Academic surgeons' knowledge of Food and Drug Administration regulations for clinical trials

OBJECTIVES

To identify knowledge levels of academic surgeons about Food and Drug Administration (FDA) and Institutional Review Board (IRB) regulations for clinical research and to determine whether being a member in an IRB, conducting or participating in clinical trials, or being a member in surgical societies affected knowledge levels.

DESIGN

Survey of surgical department faculty members in 20 universities.

RESULTS

Sixty-five responses were received from 14 sites. Overall mean (+/- SEM) correct score was 6.7 +/- 0.2 of a possible 20 points. The best predictor of overall score was being a primary investigator of a clinical trial (P < .001), followed by being or having been a member of an IRB (P < or = .02). The total mean score of members of the Surgical Infection Society (8.2 +/- 0.5) was significantly higher (P < .001) than that of nonmembers (6.1 +/- 0.2), a phenomenon not observed with other surgical societies. In certain hypothetical clinical scenarios, all respondents were mistakenly willing to conduct clinical trials without obtaining appropriate approval from the FDA. Four (22%) of 18 IRB member respondents and 16 (25%) of the 65 respondents were willing to conduct human research without appropriate approval from patients, the IRB, or both.

CONCLUSIONS

Knowledge deficits exist in the academic surgical community about the role and requirements of the FDA and local IRBs for conducting clinical research. Further study is required to determine the reasons for this deficit and to identify appropriate interventions.

Recombinant human growth hormone accelerates wound healing in children with large cutaneous burns

OBJECTIVE

Two forms of recombinant growth hormone that accelerate the healing of skin graft donor sites in severely burned children were evaluated.

SUMMARY BACKGROUND DATA

Growth hormone has been shown to reduce wound healing times in burned pediatric patients. Through genetic engineering, several different forms have been synthesized; however, not all are marketed currently. Two forms of growth hormone were used in these studies, Protropin (Genentech, Inc., San Francisco, CA), a commercially available product that possesses a N-terminal methionine residue not found in the second form Nutropin (Genentech, Inc., San Francisco, CA), which, as yet, is not commercially available. Through the use of recombinant human growth hormone, rapid wound healing may reduce the hypermetabolic period, the risk of infection, and accelerate the healing of donor sites used for grafting onto burned areas. The two structurally different forms of growth hormone were tested for their efficacy in healing donor sites in severely burned children.

METHODS

Forty-six children, with a > 40% total body surface area and > 20% total body surface area full-thickness burn were entered in a double-blind, randomized study to receive rhGH within 8 days of injury. Twenty received (0.2 mg/kg/day) Nutropin or placebo by subcutaneous or intramuscular injection beginning on the morning of the initial excision. Eighteen patients who failed the entry criteria for receiving Nutropin received Protropin therapeutically (0.2 mg/kg/day). Donor sites were harvested at 0.006 to 0.010 inches in depth and dressed with Scarlet Red impregnated fine mesh gauze (Sherwood Medical, St. Louis, MO). The initial donor site healing time, in days, was reached when the gauze could be removed without any trauma to the healed site.

RESULTS

Donor sites in patients receiving Nutropin (n = 20) or Protropin (n = 18) healed at 6.8 +/- 1.5 and 6.0 +/- 1.5 (mean +/- SD) days, respectively, whereas those receiving placebo (n = 26) had a first donor site healing time of 8.5 +/- 2.3 days. Both groups receiving rhGH showed a significant reduction in donor site healing time compared with placebo at p < 0.01. When subgroups were compared, no difference in healing times could be shown with regards to age or time of admission after injury.

CONCLUSION

Our results indicate that both forms of rhGH are effective in reducing donor site healing time compared with placebo and suggest that accelerating wound healing is of clinical benefit because the patients' own skin becomes rapidly available for harvest and autografting. With this increase in the rate of wound healing, the total length of hospital stay can be reduced by more than 25%.

Recent advances in burn care

Over the past few decades, the mortality related to thermal injuries has been significantly reduced. This has been accomplished through an increased understanding and subsequent management of inhalation injury, the postburn hypermetabolic response, and immunocompromise. In addition, the prompt excision of the burn wound and early permanent closure has decreased the length of hospital stay and has facilitated timely social reintegration of the burned patient.

