Burn Excision Research Articles

The treatment effect of operative intervention for flame versus scald burns in resource-limited settings

IntroductionIn resource-limited environments, it is critical to triage burn patients most likely to benefit from operative intervention. This study sought to identify patients with a more significant treatment effect after operative intervention following burn injury at a tertiary burn center in Lilongwe, Malawi. MethodsThis is a retrospective analysis of burn patients presenting to Kamuzu Central Hospital from 2011 to November 2022. We compared patients based on whether they had scald or flame burns. Using logistic regression, we estimated the adjusted treatment effect of operative intervention on in-hospital mortality. Operative intervention was defined as burn excision and debridement with or without skin grafting. ResultsWe included 3266 patients. 2099 (64.7 %) patients had a scald burn, and 1144 (35.3 %) had a flame burn. 630 patients (19.3 %) underwent surgery. Crude mortality among all patients was 18.1 %, and for patients who underwent surgery, it was 9.7 %. When adjusted for total body surface area burned (TBSA) and age, the average treatment effect of surgery on mortality was − 0.07 (95 % CI − 0.11, − 0.033) for patients with scald burns and − 0.17 (95 % CI − 0.22, − 0.11) for patients with flame burns (Fig. 1). For patients with flame burns, the adjusted odds ratio of death associated with surgery was 0.26 (95 % CI 0.17, 0.39). ConclusionsOperative intervention confers a survival advantage for patients with flame burns, and the average treatment effect was more significant compared to patients with scald burns. In general, in resource-limited environments flame burns should be prioritized for surgery over scald burns to improve patient outcomes.

Study of the Influencing Factors and their Predictive Value of Skin Graft Take in Early Excision and Grafting in Severe Burns: A Prospective Study

Abstract Background Burn injury is one of the most life-threatening traumas worldwide especially in developing countries. After severe burns, the patients suffer from loss of multiple functions of skin, such as fluid loss, and high infection rate with burn sepsis and septic shock. Objective To investigate the various factors that affect the survival rate of skin grafts in early excision and grafting procedures (from 3rd to 7th day after burn) in patients with severe burns. Patients and Methods This Prospective cohort study was done in Ain Shams University Burn Center attached to Plastic, burn and maxillofacial department during the period from May 2021 to May 2022. Results Analysis was performed on 75 individuals who had early burnt skin excised and early skin graft coverage. Two patient groups were analyzed, in the form of good skin graft take >70% in 45 patients, and poor skin graft take < 70% in 30 cases, based on the survival rate of the skin graft post operatively. Conclusion The univariate analysis and repeated measurement showed that burn intensity, the post-operative sepsis, the neutrophil lymphocytic ratio on day 3 (NLR3) in the poor skin graft take group were significantly higher than those in the good skin graft take group, while the estimated albumin levels in perioperative period and the estimated pre-albumin levels in perioperative period were higher in the good skin graft take group. Receiver operating characteristic curve showed that NLR3, the estimated albumin levels and pre-albumin levels in perioperative period had a good predictive value for the survival of skin grafts. The estimated albumin levels ≤3.18 gm/dl, estimated pre-albumin ≤23.9 mg/dl, and NLR3 ≥ 12 were independent risk factors for graft take in perioperative period.

Pediatric Facial Burn Reconstruction.

Contrary to prior pediatric burn treatment philosophies, we now know that early burn excision and grafting for non life-threatening burns can compromise future reconstruction. Extensive scar excision should be minimized and scar rehabilitation maximized, as secondary iatrogenic deformities can become even more difficult to fix. Scar remodeling with local tissue rearrangement can relieve tension and soften scars over time. The majority of facial burns often only involve skin and can be adequately treated without the need for complex flap reconstruction. Facial burn scars are a different problem than facial burn scar contracture. The former needs scar rehabilitation, whereas the latter needs the addition of skin. Laser therapy has transformed the treatment of burn scars and is an incredibly valuable adjunct to local tissue rearrangement and grafting. The most favorable functional, aesthetic, and psychological outcomes require a long-term multidisciplinary effort and customized protocol utilizing the vast armamentarium of reconstructive tools described below.

