Consecutive Burn Patients Research Articles

A Clinico-Epidemiological Study among Burn Injury Patients in a Tertiary Care Hospital of Eastern India

Background: Every year in India about 7 million people suffer from burn injury, which is a leading cause of not only mortality, but morbidity and disability among the burn patients, leading to emotional trauma and stigma. Objectives: The present study was conducted in a peripheral medical college of West Bengal to describe the epidemiology, clinical presentation, and outcome in burn patients and also to identify contributing factors influencing the outcome in burn patients. Methodology: In this descriptive cross-sectional study, all consecutive burn patients admitted in Dept of surgery in 2018 were included. Data was collected regarding socio demographic profile, mechanism, type and degree of burn, total body surface area involved, time taken to reach health facility and outcome. Results: Out of 514 burn patients, majority were 20 to 60 years age group, females, Muslim in religion, from rural background, completed primary education, homemaker and having monthly income of the family below Rs 5000. Most of the burns were accidental, thermal in nature occurred at household level. About one third had burns involving dangerous areas of body. Average length of stay in hospital was 6.104 days with 20% case fatality and directly proportional with body surface area involved. Conclusion: Safety measures and building awareness can prevent burn injury at household level. Early initiation of treatment, infection control and following standard management protocol can avert mortality in tertiary setting. Rehabilitation and psychosocial care are urgently needed to combat disability. Keywords: Burn, Clinico-epidemiology, Length of stay, Outcome

Periodontal damage after thermal inhalation injury — The impact of high temperature inhalation injury on long term periodontal health

PurposeThermal inhalation injury is a common, life-threatening problem in burned patients. Whether or not this single event of damage to the oral integrity causes long term health problems is yet to be examined. Material and methodsAll consecutive burn patients between 2014 and 2017 of Marienhospital Stuttgart (MHS), Germany, with at least 10% of burned skin surface were included and compared. The Periodontal Screening Index as well as Vitamin D levels were examined. Vitamin D has been suspected to contribute to the genesis of periodontitis. Risk factors and subjective oral life quality were prompted. ResultsWe included a total of 32 patients, 15 of which had an inhalation injury in their medical history. Risk factors were examined via Renatus' questionnaire. While risk factors were equally distributed in both groups we saw a remarkable difference in periodontal integrity, with the Periodontal Screening Index (PSI) per sextant differing drastically (with inhalation injury: 2.40, without inhalation injury: 1.10, p < 0.001). Patients with an inhalation injury had a mean of 5.2 out of 6 possible sextants with a pathologic PSI (with the median being 6/6), while patients without an inhalation injury had a mean of 1.83 out of 6 (median: 1/6), p < 0.001. The oral health impact profile showed a difference as well, albeit without statistical significance (with inhalation injury: median = 11, without: median = 3.5, p = 0.414).A correlation between Serum Vitamin D levels and periodontal integrity could not be seen in this group. ConclusionInhalation injury is a possible cause for periodontitis and hence impacts the quality of life of burned patients.

English

BACKGROUND Burn treatment is complex and involves many components. Topical solutions that contain antiseptic, antibiotic, and growth factor properties are effectively used in superficial burns. Heparin satisfies all the parameters. Routes of heparin administration described are subcutaneous, topical, intravenous, and inhalation. In this study, the need was felt to evaluate the efficacy of various heparin routes such as topical against nebulised heparin. METHODS 100 consecutive thermal burn patients were studied prospectively under two groups i.e., topical heparin (T group) and nebulised heparin (N group). Hospital stay, final scar outcome, wound infection rate, secondary procedures, pain medication, dressings and antibiotics required were compared. RESULTS It was found that the T patients complained of less pain and received less pain medication, fewer dressings and antibiotics compared to N group. Significantly less IV fluids were infused to T group 36 vs 64 litres compared to N group (P &lt; 0.01). T group had fewer secondary procedures 6 vs 14 compared to N group. The number of days in hospital for T was significantly less (over all P &lt; 0.0001). 14 patients (28 %) in the topical group were discharged from the hospital in 10 days or less compared with 8 patients (16 %) in the nebulised group (P &lt; 0.001, S). 38 out of the 50 H patients (76 %) were discharged in less than 3 weeks compared with 22 nebulised group patients (32 %) (P &lt; 0.001, S). CONCLUSIONS Usage of Heparin is safe, needs no monitoring by bleeding time (BT), clotting time (CT), or partial thromboplastin time (PTT). The final scar outcome with parameters such as scar itchiness, texture, the wound infection rate, secondary procedures like a skin graft, post-burn contractures release were fewer in burn patients treated with topical heparin. KEYWORDS Topical Heparin, Nebulised Heparin, Hospital Stay, Scar Outcome, Secondary Procedures, Pain

