Early Wound Excision Research Articles

Comprehensive Care for Burn Patients

Burn injuries represent a primary public health concern with significant global and personal repercussions. These injuries can create complex and potentially life-threatening situations that require advanced care. This review delves into the epidemiology, significance, and state-of-the-art treatments for burn injuries. It covers definitions, risk factors, complications, and various management strategies. The discussion highlights recent advancements in burn care, such as early wound excision, fluid resuscitation, infection control, and rehabilitation support. Emphasis is placed on the evolving research landscape in burn treatment, which aims to improve patient outcomes. The article underscores the importance of a multidisciplinary approach in managing burn patients and the ongoing need for research to enhance the quality of life for burn survivors.

Early wound excision within three days decreases risks of wound infection and death in burned patients

IntroductionIn lieu of limited studies on the timing of burn wound eschar excision for burns, a more comprehensive analysis is indicated to determine the effects of early wound excision following burns. This study aims to address the outcomes of early wound excision in burn patients. MethodsData collection were from TriNetX research database. Three groups of burn patients were stratified by the number of days in which they received burn wound excision within 14 days of injury. Five outcomes were observed: death, wound infection, sepsis, myocardial contractile dysfunction, and blood transfusion. Risk and incidence of various health outcomes were compared between the groups after propensity-matching age, sex, ethnicity, race and burn size using a z-test with p < 0.05 considered significant. ResultsWe identified 6158 burn patients with wound excision within 14 days of injury, the majority of whom (60.1%) received burn wound excision between 0 and 3 days after burn. 72.5% of patients had burns covering less than 20% of total body surface area. After propensity matching, we found a significantly lower risk of mortality in those who received burn wound excision within the first three days (3.84%) as compared to 8–14 days after burn (6.09%) (p < 0.05). Moreover, we found a decreased risk of wound infection in patients with burn wound excision within 0–3 days (37.84%) compared to those 4–7 days (42.48%) (p < 0.05). No statistical difference was detected in propensity-matched groups for myocardial contractile dysfunction, blood transfusion, or sepsis. In addition, the risk of hypertrophic scaring significantly decreased when wound excision was performed within 0–3 days (22% within 0–3 days, 28% within 4–7 days, p < 0.05). ConclusionBurn wound excision within 3 days of injury is beneficial when comparing to later treatment between 4 and 14 days, which results in a significantly lowered risk of mortality and infection in burn patient.

Advanced Physiotherapy Rehabilitation Approach For Post-Crush Injury Stiffness Patient– A Case Report On Palliative Physiotherapy

A tensile force, normally caused by a high-energy force, including an automobile or industrial accident, crushes and elevates the pressure within the hand abruptly. To achieve good results in its recovery, mutilated arm and its treatment require a thorough knowledge of rehabilitative methods and a thorough knowledge of hand anatomy. Early wound excision, aggressive hand rehabilitation for perioperative care, low reconstructive surgery threshold and rehabilitative care is recommended Patient’s main concerned was stiffness in wrist and elbow joint, reduced range of motion with difficulty in doing daily activities. She was diagnosed with crush injury over right forearm back while working on a machine. Main clinical findings were reduced range of motion over elbow and wrist joint. Joint stiffness over elbow joint with reduced muscle strength. Diagnosis of this case was crush injury over right forearm which resulted into scar adhesion and joint stiffness. For six weeks, the patient received physiotherapy treatment. Session included range of motion exercises, strengthening exercises, patient education, scar mobilization, joint mobilization, gripping exercises and home program. Alexios Pitsillides and Dimitrios Stasinopoulos suggested that every third day, tendons and ligaments are treated to maintain a balance between collagen synthesis and degradation and also because type I collagen's response to high load in a normal tendon peaks around 3 days after intense loading in a normal tendon. Treatment plan made proved beneficial to the patient we were able to increase the range of motion and patient was able to perform daily activities. Keywords: Crush Injury, Joint Stiffness, Rehabilitation.

Evidence and Trends in Burn Wound Debridement: An Evidence Map.

