were transported by CCATTs. Compared with patients transported by CCATTs, patients transferred by the BFT had higher median TBSA and full-thickness burn size, higher prevalence of chest, back and groin burns, and higher prevalence of inhalation injury. BFT patients had increased hospital days (62 vs. 37; P = .08), ICU days (29 vs. 12; P = .003) and ventilator days (14 vs. 6; P < .001). TBSA was the only variable significantly associated with ARDS (aOR = 1.04; 95% CI: 1.01, 1.08; P = 0.04), renal failure (aOR = 1.07; 95% CI: 1.03, 1.11; P = .002), and mortality (aOR = 1.08; 95% CI: 1.03, 1.13; P = .001). CONCLUSIONS Evacuation by the BFT was associated with increased ICU and ventilator days, increased mortality, and a greater risk for developing renal failure. The severity of injury/TBSA likely accounted for most of these differences.
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Affiliation(s)
- Shelia C Savell
- United States Air Force En route Care Research Center/59th MDW/ST, Fort Sam Houston, TX 78234, USA
| | - Jeff T Howard
- United States Air Force En route Care Research Center/59th MDW/ST, Fort Sam Houston, TX 78234, USA
- Oak Ridge Institute of Science and Education, Oakridge, TN 37830, USA
- University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Christopher A VanFosson
- Brooke Army Medical Center/San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
| | - Kimberly L Medellín
- United States Air Force En route Care Research Center/59th MDW/ST, Fort Sam Houston, TX 78234, USA
| | | | - Julie A Rizzo
- Brooke Army Medical Center/San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
- Uniformed Services University, Bethesda, MD 20814, USA
| | - Joseph K Maddry
- Brooke Army Medical Center/San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
- Uniformed Services University, Bethesda, MD 20814, USA
- US Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Leopoldo C Cancio
- Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
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Batchinsky AI, Roberts TR, Antebi B, Cancio LC. Reply to: Mesenchymal Stromal Cells in ARDS: Shoulder Heavy Responsibilities, and a Long Way to Go. Am J Respir Crit Care Med 2024. [PMID: 38382067 DOI: 10.1164/rccm.202312-2364le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/21/2024] [Indexed: 02/23/2024] Open
Affiliation(s)
- Andriy I Batchinsky
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas, United States;
| | | | - Ben Antebi
- Maryland Stem Cell Research Fund, 550443, Columbia, Maryland, United States
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, 110230, Fort Sam Houston, Texas, United States
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Surette KE, Abouzeid C, Shepler LJ, McMullen KA, Cancio JM, Cancio LC, Hickey SA, Mandell SP, Stewart BT, Wolf SE, Kazis LE, Ryan CM, Schneider JC. Examining the association between military service history and outcomes after burn injury. Burns 2024; 50:59-65. [PMID: 37709564 PMCID: PMC10872572 DOI: 10.1016/j.burns.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/30/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION The association between military service history and long-term outcomes after burn injury is unknown. This study uses data from the Burn Model System National Database to compare outcomes of individuals with and without self-reported military service history. METHODS Outcome measures were assessed at 12 months after injury including the Veterans Rand-12 Item Health Survey/Short Form-12, Satisfaction With Life Scale, Patient Reported Outcomes Measure Information System 29, 4-D Itch scale, Post Traumatic Stress Disorder Check List - Civilian Version, self-reported Post Traumatic Stress Disorder, and employment status. This study included 675 people with burns of whom 108 reported a history of military service. RESULTS The military service history group was more likely to be older, and male. Those with military service were most likely to be on Medicare insurance and those without military service history were most likely to be on Private Insurance/HMP/PPO. No significant differences were found between those with and without military service history in the outcome measures. CONCLUSIONS Further research should examine differences in outcomes between civilians and those with military service history, including elements of resilience and post traumatic growth.
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Affiliation(s)
- Kate E Surette
- Shriners Children's Hospital-Boston, 51 Blossom St., Boston, MA 02114, United States
| | - Cailin Abouzeid
- Spaulding Rehabilitation Hospital, 300 1st Ave., Charlestown, MA 02129, United States
| | - Lauren J Shepler
- Spaulding Rehabilitation Hospital, 300 1st Ave., Charlestown, MA 02129, United States
| | - Kara A McMullen
- Harborview Medical Center, University of Washington, 325 9th Ave., Seattle, WA 98104, United States
| | - Jill M Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, 3698 Chambers Rd., San Antonio, TX 78234, United States
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, 3698 Chambers Rd., San Antonio, TX 78234, United States
| | - Sean A Hickey
- Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States
| | - Samuel P Mandell
- University of Texas Southwestern, 5323 Harry Hines Blvd., Dallas, TX 75390, United States
| | - Barclay T Stewart
- Harborview Medical Center, University of Washington, 325 9th Ave., Seattle, WA 98104, United States
| | - Steven E Wolf
- University of Texas Medical Branch, 1302 Mechanic St., Galveston, TX 77550, United States
| | - Lewis E Kazis
- Boston University School of Public Health, 715 Albany St., Boston, MA 02218, United States; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, United States; Spaulding Rehabilitation Outcomes Center, 300 1st Ave., Charlestown, MA 02129, United States
| | - Colleen M Ryan
- Shriners Children's Hospital-Boston, 51 Blossom St., Boston, MA 02114, United States; Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, United States
| | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, 300 1st Ave., Charlestown, MA 02129, United States; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, United States; Spaulding Rehabilitation Outcomes Center, 300 1st Ave., Charlestown, MA 02129, United States.
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Batchinsky AI, Roberts TR, Antebi B, Necsoiu C, Choi JH, Herzig M, Cap AP, McDaniel JS, Rathbone CR, Chung KK, Cancio LC. Intravenous Autologous Bone Marrow-derived Mesenchymal Stromal Cells Delay Acute Respiratory Distress Syndrome in Swine. Am J Respir Crit Care Med 2023; 208:1283-1292. [PMID: 37797214 DOI: 10.1164/rccm.202305-0865oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/05/2023] [Indexed: 10/07/2023] Open
Abstract
Rationale: Early post injury mitigation strategies in ARDS are in short supply. Treatments with allogeneic stromal cells are administered after ARDS develops, require specialized expertise and equipment, and to date have shown limited benefit. Objectives: Assess the efficacy of immediate post injury intravenous administration of autologous or allogeneic bone marrow-derived mesenchymal stromal cells (MSCs) for the treatment of acute respiratory distress syndrome (ARDS) due to smoke inhalation and burns. Methods: Yorkshire swine (n = 32, 44.3 ± 0.5 kg) underwent intravenous anesthesia, placement of lines, severe smoke inhalation, and 40% total body surface area flame burns, followed by 72 hours of around-the-clock ICU care. Mechanical ventilation, fluids, pressors, bronchoscopic cast removal, daily lung computed tomography scans, and arterial blood assays were performed. After injury and 24 and 48 hours later, animals were randomized to receive autologous concentrated bone marrow aspirate (n = 10; 3 × 106 white blood cells and a mean of 56.6 × 106 platelets per dose), allogeneic MSCs (n = 10; 6.1 × 106 MSCs per dose) harvested from healthy donor swine, or no treatment in injured control animals (n = 12). Measurements and Main Results: The intravenous administration of MSCs after injury and at 24 and 48 hours delayed the onset of ARDS in swine treated with autologous MSCs (48 ± 10 h) versus control animals (14 ± 2 h) (P = 0.004), reduced ARDS severity at 24 (P < 0.001) and 48 (P = 0.003) hours, and demonstrated visibly diminished consolidation on computed tomography (not significant). Mortality at 72 hours was 1 in 10 (10%) in the autologous group, 5 in 10 (50%) in the allogeneic group, and 6 in 12 (50%) in injured control animals (not significant). Both autologous and allogeneic MSCs suppressed systemic concentrations of TNF-α (tumor necrosis factor-α). Conclusions: The intravenous administration of three doses of freshly processed autologous bone marrow-derived MSCs delays ARDS development and reduces its severity in swine. Bedside retrieval and administration of autologous MSCs in swine is feasible and may be a viable injury mitigation strategy for ARDS.
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Affiliation(s)
- Andriy I Batchinsky
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas
| | - Teryn R Roberts
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, Texas
| | - Ben Antebi
- Maryland Stem Cell Research Fund, Columbia, Maryland
| | - Corina Necsoiu
- U.S. Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Fort Sam Houston, Texas
| | - Jae H Choi
- 59th Medical Wing, Joint Base San Antonio Lackland Air Force Base, San Antonio, Texas
| | - Maryanne Herzig
- U.S. Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Fort Sam Houston, Texas
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Fort Sam Houston, Texas
| | - Jennifer S McDaniel
- 59th Medical Wing, Joint Base San Antonio Lackland Air Force Base, San Antonio, Texas
| | | | | | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Fort Sam Houston, Texas
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Cindass R, Cancio TS, Cancio JM, Pruskowski KA, Park SE, Shingleton SK, Yugawa CM, Cancio LC. Management of multiple frostbite casualties at a burn center: San Antonio, Texas, 12-20 February 2021. Burns 2023; 49:1990-1996. [PMID: 37821276 DOI: 10.1016/j.burns.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/14/2023] [Accepted: 04/15/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Frostbite is an insidious disease that normally affects people of cold climates. Winter Storm Uri, which occurred from February 12-20, 2021, created unique metrological conditions for Texas. It caused prolonged sub-freezing temperatures and led to rolling blackouts, affecting 2.8 million Texans including 300,000 people in San Antonio. We report 13 frostbite patients admitted to one burn center during this event. OBJECTIVE We aimed to determine the at-risk population for frostbite, to categorize their injury severity, and to describe their treatment. A secondary aim was to describe the rehabilitation management of these patients. METHODS This is a single-center retrospective study. Each patient's injuries were assessed by a topographical grading system. Comparisons were made among those who were admitted to the intensive care unit (ICU), admitted to the progressive care unit (PCU), and treated as outpatients. RESULTS Thirteen patients were identified. Ten (76.9 %) considered themselves homeless, and 9 (69.2 %) were directly exposed to the elements. The median delay between time of injury and presentation to a medical facility was 3 days (IQR 1-6). Only 3 patients presented to a medical facility within 24 h. Six (46 %) sustained grade 2 injuries, 2 (15 %) sustained grade 3 injuries, and 5 (38%) sustained grade 4 injuries. Only one patient met criteria to receive tissue plasminogen activator (tPA), which was discontinued due to hematochezia. Patients admitted to the ICU, when compared to patients admitted to the ward, had a longer length of stay (median 73 days v. 12 days, p = 0.0215), and required more amputations at below-the-knee or higher levels (3 v. 0, p-value 0.0442). CONCLUSION In a region unaccustomed and perhaps unprepared to deal with winter storms, the population is particularly vulnerable to frostbite. Lack of awareness of frostbite injuries likely led to the delay in the presentation of patients, which prevented the timely use of tPA. Increasing public awareness may increase readiness.
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Affiliation(s)
| | - Tomas S Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Jill M Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Kaitlin A Pruskowski
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA; Uniformed Services University, Bethesda, MD, USA.
| | - Sanghwa E Park
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Sarah K Shingleton
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Craig M Yugawa
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
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Shields BA, Fossati SO, Cole RE, Kieffer AJ, Vega SJ, Aden JK, Williams AM, Cancio LC. Corrigendum to "Adjusting body weight for edema in severely burned patients" [Burns 49(3) (2023) 562-565]. Burns 2023; 49:1782. [PMID: 37821279 DOI: 10.1016/j.burns.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Affiliation(s)
- Beth A Shields
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States.
| | - Sandrine O Fossati
- United States Military-Baylor University Graduate Program in Nutrition, Fort Sam Houston, TX, United States
| | - Renee E Cole
- United States Military-Baylor University Graduate Program in Nutrition, Fort Sam Houston, TX, United States
| | - Adam J Kieffer
- United States Military-Baylor University Graduate Program in Nutrition, Fort Sam Houston, TX, United States
| | - Saul J Vega
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - James K Aden
- Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Alicia M Williams
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
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King B, Cancio LC, Jeng JC. Military Burn Care and Burn Disasters. Surg Clin North Am 2023; 103:529-538. [PMID: 37149388 DOI: 10.1016/j.suc.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Mass-casualty incidents can occur because of natural disasters; industrial accidents; or intentional attacks against civilian, police, or in case of combat, military forces. Depending on scale and type of incident, burn casualties often with a variety of concomitant injuries can be anticipated. The treatment of life-threatening traumatic injuries should take precedent but the stabilization, triage, and follow-on care of these patients will require local, state, and often regional coordination and support.
