Body Surface Area Burn Research Articles

Treatment of Anaemia in Patients with Acute Burn Injury: A Study of Blood Transfusion Practices.

Objective: To determine blood transfusion practices, risk factors, and outcomes associated with the use of blood products in the setting of the acute management of burn patients at the Victorian Adult Burn Service. Background: Patients with burn injuries have variable transfusion requirements, based on a multitude of factors. We reviewed all acute admissions to the Victorian Adult Burns Service (VABS) between 2011 and 2017: 1636 patients in total, of whom 948 had surgery and were the focus of our analysis. Method and results: Patient demographics, surgical management, transfusion details, and outcome parameters were collected and analyzed. A total of 175 patients out of the 948 who had surgery also had a blood transfusion, while 52% of transfusions occurred in the perioperative period. The median trigger haemoglobin in perioperative was 80mg/dL (IQR = 76–84.9 mg/dL), and in the non-perioperative setting was 77 mg/dL (IQR = 71.61–80.84 mg/dL). Age, gender, % total body surface area (TBSA) burn, number of surgeries, and intensive care unit and hospital length of stay were associated with transfusion. Conclusions: The use of blood transfusions is an essential component of the surgical management of major burns. As observed in our study, half of these transfusions are related to surgical procedures and may be influenced by the employment of blood conserving strategies. Furthermore, transfusion trigger levels in stable patients may be amenable to review and reduction. Risk adjusted analysis can support the implementation of blood transfusion as a useful quality indicator in burn care.

A Novel Human Glucocorticoid Receptor Variant, G459V, is Hyperactive in Response to Steroids.

A potential cause of the variable response to injury and sepsis is the variability of a patient's human glucocorticoid receptor (hGR) profile. To identify hGR variants, blood samples were collected on admission and biweekly thereafter from hospitalized patients who sustained at least a 20% total body surface area burn injury. A hyperactive G1376T single-nucleotide polymorphism (SNP) isoform was identified. This SNP led to a single amino acid change of glutamine to valine at site 459, "G459V," in the DNA-binding domain. The isoform's activity was tested in a reporter assay after treatment with steroids, the hGR antagonist RU486 (mifepristone) alone, or RU486 followed by steroids. When treated with hydrocortisone, the hGR G459V isoform had a hyperactive response; its activity was over 30 times greater than the reference hGRα. Unexpectedly, G459V had significantly increased activity when treated with the hGR antagonist RU486. With the combination of both RU486 and hydrocortisone, G459V activity was repressed, but greater than that of RU486 alone. Finally, when hGRα was cotransfected with G459V to simulate isoform interaction, the activity was closer to that of the hGRα profile than the G459V isoform. The unique activity of the G459V isoform shows that some variants of hGR have the potential to alter a person's response to stress and steroid treatment and may be a factor as to why mitigating the clinical response to sepsis and other stressors has been so elusive.

Does the estimation of burn extent at admission differ from the assessment at discharge?

Introduction:Estimation of total body surface area (TBSA) burnt and burn depth are among the most central parts of acute burn assessment/treatment as they determine the level and type of care needed. Traditional methods for determining burn extent on admission often lead to inaccurate estimations, especially in paediatric or overweight patients.Aim:To compare %TBSA at admission with validated %TBSA at discharge in different patient populations to investigate if significant over- or underestimation occurs.Method:This retrospective observational study is based on a patient registry of all the patients (n = 863) treated at the Uppsala University Hospital’s Burn Centre between 2010 and 2018. The patients were divided into subgroups based on age, gender, body mass index (BMI) and validated burn extent. The %TBSA estimated at admission was compared to the validated %TBSA in all groups separately.Results:As has been published before, we also found that the %TBSA in paediatric patients was more often overestimated as were the smaller injuries, whereas larger injuries were often underestimated. BMI did not clearly affect the estimations and there was no clear difference between the genders in estimated %TBSA.Conclusion:Inaccurate estimations of %TBSA are common, particularly for paediatric patients and small or large injuries. We recommend a careful accurate approach when calculating %TBSA in the paediatric population to avoid over- and under-resuscitation. Increased education and training are recommended to improve accurate estimation in the future.Lay SummaryThe correct estimation of both extent and depth of burn is very important. This assessment guides the lever of care needed, the necessary amount of fluid resuscitation, the predicted outcome and more. It has been proven notably difficult to correct assess, especially the extent of a burn. Despite different tools as the “Rule of Nine” (body area divided into multiples of 9% body surfaces), the “Rule of Palm” (Patient’s palm, fingers included, approximates 1% of body surfaces), the Lund & Browder chart (detailed, age-specific body areas) and different more technical solutions. Often inaccurate estimations are done which thus affect the treatment. This depth and extent estimation is usually performed when the patient is admitted. However, it is known that burns change appearance during the first few days of care. In our Burn Center we have also performed this estimation when the patient is discharged. At this point it is known the true extent and depth of the initial burn. In this retrospective observational study, we compared the burn extent estimated on admission with the one on discharge to investigate whether the initial assessment is accurate. This study highlights the issue of frequent inaccurate burn extent estimations, especially in subgroups as overweight patient or pediatric patients.