Influence of incentive nursing intervention on recovery of burn patients after vacuum sealing drainage.

To observe the effect of application of incentive nursing intervention (INI) on recovery in burn patients undergoing vacuum sealing drainage (VSD). From January 2017 to January 2020, a total of 82 consecutive burn patients were prospectively enrolled, and divided into INI group and routine nursing intervention (RNI) group according to random number table method. The causes of inadequate drainage were collected, the incidence was calculated, and the occurrence of inadequate drainage at different locations was compared. The pain degree and comfort status before and after the intervention were observed, and the wound healing time, hospital stay, and satisfaction after the intervention were recorded. The reasons for inadequate drainage during the treatment of VSD included negative pressure insufficient, drainage tube blockage because of escharosis, replacement of negative pressure internal sac not standard, loose sealing of the semi‐permeable membrane, and the negative pressure tube fell off, compressed or reflexed. The baseline characteristics between the two groups were comparable (P > .05). The incidence of each cause and total incidence of inadequate drainage in INI group were lower than those in RNI group (P < .05, respectively). The incidences of inadequate drainage of all burn sites in INI group were lower than those in RNI group, and the difference of limbs wound between the two group was statistically significant (P < .05). After intervention, the pain intensity of INI group was lower than that of RNI group (P < .05), and the holistic comfort of INI group was higher than that of RNI group (P < .05). The wound healing time and hospital stay time in INI group were lower than those in RNI group, and the total satisfaction rate in INI group was higher than that in RNI group (P < .05, respectively). Applying INI can effectively reduce the incidence of insufficient drainage, reduce pain, improve comfort, shorten wound healing time and hospital stay, and thus improve the overall satisfaction rate of patients, which is worthy of clinical promotion and application.

Nerve Pain after Burn Injury: A Proposed Etiology-Based Classification.

Understanding the mechanism of nerve injury may facilitate managing burn-related nerve pain. This proposed classification, based on cause of nerve injury, was developed to enhance the understanding and management of burn-related nerve pain. This retrospective investigation included patients aged 15 years or older admitted to the burn center from 2014 to 2019. Burn-related nerve pain was patient-reported and clinically assessed as pain 6 months or more after burn injury, unrelated to preexisting illnesses/medications. The pain classification consisted of direct nerve injury, nerve compression, electrical injury, and nerve dysfunction secondary to systemic injury. The four categories were statistically analyzed between groups, using 52 variables. Of the 1880 consecutive burn patients, 113 developed burn-related nerve pain and were eligible for validation of the classification: direct nerve injury, n = 47; nerve compression, n = 12; electrical injury, n = 7; and nerve dysfunction secondary to systemic injury, n = 47. Factors, significantly increased, that distinguished one category from another were as follows: for direct nerve injury, continuous symptoms (p < 0.001), refractory nerve release response (p < 0.001), nerve repair (p < 0.001), and pruritus (p < 0.001); for nerve compression, Tinel signs (p < 0.001), shooting pain (p < 0.001), numbness (p = 0.003), intermittent symptoms (p < 0.001), increased percentage total body surface area burned (p = 0.019), surgical procedures (p < 0.001), and nerve release (p < 0.001); and for electrical injury, Tinel sign (p < 0.001), intermittent symptoms (p = 0.002), amputations (p = 0.002), fasciotomies (p < 0.001), and nerve release (p < 0.001). Nerve dysfunction secondary to systemic injury was distinguished by significantly less Tinel signs (p < 0.001), shooting pain (p < 0.001), numbness and tingling (p < 0.001), pruritus (p < 0.001), fascial excision (p = 0.004), skin grafts (p < 0.001), amputation (p = 0.004), nerve releases (p < 0.001), and third-degree burns (p = 0.002). A classification consisting of direct nerve injury, nerve compression, electrical injury, and nerve dysfunction secondary to systemic injury is presented that may guide patient management and research methods, with the goal of improving pain outcomes in burn-related nerve pain.

