TBSA Burn Research Articles

Recovery in patients undergoing ablative fractional carbon dioxide laser for adult hypertrophic burn scars: A longitudinal cohort study

IntroductionAblative fractional carbon dioxide laser (AFCO2L) is widely used as a treatment for hypertrophic burn scars. This study aimed to evaluate clinician and patient-reported outcomes after AFCO2L treatment, safety, and identify factors influencing outcomes. MethodsThis longitudinal study recruited adult patients with hypertrophic burn scars treated with AFCO2L at a single Australian burn unit. Patients received up to four AFCO2L treatments over approximately 12 months. Outcomes were ultrasound scar thickness, the Patient and Observer Scar Assessment Scale (POSAS), and the Brisbane Burn Scar Impact Scale (BBSIP), measured at baseline and 3, 6, and 12 months after the first AFCO2L treatment. Analysis used mixed effects linear models. Results47 patients were included with median age 32 years (IQR: 24, 53) and median burn TBSA of 35 % (IQR: 7.5 %, 48 %). Statistically significant improvements between baseline and 12-month follow-up occurred in scar thickness, and all POSAS and BBSIP subscores. Most improvements remained when accounting for TBSA, Fitzpatrick skin type, scar maturity, and body area treated. Patients reported transient symptoms after 61 of 89 (69 %) AFCO2L treatments, but infection or delayed wound healing occurred after only 4 of 89 (4 %) treatments. ConclusionThis study supports safety and improved clinician and patient-reported outcomes in patients undergoing AFCO2L for hypertrophic burn scars.

Graft take outcomes of burn patients transplanted with CEA derived from a modified composite culture technique: A case series.

Low-cost and efficient culture environments comparable to standard techniques would undoubtedly improve burn outcomes in under-resourced settings. The aim of this case series was to report on the CEA graft-take using a modified composite culture technique. CEA transplants, following emergency ethical approval, occurred for burn patients (n=25) with low survival prognosis and/or exhausted donor sites. Keratinocytes were retrieved from skin biopsies, seeded centrally on routinely-used dressing gauze and incubated at 37 °C in pediatric incubators. Fresh autogenous plasma was applied daily and hydrogel every third or fourth day. After confluence, the CEA was transplanted onto debrided wound beds. Xenografts were used for temporary cover during the culture period. Final graft take assessment (21 days) was assessed and calculated as a graft take percentage for total CEA area transplanted. Central indices were described as mean (95% CI) and frequency (%) for age, total body surface area, abbreviated burn severity index scores, survival prognosis and graft take. Eleven patients survived with a mean age of 36.1 years (95% CI 25.8-46.4), 45.0 %TBSA burns (95% CI 35.1-54.9), 9.7 ABSI scores (95% CI 8.6-10.8) and 79.5% graft take (95% CI 62.9-96.0). Reduced graft take (61.2%) was observed in patients with perineum burns and increased graft take (97%) in uncomplicated burns. The average CEA graft take was 79.5% using a low-cost culture technique and comparable to the largest case series in literature. The survival of the major burn cases was highly favourable considering injury severity, expected outcomes without CEA and the observed challenges.

Repeat Bronchoscopies Are Poorly Predictive of Outcomes Following Inhalation Injury

Abstract Inhalation injury is an independent predictor of mortality after burn injury. Although bronchoscopy remains the gold standard for diagnosing inhalation injury, there is a paucity of evidence to support repeat bronchoscopies for following inhalation injuries during a patient’s clinical course. This study looks at the ability of serial bronchoscopies to prognosticate outcomes. This was a secondary analysis of a previously reported prospective observational study. Patients diagnosed with inhalation injury had repeat bronchoscopies with blinded investigators assigning severity scores. The study used multivariate regression analysis to investigate whether inhalation injury severity scores of the carinal images were predictive of mortality. Secondary outcomes included diagnosis of acute respiratory distress syndrome or pneumonia during hospitalization. The final analysis included 99 patients. After accounting for age, percent TBSA burn, and injury severity scores, there were no days that were significant for predicting outcomes. All days were poor predictors overall, with the area under the receiver operating curve being <0.8 in all instances. These results do not support the use of serial bronchoscopies for prognostication purposes. Until a larger, randomized clinical trial can evaluate this further, serial bronchoscopies performed for assessment of the progression of inhalation injury may provide more risk than benefit.