Treatment of the burn wound is crucial in care of severely burned patients. Surgical strategies differ in technique and timing of wound excision and are considered to have an impact on morbidity and mortality of burn patients. Most techniques and strategies have been established during the last century and are still standard of care. Nonetheless, several newer techniques have been presented and evaluated recently. To summarize the evidence and trends for eschar removal by burn wound debridement currently available, an evidence map as variant of the systematic review, was prepared. For this purpose, a systematic literature search was performed in the PubMed databases until December 2016. While overall evidence in this domain is low, recent publications focus on optimal timing of wound excision, enzymatic debridement, and hydrosurgery. Several studies report the benefit of an early wound excision in terms of shorter hospital stay, lower wound infection rate, and reduction of postburn metabolic changes. Enzymatic debridement has been shown to be an effective tool for early eschar removal and in addition reduces the need for autografting of the debrided burn wound with a relatively high level of evidence (LoE 2-). Wound debridement by means of hydrosurgery is more precise compared to conventional wound excision and preserves viable dermis, but a positive effect on wound healing or scar formation could not been shown (LoE 2). Furthermore, rarely reported techniques comprise larvae therapy, debridement by laser, and other technical adjuncts, but the level of evidence is limited (LoE 4-/5).

Role of Negative Pressure Therapy as Damage Control in Soft Tissue Reconstruction for Open Tibial Fractures.

The concept of damage control orthopaedics (DCO) is a strategy that focuses on managing orthopaedic injuries in polytrauma patients who are in an unstable physiological state. The concept of DCO is an extension of damage control surgery or damage limitation surgery (DCS/DLS). Recently, it has become clear that certain patients, following extensive soft tissue trauma, could benefit from the idea of DCS. In the management of severe lower extremity trauma with exposed fracture sites, aggressive early wound excision debridement, early internal fixation, and vascularized wound coverage within a few days after trauma were proposed. A negative-pressure dressing can be easily and rapidly applied to obtain a temporary closure between surgical stages. While negative pressure wound therapy (NPWT) has clear indications in the management of chronic wounds, its applications in the acute setting in victims of polytrauma are uneven. We conducted a review of the current clinical literature to evaluate the role of NPWT in this field, which points out that the negative pressure, applied immediately after the first debridement, seems to be an optimal bridge to the final reconstruction up to 7 days.

The totality of burn care

The overall improvement in mortality following severe burns has dramatically increased in the last half century with enhanced methods of resuscitation, treatment of inhalation injury, control of infection, early wound excision and novel methods of skin resurfacing. Although burn care begins at the onset of injury, reconstruction and rehabilitation feature highly throughout the various stages of treatment. Ultimately, we will have achieved little if the patient cannot be integrated back into society. For descriptive purposes burn care has been considered chronologically under the following headings: (1) First Two Minutes (Prehospital Care/First Aid), (2) First Two Hours (Emergency Room care), (3) First two days (resuscitation), (4) First Two Weeks (surgical excision and grafting), (5) First Two Months (rehabilitation and psychology), (6) First Two Years (reconstruction).

Severe burn injury, burn shock, and smoke inhalation injury in small animals. Part 2: diagnosis, therapy, complications, and prognosis

To review the evaluation and treatment of patients suffering from severe burn injury (SBI), burn shock, and smoke inhalation injury. Potential complications and prognosis associated with SBI are also discussed. Diagnosis of burn injury and burn shock is based on patient history and clinical presentation. Superficial burn wounds may not be readily apparent for the first 48 h whereas more severe wounds will be evident at presentation. Patients are diagnosed with local or SBI by estimating total body surface area involved using the 'Rule of Nines' or the Lund-Browder chart adapted from the human literature. Patients suffering from SBI require immediate and aggressive fluid therapy. Burn wounds require prompt cooling to prevent progressive tissue damage. Due to significant pain associated with burn wounds and therapeutic procedures, multimodal analgesia is recommended. Daily wound management including hydrotherapy, topical medications, and early wound excision and grafting is necessary with SBI. There are numerous complications associated with SBI. The most common complications include infections, hypothermia, intra-abdominal hypertension, and abdominal compartment syndrome. The prognosis of SBI in domestic animals is unknown. Based on information derived from human literature, patients with SBI and concomitant smoke inhalation likely have a worse prognosis than those with SBI or smoke inhalation alone.