Management of perineal and genital burns

Burn injuries to the perineum and genitals present the bedside care provider with a unique set of management problems. Traditionally, thermal injuries to these areas have been allowed to close by secondary intention, with epithelialization occurring from remnants protected within skin folds. Partial-thickness wounds of the perineum and genitals must be kept clean and free of bacterial infection to prevent necrosis and development of full-thickness injury. Although full-thickness thermal injuries to the penis and vulva are rare, they require special attention during the immediate postgrafting period to ensure complete engraftment. Control of scarring in this area requires tailor-made pressure garments, with customized inserts to provide controlled pressure to the skin folds.

Thermal injuries caused by ignition of volatile substances by gas water heaters

Based on the cumulative data of this tertiary care facility over the past 25 years, one out of every 70 pediatric patients admitted to our institution sustained their injuries during an explosive event instigated by the ignition of volatile substances from gas water heaters. The majority of injuries related to gas water heaters can be prevented by decreasing the temperature setpoint of the heater, by protecting the heater element itself, and by elevating the water heater to 18 inches above the floor. The first two issues have been adequately addressed; however, gas-fueled water heaters continue to be installed at floor level. Current national guidelines are too rigid and do not adequately address water-heater installation in private residences. Although general prevention campaigns target appropriate storage of volatile substances, they rarely address the explosive potential of gas water heaters in combination with combustible fumes.

Management of the pediatric patient with burns

Two million people in the United States receive medical treatment each year for burn injuries. One hundred thousand of these patients are hospitalized, and 7800 die as a direct result of their injuries. Of the patients that are hospitalized 30% to 40% are under 15 years of age. Sixty-seven percent are male. The average age of children with burns is 32 months. Flame burns account for approximately 13% of accidents, scalds account for 85%, and electrical and chemical burns account for approximately 2%. The majority of scald injuries are small. Sixteen percent of burn injuries are not accidental, and approximately half of these are a result of documentable, inflicted abuse.

Longitudinal hand grip and pinch strength recovery in the child with burns

Hand strength of seven patients was evaluated prospectively. A range-of-motion exercise program, compression therapy, and splinting schedules were provided. Fine prehension; lateral, tip-to-tip, and tripod pinch were measured by pinch meter. Grip strength was measured by dynamometer. Comparisons were made between test strengths and published norms for age and sex with analysis of variance. Significance was accepted at p < 0.05. At discharge, all four strength measurements were significantly less than normal for age and sex. Grip and tripod strengths were improved by 6 weeks. All measurements were improved at 6 months after discharge, although grip and lateral pinch remained significantly less than norms. In conclusion, the measurements of tip-to-tip and tripod pinch at 6 months may not signify limitations in performance of activities of daily living. In spite of significantly lower than normal grip and lateral strength measurements at 6 months, it cannot be determined whether this hinders performance of daily living skills.

Effect of prostaglandin E on immune function in normal healthy volunteers

Prostaglandin E (PGE) has been hypothesized to be the endogenous metabolite that results in the immunosuppression seen in patients with tumor and trauma. This has resulted in multiple investigators proposing that administration of PGE inhibitors, such as aspirin and indomethacin, might improve immune function in such patients. We administered a long acting PGE analog, misoprostol, to nine normal healthy volunteers for five days and assayed immune function before and after therapy. The PGE analog improved lymphocyte blastogenesis and increased tumor necrosis factor production. The PGE analog also resulted in the volunteers having symptoms similar to those seen in patients with sepsis. The results of these studies indicate that elevated levels of PGE do not seem to result in impairment of immune function, but may be the endogenous metabolite responsible for the symptologic factors seen in infected patients.

The effect of erythropoietin in normal healthy volunteers and pediatric patients with burn injuries

BACKGROUND

Surgical procedures result in blood loss that can require replacement transfusions. Such therapy may result in multiple adverse sequelae, including transmission of infectious diseases and immune impairment. Alternative therapies are therefore desirable.

METHODS

We evaluated the ability of recombinant human erythropoietin (rEPO) to increase red blood cell production in both normal healthy volunteers and patients with burn injuries. The effect of rEPO on immune function in the volunteers was also evaluated. The volunteers received 150 units/kg rEPO daily for 7 days, with immune function and hematopoiesis assayed on days 0, 7, and 14. The patients with burn injuries received either 500 units/kg/day rEPO with iron supplementation or merely the iron.