772 Analysis of Therapeutic Time and Functional Outcomes After a 92% TBSA Burn Injury

772 Analysis of Therapeutic Time and Functional Outcomes After a 92% TBSA Burn Injury

Is the Preoperative Wound Culture Necessary Before Skin Grafting Minor Burns? A Pilot Study in a Low Resource Setting Burn Service.

The most common cited cause of split-thickness skin graft failure is infection and due to the association between bacterial findings in wound beds an attempt to decrease the bacterial burden before skin-grafting evolved. Thus, preoperative microbiology swabs of the wound bed became routine at some institutions prior to grafting. This is not standard practice in the Pietermaritzburg Burn Service. Emphasis is instead placed on a strict protocol of intraoperative wound bed preparation to promote adequate graft take. This pilot study aims to evaluate whether preoperative wound swabs are appropriate. We performed a prospective observational study to determine if positive wound cultures were associated with graft failure. All patients with a burn surface area of less than 10%, where delayed grafting (later than 28 days from the time of burn injury) was performed, from March to December 2021 were analyzed. Patient demographics, days from burn to graft, %TBSA burn, %TBSA grafted, whether sharp debridement prior to grafting in the same procedure was performed or not, use of topical gentamicin intraoperatively, graft outcome (% graft loss), need for regraft, and organism grown were recorded into an excel spreadsheet for analysis. The sample included 52 patients. Of these, 17 (31.5%) were female. The median %TBSA grafted was 8% (IQR 4%-13%) and similar in both groups. The median days from burn to grafting were 35 days. Thirty-nine patients (75%) had graft Take and 13 (25%) had graft Failure. In the failed group, the median % graft failure was 50% (30%-70%). Of the group with successful graft take, 90% were noted to have had a positive wound culture prior to grafting. A positive wound culture was not found to be a risk factor for graft failure (P = .993). Despite the positive wound cultures graft take was more than 90% in 75% of grafts performed and only 2/52 patients required supplementary grafting. We believe that this demonstrates that our local protocol is reasonable in this setting and that waiting for negative wound swabs prior to grafting should not be a reason to delay grafting.

Precursors to oliguria during major burn resuscitation: An analysis of a prospective observational trial at 5 major US burn centers

Currently, urine output is the leading variable used to tailor fluid resuscitation in patients with large TBSA burns. However, this metric often lags with respect to resuscitation. Our group sought to identify derangements in variables that precede development of oliguria (<30 cc/hr) that we hypothesize will aid in more efficient resuscitation. We performed a retrospective analysis of 146 adult patients admitted within 4 h of a large TBSA (>20%) burn. We then divided them into two cohorts: those who developed oliguria within 6 h of admission and those who did not. Patients who experienced early oliguria had a higher incidence of invasive SBP < 90 (p = 0.02) or DBP < 40 (p = 0.009), lower minimum bicarbonate level (p = 0.04), more full thickness burns (p = 0.004), and higher TBSA (p = 0.01). More female patients were found in the oliguric group (p = 0.003). Multivariate analysis was used to develop a model to predict development of oliguria. When evaluated together, minimum DBP, sex, TBSA (or percent full thickness burn), and maximum base deficit constituted the most parsimonious model that significantly predicted oliguria (AUC = 0.92). Interestingly, the model lost significance when DBP was omitted, highlighting the importance of diastolic pressure in the development of oliguria.

Inpatient Complications and Outcomes for Burn Patients Admitted With Methamphetamine Intoxication.

