Burn Size Research Articles

A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries

BackgroundGlutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation.MethodsIn a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk.ResultsA total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P=0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed.ConclusionsIn patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.)

Length of Stay and Costs with Autologous Skin Cell Suspension Versus Split-Thickness Skin Grafts: Burn Care Data from US Centers.

IntroductionAutologous skin cell suspension (ASCS) significantly reduces donor skin requirements versus conventional split-thickness skin grafts (STSG) for thermal burn treatment. In analyses using the Burn-medical counter measure Effectiveness Assessment Cost Outcomes Nexus (BEACON) model, ASCS was associated with shorter hospital length of stay (LOS) and cost savings versus STSG. This study hypothesized that daily practice data from the USA would support these findings.MethodsElectronic medical record data from 500 healthcare facilities (January 2019–August 2020) were used to match adult patients who received inpatient burn treatment with ASCS (± STSG) to patients treated with STSG alone on the basis of sex, age, percent total body surface area (TBSA), and comorbidities. Based on BEACON analyses, LOS was assumed to represent 70% of total costs and used as a proxy to assess the data. Mean LOS, costs, and the incremental revenue associated with inpatient capacity changes were calculated.ResultsA total of 151 ASCS and 2443 STSG patients were identified: 63.0% were male and average age was 44.5 years. Eight-one matches were made between cohorts. LOS was 21.7 days with ASCS and 25.0 days with STSG alone (difference 3.3 days [13.2%]). LOS was lower with ASCS than STSG in four of five TBSA intervals. The LOS difference led to hospital bed cost savings of $25,864 per ASCS patient; overall cost savings were $36,949 per patient. Similar cost savings were observed in TBSA groupings < 20% and ≥ 20%. The reduced LOS with ASCS translated into an increased capacity of 2.2 inpatients/bed annually, which increased hospital revenue by $92,283/burn unit bed annually.ConclusionsReal-world data show that ASCS (± STSG) is associated with reduced LOS and cost savings versus STSG alone across all burn sizes, supporting the validity of the BEACON analyses. ASCS use may also increase patient capacity and throughput, leading to increased hospital revenue.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-022-02306-y.

The Role of the Outpatient Occupational Therapist Treating Patients With Small Burns: A Retrospective Audit of Practice.

Current Australian burn care practice guidelines recommend therapies prescribed for burn injuries, irrespective of burn size. These guidelines have been informed by research related to large burns and associated treatment burden. This article describes the clinical management of small burns by occupational therapists at a large tertiary facility in Australia. A retrospective clinical chart audit was conducted for the 12-month period from January to December 2019. Participants were eligible if they had sustained a burn of 1% TBSA or less. Eligibility criteria were met for 454 patients, reflecting 77% of new outpatients in 2019. Of these, 247 or 54% of patients saw an occupational therapist. Noninvasive therapies such as scar massage, compression, silicone and taping were prescribed for 35%, 32.6%, 22.6%, and 5.9% of patients, respectively. Occupational therapist involvement was more likely postsurgical intervention (84.5%). The data presented contribute to limited research available for the management of small burns. Findings reflect use of traditional forms of therapies for small scar management; however, there appeared little use of alternative therapies, such as tapes, which may be beneficial. This study highlights the potential need for current standard practice guidelines be nuanced according burn surface area.

Mortality and Survival Analysis of Burn Patients Admitted in a Critical Care Burn Unit, Saudi Arabia.

BackgroundBurn injury is associated with a high mortality risk. Recent epidemiological data on burn injury and mortality rate from Saudi Arabia is lacking.Objective:This study aimed to analyze the survival rates and its predictability using the Baux score in patients with burn injury at a tertiary care hospital in Saudi Arabia.Materials and Methods:This retrospective study included all patients admitted to the burn unit at King Fahd Hospital of the University, Al Khobar, between March 2014 and February 2020. Patients' burn characteristics and calculated revised Baux scores were collected. The age, burn wound size, type of burn, burn extension, and Baux score of the survivors and non-survivors were compared.Results:A total number of 102 patients were included, and their mean age was 24.2 years (range: 9 months to 78 years). The mean affected total body surface area was 26.4%. Ninety patients (88%) suffered from flame/scald burn. The mortality rate was 17.6% (18 patients); all these patients had flame burns. No patient with a revised Baux score ≥110 survived (n = 14; 77% of the total deaths), while there was no mortality at score <36. Inhalational injuries were reported in 18 patients, of which 13 (72%) died. Patients with patent airway and no inhalation injury were 19 times more likely to survive than those with a compromised airway (P < 0.001). In terms of the depth of burn, partial thickness increased the likeliness of survival by 10 times compared with full thickness (P < 0.003).Conclusion:Inhalational injury and burn size were the most prognostic factors of burn injury in this study. As all cases of mortality were from flame burns, regulation on flammable materials and safety measures should be promoted to the public.

