Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT)

OBJECTIVES

ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial.

SUMMARY BACKGROUND DATA

No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation.

METHODS

Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols.

RESULTS

Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone.

CONCLUSIONS

Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.

Spanning External Fixation for the Treatment of Open Joint Injuries in Pediatric Burn Patients

In this article, we report a case series on spanning external fixation for the treatment of open joint burn injuries in a pediatric population. We reviewed the case logs of all orthopedic surgeons from 2000 to 2010 at a burn hospital to identify pediatric patients with open joints secondary to burn injuries.

Nine patients who sustained open joint injuries after a burn and treated with a spanning external fixator (SEF) were identified. Characteristics of the burns included: five elbow, four knee; seven flame, two electrical; average total body surface area affected 49.4% (range 25%–79%); substantial third-degree burn in all patients. Average age at the time of the burn was 8.6 years (range: 2 months–17.9 years). Average time from the burn to SEF placement was 7.1 weeks (range: 3–10.5 weeks). Before SEF placement, an average of 3.8 skin grafting procedures (range: 1–7) were performed to treat the open joint injuries. SEFs remained in place for an average of 6.4 weeks (range: 3–9 weeks). After SEF application, skin graft procedures were performed on average 0.6 times (range: 0–3). There were two complications (22%) considered to be directly associated with the SEF procedure due to the failure of fixation.

Placement of an SEF for an open joint burn injury in children is an effective means to treat these uncommon and difficult injuries. We recommend early SEF to help assist with soft tissue healing and decrease the number of skin grafting procedures in this population.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in the Nodal Staging of Stereotactic Ablative Body Radiotherapy Patients

BACKGROUND

Patients with non-small cell lung cancer (NSCLC) being evaluated for stereotactic ablative body radiotherapy (SABR) are typically staged noninvasively with positron emission tomography/computed tomography (PET/CT). Incorporating endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) into the staging workup of these patients has not been evaluated. Our primary objective was to compare the performance of PET/CT with EBUS-TBNA for intrathoracic nodal assessment among SABR-eligible patients.

METHODS

This was a retrospective study consisting of two parts. First, we assessed the concordance for nodal metastasis of PET/CT and EBUS-TBNA. Second, we evaluated clinical outcomes among patients who underwent SABR with and without a prior EBUS-TBNA.

RESULTS

We identified 246 eligible patients. Compared with PET/CT, EBUS-TBNA led to a stage shift in 48 of 246 patients (19%). Of 174 N0 patients by PET/CT, 6 (3.4%) had nodal metastasis on EBUS-TBNA. Among 72 clinical N1 patients, 36 (50%) were downstaged to N0 after EBUS-TBNA, therefore becoming eligible for SABR. Concordance between PET/CT and EBUS-TBNA for nodal metastasis was 83% (κ = 0.53). Clinical outcomes of patients who underwent SABR with or without a prior EBUS-TBNA did not differ significantly.

CONCLUSIONS

Concordance of PET/CT and EBUS-TBNA for nodal disease was only moderate. Incorporating EBUS-TBNA into the staging workup was beneficial in identifying occult nodal metastasis that would otherwise be left untreated with SABR and in expanding the pool of potentially SABR-eligible patients.

Epidemiology and patterns of musculoskeletal motorcycle injuries in the USA

INTRODUCTION

Motorcycles have become an increasingly popular mode of transportation despite their association with a greater risk for injury compared with automobiles. Whereas the recent incidence of annual passenger vehicle fatalities in the United States of America (USA) has progressively declined, motorcycle fatalities have steadily increased in the past 11 years. Although motorcycle injuries (MIs) have been studied, to the author's knowledge there are no published reports on MIs in the USA during this 11-year period. Methods : Study data were derived from a prospectively collected Level I trauma center database. Data sampling included motorcycle crash injury evaluations for the 10-year period ending on 31 August 2008. This retrospective analysis included patient demographic and medical data, helmet use, Glasgow coma scale (GCS) score, injury severity score (ISS), length of hospital stay (LOS), specific injury diagnosis, and death. Data statistics were analyzed using the Spearman correlation coefficient, Kruskal-Wallis tests, and logistic regression.

RESULTS

The study identified 1252 motorcycle crash injuries. Helmets were worn by 40.7% of patients for which helmet data were available. The rates of the most common orthopedic injuries were tibia/fibula (19.01%), spine (16.21%), and forearm (10.14%) fractures. The most common non-orthopedic motorcycle crash injuries were concussions (21.09%), skull fractures (8.23%), face fractures (13.66%), and hemo- and pneumothorax (8.79%). There was a significant correlation between greater age and higher ISS (r=0.21, P<0.0001) and longer LOS (r=0.22, P<0.0001). Older patients were also less likely to wear a helmet (OR=0.99, 95% CI: 0.98, 0.997), associated with a significantly higher risk for death (after adjustment for helmet use OR=1.03, 95% CI: 1.00, 1.05). All patients without helmets had a significantly lower GCS score (P=0.0001) and a higher mortality rate (after adjustment for patient demographic data OR=2.28, 95% CI: 1.13, 4.58).  Conclusion : Compared with historical reports, the prevalence of skull, face, spine, and pelvis fractures have increased in American motorcycle crashes. Compared to recent European studies, the incidence of USA skull and face fractures is much higher, while the incidence of USA spine and pelvis fractures is more comparable; however, this is not associated with increased in-hospital mortality.

Implementation of a critical pathway for complicated gallstone disease: translation of population-based data into clinical practice

BACKGROUND

Evidence-based guidelines recommend cholecystectomy during initial hospitalization for complicated gallstone disease. Previous studies and quality initiative data from our institution demonstrated that only 40% to 75% of patients underwent cholecystectomy on index admission.

STUDY DESIGN

In January 2009, we implemented a critical pathway to improve cholecystectomy rates for all patients emergently admitted for acute cholecystitis, mild gallstone pancreatitis, or common bile duct stones. We compared cholecystectomy rates during initial hospitalization, time to cholecystectomy, length of initial stay, and readmission rates in prepathway (January 2005 to February 2008) and postpathway patients (January 2009 to May 2010).

RESULTS

Demographic and clinical characteristics were similar between prepathway (n = 455) and postpathway patients (n = 112). Cholecystectomy rates during initial hospitalization increased from 48% to 78% after pathway implementation (p < 0.0001). There were no differences in operative mortality or operative complications between the 2 groups. For patients undergoing cholecystectomy on initial hospitalization, the mean length of stay decreased after pathway implementation (7.1 days to 4.5 days; p < 0.0001), primarily due to a decrease in the time from admission to cholecystectomy (4.1 days to 2.1 days; p < 0.0001). Thirty-three percent of prepathway and 10% of postpathway patients required readmission for gallstone-related problems or operative complications (p < 0.0001), and each readmission generated an average of $19,000 in additional charges.

CONCLUSIONS

Implementation of a multidisciplinary critical pathway improved cholecystectomy rates on initial hospitalization and lowered costs by shortening length of stay and markedly decreasing readmission rates for gallstone-related problems. Broader implementation of similar pathways offers the potential to translate evidence-based guidelines into clinical practice and minimize the cost of medical care.

Filipino workers in the Middle East: social profile and policy implications

The characteristics of international labor migrants from the Philippines are examined. "Based on an analysis of a sample of 495 Middle East workers and 1983 worker placements, this paper presents a profile of Filipino workers in the Middle East with reference to such variables as occupation, gender, age and work experience, civil status, education, Philippine residence, household size and number of dependents." (summary in FRE, SPA)