Methamphetamine intoxication frequently complicates inpatient burn admissions. While single-institution studies describe adverse outcomes during resuscitation, little is known about the risks of amphetamine intoxication on inpatient complications and perioperative management. The US National Trauma Data Bank was queried for burn encounters between 2017 and 2021. Amphetamine intoxication was identified on admission. Primary outcomes included death, stroke, and myocardial infarction (MI). Secondary outcomes included organ failure and surgical management. Multivariable regressions modeled outcomes adjusting for available covariates including demographics, TBSA burned, and inhalation injury. Bonferroni adjustments were applied. Our study identified a total of 73,968 primary burn encounters with toxicology screens. Among these, 800 cases (1.1%) were found to have positive methamphetamine drug screens upon admission. Methamphetamine users were significantly older (41.7 vs 34.9 years, P < .001), had a greater percentage of males (69.6 vs 65.4, P = .045), were more likely to have inhalation injury (P < .001), and had larger %TBSA burns (16% vs 13%, P < .001). Methamphetamine users were no more likely to die, experience MI, or experience stroke during admission. In contrast, methamphetamine users were significantly more likely to have alcohol withdrawal (P = .019), acute kidney injury (AKI) (P < .001), deep vein thrombosis (P = .001), pulmonary embolism (PE) (P = .039), sepsis (P = .026), and longer intensive care unit (ICU) stays (P < .001). Methamphetamine use was associated with a longer number of days to the first procedure (P = .005). Of all patients who required surgery (15.0%), methamphetamine users required significantly more total debridements and reconstructive procedures (P < .001). While not associated with mortality, methamphetamine intoxication was associated with an increased risk of many complications including PE, deep vein thrombosis, AKI, sepsis, and longer ICU stays. Methamphetamine intoxication was associated with delays in surgical care.

Factors Predicting Burn Surgery Operative Time in a Middle-Income Country Regional Burn Service.

Access to theater is essential for the surgical management of deep burns. This is a scarce resource in low-middle-income countries. It underpins the importance of optimizing theater time. We sought to look at specific factors and their influence on operative time in minor to moderate burn surgery. This knowledge can assist teams where theater planning and optimization may be beneficial in resource-limited settings. Operative records between January and December 2018 at the Regional Hospital were analyzed. Data fields included age, gender, TBSA of burn, surface area burn operated on, intraoperative position change, seniority of surgeon, presence of an assistant, inclusion of special areas, predicted operative time, and actual operative time. Operative records for 265 patients were analyzed, with a median operative time of 40 minutes (interquartile range 25-64). Overall factors that predict longer operating time are larger total body surface area burn, larger surface area burn operated on, an operation involving at least one special area, number of special areas operated on, position change, presence of an assistant, and longer predicted operative time. Total percentage burn, operated percentage, special areas to be operated, and position change are overall factors to be considered when planning a burns list for the nonspecialist burn surgeon. This knowledge may be useful for an inexperienced surgeon to understand and aid in the effective utilization of limited operative time available for the surgical management of deep burns in resource-limited settings.

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation.

This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.

A heterogenous population of extracellular vesicles mobilize to the alveoli postinjury.

Acute lung injury and subsequent resolution following severe injury are coordinated by a complex lung microenvironment that includes extracellular vesicles (EVs). We hypothesized that there is a heterogenous population of EVs recruited to the alveoli postinjury and that we could identify specific immune-relevant mediators expressed on bronchoalveolar lavage (BAL) EVs as candidate biomarkers of injury and injury resolution. Mice underwent 30% TBSA burn injury and BAL fluid was collected 4 hours postinjury and compared with sham. Extracellular vesicles were purified and single vesicle flow cytometry (vFC) was performed using fluorescent antibodies to quantify the expression of specific cell surface markers on individual EVs. Next, we evaluated human BAL specimens from injured patients to establish translational relevance of the mouse vFC analysis. Human BAL was collected from intubated patients following trauma or burn injury, EVs were purified, then subjected to vFC analysis. A diverse population of EVs were mobilized to the alveoli after burn injury in mice. Quantitative BAL vFC identified significant increases in macrophage-derived CD44+ EVs (preinjury, 10.8% vs. postinjury, 13%; p < 0.05) and decreases in IL-6 receptor alpha (CD126) EVs (preinjury, 19.3% vs. postinjury, 9.3%, p < 0.05). Bronchoalveolar lavage from injured patients also contained a heterogeneous population of EVs derived from myeloid cells, endothelium, and epithelium sources, with CD44+ EVs being highly detected. Injury causes mobilization of a heterogeneous population of EVs to the alveoli in both animal models and injured patients. Defining EV release after injury will be critical in identifying diagnostic and therapeutic targets to limit postinjury acute lung injury.