RESULTS

rEPO increased erythropoiesis in both the volunteers and the patients with burn injuries. Failure to provide iron supplementation to the volunteers resulted in significant depletion of iron stores with a concomitant impairment in immune function that paralleled the iron depletion.

CONCLUSIONS

rEPO therapy offers the potential to increase red blood cell production in surgical patients. Failure to provide iron supplementation in patients receiving rEPO can lead to a rapid depletion of iron stores and may contribute to an immune dysfunction.

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.

Incidence of HIV seroconversion in paediatric burn patients

A retrospective review of paediatric patients treated for acute burn injuries and receiving blood/blood products between 1978 and 1985, identified 52 patients at risk for HIV infection. Over 50 per cent of the identified population had received 3 or more units of blood/blood products during their acute hospital stay. A total of 214 patients (36.8 per cent) have been tested for HIV seroconversions: five tested HIV positive by ELISA and four were confirmed by Western Blot, yielding a 1.9 per cent incidence. The four confirmed patients received 2-9 total body blood volume turnovers during their postburn period in hospital. At 4 years post-exposure, two patients show active disease, one is currently asymptomatic and one has died from AIDS-related sepsis.

Effect of recombinant human growth hormone on catabolic hormones and free fatty acids following thermal injury

Severe burn injury elicits the release of catabolic hormones that contribute to negative nitrogen balance, protein wasting, and impaired wound healing. Previous studies have shown that burn patients receiving recombinant human growth hormone (rhGH) therapy have an increase in the rate of skin donor site healing and a shorter hospital stay. The mechanism by which rhGH exerts its effects, however, is not clearly understood. This study examines the effects of rhGH on circulating levels of catabolic hormones and nonesterified fatty acids in pediatric burn patients. Patients with greater than 40% total body surface area burn were randomly assigned to receive placebo (n = 8) or 0.2 mg/kg/day rhGH (n = 6) throughout their hospitalization. All patients had early morning blood samples assessed for catecholamines (CAT), cortisol, insulin, glucagon, and free fatty acid (FFA) levels during a period of hypermetabolism. No differences could be demonstrated in age, burn size, postburn day of evaluation, resting energy expenditure per kilogram, respiratory rate, heart rate, respiratory quotient, serum cortisol, and serum glucose between placebo- and rhGH-treated patients. The rhGH-treated group did show a significant elevation (p less than 0.05) in insulin-like growth factor-1 (55.9 +/- 14.5 vs. 168 +/- 23.7 mU/mL), total catecholamines (1,817 +/- 177 vs. 1,117 +/- 137 pg/mL), norepinephrine (1,257 +/- 121 vs. 867 +/- 113 pg/mL), epinephrine (385 +/- 175 vs. 147 +/- 36 pg/mL), insulin (32.8 +/- 3.3 vs. 25.0 +/- 3.0 mU/mL), glucagon (215 +/- 18 vs. 158 +/- 22 pg/mL), and free fatty acids (0.74 +/- 0.01 vs. 0.59 +/- 0.04 mEq/L) compared with the placebo group (data expressed as mean +/- SE).(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Candida infection with and without nystatin prophylaxis. A 11-year experience with patients with burn injury

The incidence of opportunistic infections after thermal injury is high. Since 1985, we have been practicing Candida prophylaxis using nystatin "swish-and-swallow" and topical therapy. Patients treated between 1980 and 1984 served as controls and received no Candida prophylaxis. Although mean burn size, full-thickness injury, and age were comparable, the incidence of Candida colonization (26.7% vs 15.6%), infection (21.3% vs 10.0%), and sepsis (12.2% vs none) was significantly different between control and nystatin-treated groups, respectively. With prophylaxis, the incidence of Candida wound infection has been significantly reduced, and systemic candidiasis has been eradicated, eliminating the need for toxic systemic antifungal agents.