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Affiliation(s)
- Booker King
- North Carolina Jaycee Burn Center, University of North Carolina Chapel Hill, Burnett Womack Building, Campus Box 7206, Chapel Hill, NC 27599-7206, USA
| | - Leopoldo C Cancio
- U.S. Army Burn Center, U.S. Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234-6315, USA
| | - James C Jeng
- University of California Irvine, 3800 West Chapman Avenue, Suite 6200, Orange, CA 92868, USA.
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Britton GW, Wiggins AR, Halgas BJ, Cancio LC, Chung KK. Critical Care of the Burn Patient. Surg Clin North Am 2023; 103:415-426. [PMID: 37149378 DOI: 10.1016/j.suc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Care of the critically ill burned patient must integrate a multidisciplinary care team composed of burn care specialists. As resuscitative mortality decreases more patients are surviving to experience multisystem organ failure relating to complications of their injuries. Clinicians must be aware of physiologic changes following burn injury and the implicated impacts on management strategy. Promoting wound closure and rehabilitation should be the backdrop for which management decisions are made.
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Affiliation(s)
- Garrett W Britton
- US Army Institute of Surgical Research, 3698 Chambers Pass Road, San Antonio, TX 78234, USA; Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA.
| | - Amanda R Wiggins
- US Army Institute of Surgical Research, 3698 Chambers Pass Road, San Antonio, TX 78234, USA
| | - Barret J Halgas
- US Army Institute of Surgical Research, 3698 Chambers Pass Road, San Antonio, TX 78234, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, 3698 Chambers Pass Road, San Antonio, TX 78234, USA; Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
| | - Kevin K Chung
- Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
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Cancio LC. Burns: Recent Advances and Perennial Challenges. Surg Clin North Am 2023; 103:xv-xvii. [PMID: 37149392 DOI: 10.1016/j.suc.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Affiliation(s)
- Leopoldo C Cancio
- Colonel (retired), Medical Corps, US Army, US Army Institute of Surgical Research Burn Center, 3698 Chambers Pass, JBSA Fort Sam Houston, TX, USA.
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12
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Murray SJ, Cancio LC. The Phenomenon of Community Reintegration for Veterans with Burn Injury: Supportive Communities and Future-Oriented Thinking. J Burn Care Res 2023; 44:555-562. [PMID: 31808802 DOI: 10.1093/jbcr/irz198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Indexed: 11/14/2022]
Abstract
Combat missions in the Middle East have resulted in approximately 52,000 U.S. veterans who have been wounded in action, with 10% of whom suffered burn injuries. More than 90% of the wounded survived, but many were unable to return to military service. The purpose of this study was to investigate the factors that impacted reintegration of veterans with combat burn injuries. Using a mixed-methods approach and analysis, we asked veterans with combat burns "What was your experience reintegrating into the civilian community?" Additionally, we administered the Community Reintegration of Injured Service Members (CRIS) tool to measure the current level of reintegration. Six veterans with combat burn injury identified two major themes: supportive communities and future-oriented thinking. Supportive communities are defined as communities that are veteran-specific, provide long-term burn/injury care, are financially beneficial, and support hobbies, education, and work opportunities. Future-oriented thinking is defined as thinking in which a veteran experiences a turning point in recovery, has a desire to serve others, develops new meaning in life, and experiences posttraumatic growth. In both themes, peer support was a key component. Community reintegration was enhanced by future-oriented thinking and a supportive community, both of which can be buoyed by peer support. These findings are similar to other studies noting the importance of peer support for veterans. Studies of civilians burn survivors describe similar reintegration issues. These two factors may also be applicable to those survivors. Further qualitative inquiry into peer support in the burn community at large may reveal more actionable evidence which could enable burn survivors to meet the long-term goal of community reintegration.
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Affiliation(s)
- Sarah J Murray
- US Army Institute of Surgical Research Burn Center, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234-6315
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research Burn Center, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234-6315
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13
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Shields BA, Fossati SO, Cole RE, Kieffer AJ, Vega SJ, Aden JK, Williams AM, Cancio LC. Adjusting body weight for edema in severely burned patients. Burns 2023; 49:562-565. [PMID: 36764841 DOI: 10.1016/j.burns.2023.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/03/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023]
Abstract
Weight loss is difficult to quantify in critically ill burn patients, as the presence of edema can mask changes in dry body weight. We sought to estimate dry body weight using measured weights adjusted for reported extremity edema. We evaluated patients with at least 20% total body surface area (TBSA) burns admitted to our intensive care unit over a 3½-year period. Body weights were collected for this analysis from admission to the time of a recorded dry weight after wound healing. Extremity edema was collected at the time of each weight measurement and was categorized into three groups: (1) no edema, (2) 1 + pitting edema, (3) 2 + or 3 + pitting edema. Logistic regression yielded the following formula for estimating dry weight (in kg): 0.66 x measured body weight + 25 - (3 for 1 + pitting edema or 4 for 2 + or 3 + pitting edema of either upper extremity) - (4 for any pitting edema to either lower extremity) (p < 0.01, R2 = 0.81). These results may allow us to better estimate dry body weight changes in our edematous patients with severe burns. Nutrition goals can be adjusted earlier, when appropriate, based on these estimated dry body weight changes.
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Affiliation(s)
- Beth A Shields
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States.
| | - Sandrine O Fossati
- United States Military-Baylor University Graduate Program in Nutrition, Fort Sam Houston, TX, United States
| | - Renee E Cole
- United States Military-Baylor University Graduate Program in Nutrition, Fort Sam Houston, TX, United States
| | - Adam J Kieffer
- United States Military-Baylor University Graduate Program in Nutrition, Fort Sam Houston, TX, United States
| | - Saul J Vega
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - James K Aden
- Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Alicia M Williams
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
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Simovic MO, Yang Z, Jordan BS, Fraker TL, Cancio TS, Lucas ML, Cancio LC, Li Y. Immunopathological Alterations after Blast Injury and Hemorrhage in a Swine Model of Prolonged Damage Control Resuscitation. Int J Mol Sci 2023; 24:ijms24087494. [PMID: 37108656 PMCID: PMC10139120 DOI: 10.3390/ijms24087494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Trauma-related hemorrhagic shock (HS) remains a leading cause of death among military and civilian trauma patients. We have previously shown that administration of complement and HMGB1 inhibitors attenuate morbidity and mortality 24 h after injury in a rat model of blast injury (BI) and HS. To further validate these results, this study aimed to develop a swine model and evaluate BI+HS-induced pathophysiology. Anesthetized Yucatan minipigs underwent combined BI and volume-controlled hemorrhage. After 30 min of shock, animals received an intravenous bolus of PlasmaLyte A and a continuous PlasmaLyte A infusion. The survival rate was 80% (4/5), and the non-survivor expired 72 min post-BI. Circulating organ-functional biomarkers, inflammatory biomarkers, histopathological evaluation, and CT scans indicated evidence of multiple-organ damage, systemic innate immunological activation, and local tissue inflammation in the injured animals. Interestingly, a rapid and dramatic increase in plasma levels of HMGB1 and C3a and markedly early myocarditis and encephalitis were associated with early death post-BI+HS. This study suggests that this model reflects the immunopathological alterations of polytrauma in humans during shock and prolonged damage control resuscitation. This experimental protocol could be helpful in the assessment of immunological damage control resuscitation approaches during the prolonged care of warfighters.
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Affiliation(s)
- Milomir O Simovic
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
| | - Zhangsheng Yang
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Bryan S Jordan
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Tamara L Fraker
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
| | - Tomas S Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Michael L Lucas
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Yansong Li
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
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15
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Mitchell TA, Baaklini GT, Carpenter EL, Cancio LC. Degloving Penile and Scrotal Injury From a Posthole Auger. Am Surg 2023; 89:1171-1172. [PMID: 33350854 DOI: 10.1177/0003134820973731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Gina T Baaklini
- Department of Urology, San Antonio Military Medical Center, TX, USA
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16
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Yang Z, Nicholson SE, Cancio TS, Cancio LC, Li Y. Complement as a vital nexus of the pathobiological connectome for acute respiratory distress syndrome: An emerging therapeutic target. Front Immunol 2023; 14:1100461. [PMID: 37006238 PMCID: PMC10064147 DOI: 10.3389/fimmu.2023.1100461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/27/2023] [Indexed: 03/19/2023] Open
Abstract
The hallmark of acute respiratory distress syndrome (ARDS) pathobiology is unchecked inflammation-driven diffuse alveolar damage and alveolar-capillary barrier dysfunction. Currently, therapeutic interventions for ARDS remain largely limited to pulmonary-supportive strategies, and there is an unmet demand for pharmacologic therapies targeting the underlying pathology of ARDS in patients suffering from the illness. The complement cascade (ComC) plays an integral role in the regulation of both innate and adaptive immune responses. ComC activation can prime an overzealous cytokine storm and tissue/organ damage. The ARDS and acute lung injury (ALI) have an established relationship with early maladaptive ComC activation. In this review, we have collected evidence from the current studies linking ALI/ARDS with ComC dysregulation, focusing on elucidating the new emerging roles of the extracellular (canonical) and intracellular (non-canonical or complosome), ComC (complementome) in ALI/ARDS pathobiology, and highlighting complementome as a vital nexus of the pathobiological connectome for ALI/ARDS via its crosstalking with other systems of the immunome, DAMPome, PAMPome, coagulome, metabolome, and microbiome. We have also discussed the diagnostic/therapeutic potential and future direction of ALI/ARDS care with the ultimate goal of better defining mechanistic subtypes (endotypes and theratypes) through new methodologies in order to facilitate a more precise and effective complement-targeted therapy for treating these comorbidities. This information leads to support for a therapeutic anti-inflammatory strategy by targeting the ComC, where the arsenal of clinical-stage complement-specific drugs is available, especially for patients with ALI/ARDS due to COVID-19.