Incidence and Risk Factors Associated with Microbial Colonization of Burn Wounds: An Observational Study

Background: Microbial colonization of burn wounds leads to infection, which is a major cause of morbidity/mortality, prolonged admission, and cost. This study aims to investigate the incidence of positive burn wound colonization and its associated risk factors in a provincial referral center within a single-payer system. Methods: We performed a retrospective review of all adult (≥18 years) patients admitted to a single, tertiary burn center, with a primary burn diagnosis between January 2011 and 2021. Microbiology records were screened to identify patients with culture-positive burn wounds. Univariable and multivariable logistic regression analyses were used to evaluate risk factors associated with burn site colonization. Results: The sample included N = 634 participants. Most were male (72.1%), with a flame injury (62%), and had a mean age of 47.6 (±18.0) years and a TBSA of 13.5% (±14.8). The incidence of positive burn wound colonization was 27.3%. Increasing participant age, diabetic status, larger burn TBSA, presence of full-thickness burns, inhalation injury, and lower limb and trunk involvement were associated with statistically significant ( P ≤ .05) increased odds of a positive burn wound culture. Conclusion: This study provides an estimate of the incidence of primary burn wound colonization at a single, tertiary care, burn center as well as identifies potential risk factors associated with this outcome. Clinicians should consider closely monitoring patients with these risk factors for possible progression to clinical burn site infection. Future research should address strategies to mitigate colonization in patients with identified risk factors.

Comparison of Efficacy of Vacuum Dressing Versus Conventional Dressing Over Autologous Split Skin Grafts in Burn Wounds: A Single-Center Prospective Cohort Study.

This study was carried out to compare the efficacy of vacuum dressing and conventional dressing over split skin grafts in burn patients. It was a single-center prospective cohort study on patients, with less than 40% TBSA burn, undergoing skin grafting at 2 different sites simultaneously over the burn wounds. One site underwent conventional dressing following grafting, and the other underwent vacuum dressing. The primary objective was to compare the percentages of skin graft uptake on Day 5 and Day 14. The secondary objectives were to compare the duration of dressings, time for complete epithelization, need for regrafting, and wound swab culture positivity rates. Three independent examiners assessed the efficacy of dressings in terms of epithelization percentage, need for continued dressing, graft loss, wound swab culture positivity rate, and qualitative assessment of grafts. A total of 16 patients were included in the study. The graft loss, number of days of dressings, and complete epithelization time were statistically lower in the negative-pressure wound therapy (NPWT) group compared with the conventional group (P values .007, .006, and 0009, respectively). The percentage of epithelization was also found to be higher in the NPWT group (P = .006). The incidence of positive cultures and clinically significant graft loss was found to be lower in the NPWT group. However, this was not found to be statistically significant. NPWT dressings can be used in burn wounds following skin grafting and have been found to reduce the time for epithelization compared to conventional dressing.

Characterizing Delirium and Associated Risk Factors Using the Cornell Assessment of Pediatric Delirium Score in Pediatric Burn Patients.