Comparison of cultured epidermal autograft and massive excision with serial autografting plus homograft overlay

The chief determinant of mortality in severe burn injuries has been the size and severity of the wound. Early massive excision of the wound has increased the median lethal dose to 98% of total body surface area burn but presents the problem of wound closure. Autograft substitutes must be used for a large burn. We report our experience with early massive excision in the treatment of 47 pediatric patients with burns who had greater than 80% total body surface area burn and greater than 80% full-thickness burn. Four patients died within hours of admission. Fifteen patients died of sepsis and multiorgan failure; the primary source of bacterial contamination was the open wound. The 28 survivors received approximately 2.0 m2 2:1 homograft until autograft became available. A case report of a 10-year-old boy illustrates the use of two types of cultured epidermal autograft, one "homegrown" and one commercially produced.

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.

The role of gentamicin iontophoresis in the treatment of burned ears

Ear cartilage heals slowly, and limited vascularity in cartilage precludes use of systemic antibiotics. Iontophoresis electrically induces drugs in solution to migrate into target tissues. Fifteen patients were randomized to receive gentamicin iontophoresis (n = 7) plus dressing changes every 6 hours and cleaning or routine care alone (n = 8) for treatment of ear burns. There were no differences between the groups in incidence of chondritis (43% vs 50%) or cartilage loss (11% vs 16%). However, gentamicin-resistant organisms developed in 29% of the patients who received iontophoresis, but in none of the patients in the control group (p less than 0.05). To identify the etiology of the resistant organisms, 10 New Zealand white rabbits receive 7 cm2 contact burns to each ear. Gentamicin iontophoresis was performed on one ear, and the other ear served as the control. Serum gentamicin levels were always subtherapeutic. Additionally, gentamicin tissue levels in both the treated and control ears were subtherapeutic. Gentamicin iontophoresis appears to offer no additional salutary effects beyond those that are provided by routine care and may encourage the development of antibiotic resistance.

Lack of long-term durability of cultured keratinocyte burn-wound coverage: a case report

Cultured epithelial autografts have been advocated for permanent closure of skin surfaces after massive thermal injuries. A 10-year-old boy sustained a nearly 100% total body surface area burn (98% full-thickness) in an explosion accident. Cultured epithelial autograft was used to cover 70% of the total body surface area on postburn day 26. In spite of early success of coverage, 60% of cultured epithelial autograft areas blistered and sloughed over the ensuing weeks. Electron microscopic examination of a biopsy specimen of the healed cultured epithelial autograft (80 days after placement) revealed a lack of dermal attachments of the anchoring fibrils. Additionally, blister fluid that was taken from the bullae of the cultured epithelial autograft revealed levels of 18 ng/ml thromboxane and 24 ng/ml prostaglandin E2. These levels are significantly higher than those seen in acute burn blister fluid and indicate an ongoing inflammatory process. Cultured keratinocytes, although they provide early wound closure, may not provide adequate long-term coverage for patients with massive burns.

Conservative treatment of scald burns is superior to early excision

Early excision of deep burns has been advocated; however, it is difficult to clinically determine the depth of scald burns during the early postburn period. This prospective, randomized study was designed to determine whether early excision was superior to conservative treatment of scald injuries. Patients with scald injuries (which were not caused by grease) of clinically indeterminant depth were randomized to early (n = 12) or late (n = 12) excision; all patients with obvious superficial and full-thickness injuries were excluded. In the early excision group, all deep wounds were tangentially excised and grafted within 72 hours of admission, whereas in the late treatment group wounds were excised and grafted after 2 weeks had passed since injury. Area excised, postburn day of excision, percent graft take, operating-room time, blood replacement, incidence of infection, and length of hospital stay were compared. No patient experienced a significant wound infection or systemic sepsis. A significantly smaller area of excision was necessary for those patients who were treated with delayed surgery, and concomitant decreases in operating-room time and blood loss were observed. Notably, only one half of the patients who were randomized to the delayed excision group ultimately required surgical intervention to achieve wound closure. Graft take was comparable for both groups, as was length of hospital stay. Early clinical evaluation of scald injuries appears to be equivocal, and later evaluations reveal a less severe injury. Financial gains can be made when surgical excision of scald injuries is delayed until 2 weeks after injury because of a related reduction in hospital expenditures.

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.