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Affiliation(s)
- Zhangsheng Yang
- Combat Casualty Care Research Team (CRT) 3, United States (US) Army Institute of Surgical Research, Joint Base San Antonio (JBSA)-Fort Sam Houston, TX, United States
| | - Susannah E. Nicholson
- Division of Trauma Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Tomas S. Cancio
- Combat Casualty Care Research Team (CRT) 3, United States (US) Army Institute of Surgical Research, Joint Base San Antonio (JBSA)-Fort Sam Houston, TX, United States
| | - Leopoldo C. Cancio
- United States (US) Army Burn Center, United States (US) Army Institute of Surgical Research, Joint Base San Antonio (JBSA)-Fort Sam Houston, TX, United States
| | - Yansong Li
- Division of Trauma Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- The Geneva Foundation, Immunological Damage Control Resuscitation Program, Tacoma, WA, United States
- *Correspondence: Yansong Li,
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17
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Perez KG, Eskridge SL, Clouser MC, Cancio JM, Cancio LC, Galarneau MR. Burn injuries in US service members: 2001-2018. Burns 2023; 49:461-466. [PMID: 35400523 DOI: 10.1016/j.burns.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/25/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Burns are an important cause of battlefield injury, accounting for 5-20% of the combat injury burden. To date, no report has examined the full range of burns, from mild to severe, resulting from post-9/11 conflicts. The present study leverages the Expeditionary Medical Encounter Database (EMED), a Navy-maintained health database describing all service member medical encounters occurring during deployment, to capture, quantify and characterize burn-injured service members and the injuries they sustained while deployed in support of post-9/11 operations. METHODS The EMED was queried for all surviving service members with at least one burn injury, identified using injury-specific Abbreviated Injury Scale codes. Demographic and additional injury information were also obtained from the EMED. RESULTS From 2001 through 2018, 2507 deployed service members sustained 5551 burns. Blasts accounted for 82% of injuries, largely attributed to the use of improvised explosive devices. Concurrent injury was common, with 30% sustaining a traumatic brain injury and 10% sustaining inhalation injury. Most burns were small, with 92% involving< 20% TBSA; 85% of burns involved< 10% TBSA. The head and the hands were the most commonly affected areas, accounting for 48% of all burns, with 80% of service members sustaining at least one burn to these areas. CONCLUSION The majority of burns tend to be small in size, with the head and hands most commonly affected. As these areas are often left uncovered by the uniform, prevention measures, particularly improvement in and increased usage of personal protective gear, may help reduce these injuries and their consequences.
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Affiliation(s)
- Katheryne G Perez
- Leidos, San Diego, CA, USA; Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, CA, USA.
| | - Susan L Eskridge
- Leidos, San Diego, CA, USA; Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, CA, USA
| | - Mary C Clouser
- Leidos, San Diego, CA, USA; Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, CA, USA
| | - Jill M Cancio
- US Army Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Leopoldo C Cancio
- US Army Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Michael R Galarneau
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, CA, USA
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18
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Yang Z, Nunn MA, Le TD, Simovic MO, Edsall PR, Liu B, Barr JL, Lund BJ, Hill-Pryor CD, Pusateri AE, Cancio LC, Li Y. Immunopathology of terminal complement activation and complement C5 blockade creating a pro-survival and organ-protective phenotype in trauma. Br J Pharmacol 2023; 180:422-440. [PMID: 36251578 PMCID: PMC10100417 DOI: 10.1111/bph.15970] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/24/2022] [Accepted: 09/17/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Traumatic haemorrhage (TH) is the leading cause of potentially preventable deaths that occur during the prehospital phase of care. No effective pharmacological therapeutics are available for critical TH patients yet. Here, we identify terminal complement activation (TCA) as a therapeutic target in combat casualties and evaluate the efficacy of a TCA inhibitor (nomacopan) on organ damage and survival in vivo. EXPERIMENTAL APPROACH Complement activation products and cytokines were analysed in plasma from 54 combat casualties. The correlations between activated complement pathway(s) and the clinical outcomes in trauma patients were assessed. Nomacopan was administered to rats subjected to lethal TH (blast injury and haemorrhagic shock). Effects of nomacopan on TH were determined using survival rate, organ damage, physiological parameters, and laboratory profiles. KEY RESULTS Early TCA was associated with systemic inflammatory responses and clinical outcomes in this trauma cohort. Lethal TH in the untreated rats induced early TCA that correlated with the severity of tissue damage and mortality. The addition of nomacopan to a damage-control resuscitation (DCR) protocol significantly inhibited TCA, decreased local and systemic inflammatory responses, improved haemodynamics and metabolism, attenuated tissue and organ damage, and increased survival. CONCLUSION AND IMPLICATIONS Previous findings of our and other groups revealed that early TCA represents a rational therapeutic target for trauma patients. Nomacopan as a pro-survival and organ-protective drug, could emerge as a promising adjunct to DCR that may significantly reduce the morbidity and mortality in severe TH patients while awaiting transport to critical care facilities.
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Affiliation(s)
- Zhangsheng Yang
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | | | - Tuan D Le
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Milomir O Simovic
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA.,The Geneva Foundation, Tacoma, Washington, USA
| | - Peter R Edsall
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Bin Liu
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Johnny L Barr
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Brian J Lund
- 59th Medical Wing Operational Medicine, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | | | - Anthony E Pusateri
- Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Yansong Li
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA.,The Geneva Foundation, Tacoma, Washington, USA
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19
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Pruskowski KA, Kiley JL, Cancio LC. 650. Cefiderocol use in burn patients admitted to an intensive care unit. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Cefiderocol is a novel cephalosporin that binds to ferric acid and is moved across the outer membrane of Gram-negative bacilli via iron transport. Once through the outer membrane, cefiderocol is able to exert typical cephalosporin activity. Because of its ‘Trojan horse’-like mechanism of action, cefiderocol is able to elude typical bacterial resistance mechanisms and has activity against multidrug-resistant organisms (MDROs), including Acinetobacter spp. and Pseudomonas spp. While cefiderocol is considered to be relatively safe, it does have the potential to predispose to secondary infection with Clostridioides difficile. We present a case series where cefiderocol was used to treat infections caused by MDROs in burn patients admitted to our burn intensive care unit (BICU).
Methods
A clinical review of patients admitted to the BICU who received cefiderocol between September 2019 and April 2022 was performed.
Results
Five patients received 6 courses of cefiderocol. Three patients (60%) had flame burns, one patient (20%) had a scald burn, and one patient (20%) had blast injury. The median burn size was 47% TBSA (IQR 31, 60 days). The median time from injury to cefiderocol initiation was 73.5 days (IQR 49.5, 108). The median duration of cefiderocol therapy was 7 days (IQR 7, 16). The most common indications for cefiderocol treatment were pneumonia (33.3%) and bacteremia (33.3%), followed by wound infection (16.7%), and discitis/osteomyelitis (16.7%). Organisms isolated included Escherichia coli (n=2), Enterobacter cloacae (n=1), Acinetobacter baumannii (n=1), and Pseudomonas aeruginosa (n=2). All isolates were carbapenem resistant, and only one isolate was susceptible to amikacin (Acinetobacter baumannii). The 2 E. coli isolates carried a New Delhi metallo-beta lactamase. Two thirds of patients (n=4) achieved a clinical cure with cefiderocol treatment. Three of the 5 patients (60%) died during their hospital stay.
All patients received appropriate doses of cefiderocol based on the current prescribing recommendations. No patients developed infection with C. difficile as a result of cefiderocol treatment.
Conclusion
Cefiderocol is a cephalosporin with novel mechanism of action that can be used to treat MDROs in burn patients, with no secondary C. difficile infections observed.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | - Leopoldo C Cancio
- US Army Institute of Surgical Research , JBSA Fort Sam Houston, Texas
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20
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Geringer M, Stewart L, Shaikh F, Carson L, Lu D, Cancio LC, Gurney JM, Tribble DR, Kiley JL. 1207. Epidemiology and Timing of Infectious Complications from Battlefield-Related Burn Injuries. Open Forum Infect Dis 2022. [PMCID: PMC9752583 DOI: 10.1093/ofid/ofac492.1040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Thermal injury alters the host response, making burn patients more susceptible to infections. In fact, infections represent the most frequent complication and cause of mortality in burn patients. We describe the epidemiology, clinical characteristics, timing, and outcomes of infections among wounded military personnel with burns. Methods Data were collected through the Trauma Infectious Disease Outcomes Study, an observational study of US service members injured in Iraq and Afghanistan (6/09-12/14). Patients who sustained ≥1 burn injury and were admitted to the Burn Center at Brooke Army Medical Center were included in the analysis. Infections were defined using standardized criteria. For patients with multiple infections, only the initial infection was assessed. Results Among 144 burn patients, 99% were males and 62% had combat-related burns with a median total body surface area (TBSA) of 6% (IQR 3-14%) thermally injured. Infections were diagnosed in 26 (18%) patients with pneumonia being the predominant initial syndrome (N=16, 62%), followed by skin and soft-tissue infections (N=6, 23%), bloodstream infections (N=3, 12%), and intra-abdominal infections (N=1, 4%). Median number of days to each of these initial infecting syndromes were 4 (IQR 3-5), 7 (IQR 4-12), 7 (IQR 6-7), and 17 (IQR 17-17) days, respectively. Patients with infections were more severely injured with greater TBSA (median 31 vs 5) and Baux scores (median 59 vs 29), and were more likely to have combat trauma, inhalation injury, require mechanical ventilation, and have longer time to definitive grafting (Table 1). Microbiology of initial infections varied with 35% of patients having polymicrobial infections (Table 2). Gram-negative organisms were recovered from 20 (77%) patients, of whom 20% had a multidrug-resistant Gram-negative. Gram-positive organisms and fungi were identified in 42% and 8% of patients, respectively.
![]() ![]() Conclusion Improved understanding of risk factors and the timing of infections in this unique population is critical for effective management. Patients with infections were more severely injured, had higher rates of inhalational injury, and longer days to definitive grafting. Initial infections were more commonly pneumonia. Disclosures David R. Tribble, DrPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.
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Affiliation(s)
- Matthew Geringer
- Brooke Army Medical Center / San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Bethesda, Maryland
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Bethesda, Maryland
| | - Leigh Carson
- Infectious Disease Clinical Research Program, Bethesda, Maryland
| | | | | | - Jennifer M Gurney
- US Army Institute of surgical research/joint trauma system, San Antonio, Texas
| | - David R Tribble
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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21
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Convertino VA, Wagner AR, Akers KS, VanFosson CA, Cancio LC. Early identification of sepsis in burn patients using compensatory reserve measurement: A prospective case series study. Burns Open 2022. [DOI: 10.1016/j.burnso.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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22
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Burmeister DM, Supp DM, Clark RA, Tredget EE, Powell HM, Enkhbaatar P, Bohannon JK, Cancio LC, Hill DM, Nygaard RM. Advantages and Disadvantages of Using Small and Large Animals in Burn Research: Proceedings of the 2021 Research Special Interest Group. J Burn Care Res 2022; 43:1032-1041. [PMID: 35778269 DOI: 10.1093/jbcr/irac091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Multiple animal species and approaches have been used for modeling different aspects of burn care, with some strategies considered more appropriate or translatable than others. On April 15, 2021, the Research Special Interest Group of the American Burn Association held a virtual session as part of the agenda for the annual meeting. The session was set up as a pro/con debate on the use of small versus large animals for application to four important aspects of burn pathophysiology: burn healing/conversion; scarring; inhalation injury; and sepsis. For each of these topics, 2 experienced investigators (one each for small and large animal models) described the advantages and disadvantages of using these preclinical models. The use of swine as a large animal model was a common theme due to anatomic similarities with human skin. The exception to this was a well-defined ovine model of inhalation injury; both of these species have larger airways which allow for incorporation of clinical tools such as bronchoscopes. However, these models are expensive and demanding from labor and resource standpoints. Various strategies have been implemented to make the more inexpensive rodent models appropriate for answering specific questions of interest in burns. Moreover, modelling burn-sepsis in large animals has proven difficult. It was agreed that the use of both small and large animal models have merit for answering basic questions about the responses to burn injury. Expert opinion and the ensuing lively conversations are summarized herein, which we hope will help inform experimental design of future research.