Early Tangential Excision and Split-Thickness Skin Graft Reduced Hospitalized Length Stays for Burn Injuries

ABSTRACT Introduction: Burns pose a physical, psychological, health system, and long-term length of stay problem. Surgical treatment of burns is an important intervention in their management. The optimal timing of early tangential excision and split-thickness skin graft varies. Early excision of burned tissue to remove dead tissue and inhibit the inflammatory process decreases the risk of infection. Early excision and grafting of burns is the standard of practice for most major burns. Methods: The research was a cross-sectional study with a descriptive design of secondary data. Burn patients were treated at Dr. Soetomo General Academic Hospital Surabaya, Indonesia, from 2018 to 2022. Inclusion criteria in this study were all patients who underwent early tangential excision and split-thickness skin graft. Achieving statistical analysis and data analysis using SPSS 25 on Windows. Results: A greater amount of time on total body surface area (TBSA) is linked to early tangential excision and split-thickness skin grafts. There are statistically significant variations in the burn area (TBSA 20.5%–30%, P = 0.036 (P = 0.05), TBSA 30.5%–40%, P < 0.001, and burn area (TBSA 40.5%–50%, P = 0.003). The current findings demonstrated that split-thickness skin grafts and early tangential excisions done on burns with TBSA 20% at partial thickness–full thickness depth had statistically significant outcomes, shortening the length of stay for burn patients. Conclusions: An analysis of the current data, burn patients’ duration of stay was reduced when burns with TBSA >20% with partial thickness–full thickness depth underwent early tangential excision and split–thickness skin transplant had statistically positive results.

Role of Dermabrasion Assisted Tangential Excision in Burns

Burn injury of second degree deep dermal and full thickness delays in healing and heals by scarring. Deep dermal burns need early treatment by tangential excision and skin grafting to promote healing. While wound irrigation, debridement, and local wound care may be sufficient for managing superficial burns (involving the epidermis and superficial dermal layer), deep burns (involving the deep dermal layer and other structures deeper to it) require tangential excision and skin grafting. If performed early it is associated with better outcomes in terms of reduced infection risk and hastened wound healing.

Role of antimicrobial coated allogenic dried amniotic membrane in partial thickness burns

Objectives: Human amniotic membrane (HAM) is the biological scaffold for burn wound management. Allogenic HAM helps in promoting the healing of partial-thickness burn wounds. In this case study, we share our experience in using the antimicrobial-coated HAM. Material and Methods: The subject was an 8-year-old male child, who had accidental electrocution while playing near the electrical transformer and developed second-degree superficial and deep burns over the chest, abdomen, and bilateral lower limb. The child underwent tangential excision of the deep burns, and partial thickness burns are covered with dried allogenic HAM. Results: Intraoperative and postoperative periods were uneventful for the patient. The raw area took up the AM well, and burn wounds healed well in the second-degree superficial burns. A deep burns wound bed was prepared, and split skin grafting was done to the raw area. The wounds healed well after two weeks with minimal scarring. No complications or side effects were noted. Conclusion: Allogenic HAM plays a role in burn wound healing in burns. It helps in promoting the wound healing process.

Amphetamine Positivity Prior to Burn Surgery Does not Adversely Affect Intraoperative Outcomes.

The treatment of burn patients using amphetamines is challenging due hemodynamic liabilty and altered physiology. Wide variation exists in the operative timing for this patient population. We hypothesize that burn excision in patients admitted with amphetamine positivity is safe regardless of timing. Data from two verified burn centers between 2017 and 2022 with differing practice patterns in operative timing for amphetamine-positive patients. Center A obtains toxicology only on admission and proceeds with surgery based on hemodynamic status and operative urgency, whereas Center B sends daily toxicology until a negative test results. The primary outcome was the use of vasoactive agents during the index operation, modeled using logistic regression adjusting for burn severity and hospital days to index operation. Secondary outcomes included death and inpatient complications. A total of 270 patients were included, and there were no significant differences in demographics or burn characteristics between centers. Center A screened once and Center B obtained a median of four screens prior to the surgery. The adjusted OR of requiring vasoactive support intraoperatively was not associated with negative toxicology result (P = .821). Having a body surface area burned >20% conferred a significantly higher risk of vasoactive support (adj. OR 13.42 [3.90-46.23], P < .001). Mortality, number of operations, stroke, and hospital length of stay were similar between cohorts. Comparison between two verified burn centers indicates that waiting until a negative amphetamine toxicology result does not impact intraoperative management or subsequent burn outcomes. Serial toxicology tests are unnecessary to guide operative timing of burn patients with amphetamine use.

The Timing of Operative Intervention for Pediatric Burn Patients in Malawi.