Heparin resistance in severe thermal injury: A prospective cohort study.

BackgroundLow molecular-weight heparin (LMWH) is routinely administered to burn patients for thromboprophylaxis. Some studies have reported heparin resistance, yet the mechanism(s) and prevalence have not been systematically studied. We hypothesized that nucleosomes, composed of histone structures with associated DNA released from injured tissue and activated immune cells in the form of neutrophil extracellular traps (NETs or NETosis), neutralize LMWH resulting in suboptimal anticoagulation, assessed by reduction in anti-factor Xa activity.MethodsBlood was sampled from >15% total body surface area (TBSA) burn patients receiving LMWH on days 5, 10 and 14. Peak anti-factor Xa (AFXa) activity, anti-thrombin (ATIII) activity, cell-free DNA (cfDNA) levels and nucleosome levels were measured. Mixed effects regression was adjusted for multiple confounders, including injury severity and ATIII activity, and was used to test the association between nucleosomes and AFXa.ResultsA total of 30 patients with severe burns were included. Mean TBSA 43% (SD 17). Twenty-three (77%) patients were affected by heparin resistance (defined by AFXa activity <0.2 IU/mL). Mean peak AFXa activity across samples was 0.18 IU/mL (SD 0.11). Mean ATIII was 81.9% activity (SD 20.4). Samples taken at higher LWMH doses were found to have significantly increased AFXa activity, though the effect was not observed at all doses, at 8000 IU no samples were heparin resistant. Nucleosome levels were negatively correlated with AFXa (r = −0.29, p = 0.050) consistent with the hypothesis. The final model, with peak AFXa as the response variable, was adjusted for nucleosome levels (p = 0.0453), ATIII activity (p = 0.0053), LMWH dose pre-sample (p = 0.0049), drug given (enoxaparin or tinzaparin) (p = 0.03), and other confounders including severity of injury, age, gender, time point of sample.ConclusionsHeparin resistance is a prevalent issue in severe burns. Nucleosome levels were increased post-burn, and showed an inverse association with AFXa consistent with the hypothesis that they may interfere with the anticoagulant effect of heparin in vivo and contribute to heparin resistance. Accurate monitoring of AFXa activity with appropriate therapy escalation plans are recommended with dose adjustment following severe burn injury.

Management of SARS-Cov-2-positive major burns: The tribulations and dilemmas

SARS-CoV-2 (COVID-19) pandemic is still ravaging territories and spreading like wildfire. Infection with this virus is already complicating many clinical and emergency situations by overlapping symptoms, development of newer protocols for disease management, by redefining prognostic indicators, and upscaling the level of protection required for health-care workers. The current report outlines the tribulations and dilemmas of managing an asymptomatic 35% total body surface area burn patient with concomitant SARS-CoV-2 infection, from its diagnosis till full wound healing. Countries with a large population and a high incidence of SARS-CoV-2 infection need to maintain a high index of suspicion for a concomitant SARS-CoV-2 infection because asymptomatic patients can present with burns and they can also be carriers. Further, there is a need to strategize the deployment of resources, workforce, and burn wound management and to adopt effective precautionary measures for better outcomes and safety of health-care workers.

Treatment delayed is treatment denied

Background: The primary care of a burn victim focuses on the resuscitation. The burns wound draws the attention, with interest of the provider as well as the patient waning after the healing of the wound. “Late burn care” is an important part of burns management that, if delayed, results in the formation of contractures. Simple methods suh as early skin grafting, splintage, and physical therapy prevent the development of these debilitating contractures. Despite this, postburns contractures are a common sequelae. Aims and Objectives: The aim of this paper is to identify the lacunae in late primary care, provided to patients presenting to us with postburn contractures. Materials: A review of all patients admitted with postburns contractures from January 2016 to December 2018, was done. Results: A total of 427 patients were admitted in this period out of which 254 responded for the interviews. The epidemiology of postburn contractures has been described. The lacunae in late primary burn care have been identified. Conclusion: Critical contracture areas are areas, which although innocuous in terms of body surface area burnt, have a high propensity to form contractures and require special care. Public health programs, effective in combating diseases like polio and tuberculosis, can also help preventing burn contractures. Spreading awareness about the basic tenets of contracture prevention will drastically reduce the burden of burn contractures.