Opioid use disorder in adult burn patients: Implications for future mental health, behavioral and substance use patterns

BackgroundBurn patients continue to have a high opioid requirement, despite current national trends to decrease opioid prescribing. While effective, long-term opioid use results in opioid dependence and possibly other mental health comorbidities. This retrospective cohort study seeks to evaluate implications of diagnosed opioid use disorder in the development of subsequent psychiatric, behavioral and substance abuse patterns. MethodsThe TriNetX database was queried for patients 18 years and older with a diagnosis of thermal or chemical burn who developed opioid use disorder after their burn injury. Two matched cohorts were studied, opioid use disorder versus non-opioid use disorder, to evaluate risk of developing subsequent mental health and behavioral conditions, use of psychiatric health services, and future substance abuse. ResultsA total of 2020 patients were identified in each cohort, matched for demographics, external trauma, and burn size. Patients in the opioid use disorder group had a significantly higher incidence of mental health diagnoses (79.7 % versus 57.7 %, OR 1.973, CI 1.741–2.236, p < 0.0001), including major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. This group was also more likely to utilize psychiatric services (16.0 % versus 10.3 %, OR 1.926, CI 1.595–2.326, p < 0.0001) and psychotherapy (12.6 % versus 7.2 %, OR 2.046, CI 1.650–2.536, p<0.0001). Furthermore, the opioid use disorder group had higher rates of polysubstance abuse (29.9 % versus 12.3 %, OR 3.048, CI 2.588–3.589, p<0.0001), suicidal / homicidal ideations (8.2 % versus 3.2 %, OR 3.057, CI 2.274–4.109, p<0.0001), and suicide attempts (2.0 % versus 0.7 %, OR 2.971, CI 1.611–5.478, p = 0.003). ConclusionsBurn patients who develop opioid use disorder have significantly higher rates of future psychiatric diagnoses, behavioral disturbances, and polysubstance abuse. A multidisciplinary team approach, including early involvement of pain and mental health services, could potentially reduce the development of opioid use disorder and its consequences.

The prevention and therapy of corneal ulcers in patients with large-area thermal burns

Objective: To evaluate the characteristics of ocular injury in patients with severe extensive thermal burns, and to explore the effective methods to prevent and treat corneal ulcers related to severe burns. Methods: A retrospective case series study. Between 2010 and 2019, Sixteen severe thermal burn patients with burn sizes>70% of the total body surface area involving the ocular region were admitted to the Burns and Plastic Surgery Division of Chinese PLA General Hospital, and consult with Ophthalmology Division. There were deep second-degree to fourth-degree burns in the eyelids. In the eleven surviving patients, 22 eyes presented ectropion. Eyelid full-thickness skin grafting (EFTSG) combined with or without tarsorrhaphy was performed in 20 eyes due to severe corneal exposure. Two eyes received partial blepharorrhaphy because of mild ectropion. The ocular manifestations and treatment outcomes were reviewed and assessed. Results: The majority of the patients were youth, and the average age was (36.8±10.4) years. The burn area was 84.0%±9.1% of the body surface area. Corneal ulcers secondary to lagophthalmos occurred at (35.1±15.6) days after burning in 75% (24/32) of eyes. Perforation was found in 18.8% (6/32) of eyes. Among the 22 operated eyes, the corneal ulcer was repaired in all 9 eyes receiving EFTSG with tarsorrhaphy, whereas ectropion recurred in 8 of 11 eyes only receiving EFTSG, and 4 eyes underwent further surgery due to corneal epithelial defects. Conclusions: In patients with severe large-area thermal burns, corneal ulcers are common complications. Prevention of corneal exposure is vital because the treatment of corneal ulceration is difficult due to eyelid deformity, inflammation and the absence of donor skin. Timely full-thickness skin grafting and blepharorrhaphy are effective approaches to preventing exposure keratopathy. To severe ulcers occur, conjunctival flap or Tenon's capsule covering combined with eyelid EFTSG and tarsorrhaphy is useful to rescue visual function.

