Prospective observational study comparing burn surgeons' estimations of wound healing after skin grafting to photo-assisted methods

INTRODUCTION

Appropriate graft healing after split-thickness skin graft and early recognition of complications (graft loss) are critical to burn patient management. Larger mesh ratio expansions and Meek micrografting may pose a greater challenge in estimating the percentage of wound healing. This study looks at the reliability of photograph assessments and the concordance of bedside evaluation to photograph assessments of wound healing after skin grafting.

METHODS

Three assessment methods for percentage of wound healing after skin Grafting were assessed: (1) clinicians' bedside rating, (2) clinician assessment of high-definition photographs, and (3) digital image analysis through color subtraction using Adobe Photoshop. We compared each method using a mixed-effects model on absolute agreement using intra-class correlation (ICC) and Bland Altman (BA) plots.

RESULTS

Fourteen burn patients were enrolled with 38 grafted wounds (100 sites). Bedside assessments had a mean ICC of 0.64 (compared to digital image analysis) and 0.69 (compared to photo assessment), with a wide range on BA-plots. Inter-rater reliability of photo assessment was excellent (0.96) among six clinicians. Repeated photo-assisted assessments had good intra-rater reliability (ICC: photo assessment: 0.88; digital analysis: 0.97).

CONCLUSIONS

Bedside wound healing assessments show variability; photograph documentation of sequential wound progression could supplement active clinical management or studies for more reliable assessments.

A comparison of oral transmucosal fentanyl citrate and oral oxycodone for pediatric outpatient wound care

Analgesia for pediatric burn wound care in the outpatient clinic is constrained by time, personnel, and/or monitoring capabilities, yet may improve patient satisfaction and comfort, clinic efficiency, and patient throughput. The ideal analgesic in this increasingly common setting should be palatable, provide potent, rapid, and brief analgesia, and require minimal appropriate monitoring. Using a placebo-controlled, double-blind design we compared oral transmucosal fentanyl citrate (OTFC, approximately 10 microg/kg) and oral oxycodone (0.2 mg/kg) in 22 pediatric outpatient wound care procedures (ages 5-14 years). Pulse oximetry, vital signs, side effects, patient pain scores, and observer scores for cooperation, anxiety, and sedation were recorded. OTFC and oral oxycodone resulted in similar outcome measures and vital signs, and no significant side effects. The taste of OTFC was preferred. We conclude that OTFC and oral oxycodone are safe and effective analgesics in the setting of monitored outpatient wound care in children, and that OTFC offers the advantage of improved palatability.

Effectiveness of virtual reality-based pain control with multiple treatments

OBJECTIVE

The current study explored whether immersive virtual reality continues to reduce pain (via distraction) with repeated use.

SETTING

The study was conducted in a burn care unit at a regional trauma center.

PATIENTS

Seven patients aged 9-32 years (mean age of 21.9 years; average of 23.7% total body surface area burned [range, 3-60%]) performed range-of-motion exercises of their injured extremity under an occupational therapist's direction on at least 3 separate days each.

INTERVENTION

For each physical therapy session, each patient spent equal amounts of time in virtual reality and in the control condition (no distraction). The mean duration of physical therapy in virtual reality was 3.5, 4.9, and 6.4 minutes for the first, second, and third session, respectively. Condition order was randomized and counter-balanced.

OUTCOME MEASURES

For each of the three physical therapy sessions, five visual analog pain scores for each treatment condition served as the dependent variables.

RESULTS

Pain ratings were statistically lower when patients were in virtual reality, and the magnitude of pain reduction did not diminish with repeated use of virtual reality. The results of this study may be examined in more detail at www.vrpain.com.

CONCLUSIONS

Although the small sample size limits generalizability. results provide converging preliminary evidence that virtual reality can function as a strong nonpharmacological pain reduction technique for burn patients during physical therapy. Results suggest that virtual reality does not diminish in analgesic effectiveness with three (and possibly more) uses. Virtual reality may also have analgesic potential for other painful procedures or pain populations. Practical implications are discussed.