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

BackgroundIntensive care (ICU) patients’ burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity. AimsTo understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients. MethodsConsecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model. ResultsOverall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged.Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant. ConclusionsEffective pain assessment, management and advocacy are assisted by evidence-based assessment practices.

Implementation and evaluation of telemedicine in burn care: Study of clinical safety and technical feasibility in a single burn center

ObjectiveThe objective of this study is to review our experience in the implementation of an innovative Telemedicine Platform (the Teleburns Project) for the acute care of burned patients. METHODS: We developed and implemented a Teleburns Platform by the creation of a new medical software and hardware for High Definition medical videoconference, in order to assist distant burned patients. After the establishment of the system and revision of technical requirements, an internal validation of the project was done: we managed 40 consecutive burned patients via telemedicine videoconference within our own Center. Following the internal validation, a pilot test with the Verge de la Cinta Hospital (VCH) – located in Tortosa, 180km away from Barcelona – was conducted. A prospective review of 43 burn patients participating in tele-encounters was performed. The data collected were: patient and injury demographics, need for transfer to our hospital, need for surgical treatment, complications, readmissions and technical problems. ResultsNo discrepancies were found between remote and face-to-face diagnosis and treatment during internal validation, obtaining a 100% reliability. No technical errors were reported. Concerning the pilot test with the VCH, 43 patients were assessed via telemedicine during a 48-month period. Mean age of the participants was 36.7 (0–85 years). The mean total burn surface area was 3.1% (range 0.5–15%). The more frequently affected areas were head and neck (27 patients) and hands (16 patients). As a result of the 43 televisits, 8 patients (18.6%) were immediately transferred to our Burn Center in Barcelona and 12 patients (27.9%) were asked to come a few days later, to be visited in our Day Care Unit. Thus 23 patients (53.5%) could avoid being transferred to the Burn Center. 5 of them were followed via Teleburns without complications and 17 patients were discharged after the first tele-encounter. All patients discharged presented an uneventful evolution and did not receive further care from our Burn Unit. Technical problems were reported in eleven occasions during this phase, none of which prevented completion of the visits. ConclusionsThe use of Telemedicine for burn assessment can improve the accuracy of burn patients triage, resulting in enhanced resource utilization, time and cost saving for the health system and increased quality of care.