Escharectomy and Allografting During Shock Stage Reduces Insulin Resistance Induced by Major Burn

Hyperglycemia and insulin resistance have long been recognized in severe burn patients. Early excision and grafting reduces cytokines and insulin resistance in burned rats. The authors hypothesized that early wound excision and grafting in patients would also reduce insulin resistance induced by major burn. Thirty-five adult surviving major burn patients (>40%TBSA burn) were recruited. The removal of dead devitalized tissue and allografting in escharectomy group was performed within 72 hours and in control group about 7 days after burn injury. The concentrations of plasma insulin, glucose, and cytokines were measured at 2 and 5 days postburn. Euglycemic-hyperinsulinemic glucose clamps were performed at 5 days after burn. The levels of phosphotyrosine, phosphoserine³¹² of insulin receptor substrate (IRS)-1, and phospho-jun N-terminal kinase (JNK) in muscle were analyzed with immunoprecipitation and Western blotting at 5 days postburn. Escharectomy and allografting during shock stage significantly reduced the levels of interleukin-6 and tumor necrosis factor-α, decreased the levels of phosphoserine³¹² and phospho-JNK, increased the level of phosphotyrosine of IRS-1, and further reduced insulin resistance at 5 days after thermal injury compared with delayed excision group. Escharectomy and allografting during shock stage seemed to have an immunomodulatory effect on the inflammatory mediators and further to reduce insulin resistance induced by major burns in patients by decreasing the phosphorylation of IRS-1 serine³¹² and JNK1/2.

Comprehensive Management of Hot-Press Hand Injuries

Hot-press hand injuries create significant challenges, in terms of acute coverage and restoration of function, and long-term outcomes are largely unknown. This article reviews the comprehensive management of hot-press hand injuries--which includes damage control procedures, resurfacing, reconstruction, and rehabilitation--and assesses outcomes such as return to work and final impairment ratings. We treated 56 patients with hot-press hand injuries, at a verified, accredited burn center in the Southeast between 1994 and 2008. Mechanism included laundry press (42 cases), industrial press (11 cases), and home appliance (3 cases). Mean burn size was 118 cm2, with 43 full-thickness and 13 partial thickness injuries. Mean follow-up was 17.7 months. During this 15-year period, 39 patients (70%) were admitted acutely (mean length of stay: 10.4 days), 48 patients (86%) required operative intervention, and 28 patients (50%) had secondary reconstruction, which included nerve decompression (11 cases), contracture release (11 cases), tendon procedures (11 cases), and joint repair (5 cases). Mean final impairment rating was 22%, with 38 patients (68%) returning to work. Hot-press hand burns can be devastating, but return to work is possible for most patients. We recommend early wound excision, aggressive perioperative hand therapy, low threshold for reconstructive procedures, and rehabilitative support.

Management of burns of over 80% of total body surface area: A comparative study

The aim of this retrospective, comparative study was to analyse the management of extensive burns so as to decrease morbidity and mortality. Over 1987–1996, 24 people with burns >80% of total body surface area and >50% full-thickness burn were admitted to the burn unit of Anhui Medical University Hospital (group A); 30 similar admissions over 1997–2006 formed group B. No significant difference was found in age, male:female ratio, % total body surface or full-thickness burn area between the two groups. Severe shock developed in 19/24 cases in group A and 23/30 cases in group B, following inadequate fluid resuscitation, although group B received a higher mean resuscitation fluid volume during the first 24 h after burn. Early excision and grafting was performed for 8/24 people in group A and 23/30 in group B. Inhalation injury was seen in 18/24 cases in group A and 28/30 cases in group B. Prophylactic tracheotomy was undergone by 8/24 casualties in group A and 22/30 in group B. Mortality in group A was significantly higher than in group B (95.8% vs. 63.3%, p < 0.05) and survival was longer in group B. These results showed that refinements in burn shock resuscitation, and advances in early wound excision, skin grafting and respiratory management were associated with decreased morbidity and mortality after severe burn.

Survival and Wound Contraction of Full-Thickness Skin Grafts are Associated With the Degree of Tissue Edema of the Graft Bed in Immediate Excision and Early Wound Excision and Grafting in a Rabbit Model