The utility of a burn specific measure of pain anxiety to prospectively predict pain and function: a comparative analysis

Patients treated for burn injuries commonly experience high levels of acute pain and anxiety during hospitalization, particularly as it relates to their dressing changes and other medical procedures. A new instrument, the burn specific pain anxiety scale (BSPAS), was designed to characterize patient's anxiety in this setting, but its predictive validity in relation to other measures of anxiety has yet to be demonstrated. In this study, 27 patients with acute burn injuries completed three measures of anxiety upon admission to a major medical burn trauma center. Scores on the anxiety measures were compared with regard to their ability to predict subsequent ratings of procedural and background pain levels, pain medication usage, and physical and emotional functioning upon discharge. In support of criterion-related validity, the BSPAS was the best predictor of procedural pain levels as rated later the same day relative to the other global anxiety measures; moreover, the BSPAS did not predict later-day background pain levels as hypothesized. Both the BSPAS and the global anxiety measures were found to significantly predict total number of pain medications over a 24-h period. Finally, the BSPAS was the only significant predictor of decreased physical role functioning at discharge whereas the other more global measures of anxiety were better predictors of emotional functioning. These results provide preliminary evidence that the BSPAS is a unique and valid indicator of pain-related anxiety surrounding burn care in hospitalized patients and may be useful in identifying those patients at risk for decreased functional capacity at the time of discharge.

Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study

OBJECTIVE

The pain experienced by burn patients during physical therapy range of motion exercises can be extreme and can discourage patients from complying with their physical therapy. We explored the novel use of immersive virtual reality (VR) to distract patients from pain during physical therapy.

SETTING

This study was conducted at the burn care unit of a regional trauma center.

PATIENTS

Twelve patients aged 19 to 47 years (average of 21% total body surface area burned) performed range of motion exercises of their injured extremity under an occupational therapist's direction.

INTERVENTION

Each patient spent 3 minutes of physical therapy with no distraction and 3 minutes of physical therapy in VR (condition order randomized and counter-balanced).

OUTCOME MEASURES

Five visual analogue scale pain scores for each treatment condition served as the dependent variables.

RESULTS

All patients reported less pain when distracted with VR, and the magnitude of pain reduction by VR was statistically significant (e.g., time spent thinking about pain during physical therapy dropped from 60 to 14 mm on a 100-mm scale). The results of this study may be examined in more detail at www.hitL.washington.edu/projects/burn/.

CONCLUSIONS

Results provided preliminary evidence that VR can function as a strong nonpharmacologic pain reduction technique for adult burn patients during physical therapy and potentially for other painful procedures or pain populations.

Virtual reality as an adjunctive pain control during burn wound care in adolescent patients

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.

A comparison of oral transmucosal fentanyl citrate and oral hydromorphone for inpatient pediatric burn wound care analgesia

The ideal oral wound care analgesic for children should be palatable, provide potent analgesia of rapid onset and short duration, and require minimal, yet appropriate, monitoring. With use of a double-blinded crossover design, we compared the efficacy and safety of oral transmucosal fentanyl citrate (OTFC) (approximately 10 micrograms/kg) with the efficacy and safety of oral hydromorphone (60 micrograms/kg) in 14 pediatric inpatients (ages 4 to 17 years) undergoing daily burn wound care in a ward setting. Pulse oximetry, vital signs, side effects, patient pain scores, and observer scores for cooperation, anxiety, and sedation were recorded. Pulse oximetry, vital signs, cooperation, sedation, incidence of nausea or vomiting, and the amount of time it took to resume normal activities were similar in both treatment groups. OTFC resulted in improved pain scores before wound care and improved anxiolysis during wound care, but at other points it was similar in effect to hydromorphone. We conclude that OTFC is a safe and effective analgesic, that it may provide minor improvements in analgesia and anxiolysis compared with hydromorphone, and that it offers a palatable alternative route of opioid administration without intravenous access for wound care procedures in children.

Management of fluid and electrolyte balance in thermal injuries: implications for perioperative nursing practice

Thermal injury results in damage to the skin and underlying subcutaneous tissues. Extensive cutaneous injuries result in loss of water and electrolytes, and a disturbance in the homeostatic balance. The purpose of this article is to describe the pathophysiological changes that occur following extensive thermal injury and the common fluid-management challenges they provide. Implications for perioperative nursing practice are discussed.

Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain

Benzodiazepines are commonly used to supplement opioid analgesics in treating procedural pain during the treatment of major burn injuries. To date, no study has investigated whether benzodiazepines actually have an analgesic or anxiolytic effect in such circumstances. Seventy-nine patients admitted to a major regional burn center were randomly assigned to groups that received 1 mg of lorazepam or a placebo in addition to their standard opioid analgesics. A strong analgesic effect of lorazepam was not observed when treatment groups were compared independent of their baseline pain ratings. However when patients who had high baseline pain were compared, lorazepam resulted in a significant reduction in pain ratings (adjusted post-treatment VAS mean score = 54.28; adjusted control VAS mean score = 69.06). Trait anxiety did not predict those patients who had an analgesic effect with lorazepam, but state anxiety did prove to be a covariate with visual analogue score decreases in pain reports.