Analysis of materials for splinting of the thermally injured patient

Good results have been achieved in the treatment of patients with burns with new splinting materials and proper splinting techniques. This article focuses on the thermoplastic splinting materials Clinic and Spectrum (Northcoast Medical Inc., San Jose, Calif.) and the comparable thermoplastic products Polyform (Smith & Nephew Rolyan, Inc., Menomonee Falls, Wis.) and Orthoplast (Johnson & Johnson Orthopedics, New Brunswick, N.J.). Qualities such as self-bonding, recyclability, and rigidity were tested for these materials. Splint rigidity was measured by a calibrated hook scale and determined by the force per pound needed to bend the material 20 degrees. Spectrum and Clinic products were judged more economical and, we contend, they are therefore better choices for splinting the thermally injured patient.

Ischemic intestinal complications in patients with burns

Enteral bacterial translocation has been implicated as a major cause of morbidity in instances of trauma, but little clinical evidence of the loss of intestinal mucosal integrity has been documented. A retrospective review of the medical and autopsy records of all patients admitted between 1982 and 1988 was performed to describe the incidence of intestinal pathologic findings. Of all deaths, a total of 53 per cent of adults (greater than 18 years old) and 61 per cent of children (zero to 17 years old) were noted to have ischemic intestinal pathologic findings on autopsy, ranging from superficial necrosis to full thickness mucosal necrosis extending into the omentum. More than 80 per cent of these patients were septic at the time of death, with endogenous intestinal flora species most frequently identified as the causative agent. Less than 1 per cent (n = 16) of the patients admitted were clinically identified with intestinal pathologic examination, surgically explored and underwent resection of the intestine. Despite intervention, this group suffered a 69 per cent mortality rate. Although the documentation of bacterial translocation in a human model may be obscured by other potential sources of contamination, for example, burn wound, in combination with the immunosuppression inherent to the thermally injured, may lead to bacterial contamination of the systemic circulation and, therefore, may be a significant contributor to morbidity and mortality after thermal injury.

A nineteen-year review of nurse-authored abstracts presented to the American Burn Association. Implications for the future

The previous investigations of nurse authors have impact on and provide guidance for the future paths of research endeavors. A review of the past 19 years of American Burn Association abstract presentations was performed to identify nurse-authored presentations and describe their nature and content. Nurse authors were identified on 18% of all abstracts presented and were primary authors of 7.7% of all abstracts presented. Those who collaborated most frequently with nurse authors were other nurses (41%) and physicians (37%). Descriptive studies were most frequently presented, followed first by reports and then by experimental designs. Fewer than one half of the reported studies possessed statistical support for their findings. Nurse authors are most frequently investigating issues of direct patient care, such as wound management, medications, complications, and psychosocial issues.

Effects of recombinant human growth hormone on donor-site healing in severely burned children

The beneficial effects of growth hormone on wound healing in severely burned children were studied. Forty patients who were 2 to 18 years old, with 40% or more total body surface area (TBSA) and 20% or more TBSA full-thickness flame or scald burns, were randomized in a double-blind study to receive placebo or 0.1 mg/kg/day recombinant human growth hormone (rHGH) until the first donor site healed or to receive 0.2 mg/kg/day rHGH or placebo from admission throughout hospitalization. Patients receiving 0.2 mg/kg/day rHGH demonstrated significantly higher serum IGF-1 levels at 4.8 +/- 1.7 U/mL compared to placebos at 1.6 +/- 0.4 U/mL (p less than 0.05) and a significant decrease in donor-site healing times compared to placebo (p less than 0.05). Length of hospital stay (LOS/%TBSA) was decreased from 0.80 +/- 0.10 days/%TBSA burned in the placebo group to 0.54 +/- 0.04 days/%TBSA burned in the 0.2 mg/kg/day treatment group (p less than 0.05). This translates, for the average 60% TBSA burned patient, to a decrease in LOS from 46 to 32 days.