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Affiliation(s)
- David M Burmeister
- Uniformed Services University of the Health Sciences, Department of Medicine, Bethesda, MD, United States of America
| | - Dorothy M Supp
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Scientific Staff, Shriners Children's Ohio, Dayton, OH, USA
| | - Richard A Clark
- Stony Brook University, Departments of Dermatology, Biomedical Engineering and Medicine, Stony Brook, NY, USA
| | - Edward E Tredget
- Firefighters' Burn Treatment Unit, Department of Surgery, 2D3.31 Mackenzie Health Sciences Centre, University of Alberta, Edmonton, AB, Canada
| | - Heather M Powell
- Department of Materials Science and Engineering, Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA.,Scientific Staff, Shriners Children's Ohio, Dayton, OH, USA
| | - Perenlei Enkhbaatar
- Department of Anesthesiology, Medical Branch, University of Texas, 301 University Boulevard, Galveston, TX, USA
| | - Julia K Bohannon
- Vanderbilt University Medical Center, Department of Anesthesiology, Department of Pathology, Microbiology, and Immunology, Nashville, TN, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - David M Hill
- Firefighters' Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN, USA
| | - Rachel M Nygaard
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN, USA
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23
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Holmes IV JH, Cancio LC, Carter JE, Faucher LD, Foster K, Hahn HD, King BT, Rutan R, Smiell JM, Wu R, Gibson AL. Pooled safety analysis of STRATA2011 and STRATA2016 clinical trials evaluating the use of StrataGraft® in patients with deep partial-thickness thermal burns. Burns 2022; 48:1816-1824. [DOI: 10.1016/j.burns.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 11/02/2022]
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24
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Melvin AC, Wick TV, Zang Y, Harea GT, Cancio LC, Reynolds MM, Batchinsky AI, Roberts TR. Development and Blood Compatibility of a Stable and Bioactive Metal-Organic Framework Composite Coating for Blood-Circulation Tubing. ACS Biomater Sci Eng 2022; 8:3438-3449. [PMID: 35776832 DOI: 10.1021/acsbiomaterials.2c00492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medical devices that require substantial contact between blood and a foreign surface would be dramatically safer if constructed from materials that prevent clot formation and coagulation disturbance at the blood-biomaterial interface. Nitric oxide (NO), an endogenous inhibitor of platelet activation in the vascular endothelium, could provide anticoagulation at the blood-surface interface when applied to biomaterials. We investigated an application of a copper-based metal-organic framework, H3[(Cu4Cl)3(BTTri)8-(H2O)12]·72H2O where H3BTTri = 1,3,5-tris(1H-1,2,3-triazole-5-yl)benzene] (CuBTTri), which has been shown to be an effective catalyst to generate NO from S-nitrosothiols that are endogenously present in blood. A method was developed to apply a CuBTTri composite coating to Tygon medical tubing used for extracorporeal lung support devices. The stability and activity of the coating were evaluated during 72 h dynamic saline flow testing (1.5-2.5 L/min, n = 3) with scanning electron microscopy imaging and inductively coupled mass-spectroscopy analysis. Compatibility of the coating with whole blood was assessed with a panel of hemocompatibility tests during 6 h circulation of swine donor blood in an ex vivo circulation loop constructed with CuBTTri tubing or unmodified Tygon (1.5 L/min blood flow rate, n = 8/group). Thrombus deposition and catalytic activity of the CuBTTri tubing were assessed following blood exposure. The coating remained stable during 72 h saline flow experiments at clinically relevant flow rates. No adverse effects were observed relative to controls during blood compatibility testing, to include no significant changes in platelet count (p = 0.42), platelet activation indicated by P-selectin expression (p = 0.57), coagulation panel values, or methemoglobin fraction (p = 0.18) over the 6 h circulation period. CuBTTri within the coating generated NO following blood exposure in the presence of biologically relevant concentrations of an NO donor. CuBTTri composite coating was stable and blood compatible in this pilot study and requires further investigation of efficacy using in vivo models conducted with clinically relevant blood flow rates and study duration.
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Affiliation(s)
- Alyssa C Melvin
- Colorado State University, 301 West Pitkin Street, Fort Collins, Colorado 80523, United States
| | - Tracey V Wick
- Colorado State University, 301 West Pitkin Street, Fort Collins, Colorado 80523, United States
| | - Yanyi Zang
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle, San Antonio, Texas 78259, United States
| | - George T Harea
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle, San Antonio, Texas 78259, United States
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research Burn Center, 3698 Chambers Road, Fort Sam Houston, Texas 78234, United States
| | - Melissa M Reynolds
- Colorado State University, 301 West Pitkin Street, Fort Collins, Colorado 80523, United States
| | - Andriy I Batchinsky
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle, San Antonio, Texas 78259, United States
| | - Teryn R Roberts
- Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, 2509 Kennedy Circle, San Antonio, Texas 78259, United States
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25
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Payne R, Glassman E, Turman ML, Cancio LC. Pathophysiology and Treatment of Burns. J Spec Oper Med 2022; 22:87-92. [PMID: 35639900 DOI: 10.55460/bggy-2lfl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
Management of burn patients in the prehospital and prolonged field care environments presents complex patient care and logistical challenges. The authors discuss the pathophysiology, diagnostics, longitudinal concerns, and treatment involved in the care of such patients.
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26
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Gyedu A, Mehta K, Baidoo H, Addo D, Abdullah M, Mesic A, Samosorn A, Cancio LC, Nakarmi K, Stewart BT. Preferences for Oral Rehydration Drinks among Healthy Individuals in Ghana: A Single-Blind, Cross-Sectional Survey to Inform Implementation of an Enterally Based Resuscitation Protocol for Burn Injury. Burns 2022; 49:820-829. [PMID: 35715342 DOI: 10.1016/j.burns.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Enterally based resuscitation for major burn injuries has been suggested as a simple, operationally superior, and effective resuscitation strategy for use in austere contexts. However, key information to support its implementation is lacking, including palatability and acceptability of widely available rehydration drinks. METHODS We performed a single-blinded, cross-sectional survey of 60 healthy children (5-14 years), adults (15-54 years) and older adults (≥55 years) to determine palatability and overall acceptability of five oral rehydration solutions (ORS) and a positive control drink (Sprite Zero®) in Ghana. Quantitative data were described and differences between our control drink and the others across age groups were visually examined with Likert plots. Qualitative responses were analyzed using a content analysis framework. RESULTS Twenty participants in each age group completed the study. Participants were as young as 5 years and as old as 84 years. Nearly two thirds of the sample identified as male (n = 38, 63% of all participants). The positive control was reported to taste 'good or 'very good' by the majority of participants (89%) followed by lemon-flavored ORS (78%) and orange-flavored ORS (78%). Conversely, homemade and low-osmolarity ORS were reported to taste 'good' or 'very good' by only 20% and 15% of participants, respectively. There were no major taste differences across the age groups. However, children more frequently reported positively (i.e., tastes 'good' or 'very good') about flavored and sweet drinks than did adults and older adults. When faced with the hypothetical situation of being critically injured and needing resuscitation, participants tended to be more agreeable to consuming all the drinks, even low-osmolarity and homemade ORS. CONCLUSIONS These findings can be used to support the development of protocols that may be more acceptable among patients undergoing enterally based resuscitation, thus improving the effectiveness of the treatment. Specifically, enterally based resuscitation should likely include citrus-flavored ORS when available, given superior palatability and the fact that different flavor additives for patients of different ages do not seem necessary.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Kajal Mehta
- Department of Surgery, University of Washington, Seattle, WA, USA.
| | - Hilary Baidoo
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Dorcas Addo
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Mohammed Abdullah
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Aldina Mesic
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Angela Samosorn
- US Army Institute of Surgical Research, Fort Sam Houston, TX, USA; US Army Nurse Corps, San Antonio, TX, USA.
| | | | | | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA; Harborview Injury Prevention & Research Center, Seattle, WA, USA; UW Medicine Regional Burn Center, Seattle, WA, USA.
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Basel AP, Britton GW, Yugawa C, Cancio LC. 758 Constant evolution: Early experiences treating COVID-19 in a burn center. J Burn Care Res 2022. [PMCID: PMC8946042 DOI: 10.1093/jbcr/irac012.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Introduction The COVID-19 pandemic came as an unexpected challenge to many healthcare systems around the world. Many centers struggled to provide COVID-19 ICU-level care while also maintaining adequate care for non-COVID-19-related conditions, especially in critical care specialty units like trauma and burn. We present a case series of our early experiences treating COVID-19 in a burn center. Methods We present a case. Results See Table 1. Though one case was admitted prior to initiation of universal testing, routine infection-control protocols limited exposure to personnel and prevented transmission to staff. In May 2020, we implemented the use of N95 mask and eye protection during all aerosolizing procedures, N95 mask use in all ORs, and universal surgical mask use in all rooms regardless of COVID-19 status. An in-house risk-stratification system was used to screen patients based on symptoms and exposure. Burn-center admissions were screened at a lower threshold than throughout the institution given the unique nature of burn injury. Eventually, because of increasing community spread, all admissions to the hospital were universally screened with RT-PCR prior to admission. To minimize exposure to non-COVID patients and Burn Center staff, COVID-19 positive burn admissions were assessed on a case-by-case basis. High acuity patients were admitted to the Burn Center and followed by the COVID consult team. Lower acuity patients were admitted to the Burn Center but were treated on the medical COVID unit and followed by the burn consult service. Conclusions The COVID 19 pandemic has strained healthcare systems worldwide. Development and implementation of universal screening, testing, infection-control precautions, and triage strategies are critical elements of burn care during the COVID-19 pandemic. As we prepare for future surges due to more transmissible variants, implementation of standard protocols enables continued provision of quality care, preservation of the healthcare workforce, and efficient use of resources.