771 Psychiatric Illness Among Burn Patients: Experience at a Single ABA Verified Burn Center

Abstract Introduction Burn injury is uniquely characterized by the initial traumatic event in addition to the psychiatric component associated with physical change and recovery. Recent work has highlighted the importance of pre-existing psychiatric illness on both recovery and final outcomes in burn patients (Tarrier et al 2005, Hudson et al 2017, Wisely et al 2009). We examined the prevalence and association of psychiatric illness in our ABA verified burn unit. Knowledge of this information is critical in allocation of limited resources aimed toward addressing both the physical and mental aspect of burn injury. Methods The burn registry at a single verified burn center was examined from July 2017-July 2018. All consecutive burn patients with psychiatric illness who were admitted were included. Psychiatric illness was broken down into: depression, anxiety, bipolar disorder, schizophrenia and delirium. Need for psychiatric consultation, %TBSA, length of hospital stay, and operative intervention was also examined. Results 416 patients were admitted during the study period—44 pts (10.5%) had a psychiatric diagnosis on admission. Seventy-five percent of pts were male. The average TBSA burned was 15.3%. Seventy-five percent of patients required psychiatric consultation, and 57% required operative intervention (Table 1). The most common psychiatric condition was anxiety (50%), followed by depression (36%), bipolar disorder (27%), schizophrenia (23%), and delirium (18%). Forty-eight percent of patients had multiple (&amp;gt;1) psychiatric conditions. Female patients had a significant less TBSA burn (5.8%) vs. male (18.2%), P=.001, as well as a shorter LOS (12.1 dys vs. 31.5 dys) p=.004. Conclusions The association between burn injury and pre-existing psychiatric illness is well known (Hudson et al 2017, Wisely et al 2009). We found that over 10% of pts admitted to our burn unit had a psychiatric diagnosis, and a large number of these required further inpatient psychiatry consultation. More than half of patients required operative intervention indicating that severity of burn injury was high, with optimization of pre-existing conditions especially important. Additionally, psychiatric illness did not occur in isolation--48% of pts had &amp;gt;1 psychiatric diagnosis —a finding which has implications for resource allocation for mental health/ dedicated psychiatrist for burn patients. Applicability of Research to Practice Implications for resource allocations for dedicated burn psychiatrist/ resources for mental health.

Multidisciplinary Treatment to Restore Vision in Ocular Burns.

Periorbital burns generate contraction and distortion of periorbital soft tissue, causing eyelid malfunction, further contributing to loss of vision from corneal scarring or perforation. We present our multidisciplinary algorithm to restore vision in patients with burn-related bilateral corneal blindness with light perception. Chart review was performed for four consecutive burn patients requiring periocular reconstruction and keratoprosthesis. Initial treatment included globe coverage with eyelid releases and grafts. Strategy of corneal replacement was determined by eyelid position and function and sufficiency of tear production. All patients were corneal blind with light perception only and cicatricial ectropion. The eye with better visual prognosis was reconstructed. Eyelid reconstruction procedures consisted of lid releases with full-thickness skin graft (FTSG) or split-thickness skin graft (STSG). Two patients regained adequate lid function and underwent standard keratoprosthesis placement. Two underwent mucous membrane grafts followed by keratoprosthesis. All patients experienced improved postoperative vision in their reconstructed eye. Corneal injury due to periocular burns can lead to blindness. Early involvement of ophthalmology, protective measures, and early ectropion release are critical. For severe burns, a multidisciplinary approach, where adequate globe protection is followed by keratoprosthesis placement, can effectively restore vision in patients with burn-related corneal blindness.

Impact of Real-Time Therapeutic Drug Monitoring on the Prescription of Antibiotics in Burn Patients Requiring Admission to the Intensive Care Unit.

As pharmacokinetics after burn trauma are difficult to predict, we conducted a 3-year prospective, monocentric, randomized, controlled trial to determine the extent of under- and overdosing of antibiotics and further evaluate the impact of systematic therapeutic drug monitoring (TDM) with same-day real-time dose adaptation to reach and maintain antibiotic concentrations within the therapeutic range. Forty-five consecutive burn patients treated with antibiotics were prospectively screened. Forty fulfilled the inclusion criteria; after one patient refused to participate and one withdrew consent, 19 were randomly assigned to an intervention group (patients with real-time antibiotic concentration determination and subsequent adaptations) and 19 were randomly assigned to a standard-of-care group (patients with antibiotic administration at the physician's discretion without real-time TDM). Seventy-three infection episodes were analyzed. Before the intervention, only 46/82 (56%) initial trough concentrations fell within the range. There was no difference between groups in the initial trough concentrations (adjusted hazard ratio = 1.39 [95% confidence interval {CI}, 0.81 to 2.39], P = 0.227) or the time to reach the target. However, thanks to real-time dose adjustments, the trough concentrations of the intervention group remained more within the predefined range (57/77 [74.0%] versus 48/85 [56.5%]; adjusted odd ratio [OR] = 2.34 [95% CI, 1.17 to 4.81], P = 0.018), more days were spent within the target range (193 days/297 days on antibiotics [65.0%] versus 171 days/311 days in antibiotics [55.0%]; adjusted OR = 1.64 [95% CI, 1.16 to 2.32], P = 0.005), and fewer results were below the target trough concentrations (25/118 [21.2%] versus 44/126 [34.9%]; adjusted OR = 0.47 [95% CI, 0.26 to 0.87], P = 0.015). No difference in infection outcomes was observed between the study groups. Systematic TDM with same-day real-time dose adaptation was effective in reaching and maintaining therapeutic antibiotic concentrations in infected burn patients, which prevented both over- and underdosing. A larger multicentric study is needed to further evaluate the impact of this strategy on infection outcomes and the emergence of antibiotic resistance during long-term burn treatment. (This study was registered with the ClinicalTrials.gov platform under registration no. NCT01965340 on 27 September 2013.).