1319. Pharmacokinetics of Ceftolozane/Tazobactam in Patients with Burns

BackgroundAntimicrobial dosing in moderate/severe burns patients is complicated due to the potential unpredictable hyperdynamic pathophysiologic states including 1) hypoproteinemia, 2) acute kidney injury and 3) onset of septicemia. Therefore, distribution assumptions about the population pharmacokinetic (PopPK) profiles of either endogenous or xenobiotic pharmacophores in this patient population can lead to biased parameter estimates. In order to prevent potential bias an agnostic nonparametric adaptive grid approach to describe ceftolozane/tazobactam (C/T) PopPK profiles in patients with partial- and full-thickness burns was employed.MethodsA human clinical PK study in burn patients was conducted using the standard approved dose of C/T (2 grams/1 gram). A single intravenous dose was administered over 60 minutes. Whole blood was obtained pre-dose and at 0.5, 1, 1.5, 2, 2.5, 3, 4, 6, 8, 12, 16, and 24 hours following the start of infusion. LC-MS/MS bioanalytical methods were developed, validated and employed to determine C/T concentrations in human plasma. PopPK were modeled using Pmetrics package for R. One-, two- and three-compartment models were examined and compared. The influence of several parameters, including %body surface area burns, creatinine clearance (CrCL), weight, albumin and age were tested.ResultsThe bioanalytical method for determination of C/T in human plasma met all recommended criteria of the LC-MS/MS. Five males and one female (ages 24 to 66 years), contributed 148 plasma PK samples. The female had 35% partial-thickness burns. The males had full-thickness burns ranging from 27 to 66%. The median CrCL was 104 mL/min (range 73-148 mL/min). Two-compartment model with absorption (Ka) from compartment 1 to 2 and elimination from compartment 2 (Ke), with nonlinear interactions between C/T elimination and CrCL best described the data. Figure A show that bias was minimal. Importantly, both drugs exhibited marked variability for both volume and elimination (Table), since volume was bimodally distributed (Figure B).A) Observation-versus-Prediction; B) Estimated Ke, V and Ka population parameter densities Summary of pharmacokinetic parameters ConclusionC/T exhibited high variability surpassing that observed with severe infections, suggesting that dose adjustment and/or may be therapeutic drug monitoring may be needed to balance target attainment from dose-related toxicities.DisclosuresRonald G. Hall, II, PharmD, MSCS, Medical Titan Group (Grant/Research Support)Merck (Research Grant or Support)

283. Epidemiology and Clinical Significance of Persistent Bacteremia in Severely Burned Patients

BackgroundRecent literature questions the utility of follow-up blood cultures (FUBC), especially for gram-negative bloodstream infections (BSIs). This has yet to be evaluated in the burn intensive care unit (BICU), where many BSIs are gram-negative. We evaluated the FUBC frequency, positivity rate, and clinical significance of persistent BSI (p-BSI) in BICU patients.MethodsPatients ≥ 18 years old admitted to the US Army Institute of Surgical Research for combat-related thermal burns from 1/2003–6/2014 were included. P-BSI was defined as the same organism isolated from initial and FUBC (within 1–5 days). Non-p-BSI (np-BSI) included patients without subsequent isolation of the same organism between 1–5 days post-positive blood culture. Exclusion criteria were initial blood culture with usual skin flora, polymicrobial BSI, fungemia, and death within 24 hours of notification of initial positive blood culture. Those factors significantly associated with mortality on univariate analysis were evaluated with binomial logistic regression (BLR).ResultsOf 126 patients meeting inclusion criteria with BSI, 53 (42.1%) had p-BSI and 73 (57.9%) had np-BSI (table 1). 50 (67.6%) np-BSI patients had FUBC. P-BSI and np-BSI patients did not differ in age, gender, or race, but p-BSI and np-BSI patients had median total body surface area (TBSA) burns of 47 (IQR 34–63) and 35.3 (IQR 23.3–56.6), respectively (p=0.021). P-BSI patients had longer hospitalizations, ICU stays, and intubations (p< 0.01; table 1). Microbiology did not differ between p-BSI and np-BSI (p=0.517). Notably, 20 (37.7%) p-BSI patients died compared to 8 (10.8%) np-BSI patients (p< 0.001; table 2). BLR revealed that p-BSI (p=0.031), TBSA (p< 0.001), ISS (p=0.008), and length of ICU stay (p=0.002) and intubation (p< 0.001) were independently significantly associated with mortality.Table 1: Clinical characteristics of burn patients with and without persistent bacteremia Table 2: Univariate analysis evaluating associations with mortality in burn patients with bacteremia ConclusionP-BSI was common in this burn population. Severe burns and longer duration of hospitalization, ICU stays, and intubation, but not microbiology were associated with p-BSI. However, p-BSI (in addition to more traditionally identified risk factors like TBSA and duration of hospitalization, ICU, and ventilator days), was independently associated with increased mortality. FUBC may serve as an additional prognostic factor in burn patients with BSI.Disclosures All Authors: No reported disclosures