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Affiliation(s)
- Anthony P Basel
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Garrett W Britton
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Craig Yugawa
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
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Basel AP, Britton GW, Evans J, Dado D, Scott LL, Grantham LE, Cancio LC, Chung KK. 3 Continuous Renal Replacement Therapy for the Treatment of Burn Shock: A Post Hoc Analysis. J Burn Care Res 2022. [PMCID: PMC8945509 DOI: 10.1093/jbcr/irac012.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Burn shock is a consequence of burns that cover ≥20% TBSA and may be complicated by acute kidney injury, which is commonly treated with continuous renal replacement therapy (CRRT). However, early initiation of CRRT has not been clinically evaluated for the treatment of burn shock. Methods Data were obtained from the Renal Replacement Therapy in Severe Burns: A Multicenter Observational Study. In that study, baseline (t0) measurements were taken at the time of CRRT initiation and ~24 (t1) and ~48 (t2) hours thereafter. Patients were included in this analysis if they had ≥20% TBSA and began CRRT within 2 days of injury. Patients were categorized as Group A (began CRRT on same day as injury), Group B (began CRRT on day 1 postburn), and Group C (began CRRT on day 2 postburn). Outcomes measured at t0, t1, and t2 and hospital and ICU length of stay (LOS) were analyzed using generalized linear mixed models. Cox proportional hazards models were used to assess survival to hospital discharge (HD). All models were adjusted, e.g. for age, % full thickness, etc. Burn center was included as a random effect. Results More than half of the 48 patients included were treated at just 2 burn centers. Timing of CRRT initiation varied by center, with all patients at one center starting CRRT on either the day of injury or the day after injury. Nearly 96% of patients had AKI at CRRT start and, of those, 22 were at stage 1 or 2. Patients generally had severe burns; Group A had more inhalation injuries and higher %TBSA, % full thickness, and Baux scores than Groups B and C. Shock index (SI) was persistently elevated across all 3 time points and did not vary by timing of CRRT initiation (p=0.37). Vasopressor dependency index (VDI) was also not associated with timing of CRRT initiation (p >0.99), although mean VDI for Groups B and C declined over time. For all 3 groups, fluid balance decreased from t0, but there were no differences among the groups (all p >0.30). Survival to HD was better for patients with lower TBSA (i.e. 20-49%) compared to those with TBSA ≥50% (hazard ratio=0.37; 95% CI=0.15-0.91). In contrast, timing of CRRT initiation was not associated with survival (p=0.73). Among patients that survived to HD, the mean hospital LOS was shorter for Groups A (13 days; p=0.01) and B (39 days; p=0.03) compared to Group C (131 days). Mean ICU LOS was also shorter for Groups A (13 days; p=0.01) and B (52 days; p=0.03) than for Group C (168 days). Conclusions In this analysis, earlier initiation of CRRT did not improve survival to hospital discharge. Nonetheless, starting patients on CRRT early may be advantageous for reducing ICU and hospital LOS for those patients that do survive. ![]()
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Affiliation(s)
- Anthony P Basel
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Te
| | - Garrett W Britton
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Te
| | - Jordan Evans
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Te
| | - David Dado
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Te
| | - Laura L Scott
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Te
| | - Lonnie E Grantham
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Te
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Te
| | - Kevin K Chung
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Te
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Basel AP, Thomas J, Williams AM, Stoffel S, Walter R, Mason P, Britton GW, Cancio LC. 709 Reconfiguration: Extracorporeal blood purification of a burn patient on ECMO. J Burn Care Res 2022. [PMCID: PMC8945435 DOI: 10.1093/jbcr/irac012.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Introduction Patients who require extracorporeal membrane oxygenation (ECMO) have a very high mortality if they develop septic shock. Extracorporeal blood purification has been studied as an adjunct to antimicrobials but has yielded mixed or even disappointing results. The Seraph-100 Microbind Affinity Blood Filter (ExThera Medical Corporation, Martinez, CA) is currently undergoing clinical trials. The filter consists of polyethylene beads, coated in heparin sulfate, that irreversibly binds bacteria, fungi, viruses, and toxins. Seraph-100 therapy is traditionally delivered through conventional hemodialysis or continuous renal replacement therapy (CRRT), with the filter being placed in-line with these circuits. We present a case of a burn patient on veno-venous (VV) ECMO in septic shock, who was treated with a Seraph filter by connecting it directly to the ECMO circuit. Methods We present a case. Results A 34-year-old male presented with 56% thermal burns and grade 1 inhalation injury from a fuel tank explosion. He underwent a large-volume resuscitation for burn shock with lactated Ringer’s and albumin, receiving 18,152 mL (163 mL/kg) in the first 24 hours. He was placed on CRRT for acute kidney injury and underwent escharotomies of the hands and legs. On day 4, he developed bacteremia, septic shock and progressed to acute respiratory distress syndrome requiring VV ECMO. Extracorporeal blood purification was started via the Seraph-100 filter. Due to limitations of blood flow rates on CRRT, the Seraph-100 filter was added directly into the ECMO circuit. Inflow tubing was connected to an existing port on the oxygenator (Fig 1) and returned to the venous drainage by cutting a new port into the drainage tubing (Fig 2). The filter itself did not require any special configuration or orientation (Fig 3). This configuration allowed for pressures generated by the ECMO circuit to drive blood flow through the Seraph-100 filter (Fig 4). After 6 hours of treatment, vasopressor requirements drastically decreased. Conclusions Complications related to the Seraph-100 filter are rare but may include catheter thrombosis. This is typically due to the type of catheter used and/or the blood-flow rate through the filter rather than the filter itself. This issue was avoided with the ECMO configuration. Similarly, clinicians can avoid transient hypotension, blood loss from a clotted circuit, catheter-site bleeding, and other complications frequently associated with a renal replacement circuit.
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Affiliation(s)
- Anthony P Basel
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, Ft. Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA F
| | - Jason Thomas
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, Ft. Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA F
| | - Alicia M Williams
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, Ft. Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA F
| | - Steven Stoffel
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, Ft. Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA F
| | - Robert Walter
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, Ft. Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA F
| | - Phillip Mason
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, Ft. Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA F
| | - Garrett W Britton
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, Ft. Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA F
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Brooke Army Medical Center, Ft. Sam Houston, Texas; Brooke Army Medical Center, San Antonio, Texas; Brooke Army Medical Center, Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA F
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Holmes JH, Cancio LC, Faucher LD, Foster KN, Gibson A. 89 Pooled Safety Analysis Evaluating Bioengineered Allogeneic Cellularized Construct in Patients with Deep Partial-thickness Thermal Burns. J Burn Care Res 2022. [PMCID: PMC8946523 DOI: 10.1093/jbcr/irac012.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Autograft (AG) is the standard of care treatment for deep burns but requires creation of a donor site wound prone to pain and scarring. Treatment with a bioengineered allogeneic cellularized construct (BACC) is an alternative approach that can reduce or eliminate the need for autografting. The BACC is a bilayer construct that was recently approved in the US for the treatment of adult deep partial-thickness (DPT) burns. Here, we report the analysis of pooled safety data from two open-label, randomized, controlled trials (STRATA2011 [NCT01437852] and STRATA2016 [NCT03005106]) that evaluated efficacy and safety of BACC versus autografting in patients with DPT burns.
Methods
The trials enrolled 101 patients aged ≥18 years with 3–49% total body surface area (TBSA) thermal burns. In each patient, two DPT areas on the torso or extremities were randomized to receive BACC or AG, where the mean total BACC dosage was 234.8 cm2 (range: 12.0–960.0 cm2). The safety endpoints assessed at each visit included: 1) treatment-emergent adverse events (TEAEs), treatment-related AEs (TRAEs), and serious AEs (SAEs); 2) changes in immunologic responses (panel reactive antibodies [PRA], anti-bovine serum albumin [BSA] antibody response [STRATA2016 only]); 3) persistence of allogeneic DNA; and 4) laboratory exam and vital signs.
Results
Eighty-seven patients (86.1%) experienced TEAEs, 30 patients (29.7%) experienced TRAEs, and 16 patients (15.8%) experienced SAEs. The most frequent TEAEs reported by ≥10% of patients in the pooled analysis were pruritus (n=31, 30.7%) and blister, hypertension, and hypertrophic scar (n=11, 10.9% each). The most frequent TRAEs (≥5% of patients) were pruritus (n=13, 12.9%) and blister (n=5, 5%). The most common SAEs were transplant (BACC or AG) failure, pneumonia, and deep vein thrombosis (n=2, 2% each), where only one SAE (impaired healing of moderate severity) was possibly related to BACC. One patient (1%) discontinued the trial due to a TEAE (traumatic brain injury). Two patients (2%) experienced SAEs that led to death, neither related to BACC. The number of patients with positive PRA values that were negative at baseline were 36 (38.7%) at Day 28 and 20 (22%) at Month 3. The number of patients with reactivity to HLA I class alleles found in the BACC increased from 4 (4%) at baseline to 39 (40.9%) at Day 28, then decreased to 22 (24.2%) at Month 3. No persistence of allogeneic DNA from the BACC was detected.
Conclusions
BACC is well tolerated and is not associated with any unexpected SAEs or TEAEs. The safety profile at BACC treatment sites is similar to that at AG treatment sites. Thus, BACC may offer a safe alternative to autografting for the treatment of DPT burns.
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Affiliation(s)
- James H Holmes
- Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; University of Wisconsin, Madison, Wisconsin; The Arizona Burn Center Valleywise Health, Phoenix, Arizona; University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Leopoldo C Cancio
- Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; University of Wisconsin, Madison, Wisconsin; The Arizona Burn Center Valleywise Health, Phoenix, Arizona; University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Lee D Faucher
- Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; University of Wisconsin, Madison, Wisconsin; The Arizona Burn Center Valleywise Health, Phoenix, Arizona; University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin N Foster
- Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; University of Wisconsin, Madison, Wisconsin; The Arizona Burn Center Valleywise Health, Phoenix, Arizona; University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Angela Gibson
- Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; University of Wisconsin, Madison, Wisconsin; The Arizona Burn Center Valleywise Health, Phoenix, Arizona; University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Pruskowski KA, Britton GW, Mitchell TA, Cancio LC. 519 Congruence of clinical suspicion of invasive fungal wound infection and biopsy positivity in burn patients. J Burn Care Res 2022. [PMCID: PMC8945827 DOI: 10.1093/jbcr/irac012.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction Invasive fungal wound infection (FWI) in burn patients is a high-mortality complication; early diagnosis and treatment may improve outcomes. Management of suspected FWI includes initiating broad-spectrum antifungals, obtaining a biopsy for histopathology and culture, and performing urgent surgical excision. However, the relationship between clinical suspicion (manifested by initiation of antifungals) and histopathological diagnosis is unknown. Methods Patients admitted between 2004 and 2019 to our burn center, and initiated on any systemic antifungal, were identified. The electronic medical record (EMR) was reviewed to determine the indication for such therapy. Patients were included if antifungals were initiated out of concern for FWI. If the indication was not clear, patients were included if the systemic antifungal agent(s) initiated were triazoles (not fluconazole), echinocandins, or amphotericin B. Results Two hundred one patients who received 251 courses of broad-spectrum antifungal therapy were included. Thirty six patients (17.9%) received more than one course of antifungal therapy. One hundred sixty five (82%) patients were male, with an average age of 41.1 ± 17.7 years. The average burn size was 49.7 ± 22.8% total body surface area (TBSA) and 60 (29.8%) patients had inhalation injury. The median time from injury to antifungal initiation was 17.5 days (IQR 10.7, 38.6 days). One hundred sixty eight biopsies were obtained within 3 days of antifungal initiation. Seventy five biopsies showed FWC (44.6% of biopsies), 37 had FWI (i.e. fungi were identified either in viable tissue or angioinvasion) (22% of biopsies), and 56 had negative biopsies (33.3% of biopsies). Despite presence of fungi on histopathology, there were only 112 positive fungal wound cultures (44.6% of 251 antifungal courses) within 3 days initiation of antifungal therapy. Aspergillus was the most commonly isolated genus (n=47) followed by Candida (n=46), Fusarium (n=26), Mucor (n=10), and other (n=20). There were 35 instances where multiple fungal organisms were recovered in tissue culture. One hundred five patients (52.2%) died during their hospital stay; 38 of these patients had FWC, 25 had FWI, 20 had negative biopsies, and 22 did not have biopsies taken. Conclusions Of 251 systemic antifungal courses initiated out of concern for FWI, FWI was biopsy-proven 14.7% of the time. Antifungal stewardship is needed to better identify appropriate high-risk patients for FWI. The development of a novel criteria or scoring system may be warranted to assist in deciding when to initiate systemic antifungal therapy for FWI in burn patients.
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Affiliation(s)
- Kaitlin A Pruskowski
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Garrett W Britton
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Thomas A Mitchell
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
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Prat NJ, Meyer AD, Scaravilli V, Cannon J, Cancio LC, Cap AP, Batchinsky AI. Regional blood acidification inhibits coagulation during extracorporeal carbon dioxide removal (ECCO 2 R). Artif Organs 2022; 46:1181-1191. [PMID: 35289412 DOI: 10.1111/aor.14233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Consumption of platelets and coagulation factors during extracorporeal carbon dioxide removal (ECCO2 R) increases bleeding complications and associated mortality. Regional infusion of lactic acid enhances ECCO2 R by shifting the chemical equilibrium from bicarbonate to carbon dioxide. Our goal was to test if regional blood acidification during ECCO2 R inhibits platelet function and coagulation. METHODS An ECCO2 R system containing a hemofilter circulated blood at 0.25 L/min in 8 healthy ewes (Ovis aries) for 36 hours. Three of the sheep received ECCO2 R with no recirculation compared to 5 sheep that received ECCO2 R plus 12 hours of regional blood acidification via the hemofilter, placed upstream from the oxygenator, into which 4.4 M lactic acid was infused. Blood gases, platelet count and function, thromboelastography, coagulation-factor activity, and von Willebrand factor activity (vWF:Ag) were measured at baseline, at start of lactic acid infusion, and after 36 hours of extracorporeal circulation. RESULTS Twelve hours of regional acid infusion significantly inhibited platelet aggregation response to adenosine diphosphate; vWF; and platelet expression of P-selectin compared to control. It also significantly reduced consumption of fibrinogen and of coagulation factors V, VII, IX, compared to control. CONCLUSIONS Regional acidification reduces platelet activation and vitamin-K-dependent coagulation-factor consumption during ECCO2 R. This is the first report of a simple method that may enhance effective anticoagulation for ECCO2 R.