Delirium is a syndrome of acute brain dysfunction with disturbance in consciousness and cognition that is increasingly recognized in critically ill pediatric patients. The Cornell Assessment of Pediatric Delirium (CAPD) tool is used to detect delirium in children of all ages and developmental stages in various hospital settings. To date, the incidence of delirium in the pediatric burn population has been poorly defined. In order to describe the incidence as well as risk factors for delirium in this patient population, we retrospectively reviewed patients <18 years of age admitted to our American Burn Association-verified pediatric burn center from March 2018 to May 2021 who underwent delirium screening using the CAPD tool. Patient demographics, burn characteristics, hospitalization details, and date of first positive delirium screening were collected, and χ2, Fisher's exact test, univariate, and multivariate analyses were performed. Delirium was identified in 42 (10.8%) of 389 patients meeting inclusion criteria. Patients screening positive for delirium were older (4 years [IQR: 2, 11] vs 2 years [IQR: 1, 6], P < .0005) and had larger TBSA burns (21.63% [IQR: 9, 42] vs 3.5% [IQR: 1.75, 6], P < .0001) than delirium-negative patients. Delirium-positive patients required a longer duration of mechanical ventilation (OR 4.23; 95% CI [1.16-15.39], P = .0289) and had higher TBSA burns (OR 1.12; 95% CI [1.06-1.17], P < .0001). Delirium-positive patients had 1.6 day longer length-of-stay adjusted for TBSA burned (95% CI [0.81-2.41], P < .0001). Compared to delirium-negative patients, delirium-positive patients had a 5.4-day longer PICU admission (95% CI [2.93-10.3]; P < .0001). Screening pediatric burn patients with risk factors known to be associated with delirium by using the CAPD score could improve delirium prevention and allow for early intervention.

Comparison of Rapid-, Kaolin-, and Native-TEG Parameters in Burn Patient Cohorts With Acute Burn-induced Coagulopathy and Abnormal Fibrinolytic Function.

Although use of thromboelastography (TEG) to diagnose coagulopathy and guide clinical decision-making is increasing, relative performance of different TEG methods has not been well-defined. Rapid-TEG (rTEG), kaolin-TEG (kTEG), and native-TEG (nTEG) were performed on blood samples from burn patients presenting to a regional center from admission to 21 days. Patients were categorized by burn severity, mortality, and fibrinolytic phenotypes (Shutdown [SD], Physiologic [PHYS], and Hyperfibrinolytic [HF]). Manufacturer ranges and published TEG cutoffs were examined. Concordance correlations (Rc) of TEG parameters (R, α-angle, maximum amplitude [MA], LY30) measured agreement and Cohen's Kappa (κ) determined interclass reliability. Patients (n = 121) were mostly male (n = 84; 69.4%), with median age 40 years, median TBSA burn 13%, and mortality 17% (n = 21). Severe burns (≥40% TBSA) were associated with lower admission α-angle for rTEG (P = .03) and lower MA for rTEG (P = .02) and kTEG (P = .01). MA was lower in patients who died (nTEG, P = .04; kTEG, P = .02; rTEG, P = .003). Admission HF was associated with increased mortality (OR, 10.45; 95% CI, 2.54-43.31, P = .001) on rTEG only. Delayed SD was associated with mortality using rTEG and nTEG (OR 9.46; 95% CI, 1.96-45.73; P = .005 and OR, 6.91; 95% CI, 1.35-35.48; P = .02). Admission TEGs showed poor agreement on R-time (Rc, 0.00-0.56) and α-angle (0.40 to 0.55), and moderate agreement on MA (0.67-0.81) and LY30 (0.72-0.93). Interclass reliability was lowest for R-time (κ, -0.07 to 0.01) and α-angle (-0.06 to 0.17) and highest for MA (0.22-0.51) and LY30 (0.29-0.49). Choice of TEG method may impact clinical decision-making. rTEG appeared most sensitive in parameter-specific associations with injury severity, abnormal fibrinolysis, and mortality.