The Effect of Distance to Treatment Center on Long-Term Outcomes of Burn Patients.

Geospatial proximity to American Burn Association (ABA)-verified burn centers or self-designated burn care facilities varies across the country. This study evaluates the effect of distance to treatment center on long-term, patient-reported outcomes. Data from the Burn Model System (BMS) National Longitudinal Database were analyzed. Demographic and clinical data were compared between three cohorts stratified by distance to BMS center (<20, 20-49.9, ≥50 miles). Distance to BMS center was calculated as driving distance between discharge and BMS center ZIP code centroids. The following patient-reported outcomes, collected at 12-months follow-up, were examined: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life (SWL) scale, employment status, and days to return to work. Mixed model regression analyses were used to examine the associations between distance to BMS center and each outcome, controlling for demographic and clinical variables. Of 726 patients included in this study, 26.3% and 28.1% were <20 and between 20 and 49.9 miles to a BMS center, respectively; 46.6% were ≥50 miles to a BMS center. Greater distance was associated with white/non-Hispanic race/ethnicity, preinjury employment, flame injury, and larger burn size (P < .001). Regression analyses did not identify significant associations between distance to BMS center and any patient-reported outcomes. This study suggests that patients treated at BMS centers have similar long-term, patient-reported outcomes of physical and psychosocial function, as well as employment, despite centralization of burn care and rehabilitation services. Given a steady decline in the incidence of burn injury, continued concentration of key resources is logical and safe.

Clinical decision-support for acute burn referral and triage at specialized centres – Contribution from routine and digital health tools

ABSTRACT Background Specialized care is crucial for severe burn injuries whereas minor burns should be handled at point-of-care. Misdiagnosis is common which leads to overburdening the system and to a lack of treatment for others due to resources shortage. Objectives The overarching aim was to evaluate four decision-support tools for diagnosis, referral, and triage of acute burns injuries in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis. Methods Study I retrospectively assessed adherence to referral criteria of 1165 patients admitted to the paediatric burns centre of the Western Cape of South Africa. Study II assessed mortality prediction of 372 patients admitted to the adults burns centre by evaluating an existing score (ABSI), and by using logistic regression. In study III, an online survey was used to assess the diagnostic accuracy of burn experts’ image-based estimations using their smartphone or tablet. In study IV, two deep-learning algorithms were developed using 1105 acute burn images in order to identify the burn, and to classify burn depth. Results Adherence to referral criteria was of 93.4%, and the age and severity criteria were associated with patient care. In adults, the ABSI score was a good predictor of mortality which affected a fifth of the patients and which was associated with gender, burn size and referral status. Experts were able to diagnose burn size, and burn depth using handheld devices. Finally, both a wound identifier and a depth classifier algorithm could be developed with relatively high accuracy. Conclusions Altogether the findings inform on the use of four tools along the care trajectory of patients with acute burns by assisting with the diagnosis, referral and triage from point-of-care to burns centres. This will assist with reducing inequities by improving access to the most appropriate care for patients.

Economic Burden of Denatured Alcohol-Induced Burns: A 20-Year Retrospective Study.

Burn care has rapidly improved over the past decades, but health innovations are expensive. We present the first study focusing on the economic burden of exclusive denatured alcohol-induced burns. The goal of this study was to determine costs for the public health system due to inpatients’ burn care because of these specific burns. Moreover, we aimed to observe the incidence of methylated spirit-related burns in the past 20 years. We performed an observational retrospective study in our burn unit including all patients with a denatured alcohol-related burn injury from 1 January 2001 to 31 December 2020. A total of 503 patients with a mean burn size of 24% were hospitalized; the mean annual total costs per patient was €43,879, varying from €31,518 to €63,274.00€; the total costs for denatured alcohol-related burns during the period 2001–2020 was €21,145,076. We noted an increasing incidence of denatured alcohol-related burns and related costs over the years, especially in the last decade. Our results highlight that burns by methylated spirits are still a real and expanding problem. Therefore, authorities should focus on sales rules, characteristics of the containers, and education of people who misuse denatured alcohol, based on historical habits of use. To reduce the socioeconomic costs of burns, future intervention strategies and studies from the dermatology community and burn specialists should focus on prevention programs and prompt wound healing to shorten the length of hospital stay, enable quick return to work, and improve the outcomes of patients with burns.