The efficacy of pediatric blood culture sets in the determination of burn bacteremia

A blood culture is an essential laboratory procedure necessary to confirm a septic episode. However, it is important to collect the blood sample at the appropriate time with an acceptable technique. The standard method is to collect at least 5 to 10 ml blood per culture bottle from patients with fevers. However, this volume of blood is an unrealistic amount to take from the frequently febrile pediatric patient. Alternatively, the pediatric blood culture bottle allows the collection of 1 ml blood per bottle to perform the same evaluation. We evaluated the two techniques of blood-culture collection over a 9-month period and compared the results between adult and pediatric blood culture bottles. Seventy-six patients, from November 1988 through February 1989, had blood cultures performed with the adult culture bottles, which produced a total of 1314 samples. A total of 113 patients, from March through July 1989, had blood cultures performed with the pediatric culture bottles, which produced a total of 758 samples. Percent recovery for the adult bottles versus the pediatric bottles was 13.95% versus 22.8% (p less than 0.0001). Since the amount of blood necessary to isolate an infectious agent is critical not only for laboratory identification but also for the volume of blood of pediatric patients, these data clearly establish the efficacy of pediatric blood culture bottles and the utilization of smaller amounts of blood. Not only did this approach significantly enhance organism recovery rate, but it may well be more cost-effective because fewer cultures need to be performed to isolate the infectious organism.

Comparison of resting energy expenditures and caloric intake in children with severe burns

Nutritional support is provided to children after severe burn injuries in amounts derived from empirical formulas or measurements of resting energy expenditure. To scrutinize these methods, indirect calorimetry measurements were performed on 74 survivors of burns (greater than or equal to 40% total body surface area) and compared to their actual caloric intake, percent weight change, and optimal caloric requirements formulated from the Curreri and Shriners' equations. These parameters showed that in spite of an initial deficit in actual caloric intake as compared to formulated goals, weight was maintained, whereas resting energy expenditures ranged from 30% to 40% below the actual caloric intake. Furthermore, a subgroup of patients (n = 42) who met +/- 20% of their formulated needs were stratified by extent of burn; this illustrated a significant weight gain in the more severely burned children. In conclusion, nutritional formulas in popular use overestimate caloric requirements in severe burns, whereas resting energy expenditure measurements require an additional factor of 30% to maintain body weight.

Topical Bactroban (mupirocin): efficacy in treating burn wounds infected with methicillin-resistant staphylococci

Bacterial antimicrobial susceptibility predictors such as the minimal inhibitory concentration (MIC) assay and Nathans Agar Well Diffusion (NAWD) assay provide essential information relevant to the therapeutic approach in burn-wound sepsis. The susceptibilities of 68 gram-positive burn-wound isolates were tested against topical Bactroban (mupirocin) (Beecham Laboratories, Bristol, Tenn.) and compared with other topical antimicrobials such as mafenide acetate, silver sulfadiazine, and bacitracin/neomycin/polymyxin (BNP). Topical susceptibility data were obtained with a modification of NAWD assay. Bactroban's antimicrobial activity was greater than that of mafenide acetate (100% vs 97%), and significantly greater than that of silver sulfadiazine and that of BNP (p less than 0.001). Of the 68 isolates that were susceptible to Bactroban, 51 were predominately methicillin-resistant staphylococci (MRSA). Bactroban showed in vitro activity against 71% of the 85 gram-negative isolates tested. Mafenide acetate showed activity against 89% of these isolates, a significant difference compared with Bactroban (p less than 0.02). In general, no significant difference was found between the activities of Bactroban and silver sulfadiazine against the gram-negative isolates. The activities of mafenide acetate and silver sulfadiazine against isolates of Pseudomonas aeruginosa were significantly greater than that of Bactroban (p less than 0.05). Bactroban may be used in the treatment of documented staphylococcal burn-wound infections. On the basis of the in vitro data, 13 patients with MRSA burn-wound infections susceptible to Bactroban were evaluated. Quantitative wound biopsies were employed to determine the efficacy of this therapeutic approach. The outcome of these infections was correctly predicted by the NAWD assay in 92.3% of the patients treated (p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

Early burn wound excision significantly reduces blood loss

The hypothesis that near-total early excision of large burns in children can be performed safely with a reduction in blood loss was tested. Of 1662 acutely burned patients admitted to this institution between 1982 and 1989, 594 underwent near-total excision of cutaneous flame or scald burn injuries in a single procedure. Operations took less than 3 hours and there were no operative deaths. Blood losses in burns of more than 30% total body surface area (TBSA) were significantly less at 0.40 +/- 0.06 mL/cm2 and 0.49 +/- 0.49 mL/cm2 excised when surgery was performed within the first 24 hours or after the 16th day after burn, respectively, when compared to 0.75 +/- 0.02 mL/cm2 for those excised between 2 and 16 days after burn (p less than 0.05). Blood loss for burns of less than 30% TBSA was of 1.19 +/- 0.13 mL/cm2. Early excision did not increase mortality rate when compared to later excision times. We suggest that near-total excision of large burns within the first 24 hours reduces blood requirements and morbidity without adversely altering hemodynamic stability or increasing mortality risks.