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Affiliation(s)
- Nicolas J Prat
- French Armed Forces Biomedical Research Institute (IRBA), Paris, France.,U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew D Meyer
- Division of Critical Care Medicine, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA.,U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Jeremy Cannon
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
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Bermudez T, Sammani S, Song JH, Hernon VR, Kempf CL, Garcia AN, Burt J, Hufford M, Camp SM, Cress AE, Desai AA, Natarajan V, Jacobson JR, Dudek SM, Cancio LC, Alvarez J, Rafikov R, Li Y, Zhang DD, Casanova NG, Bime C, Garcia JGN. eNAMPT neutralization reduces preclinical ARDS severity via rectified NFkB and Akt/mTORC2 signaling. Sci Rep 2022; 12:696. [PMID: 35027578 PMCID: PMC8758770 DOI: 10.1038/s41598-021-04444-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 12/22/2021] [Indexed: 12/18/2022] Open
Abstract
Despite encouraging preclinical data, therapies to reduce ARDS mortality remains a globally unmet need, including during the COVID-19 pandemic. We previously identified extracellular nicotinamide phosphoribosyltransferase (eNAMPT) as a novel damage-associated molecular pattern protein (DAMP) via TLR4 ligation which regulates inflammatory cascade activation. eNAMPT is tightly linked to human ARDS by biomarker and genotyping studies in ARDS subjects. We now hypothesize that an eNAMPT-neutralizing mAb will significantly reduce the severity of ARDS lung inflammatory lung injury in diverse preclinical rat and porcine models. Sprague Dawley rats received eNAMPT mAb intravenously following exposure to intratracheal lipopolysaccharide (LPS) or to a traumatic blast (125 kPa) but prior to initiation of ventilator-induced lung injury (VILI) (4 h). Yucatan minipigs received intravenous eNAMPT mAb 2 h after initiation of septic shock and VILI (12 h). Each rat/porcine ARDS/VILI model was strongly associated with evidence of severe inflammatory lung injury with NFkB pathway activation and marked dysregulation of the Akt/mTORC2 signaling pathway. eNAMPT neutralization dramatically reduced inflammatory indices and the severity of lung injury in each rat/porcine ARDS/VILI model (~ 50% reduction) including reduction in serum lactate, and plasma levels of eNAMPT, IL-6, TNFα and Ang-2. The eNAMPT mAb further rectified NFkB pathway activation and preserved the Akt/mTORC2 signaling pathway. These results strongly support targeting the eNAMPT/TLR4 inflammatory pathway as a potential ARDS strategy to reduce inflammatory lung injury and ARDS mortality.
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Affiliation(s)
- Tadeo Bermudez
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Saad Sammani
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Jin H Song
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Vivian Reyes Hernon
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Carrie L Kempf
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Alexander N Garcia
- Department of Radiation Oncology, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Jessica Burt
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Matthew Hufford
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Sara M Camp
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Anne E Cress
- Department of Cellular and Molecular Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Ankit A Desai
- Department of Medicine, Indiana University, Indianapolis, IN, USA
| | | | - Jeffrey R Jacobson
- Department of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Steven M Dudek
- Department of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | | | - Julie Alvarez
- Institute of Surgical Research, San Antonio, TX, USA
| | - Ruslan Rafikov
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Yansong Li
- Institute of Surgical Research, San Antonio, TX, USA
| | - Donna D Zhang
- College of Pharmacy, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Nancy G Casanova
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Christian Bime
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Joe G N Garcia
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA.
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Beely BM, Harea GT, Wendorff DS, Choi JH, Sieck K, Karaliou V, Cannon JW, Lantry JH, Cancio LC, Sams VG, Batchinsky AI. Expeditionary Mechanical Ventilation in Conjunction With Extracorporeal Life Support During Ground Transport. J Spec Oper Med 2022; 22:64-69. [PMID: 35278316 DOI: 10.55460/li26-w9ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND We assessed the use of an FDA-cleared transport ventilator with limited functions and settings during ground transport in a swine model of ground evacuation. We hypothesized that when used as an adjunct to extracorporeal life support (ECLS), the device would enable safe mobile ventilatory support during ground evacuation. METHODS Female Yorkshire swine (n = 11; mean, 52.4 ± 1.3 kg) were sedated and anesthetized and received mechanical ventilation (MV) with a standard intensive care unit (ICU) ventilator and were transitioned to the Simplified Automated Ventilator II (SAVe II; AutoMedx) during ground transport. MV served as an adjunct to ECLS in all animals. Ventilator performance was assessed in the uninjured state on day 1 and after bilateral pulmonary contusion on day 2. Data were collected pre- and post-transport on both days. RESULTS During 33 transports, the SAVe II provided similar ventilation support as the ICU ventilator. Mean total transport time was 38.8 ± 2.1 minutes. The peak inspiratory pressure (PIP) limit was the only variable to show consistent differences pre- and post-transport and between ventilators. No adverse events occurred. CONCLUSION As an adjunctive supportive device during ground transport, the SAVe II performed adequately without failure or degradation in subject status. Further testing is warranted to elucidate the clinical limits of this device during standalone use.
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Carney BW, Rizzo JA, Alderete JF, Cindass R, Markelz AE, Cancio LC. Carbapenem-Resistant Enterobacterales Infection After Massive Blast Injury: Use of Cefiderocol Based Combination Therapy. Mil Med 2021; 186:1241-1245. [PMID: 34453163 DOI: 10.1093/milmed/usab350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 11/12/2022] Open
Abstract
A military soldier sustained a blast injury in Afghanistan, resulting in amputations and hemipelvectomy. He developed New Delhi metallo-beta-lactamase-producing E. coli bacteremia, soft-tissue infection, and sacral osteomyelitis. These organisms are being increasingly discovered in different communities around the world. He was successfully treated with tigecycline and cefiderocol. Cefiderocol is a novel siderophore-based cephalosporine developed to treat serious infections, including those caused by carbapenem-resistant Enterobacterales.
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Affiliation(s)
- B W Carney
- Brooke Army Medical Center, San Antonio, TX 78234, USA
| | - J A Rizzo
- United States Army Institute of Surgical Research, San Antonio, TX 78234, USA
- Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - J F Alderete
- Brooke Army Medical Center, San Antonio, TX 78234, USA
| | - R Cindass
- United States Army Institute of Surgical Research, San Antonio, TX 78234, USA
| | - A E Markelz
- Brooke Army Medical Center, San Antonio, TX 78234, USA
| | - L C Cancio
- Brooke Army Medical Center, San Antonio, TX 78234, USA
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36
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Santamaria JA, Cancio LC, Reed D, Phillips H, Chen S, Carlton DK, Johnson AJ. Complete Fusion of Both Eyelids in Stevens-Johnson Syndrome: Case Report. J Burn Care Res 2021; 42:1023-1025. [PMID: 33528572 DOI: 10.1093/jbcr/irab024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
An 18-year-old woman developed Stevens-Johnson syndrome (SJS) with ocular involvement after taking ibuprofen. She was admitted to another hospital, received saline flushes and bacitracin ophthalmic ointment to the eyes, and became unable to open them. Upon transfer to this burn center 3 weeks after symptom onset, there was complete fusion of both eyelids with no visible cornea or sclera. She underwent bilateral operative scar release. After opening the lids, meticulous debridement of cicatricial membranes and release of symblephara were performed with subsequent placement of amniotic membrane grafts. Her vision slowly improved, though her long-term visual prognosis remains guarded. Early recognition and treatment of SJS or toxic epidermal necrolysis (TEN) with ocular involvement is imperative. Even mild cases may require intensive topical lubrication, steroids, and antibiotics, with early placement of amniotic membrane grafts in severe cases. Prompt intervention and daily evaluation are paramount in preventing lifelong visual disability.
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Affiliation(s)
- Joseph A Santamaria
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Donovan Reed
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Hunter Phillips
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Sien Chen
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Darrel K Carlton
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Anthony J Johnson
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
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37
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Thomas JM, Dado DN, Basel AP, Aden JK, Thomas SB, Piper L, Britton GW, Cancio LC, Batchinsky A, Mason PE, Walter RJ, Sobieszczyk MJ, Biscotti M, Lee TJ, Read MD, Sams VG. Adjunct Use of Continuous Renal Replacement Therapy with Extracorporeal Membrane Oxygenation Achieves Negative Fluid Balance and Enhances Oxygenation Which Improves Survival in Critically Ill Patients without Kidney Failure. Blood Purif 2021; 51:477-484. [PMID: 34515075 DOI: 10.1159/000517896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 06/04/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Fluid overload in extracorporeal membrane oxygenation (ECMO) patients has been associated with increased mortality. Patients receiving ECMO and continuous renal replacement therapy (CRRT) who achieve a negative fluid balance have improved survival. Limited data exist on the use of CRRT solely for fluid management in ECMO patients. METHODS We performed a single-center retrospective review of 19 adult ECMO patients without significant renal dysfunction who received CRRT for fluid management. These patients were compared to a cohort of propensity-matched controls. RESULTS After 72 h, the treatment group had a fluid balance of -3840 mL versus + 425 mL (p ≤ 0.05). This lower fluid balance correlated with survival to discharge (odds ratio 2.54, 95% confidence interval 1.10-5.87). Improvement in the ratio of arterial oxygen content to fraction of inspired oxygen was also significantly higher in the CRRT group (102.4 vs. 0.7, p ≤ 0.05). We did not observe any significant difference in renal outcomes. CONCLUSIONS The use of CRRT for fluid management is effective and, when resulting in negative fluid balance, improves survival in adult ECMO patients without significant renal dysfunction.
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Affiliation(s)
- Jason M Thomas
- Pulmonary and Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - David N Dado
- Nephrology, Keesler Medical Center, Biloxi, Mississippi, USA
| | - Anthony P Basel
- Burn Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - James K Aden
- Statistics and Epidemiology, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Sarah B Thomas
- Surgery and Trauma Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Lydia Piper
- Surgery and Trauma Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Garrett W Britton
- Burn Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Leopoldo C Cancio
- Burn Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Andriy Batchinsky
- US Army Institute of Surgical Research, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Phillip E Mason
- Burn Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Robert J Walter
- Pulmonary and Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Michal J Sobieszczyk
- Pulmonary and Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Mauer Biscotti
- Burn Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - T Jake Lee
- Burn Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Matthew D Read
- Burn Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Valerie G Sams
- Surgery and Trauma Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA
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Moffatt LT, Madrzykowski D, Gibson ALF, Powell HM, Cancio LC, Wade CE, Choudhry MA, Kovacs EJ, Finnerty CC, Majetschak M, Shupp JW. Standards in Biologic Lesions: Cutaneous Thermal Injury and Inhalation Injury Working Group 2018 Meeting Proceedings. J Burn Care Res 2021; 41:604-611. [PMID: 32011688 PMCID: PMC7195554 DOI: 10.1093/jbcr/irz207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
On August 27 and 28, 2018, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn and inhalation injury in Washington, DC. The goal of the meeting was to identify and discuss the existing knowledge, data, and modeling gaps related to understanding cutaneous thermal injury and inhalation injury due to exposure from a fire environment, and in addition, address two more areas proposed by the American Burn Association Research Committee that are critical to burn care but may have current translational research gaps (inflammatory response and hypermetabolic response). Representatives from the Underwriters Laboratories Firefighter Safety Research Institute and the Bureau of Alcohol, Tobacco, Firearms and Explosives Fire Research Laboratory presented the state of the science in their fields, highlighting areas that required further investigation and guidance from the burn community. Four areas were discussed by the full 24 participant group and in smaller groups: Basic and Translational Understanding of Inhalation Injury, Thermal Contact and Resulting Injury, Systemic Inflammatory Response and Resuscitation, and Hypermetabolic Response and Healing. A primary finding was the need for validating historic models to develop a set of reliable data on contact time and temperature and resulting injury. The working groups identified common areas of focus across each subtopic, including gaining an understanding of individual response to injury that would allow for precision medicine approaches. Predisposed phenotype in response to insult, the effects of age and sex, and the role of microbiomes could all be studied by employing multi-omic (systems biology) approaches.