Duration of stay and outcome in different types of burn cases in paediatric age group

The incidence of burns, their treatment and rehabilitation have considerably marked effect on children both physically and psychologically. The hospital stay and the outcome also important in the cases of burns patients because the socio economic status and chances of life long disability. Aim of the study is to analyze the duration of stay and outcome in different types of burn cases in paediatric age group. The Data was collected from 83 paediatric patients less than 15 years admitted in GMC, Miraj, Maharashtra during the period from September 2014 to September 2016. The overall length of stay at hospital, factors influencing length of stay and outcome of patients were analyzed. Out of 83 patients 50 percent was cured over the period of time. The death rate was 10.8%.Lower the percentage of burns had good outcome and higher percentage of burns had poor outcome (66.7% had mortality when burns was &gt;60%). In the study 30% patients were cured with duration of stay 6 to 10 days. Out of subjects who died 44.4% stayed for less than 5 days in hospital, as they were having more % of burn area. Also 72.7% patients who improved was stayed &lt; 5 days. Subjects cured in scald and flame burn were 60.66% and 59.1% respectively with no significant difference, while subjects died in scald and flame burn 6.56% and 22.72% respectively more in flame burn. In our study 8.4% of subjects underwent Escharotomy. It is concluded that surgical intervention increases the hospital stay and outcome of the mean duration of stay was high among subjects who deteriorated, followed by cured subjects. Lowest duration of hospital stay was observed among improved subjects, as they were having lower percent total body surface area (TBSA) burn. More hospital stay increase the chance of infections and vice versa.

Epidemiology and outcome of acute burn patients at a new dedicated burn centre in Nepal

Introduction: Burn injury remains one of the biggest health concerns in the developing world. It has been regarded as a formidable public health issue in terms of mortality, morbidity and permanent disability. We aim to provide an overview of the basic epidemiological characteristics of burn patients admitted at a dedicated burn center in Chitwan, Nepal.&#x0D; Methods: This was a retrospective, hospital-based observational study conducted at Chitwan Medical College Teaching Hospital (CMCTH) burn ward from September 2017 to August 2019. Patients’ records from admission/discharge book, admission/discharge summaries as well as patient’s individual files were reviewed to obtain the necessary data. Demographic data, clinical characteristics, treatments and outcomes were statistically analyzed.&#x0D; Results: Among the 202 patients, the number of males slightly predominated that of females with a ratio of 1.02:1. The median age was 24 years, and the median total body surface area (TBSA) burned was 15%. Children less than 10 years comprised one third of all patients while more than one fifth were elderly. The commonest etiological factor was flame burn, closely followed by scald. The mortality rate was 12.38% for the period under review. Majority of the patients spent less than 10 days on admission and around one fifth needed surgical intervention aimed at earlier coverage. Binary logistic regression analysis showed that age, Body Mass Index (BMI) and total body surface area (TBSA) burnt were the major predictors of burn mortality.&#x0D; Conclusions: The outcome of burn injuries is poor. Appropriate preventive &amp; therapeutic measures need to be taken in terms of social education &amp; provision of quality healthcare to reduce the incidence &amp; improve the survival outcome of burn patients which should focus on children and elderly especially during the winter season.