The scalp as a donor site: revisited

The scalp cannot be used as skin graft donor site with impunity. A review of 2,620 charts identified 194 pediatric patients whose scalps served as donor sites for split-thickness skin grafts for the treatment of acute burns. The overall incidence of alopecia was 32%. However, the incidence of alopecia in unburned scalps was 13%. The occurrence of alopecia in this group was associated with larger burn area requiring more frequent use of the scalp and shorter intervals between graft harvests (p less than 0.05). Among this group of patients (n = 15), nine had mild spotty alopecia, four had surgically correctable alopecia, and two had global patchy alopecia not amenable to surgical correction. In the patients with concomitant burns to their scalps, the incidence of alopecia was 61%. Whether the burn or the graft harvest caused alopecia could not be established. Meticulous donor site care is mandatory in this latter group when the scalp donor site is indicated.

Growth delay in postburn pediatric patients

Dampened height and weight velocities have been observed in our postburn pediatric population. To validate this phenomenon, the medical records of 80 patients who had sustained a greater than 40% total body surface area burn, were older than 2 years of age at the time of the burn, and were at least 1 year post burn were reviewed. All patients were treated with early excision of the burn wound within 72 hours of injury and received standard post burn resuscitational and nutritional support. Admission height and weight plots were within normal distribution parameters. Yearly growth velocities were calculated for up to 3 years after the burn. Despite adequate nutritional support and maximal exercise and/or long-bone stresses, a profound growth arrest was noted during postburn year 1, which slowly resolved to near normal distribution by postburn year 3. This retrospective study demonstrates that severe thermal injury is associated with a growth delay in the pediatric population. The exact cause of this phenomenon remains unknown.

Managing smoke inhalation injuries

Inhalation injuries most often occur with cutaneous burns, and the likelihood of an inhalation injury increases incrementally with age of the patient and size of the burn. Damage to the pulmonary parenchymal tissue manifests as increased capillary permeability leading to excessive lung fluid formation and increasing hypoxia. An inhalation injury may be diagnosed using observation of indirect criteria in conjunction with fiberoptic bronchoscopy, xenon 133 radiospirometry, and/or measurement of extravascular lung water. Initially, carbon monoxide poisoning threatens the patient's oxygenation capacity. High-flow oxygen therapy reduces the half-life of carbon monoxide to an acceptable period. The patient proceeds through three stages: pulmonary insufficiency, pulmonary edema, and bronchopneumonia. Treatment is directed toward supporting oxygenation using endotracheal intubation with mechanical ventilation, humidification of inspired air, early mobilization, chest physiotherapy, antibiotics for documented infection, and adequate systemic hydration.

A comparison of conservative versus early excision. Therapies in severely burned patients

Early excision and grafting of small burn wounds is a generally accepted treatment. Early excision of burn injuries greater than 30% total body surface area (TBSA) in adults, however, has not been universally accepted. In this study, 85 patients whose ages ranged from 17 to 55 years with greater than 30% total body surface area (TBSA) burns were randomly assigned to either early excision or topical antimicrobial therapy and skin grafting after spontaneous eschar separation. Mortality from burns without inhalation injury was significantly decreased by early excision from 45% to 9% in patients who were 17 to 30 years of age (p less than 0.025). No differences in mortality could be demonstrated between therapies in adult patients older than 30 years of age or with a concomitant inhalation injury. Children (n = 259) with similar large burns treated by early excision showed a significant increase in mortality with increasing burn size and with concomitant inhalation injury (p less than 0.05). The mean length of hospital stay of survivors was less than one day per per cent of TBSA burn in both children and adults.