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Affiliation(s)
- Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC
| | | | - Angela L F Gibson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Heather M Powell
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH.,Department of Biomedical Engineering, The Ohio State University, Columbus, OH.,Research Department, Shriners Hospitals for Children, Cincinnati, OH
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Charles E Wade
- Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Mashkoor A Choudhry
- Department of Surgery, Burn & Shock Trauma Research Institute, Health Sciences Division, Loyola University, Maywood, IL
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora CO
| | - Celeste C Finnerty
- Departments of Surgery and Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch and Shriners Burns Hospital, Galveston TX
| | - Matthias Majetschak
- Departments of Surgery and Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC.,The Burn Center, MedStar Washington Hospital Center, Washington DC.,Department of Surgery, Georgetown University School of Medicine, Washington, DC
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Tadlock MD, Gurney J, Tripp MS, Cancio LC, Sise MJ, Bandle J, Cubano M, Lee J, Vasquez M, Acosta JA. Between the devil and the deep blue sea: A review of 25 modern naval mass casualty incidents with implications for future Distributed Maritime Operations. J Trauma Acute Care Surg 2021; 91:S46-S55. [PMID: 34324471 DOI: 10.1097/ta.0000000000003199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In the future, United States Navy Role 1 and Role 2 shipboard medical departments will be caring for patients during Distributed Maritime Operations in both contested and noncontested austere environments; likely for prolonged periods of time. This literature review examines 25 modern naval mass casualty incidents over a 40-year period representative of naval warfare, routine naval operations, and ship-based health service support of air and land operations. Challenges, lessons learned, and injury patterns are identified to prepare afloat medical departments for the future fight. LEVEL OF EVIDENCE Literature Review, level V.
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Affiliation(s)
- Matthew D Tadlock
- From the Navy Medicine Readiness & Training Command (M.D.T., J.B., M.C., M.V.), San Diego, California; US Army Institute of Surgical Research (J.G.), Fort Sam Houston; Joint Trauma System, Defense Health Agency (J.G.), San Antonio, Texas; Bureau of Medicine and Surgery (M.S.T.), Falls Church, Virginia; Division of Trauma (M.J.S.), Scripps Mercy Hospital, San Diego, California; Uniformed Services University of the Health Sciences (J.L.), Bethesda, Maryland; and Veterans Administration Loma Linda Healthcare System (J.A.A.), Loma Linda, California
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40
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Baird EW, Reid CM, Cancio LC, Gurney JM, Burmeister DM. A case study demonstrating tolerance of the gut to large volumes of enteral fluids as a complement to IV fluid resuscitation in burn shock. Int J Burns Trauma 2021; 11:202-206. [PMID: 34336386 PMCID: PMC8310868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 05/11/2021] [Indexed: 06/13/2023]
Abstract
Appropriate intravenous fluid resuscitation has improved early post burn outcomes. However, clinical and pre-clinical evidence suggests that enteral or oral resuscitation may complement intravenous fluid administration. While this strategy is often discussed in the context of resource-limited settings, its implementation could reduce overall IV fluid requirements and simplify management during routine care. Conversely, concerns about this strategy have been raised over impaired gut perfusion and function leading to adverse effects. We present a case of an 82-year-old man with a total burn size of 14% who was encouraged to ingest the oral rehydration solution Drip Drop® starting 7 hours post-burn. In the ensuing 17 hours he consumed over 5 L of oral rehydration solution, which was nearly 1 L more than the total amount of IV fluids he received. There were no adverse gastrointestinal side effects. This demonstrates tolerance of a significant volume of voluntary oral fluids in combination with IV resuscitation. Clinical trials are warranted.
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Affiliation(s)
- Emily W Baird
- Department of Medicine, Uniformed Services University of The Health SciencesBethesda, MD, 20814, USA
| | - Colleen M Reid
- Burn Center, United States Army Institute of Surgical ResearchJBSA Ft. Sam Houston, TX 78234, USA
| | - Leopoldo C Cancio
- Burn Center, United States Army Institute of Surgical ResearchJBSA Ft. Sam Houston, TX 78234, USA
| | - Jennifer M Gurney
- Burn Center, United States Army Institute of Surgical ResearchJBSA Ft. Sam Houston, TX 78234, USA
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of The Health SciencesBethesda, MD, 20814, USA
- Burn Center, United States Army Institute of Surgical ResearchJBSA Ft. Sam Houston, TX 78234, USA
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41
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Murphy ST, Cancio LC. Hand sanitiser-fuelled fire performance and thermal injury: case report. BMJ Case Rep 2021; 14:14/6/e235106. [PMID: 34083184 DOI: 10.1136/bcr-2020-235106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 23-year-old man presented to our burn center after sustaining a 62.5% total body surface area burn during a fire performance, in which he applied alcohol-based hand sanitiser to his body and ignited it. The patient underwent 6 operations at this facility and was discharged after 41 days. Fire-performance art is a growing pastime and profession. This case demonstrates the hazards of using hand sanitiser during such activities.
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Affiliation(s)
- Samantha T Murphy
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Leopoldo C Cancio
- US Army Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
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42
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Mitchell TA, Schroder TA, McGovern KP, Cancio LC. Freeze branding: a novel injurious mechanism for humans. Int J Burns Trauma 2021; 11:112-114. [PMID: 34094703 PMCID: PMC8166665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/31/2021] [Indexed: 06/12/2023]
Abstract
Freeze branding was first performed in 1966 to identify animals for agricultural purposes, and remains relevant today in veterinary medicine. In contrast, human branding for aesthetics, punishment, identification, and purported medicinal benefits is standardly performed through transfer of thermal energy via heat. Uniquely, this case report documents the first description of freeze branding as a mechanism of injury in humans resulting in a 0.25% total body surface area mixed partial thickness/full thickness forearm burn that was managed non-operatively with out-patient daily wound care over six-months without morbidity. The overall clinical management of freeze branding injuries, anticipated sequelae, and co-morbid diseases will be discussed to provide an educational foundation for future clinical encounters.
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Affiliation(s)
- Thomas A Mitchell
- Department of Burn Surgery, United States Army Institute of Surgical ResearchFort Sam Houston, TX, USA
| | - Terry A Schroder
- Department of Burn Surgery, United States Army Institute of Surgical ResearchFort Sam Houston, TX, USA
| | - Kevin P McGovern
- Department of General Surgery, San Antonio Military Medical CenterFort Sam Houston, TX, USA
| | - Leopoldo C Cancio
- Department of Burn Surgery, United States Army Institute of Surgical ResearchFort Sam Houston, TX, USA
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43
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Rizzo JA, Haq M, McMahon RA, Aden JK, Brillhart DB, Cancio LC. Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing Factors. J Burn Care Res 2021; 42:177-181. [PMID: 32918478 DOI: 10.1093/jbcr/iraa162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Extubation failure is associated with negative outcomes making the identification of risk factors for failure paramount. Burn patients experience a high incidence of respiratory failure requiring mechanical ventilation. There is no consensus on the acceptable rate of extubation failure and many conventional indices do not accurately predict extubation outcomes in burn patients. The purpose of this study was to examine the rate of extubation failure in the burned population and to examine the impact of factors on extubation outcomes. Burn patients from a single center over 9 years were examined and included if they were intubated prior to arrival or within 48 hours of admission and underwent a planned extubation. From this cohort, a matched case-control analysis based on age, TBSA, and sex was performed of patients who succeeded after extubation, defined as not requiring reintubation within 72 hours, to those who failed. Characteristics and clinical parameters were compared to determine whether any factors could predict extubation failure. There was a 12.3% incidence of extubation failure. In the matched case-control analysis, the presence of inhalation injury was associated with extubation success. Higher heart rate and lower serum pH were associated with extubation failure. ANCOVA analysis demonstrated that a sodium trending higher before extubation was associated with more successes, possibly indicative of a lower volume status. Classic extubation criteria do not accurately predict extubation outcomes in burn patients; analysis of other parameters may be able to provide better predictions. A constellation of these parameters needs to be studied prospectively.
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Affiliation(s)
- Julie A Rizzo
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas.,Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Mahdi Haq
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas.,Metis Foundation, San Antonio Texas
| | - Ryan A McMahon
- Brooke Army Medical Center, Fort Sam Houston, Texas.,United States Army Medical Center of Excellence, Joint Base San Antonio, Texas
| | - James K Aden
- Brooke Army Medical Center, Fort Sam Houston, Texas
| | | | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
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44
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Kemp Bohan PM, Cooper LE, Lu KN, Raper DM, Batchinsky M, Carlsson AH, Cancio LC, Chan RK. Fractionated Ablative Carbon Dioxide Laser Therapy Decreases Ultrasound Thickness of Hypertrophic Burn Scar: A Prospective Process Improvement Initiative. Ann Plast Surg 2021; 86:273-278. [PMID: 32826444 DOI: 10.1097/sap.0000000000002517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Carbon dioxide (CO2) laser treatment is routinely used to treat hypertrophic burn scars (HBS). Although prior research has documented subjective improvement in HBS after treatment, there is little data evaluating objective changes in scar characteristics after therapy. The aim of our process improvement project was to evaluate changes to scar thickness (ST) using high-frequency ultrasound in patients with HBS undergoing CO2 laser therapy. METHODS Ultrasound measurements of ST were obtained from patients with HBS before initial and at each subsequent treatment. ST, reduction in ST per treatment, and percentage reduction in ST from baseline were tabulated. Post hoc analyses examining the effect of initial ST and scar maturity on outcome were performed. First, patients were grouped by baseline ST into thicker (group 1, initial ST ≥ median value) and thinner (group 2, initial ST < median value) scar groups. Second, patients were divided into quartiles based on time from injury to treatment. Outcomes at each time point were compared with either Mann-Whitney U or Kruskal-Wallis tests, with Bonferonni corrections performed for post hoc subgroup analyses. Significance was set at P < 0.05. RESULTS Twenty-one consecutive patients with HBS treated with CO2 laser were included. All patients completed 1 or more treatment, 48% completed 2 or more treatments, and 28% completed 3 treatments. Median initial ST was 0.71 cm (0.44-0.98 cm), and median scar maturity was 7.5 months (4.9-9.8 months). Overall, ST decreased over the treatment course (P < 0.001), with post hoc analysis demonstrating that 2 treatments were required to achieve a significant ST reduction (P < 0.01). On subgroup analysis comparing initial ST, ST decreased significantly in group 1 (thicker scars) overall (P < 0.001) but not in group 2 (P = 0.109). ST reduction was greatest after 1 treatment in group 1 (P = 0.022) and group 2 (P = 0.061). Percent reduction was greater in group 1 relative to group 2 after 1 treatment (P = 0.016). On subgroup analysis of scar maturity, there were no significant differences in either baseline ST or ST at any subsequent visit. CONCLUSIONS Fractionated ablative CO2 laser treatment improved ST after 1 to 2 treatments. Patients with thicker scars demonstrated greater ST reduction than those with thinner scars. Ultrasound adequately assessed treatment response.