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

Burns patients exhibit all factors of Virchow's triad and are thus at high theoretical risk of venous thromboembolism (VTE). At our tertiary referral burns unit, a standard dose of low molecular weight heparin, which acts primarily by inhibiting Factor Xa, is given for thromboprophylaxis. However, the pharmacokinetics of enoxaparin are altered following a burn injury, and thus burns patients are likely underdosed on their thromboprophylaxis. The objectives of this study were to determine the incidence and risk factors for VTE among burns patients at the Victorian Adult Burns Service (VABS) and to determine the adequacy of the current enoxaparin thromboprophylaxis regimen through measurement of anti-factor Xa (AFXa) levels and comparison with established reference ranges. This study consisted of two parts. In part 1, the Burns Registry of Australia and New Zealand (BRANZ) was reviewed for cases of VTE in burns patients admitted to the VABS from 2013 - 2018. Part 2 was a prospective study that determined peak and trough AFXa levels in patients admitted to the VABS with >10% total body surface area (TBSA) burns. Part 1. Totally, 1,475 patients were admitted to the VABS between 2013 - 2018. There were 20 cases of VTE (1.36%). Percent TBSA of burn (OR = 1.04, 95% CI: 1.03 - 1.06), full thickness burns (OR = 2.78, 95% CI: 1.15 - 6.73), ICU admission (OR = 15.08, 95% CI: 5.01 - 45.44), mechanical ventilation (OR = 10.62, 95% CI: 4.05 - 27.91), operative procedures (OR = 1.43, 95% CI: 1.29 - 1.59), and a longer hospital stay (OR = 1.05, 95% CI: 1.04 - 1.07) were all associated with an increased VTE risk. Part 2. A total of 20 participants with >10% TBSA burns were recruited to the prospective study. Peak anti Factor Xa (AFXa) levels were measured for all 20 participants with 15% recording an initial prophylactic peak AFXa level within reference range. Upon subsequent measurements, 50% of participants reached a prophylactic peak AFXa level. Trough AFXa levels were measured for 17 participants with no participant recording an initial or subsequent trough AFXa level at or above the prophylactic threshold. Our study demonstrates a high incidence of VTE among burns patients at the VABS, especially among the major burns patients, and a thromboprophylaxis protocol that is ineffective in achieving prophylactic levels of AFXa level. The evidence suggests a need to evaluate different dosing protocols among burns patients in order to improve AFXa levels, with the aim of decreasing incidence of VTE in high-risk patients.

Advanced age heightens hepatic damage in a murine model of scald burn injury.

Elderly burn patients exhibit a lower survival rate compared with younger counterparts. The liver is susceptible to damage after burn injury, which predisposes to poor outcomes. Lipid homeostasis and the antioxidant glutathione system play fundamental roles in preserving liver integrity. Herein, we explored changes in these major pathways associated with liver damage in the aging animals after burn injury. We compared liver enzymes, histology, lipid-peroxidation, and glutathione-metabolism profiles from young and aged female mice after a 15% total body surface area burn. Mice were euthanized at 24 hours after injury, and livers and serum were collected. Aged burn animals exhibited elevated (p < 0.05) aspartate aminotransferase and alanine aminotransferase levels and increased inflammatory cell infiltration, edema, and necrosis compared with their younger counterparts. The percentage of adipophilin-stained area in livers from young sham, young burn, aged sham, and aged burn groups was 10%, 44%, 16%, and 78% (p < 0.05), respectively. Liver malondialdehyde levels were 1.4 ± 0.5 nmol/mg, 2.06 ± 0.2 nmol/mg, 1.81 ± 0.12 nmol/mg, and 3.45 ± 0.2 nmol/mg (p < 0.05) in young sham, young burn, aged sham, and aged burn mice, respectively. Oxidized glutathione (GSSG) content increased 50% in the young burn, and 88% in aged burn animals compared with the young sham group (p < 0.05). The reduced glutathione GSH/GSSG ratio was significantly reduced by 54% in aged burn mice compared with young sham animals (p < 0.05). Furthermore, glutathione peroxidase gene expression showed a 96% decrease in the aged burn group compared with young sham mice (p < 0.05). Aged burn animals exhibit severe liver damage from heightened lipid peroxidation and inadequate antioxidative response. The increased peroxidation is associated with abundant lipid deposits in hepatic tissue postburn and a weak antioxidative response due to hepatic glutathione peroxidase downregulation. Further studies will focus on the functional significance of these findings concerning hepatic homeostasis.