Blood transfusions in non-major burns patients

BackgroundBlood transfusions are essential to treating anaemia of burn injuries. It has recently been observed that patients with non-major burns < 20%TBSA may also develop anaemia requiring transfusion of blood products. Due to the morbidity and mortality rate associated with blood transfusions better understanding of risk factors may guide clinical practices to improve patient care. ObjectiveTo determine risk factors for transfusion of blood products in patients with non-major burn injuries and assess transfusion practices to establish impact on patient outcome. MethodOur study included 182 adult patients with non-major burn injuries, < 20%TBSA admitted over a 3-year period at the Department of Plastic Surgery and Burns Unit of the Emergency County Hospital Cluj-Napoca. We analysed patient and injury characteristics: age, gender, %TBSA burn, %FT burn, burn site, mechanism of injury, inhalation injury, Hb lab determinations throughout admission and surgical management. Charlson comorbidities index has been determined based on cardiovascular, neurological, gastrointestinal and renal comorbidities as well as diabetes mellitus. We selected blood transfusions, wound infections and length of hospital stay as outcome for our analysis. Results37.9% of patients included in our study developed anaemia throughout admission and 7.7% underwent blood transfusions. Mean Hb levels triggering blood transfusions have been recorded at 7.4 (IQR=8.8–9.9) g/dL. Patients who received transfusions were older, presented with higher %TBSA and associated a higher comorbidity index. They also tended to develop coagulopathy and underwent more surgical procedures to achieve wound closure. In transfused patients who associate comorbidities we observed a higher rate of wound infections and longer hospital stay. ConclusionsPatient related comorbidities correlate with higher transfusion rates in non-major burn injuries. Due to the risk associated with the use of blood products decision to transfuse should adhere to current guideline practices and be tailored to specific patient requirements.

Impact of pre-burn statin use on metabolic and cardiovascular disorders

IntroductionStatins are among the most widely prescribed medications with proven effectiveness in patients with hyperlipidemia and atherosclerotic cardiovascular diseases. We investigated the relationship between statin use, metabolic and cardiovascular outcomes after burn. MethodsWe utilized data from the TriNetX electronic health database. Burn patients with prior statin use were compared to patients without prior use and analyzed the occurrence of metabolic and cardiovascular disorders. ResultsPrior statin use burn patients were 1.33 times as likely to develop hyperglycemia, 1.20 times for cardiac arrhythmia, 1.70 times for coronary artery disease (CAD), 1.10 times for sepsis, and 0.80 times for death. High percent TBSA burn, male sex, and lipophilic statin use were associated with higher odds of outcome development. ConclusionPrior statin use in severely burned patients is associated with an increased risk of developing hyperglycemia, arrhythmias, and CAD, with higher odds in males, higher TBSA burn, and lipophilic statin users.

Pressure in the Operating Room: A Potential Contributor to Hospital Acquired Pressure Injuries (HAPIs).

Burn patients are at risk for hospital acquired pressure injuries (HAPIs). An unexamined factor that may contribute to HAPI development is the effect of pressure from the operating table during surgery. The purpose of this study was to measure pressure on the buttocks and sacral area during burn surgery under general anesthesia (GA). Prospective study of consecutive adult burn patients admitted to an ABA- verified burn center who required surgery under GA between 06/01/22 and 08/12/22. We studied only cases that were supine, including those with both legs down (LD), one leg suspended (1LU) or both legs suspended (2LU). Interface pressures on the buttocks and sacral area were measured using a commercial sensor mat. Thousands of individual pressure measurements were integrated to show average and peak pressures over repetitive 10-minute intervals during the entire operation. Recordings were completed in 41 procedures among 28 patients (48.3 ± 16.9 yrs, % TBSA burn 19.2 ± 17.1, weight 80.2 ± 19.7kg, BMI 26.7 ± 6.2). Both average pressure (Pave) and peak pressure (Ppeak) increased significantly with greater number of elevated legs (p<0.001). During 2LU periods, Ppeak exceeded 100 mmHg for almost half the operative duration. Pave crept steadily upwards over time and had a positive relationship with weight, regardless of leg elevation. Prolonged moderate to high pressures are exerted on the sacral and buttock areas, especially with one or both legs suspended, during burn surgery. These novel observations suggest that pressure from the operating table could contribute to HAPI development.