The relationships between routine admission blood tests and burn size, and length of stay in intensive care unit

Although blood test is a routine in major burns, its relationship with burn size and intensive care unit length of stay (ICULOS) remains undetermined. We investigated the feasibility of using these tests as a reference for definite diagnosis of major burn size, burn size >20% of the total body surface area (TBSA), and their relationships with ICULOS. Data of routine laboratory blood tests within 24h after burns (n=73) were collected retrospectively. Correlation tests and regression analyses were performed. Burns ≥20TBSA had higher incidences of leucocytosis, hypoalbuminaemia, elevated haemoglobin (Hb), and elevated haematocrit (Hct). Burn size was correlated negatively with albumin but positively with Hb, Hct, and white blood cell (WBC) count. For each unit increase in blood urea nitrogen (BUN)/creatinine (Cr), there was an increase of 1.2 days of ICULOS in females, while in males, there was a 6.7 day increase for every unit increase in Hb and a 3.1 day increase for each unit increase in BUN. A female model including Hb and WBC was derived, discriminating burns ≥20TBSA with sensitivity and specificity 0.94 and 1.0 respectively, and area under the receiver operating characteristic curve (AUROC) 0.96 (95% CI 0.91-1.00). The male model had sensitivity 0.96, specificity 1.0, and AUROC 0.96 (95% CI 0.89-1.00). Admission Hb and WBC could be used as a reference for definite diagnosis of major burn size, especially in borderline cases. BUN/Cr in females, and Hb and BUN in males, were related to ICULOS.

Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes

BackgroundBurn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management. ObjectiveOur aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries. MethodsWe performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center. ResultsA total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia. ConclusionsBetter understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

Burn-Induced Local and Systemic Immune Response: Systematic Review and Meta-Analysis of Animal Studies

Because burn injuries are often followed by a derailed immune response and excessive inflammation, a thorough understanding of the occurring reactions is key to preventing secondary complications. This systematic review, which includes 247 animal studies, shows the postburn response of 14 different immune cell types involved in immediate and long-term effects in both wound tissue and circulation. Peripheral blood neutrophil and monocyte numbers increased directly after burns, whereas thrombocyte numbers increased near the end of the first week. However, lymphocyte numbers were decreased for at least 2 weeks. In burn wound tissue, neutrophil and macrophage numbers accumulated during the first 3 weeks. Burns also altered cellular functions because we found an increased migratory potential of leukocytes, impaired antibacterial activity of neutrophils, and enhanced inflammatory mediator production by macrophages. Neutrophil surges were positively associated with burn size and were highest in rats. Altogether, this comprehensive overview of the temporal immune cell dynamics shows that unlike normal wound healing, burn injury induces a long-lasting inflammatory response. It provides a fundamental research basis to improve experimental set-ups, burn care, and outcomes.

C-reactive protein elevation is associated with increased morbidity and mortality in elderly burned patients