The objective of this study was to evaluate the survival of skin grafts on graft beds of immediate excision and early wound excision at various time periods after burns and to establish the appropriate timing of burn excision and grafting in a rabbit model. Eight groups of male Japanese white rabbits (n = 5 per group) were established. Animals of all groups were given a 5 x 10-cm full-thickness burn on their shaved back and received the autografting 3, 6, 12, 18, 24, 48, and 72 hours and 5 days after receiving burns, respectively. Weekly skin-graft evaluation was performed for 5 weeks after grafting by measurement of the secondary skin graft contracture (in size) and the survival area of grafts, with use of computerized planimetry. In addition, relative quantitative analysis of exudation on the burned wound was evaluated. Our results indicated that the exudate-related graft loss and graft contracture varied according to the timing of wound excision. The wound contractures of the grafts were maximal in both the 18-hour and 24-hour groups at 2, 3, 4, and 5 weeks after grafting. The 18-hour and 24-hour groups exhibited significantly greater graft loss than the 72-hour and 5-day groups (P < .05). An apparent increase in the amount of exudation on the graft bed was shown in the 18- and 24-hour groups vs the other groups (P < .05). A reverse correlation was detected between the survival area of the skin graft and the degree of exudation of the graft bed. In conclusion, the survival area and secondary contraction of skin grafts are associated with the degree of tissue edema of the graft bed in immediate excision and early excision in the rabbit model. The adverse affect of edema leakage on the graft bed for skin graft survival was shown. We believe that immediate excision or early wound excision and grafting performed within 12 hours after burn or 48 hours later should be considered in the rabbit model.

Early wound excision and skin grafting restores cellular immunity after severe burn trauma.

Suppression of cellular immunity following thermal injury may contribute to the high incidence of postburn sepsis. Early excision and skin grafting may remove deleterious local wound factors and prevent immunosuppression. The effect on cellular immunity of early burn wound excision and skin grafting was investigated in an animal model using female Wistar rats. The development of immunosuppression shortly after burn injury was shown by popliteal lymph node assay and a 2,4-dinitrofluorobenzene skin reaction test. Excision and skin grafting 2 days after burn trauma restored parameters to normal. Burned tissue suppresses cellular immunity; this effect is preventable by early excision and skin grafting.

The use of Flammacerium in British Burns Units

Introduction: Flammacerium (cerium nitrate–silver sulphadiazine) is marketed throughout Europe, but is only available in UK on a named patient basis. Anecdotally it is widely used in civilian burns units across the country despite the regulatory constraint, although little literature exists regarding its use in UK. We designed a postal survey to assess the use of Flammacerium countrywide and whether its ‘named patient only’ designation causes problems in treating burns patients. Methods: Postal questionnaires were sent to the directors of the 18 adult burns units listed by the British Burns Association, requesting information on the use of Flammacerium. The indications and limitations of its use were recorded, as were any problems obtaining supplies. Finally, burns units were asked if they would like to see Flammacerium fully licensed in this country. Results: Replies were received from 14 units (response rate = 78%). Six units use Flammacerium frequently, six occasionally and two units never use it. It is used in those patients not undergoing early wound excision and closure because of co-morbidity, general age or frailty, paucity of donor sites or mixed depth pattern burns. It was generally used in the belief that it reduces the inflammatory response to burn injury (8/12), decreases bacterial colonization (10/12) and provides a firm eschar for easier wound management (11/12). Although 8 units had no problems with supplies of the agent, 10 respondents indicated they would like to see Flammacerium fully licensed in UK.

Effect of early wound excision on changes in plasma nitric oxide and endothelin-1 level after burn injury: an experimental study in rats

The purpose of this study was to evaluate effects of early wound excision on changes in NO and endothelin-1 (ET-1) level in the plasma after extensive burn injury. The effects on vascular permeability and hepatic blood flow (HBF) were also assessed. Male Wistar rats were used for this study. A 30% total body surface area (TBSA) third-degree burn was made on the back. Then animals were divided into four groups. Burn group ( n = 13), burn alone; infusion group ( n = 13), burn injury and fluid resuscitation; early excision group ( n = 13), burn injury, total wound excision at 30 min after the injury followed with immediate allogenic skin graft and fluid resuscitation; and the sham group ( n = 15). The sham group and the early excision group did not show significant changes in the NO and ET-1 level in plasma during experimental period, while the burn group and the infusion group showed significant increase in the NO and ET-1. The early excision group also did not show hypovolemia, and the significant decrease in the HBF. These data suggest that the increased NO and ET-1 in plasma following thermal injury were originated from burned tissue and the removal of these injured tissue has beneficial effect on the vascular permeability and the changes in HBF.