520 Use of Phenobarbital for Alcohol Withdrawal in Small Burn Patients: Evaluation of a Pilot Protocol

Abstract Introduction Phenobarbital is a long-acting barbiturate that has primarily been used an antiepileptic in clinical practice. However its use as a sedative has seen a resurgence recently especially for the prevention and/or treatment of alcohol withdrawal. It has several characteristics that make it appealing for this indication, including its long half-life and its distinct binding to GABAA receptors that, unlike benzodiazepines, does not depend on endogenous GABA to produce its effects. Several recent studies have evaluated its use for the treatment of alcohol withdrawal both inside and outside of the ICU setting, however reports of its use in patients with burn injury are sparse. A pilot treatment protocol utilizing phenobarbital for patients with less than 20% TBSA burns at high risk of alcohol withdrawal was formulated and put into practice at our center in January of 2022. We sought to evaluate the safety and efficacy of this protocol for quality improvement. Methods This was a retrospective chart review of patients admitted from January to August 2022 with less than 20% TBSA burns who received treatment with phenobarbital for alcohol withdrawal at a major burn center in North Central Florida. There were no exclusion criteria. This project was registered as a Quality Improvement Project with the institution. Results Ten patients were included in the evaluation. Median age was 63 yo, 90% were male, and 70% were Caucasian. Median % TBSA burn was 6.5% (range 0.5-12%) and median length of stay was 16 days (range 9-50 days). Most patients were injured by Fire/Flame (80%). Most patients had a history of binge drinking (70%), and most reported drinking at least 3-4 alcoholic drinks 4 or more times per week (70%). Of those that had a detectable blood alcohol concentration on admission, the median was 163 mg/dL (range 44-325 mcg/dL). Over half of the patients (60%) received an IV bolus (either 5 or 10 mg/kg based on ideal body weight) of phenobarbital followed by an oral taper, with the remaining 40% having received an oral taper without a bolus dose. Median RASS prior to initiation of the protocol was +1, and the majority of patients remained RASS +1 or less throughout the duration of the protocol (70%). No rescue benzodiazepines were needed, no seizures were identified, and no intubations occurred while patients were on the protocol. Conclusions The phenobarbital protocol was well tolerated and controlled agitation in the majority of the patients who received it. No obvious safety concerns were identified during this review. Although this was a small sample size, these results are encouraging and support continued use of phenobarbital in preventing and controlling symptoms of alcohol withdrawal in patients with less than 20% TBSA burns. Applicability of Research to Practice Phenobarbital may be a safe and effective benzodiazepine-free option for preventing and/or treating alcohol withdrawal in small burn patients.