N-Terminal Brain Natriuretic Peptide First Week After Burn Injury.

B-type natriuretic peptide has shown promising results as a biomarker for acute kidney injury in general intensive care patients. It may also indirectly reflect fluid balance of the circulation. Among burn patients, it has been observed to indicate excessive fluid resuscitation and organ dysfunction, although its clinical use to indicate acute kidney injury or guide fluid resuscitation has not been validated. The aim of this study was to evaluate whether the N-terminal pro-brain natriuretic peptide values are related to the amount of fluids given after severe burn injury and whether it can act as a novel biomarker for acute kidney injury in these patients. Nineteen consecutive burn patients were included. Plasma N-terminal pro-brain natriuretic peptide was measured daily during 1 week from admission. Other variables such as laboratory values and intravenous infusions were also recorded. The association between acute kidney injury and N-terminal pro-brain natriuretic peptide values was analyzed with a multivariable panel regression model, adjusted for burned total body surface area, age, body mass index, and laboratory values. N-terminal pro-brain natriuretic peptide values varied between single patients, and even more between the patients who developed acute kidney injury. Older age, lower body mass index, and cumulative infusions were independently associated with higher N-terminal pro-brain natriuretic peptide values, whereas acute kidney injury was not. N-terminal pro-brain natriuretic peptide values correlated with cumulative infusions given during the first week. The authors could not validate the role of N-terminal pro-brain natriuretic peptide as a biomarker for acute kidney injury in burns.

Health-related quality of life (EQ-5D) early after injury predicts long-term pain after burn

BackgroundChronic pain after burn can have severe physical and psychological effects on former patients years after the initial injury. Although the issue of pain after burn has gained increased attention over the past years, prospective, longitudinal studies are scarce. Our aim was to prospectively investigate consecutive burn patients for pain severity over time and to evaluate the prevalence and characteristics of post-burn pain to 2–7 years after the burn. As an additional aim, the effects of burn and individual-related factors, especially health-related Quality of Life (HRQoL), were investigated. MethodSixty-seven consecutive burn patients were assessed during acute care at 3, 6, 12 and 24 months, as well as at 2–7 years post-burn. HRQoL, symptoms of post-traumatic stress disorder (PTSD) and other psychiatric disorders were investigated. During the interviews that took place 2–7 years after the injury (mean 4.6±1.9 years), current chronic post-burn pain was assessed using the Brief Pain Inventory-Short Form (BPI-SF). ResultsOne-third of the patients still reported pain 2–7 years after the injury. Pain severity and interference with daily life were mainly mild to moderate though they were found to be associated with significantly lower HRQoL. Chronic pain after burn was associated with both burn- and individual-related factors. In logistic regression analysis HRQoL at 3 and 12 months and symptoms of PTSD at 12 months were independent factors in predicting chronic pain after burn. ConclusionPain after burn becomes a chronic burden for many former burn patients and decreases HRQoL. A novel finding in this study was that HRQoL assessed early after burn was a predictor for the development of chronic pain. This finding may help to predict future pain problems and serve as an indicator for pain preventive measures.