The effect of burn mechanism on pediatric mortality in Malawi: A propensity weighted analysis

IntroductionThe burden of global trauma disproportionately affects low- and middle-income countries, with a high incidence in children. Thermal injury represents one of the most severe forms of trauma and is associated with remarkable morbidity and mortality. The predictors of burn mortality have been well described (age, % total body surface area burn [TBSA], and presence of inhalation injury). However, the contribution of the burn mechanism as a predictor of burn mortality is not well delineated. MethodsThis is a retrospective analysis of prospectively collected data, utilizing the Kamuzu Central Hospital (KCH) Burn Surveillance Registry from May 2011 to August 2019. Pediatric patients (≤12 years) with flame and scald burns were included in the study. Basic demographic variables including sex, age, time to presentation, %TBSA, surgical intervention, burn mechanism, and in-hospital mortality outcome was collected. Bivariate analysis comparing demographic, burn characteristics, surgical intervention, and patient outcomes were performed. Standardized estimates were adjusted using inverse-probability of treatment weights (IPTW) to account for confounding. Following weighting, logistic regression modeling was performed to determine the odds of in-hospital mortality based on burn mechanism. ResultsDuring the study period, 2364 patients presented to KCH for burns and included in the database with 1794 (75.9%) pediatric patients. Of these, 488 (27.6%) and 1280 (72.4%) were injured by flame and scald burns, respectively. Males were 47.2% (n = 230) and 59.2% (n = 755) of the flame and scald burn cohorts, respectively (p < 0.001.) Patients presenting with flame burns compared to scald burns were older (4. 7 ± 3.1 vs. 2.7 ± 2.3 years, p < 0.001) with greater %TBSA burns (17.8 [IQR 10–28] vs 12 [IQR 7–20], p < 0.001). Surgery was performed for 42.2% (n = 206) and 19.9% (n = 140) of the flame and scald burn cohorts, respectively (p < 0.001.) Flame burns had a 2.6x greater odds of in-hospital mortality compared to scald burns (p < 0.001) after controlling for sex, %TBSA, age, time to presentation, and surgical status. ConclusionIn this propensity-weighted analysis, we show that burn mechanism, specifically flame burns, resulted in a nearly 3-fold increase in odds of in-hospital mortality compared to scald burns. Our results emphasize flame and scald burns have major differences in the inflammatory response, metabolic profile over time, and outcomes. We may further utilize these differences to develop specialized treatments for each burn mechanism to potentially prevent metabolic dysfunction and improve clinical outcomes.

The A2B trial, antibiotic prophylaxis for excision-graft surgery in burn patients: a multicenter randomized double-blind study

BackgroundThe indication for antibiotic prophylaxis in burn patients remains highly controversial, with no consensus having been reached. The objective of antibiotic prophylaxis is to reduce the risk of postoperative local and systemic infections. Burn surgery is associated with a high incidence of bacteremia, postoperative infections, and sepsis. However, antibiotic prophylaxis exposes patients to the risk of selecting drug-resistant pathogens as well as to the adverse effects of antibiotics (i.e., Clostridium difficile colitis). The lack of data precludes any strong international recommendations regarding perioperative prophylaxis using systemic antibiotics in this setting.The goal of this project is therefore to determine whether perioperative systemic antibiotic prophylaxis can reduce the incidence of postoperative infections in burn patients.MethodsThe A2B trial is a multicenter (10 centers), prospective, randomized, double-blinded, placebo-controlled study. The trial will involve the recruitment of 506 adult burn patients with a total body surface area (TBSA) burn of between 5 and 40% and requiring at least one excision-graft surgery for deep burn injury. Participants will be randomized to receive antibiotic prophylaxis (antibiotic prophylaxis group) or a placebo (control group) 30 min before the incision of the first two surgeries. The primary outcome will be the occurrence of postoperative infections defined as postoperative sepsis and/or surgical site infection and/or graft lysis requiring a new graft within 7 days after surgery. Secondary outcomes will include mortality at day 90 postrandomization, skin graft lysis requiring a new graft procedure, postoperative bacteremia (within 48 h of surgery), postoperative sepsis, postoperative surgical site infection, number of hospitalizations until complete healing (> 95% TBSA), number of hospitalization days living without antibiotic therapy at day 28 and day 90, and multiresistant bacterial colonization or infection at day 28 and day 90.DiscussionThe trial aims to provide evidence on the efficacy and safety of antibiotic prophylaxis for excision-graft surgery in burn patients.Trial registrationClinicalTrials.gov NCT04292054. Registered on 2 March 2020