Longitudinal assessment of breast development in adolescent female patients with burns involving the nipple-areolar complex

Long-term follow-up of breast development in adolescent female patients with burns of the anterior chest wall is poorly documented. Between 1971 and 1976, 28 female patients with photographic documentation of burns to the anterior chest wall involving the nipple-areolar complex were reviewed. All patients were followed at least until their early teens. The mean age at the time of thermal injury was 5.9 +/- 2.5 years, with a mean follow-up time of 8.9 +/- 2.6 years. Thirteen patients (46 percent) were admitted to the Shriners Burns Institute in Galveston for acute care of their burns. Fifteen patients (54 percent) were referred for long-term follow-up or specific reconstructive procedures following care of the acute burns. In spite of significant thermal injury to the anterior chest wall with involvement of the nipple-areolar complex, no patient failed to develop breasts. Twenty patients (71 percent) required releases of the anterior chest wall to assist breast development. All anterior chest wall releases were accomplished with the use of skin grafts or local skin flaps.

An unusual donor site, a lifesaver in extensive burns

The availability of donor sites is a limiting factor in autologous skin grafting and, therefore, the survival of patients with large total body surface area (TBSA) burns. Of 19 males admitted to our facilities with burns greater than 80% TBSA, eight had the scrotum spared injury. The remaining 11 patients served as a control population to study the efficacy of scrotal donor harvests. The scrotal skin was expanded using the Pitkin syringe and harvested at a depth of 5/1000 to 8/1000 in, with a mean yield of 73 +/- 8 sq cm. Expanded 4:1, this tissue covered an area of 280 +/- 33 sq cm. The scrotum was harvested 2 +/- 0.4 times, compared to 4 +/- 1 harvests of the other donor group. There were no statistical differences in the number of surgical procedures or the length of hospitalization between the two groups. The scrotal donor sites healed within the same length of time as other donor sites and were harvestable as frequently. Due to the natural expandability of scrotal skin, a large surface area of usable donor site is available and their harvest may be lifesaving in male patients with large TBSA burns.

Inhalation injury in burned patients: effects and treatment

Pulmonary pathology in major thermal injury is found in 30-80 per cent of burn fatalities. The incidence and mortality from inhalation injury increases both with age and increasing burn size. Toxic smoke inhalation injury, characterized by increased lung microvascular permeability, is attenuated by increasing cardiac output to normal levels, indicating that fluid restriction after inhalation injury may lead to excessive lung fluid formation and hypoxia. Fluid administration of approximately 2 ml/kg/% area burned above the calculated resuscitation volume is required following an inhalation injury to provide adequate support for the systemic circulation and maintain cardiac output at normal levels. This additional volume does not contribute to the development of pulmonary oedema, but may decrease its formation by increasing shear forces thus reducing polymorphonuclear leucocyte deposition in the pulmonary microcirculation. Nasotracheal intubation is preferred when airway integrity is compromised by inhalation injury. The advantages are non-operative placement, ease of discontinuation, minimal bacterial contamination and leaving neck burns undisturbed. The administration of the appropriate antibiotics for documented infection is recommended, while steroids have been shown to be of no benefit.

Extravascular lung water changes following smoke inhalation and massive burn injury

During a 3-year period (1984 through 1987), 40 patients with smoke inhalation, cutaneous burns, or a combination of both injuries were studied. Injuries were assigned to the three categories on the basis of bronchoscopic findings and clinical history. Eleven patients had simultaneously sustained a common smoke-inhalation injury without burns while trapped in a burning ship; twelve patients had massive cutaneous burns over 50% of the total body surface area (TBSA); and seventeen patients had cutaneous burns over more than 30% of the TBSA and inhalation injury. Colloid oncotic pressure was maintained with salt-poor albumin infusion. Central venous pressure, arterial saturation, inspired oxygen, arterial pressure, and urine output were continuously monitored. Extravascular lung water (EVLW) and cardiac output were measured by the double indicator (thermal dye dilution) technique. EVLW remained normal throughout the study period in the group of patients with burns alone. In the first 24 hours after injury, EVLW increased in both groups with smoke injury and remained elevated for more than 48 hours after injury in patients with smoke injury only. The group with both smoke-inhalation and burn injuries showed an early increase in EVLW, which returned to normal by 28 hours after injury and which remained normal until 5 days after injury. The EVLW level then increased again until the end of the study period. In this study, lung edema formation is attributed to the toxic effect of smoke inhalation.