Discrepancy in Initial Pediatric Burn Estimates and Its Impact on Fluid Resuscitation

One of the fundamental aspects of initial burn care is the ability to accurately measure the TBSA of injured tissue. Discrepancies between initial estimates of burn size and actual TBSA (determined at the burn unit) have long been reported. These inconsistencies have the potential for unnecessary patient transfer and inappropriate fluid administration which may result in morbidity. In an effort to study these inconsistencies and their impact on initial care, we evaluated the differences between initial TBSA estimates and its impact on fluid resuscitation at an American Burn Association-verified pediatric burn center. A prospective observational study of 50 consecutive burn patients admitted to Shriner's Hospital for Children in Boston, Massachusetts, between October 2011 and April 2012 was performed. Data collected included age, mechanism of burn injury, type of referral center, referring hospital TBSA, and volume of fluid administration as well as admission TBSA and volume of fluid administration. Determination of over or under resuscitation was based on comparing the amount of fluids received at the referral center to that received at the pediatric burn center. A total of 50 patients were admitted during the 7-month study period. The average age was 4.1 years old (25 days-16 years) and the average TBSA was 2.5% (0.25-55%). There were significant differences in the TBSA calculations between referring centers and the pediatric burn center. Overestimation of scald and contact burn size (P < .05) was noted with no difference in flame burn size estimation. Community referrals were more likely than tertiary centers to overestimate TBSA (P < .05 vs P = .29). Overall, 59% of study patients were administered more fluid at the referring hospital than would have been expected by the burn size calculated at our facility. Inconsistencies with the estimation of TBSA burn between referring hospitals and tertiary referral centers remains a problem in pediatric patients and may lead to inappropriate resuscitation. This study highlights the continued need for educational outreach programs and for the provision of novel resources to initial burn providers. Additional support through online resources (eg, Lund-Browder diagram) and remotely assisting providers during their TBSA measurements are potential options which may help to improve the initial care of burn patients.

Prevalence and prediction of prolonged pruritus after severe burns.

Years after injury, pruritus is a common and severe problem for many burn patients. However, its characteristics and consequences are often only partially described. The authors therefore performed a prospective detailed examination of burn- and individual-related factors and considered those in relation to pruritus severity. Sixty-seven consecutive burn patients were assessed during acute care, and at 3 and 12 months postburn regarding preburn psychiatric disorders, health-related quality of life, post traumatic stress disorder, and personality traits. Postburn pruritus was subsequently assessed 2 to 7 years postburn using the Questionnaire for Pruritus Assessment. Fifty-one individuals, 76% of the participants, reported burn pruritus any time after the burn. Thirty-three individuals, 49% of the participants, reported ongoing pruritus the last 2 months. Information on the characteristics of pruritus was obtained from 32 of these individuals. Most perceived pruritus as bothersome or annoying and as present every day, 16 (50%) were considered to have severe pruritus, and 11 (34 %) scratched themselves to the point of bleeding. In logistic regressions, this was independently related to TBSA full-thickness burn and health-related quality of life at 3 months, and to TBSA full thickness burn and the personality trait impulsiveness, respectively. About half of the previous burn patients experienced ongoing pruritus on an average of 4.5 years after injury, and half of them had severe pruritus. Scratching oneself to the point of bleeding is linked both to a certain personality and to pruritus. It is suspected that many patients are left without access to the best available treatment.