Inhalation injury

Inhalation injury remains a primary determinant of patient survival, with 60% to 70% of burn center fatalities attributed to the pulmonary complications of inhalation injury. Substantial airway damage and pulmonary complications can result from the inhalation of toxic fumes and gases found in smoke. Partial to complete airway obstruction, pulmonary edema, pneumonia, and progressive pulmonary failure may occur. Early diagnosis of inhalation injury and vigorous pulmonary care and support are vitally important to patient survival. Bronchoscopy and xenon 133 ventilation-perfusion scans are two of the newer diagnostic tools used to identify burn patients with inhalation injury. Treatment measures for patients with inhalation injury and recommendations for nursing practice are discussed.

Research priorities for burn nursing: rehabilitation, discharge planning, and follow-up care

Fourteen of the 101 research questions that were proposed in the Burn Nursing Delphi study by Marvin et al. (J Burn Care Rehabil 1991;12:190-7) were concerned with the rehabilitation, discharge planning, and follow-up care of patients with burns. Questions that were ranked as top priorities for patient welfare related to control of postburn itching, prevention of contractures, and effective means of community-based follow-up to meet physical, social, and emotional needs of patients and families. Burn nurses identified the study of nursing interventions that are the most effective means for preparing patients, families, and community nurses for posthospitalization care as the research priority that has the greatest potential impact on the profession of burn nursing. Respondents to the Delphi study favored a collaborative approach to research for most of the questions in the rehabilitation subgroup. Suggestions are made for nurses who wish to take the lead in designing and implementing qualitative and quantitative studies that relate to the increasingly prevalent problems that are encountered by survivors of burn injury.

Research priorities for burn nursing: report on physiologic issues

This Delphi study was designed and conducted to identify the issues of greatest concern to care of patients with burns and to the profession of burn nursing, so that nursing research could be directed toward these ends. One hundred and one questions were prioritized by the 94 participants who completed the four sequential rounds of questionnaires. A total of 11 questions (10.9%), which addressed physiologic-based issues, were identified.

Research priorities for burn nursing: nursing recruitment, retention, and other administrative issues

This Delphi study was designed to identify nursing research priorities. Ninety-four participants completed four rounds of questionnaires that contained 101 potential research questions. Twenty questions addressed nursing administrative issues. In this category, the highest priority for potential impact on patient welfare related to the cost-effectiveness of various infection control measures. Questions concerning recruitment, retention, staffing, and cost/quality issues had the highest priority for research that could have an impact on the profession of nursing.

Research priorities for burn nursing: report of the psychosocial issues group

This study was designed to identify nursing research priorities in burn care. The Delphi technique of sequential questionnaires was used for data collection. Ninety-four participants completed four rounds of questionnaires. One hundred and one research questions were identified, and priorities were assigned according to their impact on patient welfare and on the profession of burn nursing. Twenty-two of these research questions concerned psychosocial issues. This group of questions was then analyzed for priority research issues. The top five ranked questions in the psychosocial issues group for impact on patient welfare concerned: (1) stress reduction techniques, (2) social reentry strategies, (3) management of psychosis and post-traumatic stress disorder, (4) strategies to assist patients with impaired communication capabilities, and (5) the role of recovered burn survivors in encouraging patient compliance with treatments. Similarly, the top five ranked questions for impact on the profession of burn nursing concerned: (1) stress reduction strategies, (2) coping techniques for burn survivors, (3) management of psychosis and post-traumatic stress disorder, (4) nursing's supportive role in regard to "do not resuscitate" orders, and (5) coping strategies to be used with patients who express a desire to die.

Research priorities for burn nursing: patient, nurse, and burn prevention education

Fifteen of the 101 research questions that were assigned priorities in the Burn Nursing Delphi study by Marvin et al. (Marvin JA, Carrougher GJ, Bayley EW, Weber B, Knighton J, Rutan RL. Burn nursing Delphi study: setting research priorities. J BURN CARE REHABIL 1991;12:190-7) addressed education from the perspectives of patients, their families, and burn nurses; the study also addressed the issue of burn prevention education. Questions concerning patient education were assigned the highest priority in this education subgroup with respect to the potential for research that would have an impact on patient welfare. The question that rated highest as a priority for its potential impact on the profession of burn nursing addressed the core competencies needed for safe and effective burn nursing practice. Prevention education was generally found to be a low priority in the Delphi study. Many of the questions in the education subgroup can best be answered by comparative or experimental studies designed to explain and predict the effects of various teaching strategies on behavioral outcomes. Research on patient, nurse, and burn prevention education provides a fertile ground for nurse researchers and an opportunity to contribute knowledge of vital importance to clinicians, educators, managers, and the public.