96 A Quality Improvement Study of Routine Mattress Exchange to Reduce Microbial Recontamination

Abstract Introduction It is industry standard for a patient to maintain a single mattress throughout admission, which may be problematic with burn injuries. Significant burn injuries are high exudate wounds which provide challenging care, including frequent dressing changes and environmental contamination. As part of an infection prevention process improvement (PI) including routine air mattress (AM) exchanges throughout admission, the purpose of this study was to examine microbial contamination of mattresses before and after utilization. Methods This single center, retrospective study was conducted in an ABA-verified burn center. Routine AM exchanges began in November 8, 2020, including logging serial numbers of incoming/outgoing AM and periodic environmental cultures. Pre- and post-occupation AM environmental cultures (EC) (outside and inside the top cover and baffles) were compared with patient culture data. All patients were admitted to the Burn Center. Results During the 91 weeks, a total of 635 AM were exchanged. A total of 34 AM were cultured with 20 (59%) being post- and 14 being the pre-occupation. For the pre-occupation AM cultures, all 14 outer and inner surfaces cultured sterile. Regarding post-occupation AM, 80% had a positive EC of the outside surface, while 58% had positive environmental culture from inside the sealed AM. The median time of AM utilization prior to culturing was 6 (6, 7) days. All microbes isolated from post-occupation AM matched culture data from each patient’s hospital course. There were a total of 42 microbes isolated from environmental swabs taken from the outside cover with the most common: S.epidermidis 38%, S.aureus 14%, and P.aeruginosa 12%. A total of 40 microbes were isolated from inside the sealed AM with the most common: S.epidermidis 25%, Acinetobacter spp. 13%, Enterobacter spp. 10%, and Pseudomonas spp. 10%. There were 5 different EC taken from inside the sealed AM resulting in fungal growth. The 34 EC were taken from AM of 9 patients during the 91 week period. The median age was 48 (22, 66) years with 42 (21.25, 44) %TBSA burned. The median weight was 92 (76, 98) kg with body mass index of 27.47 (23.72, 37.11) kg/m2. Two of the 9 patients were below 20 % TBSA burned (9 and 19.5%) while the remaining 7 patients had greater that 20% TBSA burns. There was an inverse signals between size of burn and amount of wound closure and contamination. Conclusions AM are not impervious to the heavy exudate of patients with large burn injuries. Over time, the mattress becomes contaminated with microorganisms specific to the patient. This study justifies the infection prevention practice of routine mattress exchanges during admission for patients with large, open burn wounds. We do not send patients back from the operatory theater or hydrotherapy with reused dressing. Given these findings mattresses should be no different. Applicability of Research to Practice First study to analyze infectious mitigation potential of routine AM exchanges in burn patients.

718 Estimation of Total Body Surface Area Burns in a Bilateral Above-Knee Amputee Patient

Abstract Introduction The burn injury extension estimate is necessary for the initial IV fluid resuscitation planning, however, current Wallace rule of nines, Lund &amp; Browder charts as well as smartphone applications are based anatomical models with full body integrity. The purpose of this paper is to accurately estimate the TBSA burned in a bilateral asymmetric above-knee amputee patient. Methods An amputation is defined as major amputation when the level is at or proximal ankle or wrist. We present a case example of an 80-year-old patient with a past medical history of long-standing type 2 diabetes mellitus with inadequate metabolic control, left above-knee amputation seven years ago, as well as a contralateral asymmetric above-knee amputation seven months before hospital admission. The patient was brought to the emergency department one hour after suffering burn injuries by fire at his shelter. Upon his arrival inhalational injury was ruled out, and at physical examination second and third-degree burns were noted circumferentially on both above-knee stumps, genitalia, right flank, lower abdomen and back, right hands and forearm, as well as left hand digits (Figure 1A-B). Initial TBSA burned was estimated using the E-burn application yielding a 27% extension; however, this percentage would correspond to patient with full integrity of both lower limbs (Figure 2A) Results This is the first major amputee burned patient of 285 cases admitted for in-hospital treatment at our institution from March 2020 to October 2022. After performing an online search on MEDLINE/Pubmed (keywords: TBSA, estimation, amputated) we found only one published paper in 2020 which presented a Correction Factor (CF) formula for a hypothetical burn patient with bilateral and symmetric fore-quarter amputation. We estimated the amputated surface area (13.7%) with e-burn, to calculate the major amputee CF published in 2020 and test it on a clinical setting. By means of the following formula (Figure 1C): CF = 100 / (100 - % of amputated body part) CF = 100 / (100 – 13.7) CF = 100 / (86.3) = 1.15 Finally, the initial TBSA burnt was multiplied by the CF to adjust it accordingly to major amputations of the patient, as follows: Originally estimated TBSA burnt (27%) x CF (1.15) = 31.05 % (Figure 2B-C) Conclusions This case report serves as an example of the clinical application of the Correction Factor for major amputees burn patients which can be easily estimated with the aid of smartphone applications such as e-burn in mismatched bilateral amputations. Applicability of Research to Practice To our knowledge this is the first clinical application of the major amputee CF, which its simplified estimation by means of E-burn could be of use for burn centers with higher volume.