Bacteriological profile of patients and environmental samples in burn intensive care unit: A pilot study from a tertiary care hospital

Objective: Prevention of nosocomial infection in burn patient is a major challenge. Endogenous flora or the colonizers of the surrounding environment are the main source of infection in this group of patients. Continuous monitoring of infection in burn patients is necessary to evaluate the source and pattern of distribution of microorganisms. The study was planned to assess the bacteriological and antimicrobial resistance profiles of burn patients in our intensive care unit (ICU). Materials and Methods: Wound swabs from 100 consecutive burn patients were collected on days 1, 4 and 7 of admission to the burn ICU. Environmental samples were also collected from the surroundings of burn ICU and studied for the bacteriological and anti-microgram profiles. Results: Acinetobacter baumanni, Pseudomonas aeruginosa remained the major isolates from the wound swabs. Acinetobacter baumanni and Staphylococcus aureus found to be the common isolates from the environmental samples. In both the instances the strains were found to be multidrug resistant (MDR) type. Majority of the environmental colonizers were isolated from sink, bed cradle and patient's bed. Conclusion: In this study, colonizers of the environment appeared to play a major role in causation of nosocomial infection in burn patients. Hence, periodic monitoring and assessment should be done to strengthen the infection control practices in burn unit.

Topical heparin versus conventional treatment in acute burns: A comparative study

Background: In order to alleviate pain, reduce scarring, and to improve the overall outcome in burn patients multitude of novel agents are being utilized. In this regard, heparin has been introduced because of its research proven role in burn wound management. Objective: The objective was to evaluate, whether the addition of heparin, administered only topically, could improve burn treatment. Materials and Methods: The subjects in this study were 40 consecutive burn patients with 10-20% burns, randomly allocated to heparin group (H-group) (20) and control group (C-group) (20). Results: All patients in the H-group were receiving analgesics on demand only from the 2 nd week onwards. This was in contrast to the C-group wherein 35% patients received twice daily dosage of analgesics in the 2 nd week of their treatment. When compared to the average hospital stay of 18.3 days in the C-group, patients belonging to the H-group had an average hospital stay of 12.3 days (P < 0.05). Conclusions: The current comparative study demonstrates that heparin significantly decreases the requirement of analgesics and the time required to prepare a burn wound for grafting. Besides as compared to silver sulfadiazine dressings, heparin appears to be cost-effective.

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Introduction: We compared the utility of the American-European Consensus Conference (AECC) and Berlin definitions in determining the prevalence of Acute Respiratory Distress Syndrome (ARDS) and its effect on mortality in consecutive burn patients on mechanical ventilation. Methods: A retrospective chart review included all patients with burns who were admitted to our burn intensive care unit (BICU) and required mechanical ventilation from January 1, 2003 to December 31, 2011. We identified all patients suffering from ARDS based on the AECC definition as well as the new Berlin definition. Various demographic data and outcomes were recorded. Logistical regression modeling with stepwise selection was performed to identify significant predictors of mortality. Results: 2071 patients were admitted to the BICU during the study period, of which 43% required mechanical ventilation (MV); of those, 37% developed ALI/ARDS as defined by the AECC vs. 34.0% by the Berlin definition. Patients with ALI/ARDS based on the AECC definition had a mortality of 41% compared to 43% in patients with ARDS classified under the Berlin definition. For the AECC defined categories of Acute Lung Injury (ALI) and ARDS the mortality rates were 15% and 46% respectively. For the Berlin defined categories of ARDS the mortality rates were: 17% for mild, 44% for moderate and 60% for severe. A subset of 22 patients met criteria for ALI or ARDS under AECC but not based on the Berlin definition due to the newly imposed requirement for PEEP support ≥ 5cm H20. On sub-analysis, the mortality rate for this group was 14%, which was not statistically different than for patients without ARDS. The following variables were found to be important predictors of the mortality in our cohort: age, injury severity score, size of burn, acute kidney injury, moderate and severe ARDS. Presence of inhalation injury or mild ARDS was not predictive of mortality (P > 0.05). Conclusions: Over a third of mechanically ventilated burn patients developed ARDS. The Berlin definition of ARDS, which incorporates more sensitive severity stratification and a minimum level of PEEP, better defines the contribution of lung injury to death in burns.