Racial And Socioeconomic Differences Affect Outcomes in Elderly Burn Patients

BackgroundRace and socioeconomic status influence outcomes for adult and pediatric burn patients, yet the impact of these factors on elderly patients (Medicare eligible, 65 years of age) remains unknown. MethodsData pooled from three verified burn centers from 2004 to 2014 were reviewed retrospectively. Age, race, gender, percent total body surface area (%TBSA) burn, mortality, length of stay (LOS), LOS per %TBSA burn, and zip code which provided Census data on race, poverty, and education levels within a community were collected. Data were analyzed using logistic and generalized linear models in SAS version 9.4 (SAS Institute, Cary, NC, USA). ResultsOur population was mainly Caucasian (63%), African American (18%), Hispanic (7.6%), and Asian (3.5%). Mean age was 76.3 ± 8.3 years, 52.5% were male. Mean %TBSA was 9 ± 13.8%; 15% of the patients sustained an inhalation injury. The mortality rate was 14.4%. Inhalation injury was significantly associated with mortality and discharge to a skilled nursing facility (SNF) (p < 0.05). Race was significantly associated with socioeconomic disparities and affected LOS/TBSA, but not discharge to SNF or mortality on univariate analysis. Poverty level, education level, and insurance status (others vs. public) independently predicted SNF discharge, while median income and insurance type independently predicted LOS/TBSA. ConclusionIn this elderly cohort, race did not predict standard markers of burn outcome (mortality and discharge to SNF). Socioeconomic status independently predicted LOS and discharge to SNF, suggesting a relationship between socioeconomic status and recovery from a burn injury. Better understanding of racial and socioeconomic disparities is necessary to provide equitable treatment of all patients.

A non-inferiority study comparing efficacy of preoperative prophylactic antibiotics for preventing infectious complications in patients with less severe burns

While international burn injury guidelines discourage prophylactic antibiotics on admission, current surgery guidelines focusing on antimicrobial prophylaxis place thermal injury under a general plastics procedure umbrella, and require significant evidential extrapolation. The purpose of this study was to determine if withholding systemic antibiotics in patients with <20% total body surface area (TBSA) burns without invasive wound infections and undergo wound excision is non-inferior to patients that receive preoperative antibiotics. Success was defined as lack of graft loss, bacteremia, or surgical site infection. One-thousand and eighty-three patients were screened and 100 patients undergoing 133 operations remained after exclusions. Seventy-four percent were male. Median age and %TBSA was 41 years (30, 55) and 5 (1.5, 8.3), respectively. We found no differences in demographics between patients that did and did not receive preoperative antibiotics. The success rates were 81.7% and 84.3%, respectively. There was one clinically significant bacteremia in each group. Withholding preoperative antibiotics was non-inferior with a percent difference of 2.6 (95% CI; −10.4, 15.6). Patients that did not receive antibiotics were no more likely to incur infection-related complications. In patients with <20% TBSA burns and without active wound infections, withholding preoperative systemic antibiotics will preserve unneeded antimicrobial exposure without increasing risk of infection-related complications.

Clinical outcomes following burn injury across the continuum of chronic glycemic control

Diabetes has been associated with poor outcomes following burn injury. There is limited data related to prediabetes in burn injury, and no studies to date have compared clinical outcomes inpatients without diabetes, with prediabetes, and with diabetes. Therefore, this study aimed to compare clinical outcomes after burn injury across the continuum of pre-injury glucose control. A propensity score weighted cohort study of adult patients admitted for initial management of burn injury was performed. Patients were categorized as no diabetes, prediabetes or diabetes based on their admission hemoglobin A1c and past medical history. The primary outcome was length of stay per percent Total Body Surface Area (TBSA) burn. Secondary outcome measures included length of stay, all-cause hospital mortality, disposition at discharge, re-grafting of same site, and amputations. A total of 2450 patients were screened; 1137 patients were included for evaluation (236 diabetes, 191 prediabetes, 710 no diabetes). After inverse probability weighing to adjust for potentially confounding factors, patients in the diabetes group had longer length of stay/%TBSA burn than both the no diabetes group (ratio of geometric means (95% CI) = 1.65 (1.25, 2.18), p < 0.001) and the prediabetes group (ratio (95% CI) = 1.49 (1.10, 2.02), p = 0.01). No statistically significant differences in secondary outcomes were observed between groups other than a higher rate of amputations in the diabetes group (2.7%) compared to the no diabetes (0.7%, p = 0.047) and prediabetes (0%, p = 0.04) groups. Further studies are needed to delineate the differences across the continuum of pre-injury glucose control in order to identify mechanisms to optimize burn-related outcomes.