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Affiliation(s)
| | | | | | - David M Raper
- Department of Oral and Maxillofacial Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX
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Harea GT, Karaliou V, Roberts TR, Choi JH, Beely BM, Cancio LC, Batchinsky AI. Dynamics of appearance and decay of gaseous microemboli during in vitro extracorporeal circulation. Perfusion 2021; 37:242-248. [PMID: 33567967 DOI: 10.1177/0267659121991423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Extracorporeal life support (ECLS) patients are at risk for complications caused by gaseous microemboli (GME). GMEs can cause hypoxia, inflammation, coagulation, and end-organ damage. The objective of this in vitro study was to assess dynamics of GME formation during circulation of whole blood or a glycerol blood surrogate. We hypothesized that there is no difference in GME counts and sizes between whole blood and the glycerol blood surrogate and that the membrane lung reduces GME counts over time. METHODS A circulation platform was developed using the Cardiohelp ECLS system to run either donor blood or glycerol solution. We conducted 10 repetitions consisting of three phases of ultrasound GME detection using the EDAC™ Quantifier (Luna Innovations, Charlottesville, VA, USA) for each group. Phases were 3-minute recordings at the initiation of 2 L/min flow (Phase 1), post-injection of a GME suspension (Phase 2), and 10 minutes after injection (Phase 3). The number and size of GME pre- and post-ML were recorded separately and binned based on diameter ranges. RESULTS In Phase 1, GME count in blood was higher than in glycerol. In Phase 2, there was a large increase in GME counts; however, most GME were reduced post-membrane in both groups. In Phase 3, there was a significant decrease in GME counts compared to Phase 2. GME > 100 μm in glycerol decreased post membrane. CONCLUSIONS We demonstrated GME formation and decay dynamics during in vitro circulation in an ECLS system with blood and glycerol. GME counts were higher in blood, likely due to varying rheological properties. There were decreases in GME levels post membrane in both groups after GME injection, with the membrane lung effectively trapping the GME, and additional reduction 10 minutes after GME injection.
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Affiliation(s)
- George T Harea
- Autonomous Reanimation and Evacuation Research Program, San Antonio, TX, USA.,The Geneva Foundation, Tacoma, WA, USA
| | - Vitali Karaliou
- Autonomous Reanimation and Evacuation Research Program, San Antonio, TX, USA.,The Geneva Foundation, Tacoma, WA, USA
| | - Teryn R Roberts
- Autonomous Reanimation and Evacuation Research Program, San Antonio, TX, USA.,The Geneva Foundation, Tacoma, WA, USA.,Department of Translational Medicine, University of the Incarnate Word, School of Osteopathic Medicine, San Antonio, TX, USA
| | - Jae-Hyek Choi
- Autonomous Reanimation and Evacuation Research Program, San Antonio, TX, USA.,The Geneva Foundation, Tacoma, WA, USA.,Department of Translational Medicine, University of the Incarnate Word, School of Osteopathic Medicine, San Antonio, TX, USA
| | - Brendan M Beely
- Autonomous Reanimation and Evacuation Research Program, San Antonio, TX, USA.,The Geneva Foundation, Tacoma, WA, USA.,Department of Translational Medicine, University of the Incarnate Word, School of Osteopathic Medicine, San Antonio, TX, USA
| | | | - Andriy I Batchinsky
- Autonomous Reanimation and Evacuation Research Program, San Antonio, TX, USA.,The Geneva Foundation, Tacoma, WA, USA.,Department of Translational Medicine, University of the Incarnate Word, School of Osteopathic Medicine, San Antonio, TX, USA.,U.S. Army Institute of Surgical Research, San Antonio, TX, USA
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Thrailkill MA, Gladin KH, Thorpe CR, Roberts TR, Choi JH, Chung KK, Necsoiu CN, Rasmussen TE, Cancio LC, Batchinsky AI. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med 2021; 29:8. [PMID: 33407759 PMCID: PMC7789715 DOI: 10.1186/s13049-020-00807-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/03/2020] [Indexed: 02/07/2023] Open
Abstract
Background In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas of promising research that may be key in further advancement of REBOA applications. Methods To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi Square Test for categorical data. Results In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter REBOA time and longer follow-up times. Conclusions Further research related to human use of REBOA must be focused on earlier initiation of REBOA after injury which may depend on development of rapid vascular access devices and techniques more so than on any new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies must involve realistic models of injury with severe clinical scenarios approximating human trauma and exsanguination, especially with long-term follow-up after injury.
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Affiliation(s)
- Marianne A Thrailkill
- Glacier Technical Solutions, El Paso, TX, USA.,Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA
| | | | - Catherine R Thorpe
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Teryn R Roberts
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - Jae H Choi
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Corina N Necsoiu
- Prolonged Field Care Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Andriy I Batchinsky
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA. .,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA.
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Burmeister DM, Smith SL, Muthumalaiappan K, Hill DM, Moffatt LT, Carlson DL, Kubasiak JC, Chung KK, Wade CE, Cancio LC, Shupp JW. An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation. J Burn Care Res 2020; 42:113-125. [PMID: 33306095 DOI: 10.1093/jbcr/iraa214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.
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Affiliation(s)
- David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Susan L Smith
- The Warden Burn Center, Orlando Regional Medical Center, Orlando, Florida
| | | | - David M Hill
- Firefighters' Burn Center, Regional One Health, Memphis, Tennessee
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Deborah L Carlson
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C Kubasiak
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Charles E Wade
- Center for Translational Injury Research, and Department of Surgery, McGovern School of Medicine and The John S. Dunn Burn Center, Memorial Herman Hospital, Houston, Texas
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
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Li Y, Dubick MA, Yang Z, Barr JL, Gremmer BJ, Lucas ML, Necsoiu C, Jordan BS, Batchinsky AI, Cancio LC. Distal organ inflammation and injury after resuscitative endovascular balloon occlusion of the aorta in a porcine model of severe hemorrhagic shock. PLoS One 2020; 15:e0242450. [PMID: 33201908 PMCID: PMC7671515 DOI: 10.1371/journal.pone.0242450] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 11/03/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA) has emerged as a potential life-saving maneuver for the management of non-compressible torso hemorrhage in trauma patients. Complete REBOA (cREBOA) is inherently associated with the burden of ischemia reperfusion injury (IRI) and organ dysfunction. However, the distal organ inflammation and its association with organ injury have been little investigated. This study was conducted to assess these adverse effects of cREBOA following massive hemorrhage in swine. METHODS Spontaneously breathing and consciously sedated Sinclair pigs were subjected to exponential hemorrhage of 65% total blood volume over 60 minutes. Animals were randomized into 3 groups (n = 7): (1) Positive control (PC) received immediate transfusion of shed blood after hemorrhage, (2) 30min-cREBOA (A30) received Zone 1 cREBOA for 30 minutes, and (3) 60min-cREBOA (A60) given Zone 1 cREBOA for 60 minutes. The A30 and A60 groups were followed by resuscitation with shed blood post-cREBOA and observed for 4h. Metabolic and hemodynamic effects, coagulation parameters, inflammatory and end organ consequences were monitored and assessed. RESULTS Compared with 30min-cREBOA, 60min-cREBOA resulted in (1) increased IL-6, TNF-α, and IL-1β in distal organs (kidney, jejunum, and liver) (p < 0.05) and decreased reduced glutathione in kidney and liver (p < 0.05), (2) leukopenia, neutropenia, and coagulopathy (p < 0.05), (3) blood pressure decline (p < 0.05), (4) metabolic acidosis and hyperkalemia (p < 0.05), and (5) histological injury of kidney and jejunum (p < 0.05) as well as higher levels of creatinine, AST, and ALT (p < 0.05). CONCLUSION 30min-cREBOA seems to be a feasible and effective adjunct in supporting central perfusion during severe hemorrhage. However, prolonged cREBOA (60min) adverse effects such as distal organ inflammation and injury must be taken into serious consideration.
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Affiliation(s)
- Yansong Li
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
- * E-mail:
| | - Michael A. Dubick
- Department of Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Zhangsheng Yang
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Johnny L. Barr
- Department of Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Brandon J. Gremmer
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Michael L. Lucas
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Corina Necsoiu
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Bryan S. Jordan
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Andriy I. Batchinsky
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Leopoldo C. Cancio
- U. S. Army Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
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Abstract
Background: Infection is the leading cause of death after thermal injury. Optimal prevention and treatment of burn wound infection is enabled by an in-depth understanding of burn wound treatment modalities not only from a technical standpoint, but also from the standpoint of the clinical context in which these modalities were originally developed. Methods: A review of the historical literature on the topical antimicrobial care of burn wounds was performed. Results: As our understanding of post-burn infection evolved, and as new products were developed for the prevention of post-burn wound infection, major advances in post-burn survival occurred. Ultimately, improvements in anesthetic, surgical, and critical care management have permitted early excision and grafting of the burn wound, decreasing but not eliminating the importance of topical antimicrobial care, and shifting much of the burden of wound infection prevention to the post-operative period. Conclusions: The development of effective topical antimicrobial agents for wound care was, arguably, the single most important advance in the care of the burn patient. Still, many gaps in our ability to treat complicated burn wounds remain. Fungal infection is an unusual but daunting challenge. Patients with impaired wound healing and those with advanced age or medical comorbidities may not benefit from early excision, and the benefits of early excision may not be available in austere or remote locations. For these reasons, research on optimal topical treatment continues.
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Affiliation(s)
- Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
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50
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Pruskowski KA, Shields BA, Ainsworth CR, Cancio LC. Evaluation of the use of sitagliptin for insulin resistance in burn patients. Int J Burns Trauma 2020; 10:237-245. [PMID: 33224612 PMCID: PMC7675198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/05/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Following severe burn injury, patients undergo profound metabolic changes, including insulin resistance and hyperglycemia. Hyperglycemia has been linked to impaired wound healing, increased risk of skin graft loss, increased muscle catabolism, increased infections, and mortality. Sitagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor that improves glycemic control by slowing the inactivation of incretin hormones, increasing insulin synthesis and release from pancreatic beta cells and lowering glucagon secretion from pancreatic alpha cells. The objective of this study was to describe our institution's experience with using sitagliptin to help mitigate insulin resistance after burn injury. METHODS This was a retrospective chart review that included 22 adult burn patients. Burn patients were prescribed sitagliptin regardless of their previous medical history of type 2 diabetes mellitus. Patients were included in this analysis if they were adults admitted for burn injury during a 13-month period and received at least 3 consecutive doses of sitagliptin. Patients were excluded if they did not have insulin use data 3 days pre- and 3 days post-sitagliptin initiation. The first day of sitagliptin initiation was considered day 0; data from day 0 were not included in either the pre- or post-sitagliptin analysis. RESULTS In the 3 days prior to sitagliptin initiation, patients received a median of 114.3 units per day (IQR 49.1, 228) in an attempt to maintain a blood glucose goal of less than 180 mg/dL. In the 3 days after sitagliptin was started, exogenous insulin requirements significantly decreased to a median to 36.3 units per day (IQR 11.7, 95) (P=0.009). Seven patients were on insulin infusions at the time of sitagliptin initiation. After sitagliptin was started, it took a median of 3 days (IQR 2, 3.25) to be liberated from the insulin infusion. In terms of safety, there were two episodes of hypoglycemia (BG<70 mg/dL) after sitagliptin initiation, compared to three episodes prior to sitagliptin initiation (P=0.7). CONCLUSION The addition of sitagliptin to burn patients' medication regimens significantly reduced insulin requirements over a 3-day period and allowed liberation from insulin drips.
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Affiliation(s)
- Kaitlin A Pruskowski
- US Army Institute of Surgical Research3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, The United States
- Uniformed Services University School of The Health Sciences, F. Edward Hébert School of Medicine4301 Jones Bridge Road, Bethesda, MD 20814, The United States
| | - Beth A Shields
- US Army Institute of Surgical Research3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, The United States
| | - Craig R Ainsworth
- Methodist Hospital7700 Floyd Curl Drive, San Antonio, TX 78229, The United States
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, The United States
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