043 Effects of Early Wound Excision on Hepatic Blood in the Extensively Burned Rat

Aim: Effects of early excision on hepatic blood flow were investigated in burned rats. Methods: 30% TBSA burned Wistar rats were allocated to four groups, infusion group (n = 13): fluid resuscitation with lactated Ringer’s; early excision group (n = 13): early escherectomy and allogenic skin grafting with fluid resuscitation; burn group (n = 13): burn injury alone without any treatment; sham group (n = 15): sham burn procedure. The hepatic blood flow was measured at 0, 0.5, 1, 2, 3, 6, 12 and 24 hours postburn. At 12 and 24 hours postburn, plasma Endothelin‐1 (ET‐1) and nitric oxide (NO) levels were detected. Results: In the infusion and the burn group, a significant decrease in hepatic blood flow compared with the sham group. In contrast in the early excision group, the hepatic blood flow was not decreased and there was a significant difference from the infusion group at 12 hours postburn. The plasma ET‐1 and NO levels were markedly elevated in the infusion and the burn group at 12 and 24 hours postburn. Whereas in the early excision group, no significant increase either in the plasma ET‐1 or NO levels were found compared with the sham group during experimental period. Conclusion: The hepatic blood flow decreases after a massive burn injury even with adequate fluid resuscitation. Early excision is helpful in stabilizing the hepatic blood flow without further aggravating the hepatic hemodynamic load. The decrease in plasma ET‐1 and NO levels after early wound excision procedure may be playing a role in improving the hepatic blood flow.

Septicaemia after burn injury: a comparative study

Seventy-nine (8.4%) patients during June 1992–May 1996 (Group-1) and 68 (7.2%) patients from June 1996 to May 2000 (Group-2) who developed septicaemia at the burns unit of Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, were retrospectively studied and compared. The mean age of 26 years, male predominance, flame burns as main aetiology and mean burn percentage of ≥40% was observed in both the groups. Both groups revealed extensive flame burn, inhalation injury, intubation and difficult resuscitation as the risk factors. The proportion of satisfactory resuscitation increased significantly ( P<0.001) in Group-2. The septicaemia commonly occurred within 2 weeks postburn but the number of episodes during 5 days postburn was less in Group-2. The surface wound was found to be the likely source of entry of the organisms into the blood stream in both the groups. The gram positive organisms were dominant aetiologic factor in both groups but an increase frequency of Acnetobacter was found in Group-2. The proportion of MRSE and Pseudomonas septicaemia was significantly higher ( P<0.01) in the Group-1. The rate of survivors, in both the groups was higher among operated patients but it was significantly higher ( P<0.001) in the Group-1. A mortality rate 20.6% in Group-2 decreased against Group-1, which can be attributed to better resuscitation, nutritional care, early detection of septicaemia, appropriate antibiotics and early wound excision and skin grafting. MOF was the cause of death of 60.9% in Group-1 and 85.7% in Group-2. There was no role of prophylactic antibiotic in burn patients in the incidence of septicaemia and mortality.

Only some septicaemic patients develop hypernatremia in the burn intensive care unit: why?

From April 1993 to January 2000, 105 patients in the burn intensive care unit (BICU) that developed septicaemia in the course of their treatment were studied retrospectively to investigate as to why only 36 septicaemic patients (34%) developed hypernatremia (serum sodium >150 mmol/l). Septicaemic burn patients who developed hypernatremia were found to have a higher incidence of inhalation injury and a larger burn area (TBSA) signifying greater free water losses in the face of increasing fluid requirements. Patients who developed hypernatremia showed a characteristic pattern of septicaemia: early onset, multiple episodes, polymicrobial, need for multiple antibiotics, longer duration and a higher mortality, indicating a more severe degree of sepsis. The level of incapacitation either from the burn itself, mechanical ventilation or from impaired mental status leading to an inadequate free water intake was more in septicaemic patients who developed hypernatremia. Increased urinary free water losses and solute diuresis from hyperglycemia were significant factors in the development of hypernatremia. Patients who were treated with early wound excisions were less prone to develop hypernatremia when compared to those who did not undergo early wound excision. The close association between the onset of hypernatremia and the onset of septicaemia noted in this study suggests the use of hypernatremia as a marker for septicaemia in burn patients. Hypernatremia in a septicaemic burn patient is multi-factorial and a thorough understanding of the underlying factors will help prevent the onset and progress of hypernatremia.