Multi-Specialty Care for Second-Degree Pressure Cooker Explosion Burn Injuries

CONTEXTAlthough pressure cookers are very common kitchen utensils used in the United States, only a few cases of serious injuries secondary to pressure cooker explosions have been reported in the medical literature. When second-degree (i.e., “partial-thickness”) burns result from pressure cooker explosions, wounds involving near to or greater than 10% of total body surface area typically require multidisciplinary treatment, with burn center referral for proper wound care, potential fluid resuscitation, and eventual scar management.EXAMPLE CASEThe example patient described in this report was an African American female in her early 30s who presented during the summer of 2020 after suffering varying levels of second-degree burns to her bilateral upper torso and left wrist (i.e., approximately 10%, total body surface area). The authors first saw the patient during a primary care office visit a week after her initial injury when she first went to a local urgent care clinic. Upon her arrival to the second author’s family medicine clinic, a multi-specialty wound recovery plan was initiated since her first urgent care visit treatment had been minimal without prophylactic antibiotic therapy or placement of a burn center referral.CONCLUSIONSPartial and full-thickness burn injuries generally warrant immediate clinical (i.e., body surface area burn assessment, fluid resuscitation, empiric antibiotics) as well as ongoing (burn center referral, debridement procedures, active scar management, provision of psychological support) treatment needs. This paper discusses the critical opportunities posed for more extensive burn patients’ physicians to first categorize the extent of burn wounds and initiate subsequent specialty care in other settings.

Review of Sepsis in Burn Patients in 2020.

Background: Severe burn injury results in substantial damage to the skin, inhibiting its ability to perform as the primary barrier to infection. Additionally, severe burn injury can lead to critical illness and extensive time in the intensive care unit (ICU). These two factors work to increase the risk of sepsis in the burn patient compared with other hospitalized patients. The increased risk of sepsis is compounded by the difficulty of diagnosing sepsis in severely burned patients because the pathophysiology of large burns mimics sepsis, leading to possible delay in diagnosis and initiation of treatment. Methods: A literature review was performed to discuss and review the diagnostic difficulties and criteria used to identify patients with sepsis. Additionally, the most current management of sepsis was reviewed and described in caring for burn patients with sepsis. Results: The incidence of sepsis in patients with more than 20% total body surface area (TBSA) burns is between 3% and 30% and is the most common cause of death in the burn patient, with pneumonia being the most common etiology. Several different diagnostic criteria for diagnosing sepsis in burn patients exist, however, none of these criteria have proven to be superior to clinical diagnosis by an experienced burn surgeon. As with sepsis in other patient populations, prompt diagnosis, initiation of antibiotic agents, and source control remain the standard management of sepsis in the burn patient. Conclusions: Because of the loss of the primary infection barrier function of the skin after a substantial burn injury, this patient population is at increased risk for sepsis. Because of the pathophysiology of burn injuries, diagnosing sepsis in the burn population remains challenging. Understanding the most common etiologies of sepsis in burn patients may help with more expedient diagnosis and initiation of treatment.

Referral Patterns of Burn Injury in Rural Kenya.

Burn injury represents a substantial burden of disease in resource-limited settings. Kenya has no formal trauma system and referral practices for burn injuries are not well understood. The purpose of this study was to determine the factors associated with burn injury referrals in rural Kenya. A retrospective chart review was conducted for patients with burn injury from January 1, 2014 to December 31, 2017 at a 300-bed faith-based, teaching hospital in southwest Kenya. Bivariate analysis compared referred and non-referred patients. Multivariable logistic regression was used to assess the association between burn severity and odds of referral adjusting for age, sex, insurance, time from injury to arrival, and estimated travel time from home to hospital. The study included 171 patients with burn injury; 11 patients were excluded due to missing referral data. Of the 160 patients, 31.9% (n = 51) were referred. Referral patients had higher average total body surface area burn (23.1 ± 2.4% vs 11.1 ± 1.2%, P < .001), were more likely to have full-thickness burns (41.3% vs 25.5%, P = .05), and less likely to present to the referral hospital within 24 hours after injury (47.8% vs 73.0%, P = .005). Referral patients had longer travel time to hospital (90+ min: 52.9% vs 22.0%, P < .001). Odds of referral increased 1.62 times (95% confidence interval: 1.19-2.22) for every 10% increase in total body surface area burn. Without a coordinated trauma system, referrals represent a substantial portion of burn injury patients at a hospital in rural Kenya. Referred patients present with more severe burns and experience delays to presentation.