BackgroundC-reactive protein (CRP) is an acute-phase protein produced in response to inflammation after traumatic injury. We posit that C-reactive protein (CRP) is reliable in predicting morbidity and mortality following severe burn. In this study, we explored the relationship between serum CRP values and clinical outcomes in the severely burned. MethodsUsing the Research Network within the TriNetX database, we queried de-identified burn patient data across the United States and enrolled 36,556 burn patients with reported CRP values from 2006 to 2020. ResultsCirculating CRP levels were elevated significantly in patients ≥60 years as well as in males and African Americans (p < 0.05). CRP levels reached the zenith on the first day after burn, and were highest when burn size reached 60% total body surface area (TBSA). After bisecting the data at 10 mg/L of CRP, we compared clinical findings between patient groups (n = 16,284/18,647 in high/low CRP levels). The risk of patient death doubled in the high CRP group from 4.687% to 9.313%, with higher incidences of sepsis, skin infection, and myocardial infarction (p < 0.05). Moreover, mortality increased from 0.9% to 1.926% in those younger than 20 years when comparing the low and high CRP groups, whereas mortality significantly increased from 8.84% to 15.818% in those ≥60 years old (p < 0.05). Both elderly and paediatric groups had significant increases in the diagnosis of sepsis-associated with increased CRP expression. However, incidences of skin infection, pneumonia, and acute kidney injury increased significantly only in the elderly group (p < 0.05). ConclusionElevated CRP expression is common in burn patients. The factor of age influenced the association of CRP expression to clinical outcomes.

The effect of Tarantula cubensis D6 on zone of stasis in a rat burn model

AimBurn injuries are one of the most devastating injuries. Saving the zone of stasis decreases burn size, morbidity, and mortality. Tarantula cubensis (TC) increases epithelization of wounds, and increases wound contraction. In this study, we investigated the effects of TC on the stasis zone. Materials and Methods36 Wistar albino female rats were divided into 3 groups. Using brass comb burn model, at days 0 and 3, physiological serum solution in group 2, TC injection in group 3and no injection in group 1 was applied. Thermal and normal images were taken on day 10 and rats were sacrificed for histopathological examination. ResultsWe found a statistically significant difference between the 1st and 3rd group, 2nd and 3rd group regarding viable wound areas (p < 0.05), temperature difference (body-stasis zone) and mean body temperature (p < 0.05). We found no statistically significant difference between groups regarding neovascularization, inflammatory density, and vital cutaneous appendages. We found a statistically significant difference in epithelial layer thickness between the1st and 3rd groups, 2nd and 3rd groups(p < 0.05). ConclusionTC increases stasis zone viability macroscopically, increases epithelial layer thickness histopathologically, thus it promotes wound healing in burn wounds. This increase in stasis zone viability was also established with thermal imaging.

Short- and long term hyposmia, hypogeusia, dysphagia and dysphonia after facial burn injury – A prospective matched cohort study

BackgroundFacial burns frequently occur in occupational or household accidents. While dysphagia and dysphonia are known sequelae, little is known about impaired smell and taste after facial burns. MethodsIn a prospective observational controlled study, we evaluated hyposmia via the Sniffin’ Stick Test (SnS), hypogeusia via a taste strip test, and dysphonia and dysphagia via validated questionnaires acutely and one-year after burn, respectively. A matched control group consisting of a convenience sample of healthy volunteers underwent the same assessments. ResultsFifty-five facial burn patients (FB) and 55 healthy controls (CTR) were enrolled. Mean burn size was 11 (IQR: 29) % total body surface area (TBSA); CTR and FB were comparable regarding age, sex and smoking status. Acutely, hyposmia was present in 29% of the FB group (CTR: 9%, p = 0.014) and burn patients scored worse on the SnS than CTR (FB: 10; CTR: 11; IQR: 2; p = 0.013). Hyposmia per SnS correlated with subjective self-assessment. Hyposmia and SnS scores improved over time (FB acute: 10.5 IQR: 2; FB one year: 11; IQR: 2; p = 0.042) and returned to normal at one-year post burn in most patients who completed the study (lost to follow-up: 21 patients). Taste strip scores were comparable between FB and CTR, as was the acute prevalence of dysphagia and dysphonia. ConclusionHyposmia acutely after facial thermal trauma appeared frequently in this study, especially when complicated by inhalation trauma or large TBSA involvement. Of all complete assessments, a fraction of burn patients retained hyposmia after one year while most improved over time to normal. Prevalence of dysphonia, dysphagia and hypogeusia was comparable to healthy controls in this study, perhaps due to overall minor burn severity.