Blood utilization in patients with burn injury and association with clinical outcomes (CME)

Uncontrolled bleeding is an important cause of increased transfusion in burn victims; however, description of blood utilization patterns in the burn population is lacking. We conducted a single-institution, retrospective cohort study to measure blood utilization in 89 consecutive burn patients with 15% to 65% total body surface area (TBSA) burn within 60 days of injury. We also evaluated the relationship of blood product utilization with clinical variables including anticoagulant usage and mortality. We determined that: 1) the predictors for increased red blood cells (RBCs) and plasma transfusions were high TBSA burn and the use of argatroban anticoagulation (for suspected heparin-induced thrombocytopenia [HIT]); 2) TBSA burn and patient age were independent predictors of mortality, but not RBC or plasma transfusion; and 3) the incidence of symptomatic venous thromboembolic events is not uncommon (11.2%), although HIT is rare (1.1%). Despite concerns about adverse correlation between increased number of transfusions and mortality in other clinical settings, we did not find this association in our study. However, we demonstrated that the type and intensity of anticoagulation carries substantial risk for increased RBC as well as plasma usage.

A comparative study of paediatric thermal burns treated with topical heparin and without heparin.

Following reports of heparin use in burn treatment, an ethics-committee-approved prospective randomized study with controls compared results obtained using traditional usual burn treatment without heparin with results in similar patients similarly treated with heparin added topically. The subjects were 100 consecutive burn patients (age <15years) with second-degree superficial and deep burns of 5-45% total body surface area size. Two largely similar cohort groups-a control group (C) and a heparin group (H) with 50 subjects per group-were randomly treated. The 50 control group patients received traditional routine treatment, including topical antimicrobial cream, debridement, and, when needed, skin grafts in the early postburn period. The 50 heparin group patients, without topical cream, were additionally treated, starting on day 1 postburn, with 200IU/ml sodium aqueous heparin solution USP (heparin) dripped on the burn surfaces and inserted into the blisters two to four times a day for 1-2days, and then only on burn surfaces for a total of 5-7days, before skin grafting, when needed. Thereafter, control and heparin group treatment was similar. It was found that the heparin patients complained of less pain and received less pain medicine than the control patients. The heparin group needed fewer dressings and oral antibiotics than the control group. The 50 heparin group patients had 4 skin graftings (8%), while the 50 control group patients had 10 (20%). Five control group patients died (mortality 10%). No heparin group patients died. The number of days in hospital for the heparin group versus control group was significantly less (overall P < 0.0001): 58% of heparin group patients were discharged within 10days versus 6% of control group patients; 82% of heparin group patients were out in 20days versus 14% of control group patients; 98% of the heparin group versus 44% of the control group were out in 30days; and while 100% of heparin group patients were discharged by day 40, 56% of the control group required up to another 10days. Burns in heparin group patients healed on average in 15days (maximum period 37days) versus an average of 25days (maximum >48days) in control group patients (P < 0.0006). Procedures and costs in the heparin group were much reduced compared with the control group. Differences between the heparin and control groups are presented for the sake of comparison. It was concluded that heparin applied topically for 5-7days improved burn treatment: it reduced pain, pain medicine, dressings, and use of antibiotics; it significantly reduced IV fluids (P < 0.04), days in hospital (P < 0.0001), and healing time (P < 0.0006); and it reduced skin grafts, mortality, and costs.

A Comparative Study of Paediatric Thermal Burns Treated with Topical Heparin and Without Heparin

Following reports of heparin use in burn treatment, an ethics-committee-approved prospective randomized study with controls compared results obtained using traditional usual burn treatment without heparin with results in similar patients similarly treated with heparin added topically. The subjects were 100 consecutive burn patients (age, 48 days) in C (p<0.0006). Procedures and costs in H were much reduced compared with C. Photographs of the differences between H and C are presented for the sake of comparison. It is concluded that heparin applied topically for 5-7 days improved burn treatment: it reduced pain, pain medicine, dressings, and use of antibiotics; it significantly reduced IV fluids (p<0.04), days in hospital (p<0.0001), and healing time (p<0.0006); and it reduced skin grafts, mortality and costs.