Management of the high-risk pediatric burn patient

Background/Purpose: Inhalation injury, flame burn exceeding 30%, and age under 48 months all have been cited as independent risk factors for mortality; the combination of all 3 risk factors is unusual. The authors have experienced an overall reduction in mortality rate and chose to examine this high-risk group to define techniques useful in improving outcome in pediatric burns. Methods: A review was done of children with all 3 risk factors over a recent 9-year interval. All were treated with a system of care emphasizing precise fluid repletion, early wound excision and closure, and avoidance of injurious pulmonary inflating pressures and concentrations of oxygen. Data are expressed as mean ± SD. Results: There were 26 children admitted with all 3 risk factors. Their average age was 2.1 ± 1.1 years (range, 5 weeks to 3.7 years), and burn size was 61% ± 21% (range, 30% to 98%) of the body surface. All required mechanical ventilation for an average of 28 ± 4.5 days (range, 7 to 74 days). Two children underwent tracheostomy; all others were treated with protracted oral intubation. Inhaled nitric oxide (NO) was used in 3 children, all of whom were considered for extracorporeal membrane oxygenator (ECMO) support, although none went on to ECMO. Only 7 children (27%) never had any bacteremia. Ventilator-related pneumonia occurred in 8 children (31%). Total lengths of stay, including acute and rehabilitation hospitalizations, averaged 105 ± 10 days (1.87 ± 0.2; range, 0.66 to 4.8 days per percent burn). After exclusion of 1 child with a 98% third-and fourth-degree burn, pre-hospital cardiac arrest, and anoxic brain injury who had support withdrawn at 6 hours, all children survived to discharge; 23 followed up in our clinic currently are alive and well with no overt residual respiratory insufficiency. Conclusion: A high rate of survival can be expected in young children with large burns and inhalation injury. J Pediatr Surg 36:1308-1312. Copyright © 2001 by W.B. Saunders Company.

The effect of early burn wound excision on regional gastric blood flow in rats

This study examined the effects of early burn wound excision on gastric blood flow and on morphologic changes in mucosal vessels. Wistar rats were given a 30% total body surface area burn and divided into four groups, consisting of control animals (group 1), animals with burn injury without and with fluid resuscitation (groups 2 and 3, respectively), and animals with both fluid resuscitation and early wound excision (group 4). Gastric mucosal blood flow (GMBF) was measured by the hydrogen gas clcarance method up to 24 h post-burn. Morphologic changes in mucosal vessels were examined by scanning electron microscopy (SEM) at 3 and 24 h post-burn. The GMBF sharply decreased in the acute period after the burn. In group 4, however, it recovered to the initial value by 6 h post-burn and there was no significant change throughout the experiment. Morphologically, although the mucosal capillaries revealed some changes such as irregularity in diameter in groups 2–4 at 3 h, most of mucosal capillaries retained their original appearance in group 4 at 24 h post-burn. These result suggest that early excision does not aggravate the state of gastric ischemia.

Mortality in Burned Children With Acute Renal Failure

During the past 13 years, mortality from acute renal failure in burned children has been on the decline. To determine which new burn therapies contributed to the decrease in mortality. The medical records of burned children admitted from February 1966 to January 1997 were reviewed, and the outcome of changes in the treatment of burned children were compared. Sixty children with acute renal failure were identified. These children were divided into those admitted from 1966 to 1983 (n=24) and those admitted from 1984 to 1997 (n=36). They were compared with matched control subjects from the same period without renal failure. Values are presented as means+/-SEMs. Statistical analysis was by the Student t test or chi2 analysis. Mortality rates in burned children with acute renal failure decreased from 100% before 1983 to 56% after 1984 (P<.001). The time between a burn injury and the initiation of intravenous fluid resuscitation was 8.6+/-1.7 hours before 1983 compared with 3.0+/-0.5 hours after 1984 (P<.005). The time between a burn injury and complete early wound excision decreased from 228+/-37 hours before 1983 to 40+/-7 hours after 1984 (P<.001). The incidence of sepsis decreased from 71% to 44% in these periods (P<.05). After 1984, survivors had a shorter time delay for fluid resuscitation than nonsurvivors (1.7+/-0.5 hours vs 4.8+/-0.9 hours; P<.005) and a lower incidence of sepsis (19% vs 60%; P<.05). From 1984 to 1997, burned children with acute renal failure who did not require dialysis had significantly shorter delays for fluid resuscitation (2.2+/-0.5 hours vs 4.4+/-0.9 hours) and complete wound excision (29+/-6 hours vs 49+/-7 hours) compared with those requiring dialysis (P<.05 for both). Early adequate fluid resuscitation, early wound excision, and better infection control may reduce mortality in burned children with acute renal failure.