P96. EXPANDING BURN EXPERTISE THROUGH TELEMEDICINE FOR THE FRONTLINERS DURING THE COVID-19 PANDEMIC

PURPOSE: Inexperience of frontliners in burn wound assessment results to unnecessary COVID-19 exposures during this pandemic. This study determined the accuracy and timeliness in diagnosing and classifying burn patients assessed by a frontliner non-burn specialist in-person (NBSP), a Burn Specialist online (BSO), and a Burn Specialist in-person (BSP). METHODS: All burn patients (January to March 2021) with signed consents for participation were photographed in a standardized manner by the NBSP and referred to a BSO via Telegram™. These patients were also assessed independently by the BSP. The % total body surface area (TBSA), burn depth classification, and the timestamps (seen by the NBSP, online referrals sent to the BSO, BSO sent the diagnoses, and assessment by the BSP) were recorded. One-Way Repeated Measures Analysis of Variance (ANOVA) with and without blocking were done. RESULTS: Data gathered from 82 patients throughout the study demonstrated that burn size (% TBSA) among the three different physicians (NBSP, BSO, BSP) was not statistically significant (p=0.8794). Our analysis showed no statistical difference for the 19 different body parts per patient and burn depth classification (p=0.9718). One-way ANOVA tests on timeliness were statistically significant with p<0.0001. Post-hoc comparison using Tukey test revealed no statistical significance between the BSO and BSP (p=0.892). CONCLUSION: Frontliners can refer to burn specialists using smartphone telemedicine platform for optimum burn care with an accurate diagnosis during and even after this pandemic. Timeliness can be improved with a dedicated 24/7 online available burn specialists and a reliable network access.

66 The Association of Burn Size and Global Functioning: A Preschool LIBRE1-5 Study

IntroductionBetween the ages of one and five, children gain increased mobility and begin to explore their surroundings. This makes them a particularly vulnerable age group for burn-related injuries, which can influence a child’s physical and psychosocial development. Previous research in adult burn survivors associated larger burn size with poorer functional outcomes for social activities. Currently, there are limited data on the association in preschool aged survivors between burn size and functioning. The aim of this study is to understand how demographic characteristics, particularly burn size, correlate with the global functioning items using data from the Preschool-LIBRE1-5 study.MethodsThe Preschool-LIBRE1-5 was field-tested with 426 parents of burn survivors. Eight global items assessed change in functioning in four domains (physical, psychological, communication & language, and social) compared to pre-burn functioning. Demographic variables included gender, race, age at survey completion, total body surface area burned (TBSA), ethnicity, and pain severity. Post-burn abilities were assessed with “Following the burn injury, my child lost abilities he/she had before the burn injury in…”, measured with a yes or no response and compared to other children without burns with, “Compared to other children in the same age, in general, how would you rate your child’s…”, measured with a 5-point Likert scale ranging from much worse to much better. Multivariate logistic regression with multiple imputation for missing values were used to measure the association between demographic characteristics and global items.ResultsThe population had a mean age at time of burn injury of 1.9 + 1.1 years and mean TBSA% of 4.2 + 8.0. Of the 426 participants, 305 have a TBSA < 5%, 45 have a TBSA between 5%-15% and 45 have a TBSA >15%. Larger TBSA was associated with lower odds of abilities in functional status for all four global functioning items. Adjusted odd ratios with 95% CI’s included communication and language 0.57(0.35,0.93), physical function 0.55(0.37,0.83), social function 0.33(0.2,0.52), and psychological/behavioral function 0.49(0.31,0.75). There was also a negative correlation of larger TBSA with weaker social abilities of the child compared to other children without burns.ConclusionsThe findings of this study show a negative association between a child’s burn size and parent-reported functioning in the four domains post-burn injury. These findings may help clinicians improve pediatric recovery and rehabilitation.

56 Evaluation of a Smartphone Application as a Method for Calculating Total Body Surface Area Burned

IntroductionCurrent methods of burn estimation can lead to incorrect estimates of the total body surface area burned, especially among injured children. Inaccurate estimation of burn size can impact initial management, including unnecessary transfer to burn centers and fluid overload during resuscitation. To address these challenges, we developed a smartphone application that calculates the total body surface area of a burn using a body-part by body-part approach. The aims of this study were to assess the accuracy of the smartphone application and compare its performance to three established methods of burn size estimation (Lund-Browder Chart, Rule of Nines, Rule of Palms).MethodsTwenty-four healthcare providers used each method to estimate burn sizes on moulaged manikins. The manikins represented different ages (infant, child, adult) with different total body surface area burns (small < 20%, medium 20-49%, large >49%). We calculated the accuracy of each method as the difference between the user-estimated and actual total body surface area. We used multivariable modeling to control for manikin size and method.ResultsAmong all age groups and burn sizes, the smartphone application had the greatest accuracy for burn size estimation (-0.01%, SD 3.59%) followed by the Rule of Palms (3.92%, SD 10.71%), the Lund-Browder Chart (4.42%, SD 5.52%), and the Rule of Nines (5.05%, SD 6.87%).ConclusionsThe smartphone application may improve the estimation of total body surface area burned compared to existing methods.

527 Practical Use of Biomarkers During Nutritional Support of Pediatric Burn Patients

IntroductionCurrent guidelines for evaluating nutritional risk in acutely ill patients incorporate the assessment of inflammation and disease burden. Inclusion of laboratory measures such as C-reactive protein (CRP) in screening criteria used to identify nutritional risk has gained credibility. Other biomarkers influenced by inflammation include visceral proteins albumin (ALB) and pre-albumin (PAB). While visceral proteins are not valid indicators of nutritional status, they may be indicators of nutritional risk, which could potentially lead to poor clinical outcome. The purpose of this study is to evaluate if PAB, ALB, CRP, are useful markers for predicting clinical outcomes in children with severe burn injury.MethodsAs part of our quality assurance program, we collect data on all nutrition support interventions, monitoring and outcome in children admitted to our hospital with significant burn injuries. This analysis describes data collected from 2006-2019 in children who had a burn injury and received nutritional support for five days or greater. Data elements collected include general demographics, weekly measures PAB, CRP, ALB; length of stay (LOS), number of intensive care unit (ICU) days, days to wound closure, and days on nutrition support. Biomarkers PAB, ALB, CRP and burn size (as an indicator of disease burden) were entered into a multiple regression model using a stepwise procedure for each dependent outcome variables (LOS, ICU LOS, Days to Wound Closure, and Days on Nutrition Support).ResultsA total of 182 patients, 7.0 ± 5.0 years of age with 41.1 ±16.9 % total body surface area (TBSA) burns were included in the analysis. TBSA, mean CRP and mean PAB were significant predictors of hospital LOS (R=0.60; p < 0.001); TBSA and PAB were significant predicters of ICU LOS (R=0.67; p< 0.000), days to wound healing (R= 0.37; p < 0.000) and days on nutrition support (R=0.60; p< 0.000). Albumin was not a significant predictor for any of the clinical outcome measures.ConclusionsOur findings indicate that monitoring PAB and CRP is useful for identifying risk of poor outcome. Mean PAB was inversely associated with LOS, ICU LOS, days to wound healing, and days on nutritional support even when controlling for CRP and burn size.

548 Toward a Burn Risk Calculator

IntroductionRisk adjusted statistical modeling of deaths in burns has two major purposes. One is to enable comparison of outcomes between centers (Benchmarking). That requires as precise a model as possible and is applied retrospectively. The other objective is to inform patient and family discussions about prognosis and plans of care. These models are applied prospectively based on limited clinical data. The purpose of this study was to derive a model that could be the basis for such a risk calculator.MethodsWe identified 128,252 records in a national burn registry for initial patient admissions to 103 burn centers between July 2015 through June 2020. Cases from centers with < 100 admissions annually were omitted. We compared a logistic regression model based on the revised Baux score (RBS) (age, burn size, inhalation injury) with a logistic regression model involving age, age2, burn size, presence of 3rd degree burn, inhalation injury, respiratory failure, burn etiology, gender, and admission year. We compared the Adjusted R2, c statistic and average precision for each model. All calculations were done using CatBoostClassifier in Python.ResultsThere were 127,018 patients that served as the basis for these analyses. The RBS model had an Adjusted R2 of 0.41 compared with 0.54 for the more detailed model, a c statistic of 0.95 vs 0.98, and an average precision of 0.69 vs 0.76.ConclusionsBoth statistical models of mortality following burn injury demonstrated good accuracy. The model with the most predictor variables had better precision. Both models could serve as useful risk calculators for patients following burn injury.