Defining the optimal timing of operative intervention for pediatric burn patients in a resource-limited environment is challenging. We sought to characterize the association between mortality and the timing of operative intervention at a burn center in Lilongwe, Malawi. This is a retrospective analysis of burn patients (<18years old) presenting to Kamuzu Central Hospital from 2011 to 2022. We compared patients who underwent excision and/or burn grafting based on the timing of the operation. We used logistic regression modeling to estimate the adjusted odds ratio of death based on the timing of surgery. We included 2502 patients with a median age of 3years (IQR 1-5) and a male preponderance (56.8%). 411 patients (16.4%) had surgery with a median time to surgery of 18days (IQR 8-34). The crude mortality rate among all patients was 17.0% and 9.1% among the operative cohort. The odds ratio of mortality for patients undergoing surgery within 3days from presentation was 5.00 (95% CI 2.19, 11.44) after adjusting for age, sex, % total burn surface area (TBSA), and flame burn. The risk was highest for the youngest patients. Children who underwent burn excision and/or grafting in the first 3days of hospitalization had a much higher risk of death than patients undergoing surgical intervention later. Delaying operative intervention till >72h for pediatric patients, especially those under 5years old, may confer a survival advantage. More investment is needed in early resuscitation and monitoring for this patient population.

Feasibility of intra-operative image guidance in burn excision surgery with multispectral imaging and deep learning

BackgroundExposing a healthy wound bed for skin grafting is an important step during burn surgery to ensure graft take and maintain good functional outcomes. Currently, the removal of non-viable tissue in the burn wound bed during excision is determined by expert clinician judgment. Using a porcine model of tangential burn excision, we investigated the effectiveness of an intraoperative multispectral imaging device combined with artificial intelligence to aid clinician judgment for the excision of non-viable tissue. MethodsMultispectral imaging data was obtained from serial tangential excisions of thermal burn injuries and used to train a deep learning algorithm to identify the presence and location of non-viable tissue in the wound bed. Following algorithm development, we studied the ability of two surgeons to estimate wound bed viability, both unaided and aided by the imaging device. ResultsThe deep learning algorithm was 87% accurate in identifying the viability of a burn wound bed. When paired with the surgeons, this device significantly improved their abilities to determine the viability of the wound bed by 25% (p = 0.03). Each time a surgeon changed their decision after seeing the AI model output, it was always a change from an incorrect decision to excise more tissue to a correct decision to stop excision. ConclusionThis study provides insight into the feasibility of image-guided burn excision, its effect on surgeon decision making, and suggests further investigation of a real-time imaging system for burn surgery could reduce over-excision of burn wounds.

Use of Cultured Epithelial Autograft in Conjunction with Biodegradable Temporizing Matrix in Massive Burns: A Case Series.

Intensive care for massively burn patients has increased survival and highlights the need for a solution to the problem of insufficient donor sites for autologous skin coverage. In this case series we present ten patients with average burn size of 81% TBSA and mean age of 24 years old, who underwent burn excision followed by either immediate or delayed biodegradable temporizing matrix (BTM) placement. After an integration period, the BTM was delaminated either the day before or immediately prior to placement of cultured epithelial autografts (CEA) over a widely meshed (4:1 or 6:1) split thickness skin graft (STSG). One patient had CEA alone, without STSG, placed on integrated BTM and had successful take. Seven patients survived to discharge and had average 95% wound closure at 135±35 days. The patients had on average 10.4 total operations and 8.7 excision and grafting operations. Five patients had complications related to the BTM requiring removal or replacement including three fungal infections, one bacterial infection and one with bleeding and a large clot burden. In conclusion, this surgical strategy is a viable option for patients with massive burns and insufficient donor for autologous skin grafting.

104 Indocyanine Green Fluorescence Differentiates Necrotic Cells from Healthy and Apoptotic Cells

Abstract Introduction No objective technique exists to distinguish necrotic from viable tissue, risking over-excision in burns and loss of wound healing potential. Using delayed fluorescence imaging of indocyanine green (ICG), a method called second window ICG (SWIG), we have shown that high dose ICG persists in burn wounds in both animals and patients 24 hours after infusion. The necrotic avidity of ICG is proposed as the underlying mechanism, although inflammation also likely has a role. The objective of this study is to examine the hypothesis at both the tissue and cellular levels. Methods To examine the localization of ICG in burn tissue, 4-mm biopsies taken from burn patients who underwent SWIG were embedded and sequentially sectioned for H&amp;E (tissue architecture) and LDH (tissue viability) and ICG fluorescence imaging. To examine whether ICG preferentially binds to necrotic cells, primary skin cells (fibroblasts or keratinocytes) were subjected to thermal injury at 65ºC for 0 (untreated), 2.5 or 5 minutes. The cells were subsequently incubated with ICG at concentrations ranging from 0.5 to 5 μg/mL at 37ºC for 30 minutes. A necrosis and apoptosis detection kit with Yo-Pro™-1 and propidium iodide (PI) was used to differentiate live, apoptotic and necrotic cell populations in flow cytometry. The ICG florescence intensity of each cell population was measured with flow cytometry. Results The fluorescence microscopic imaging revealed that ICG intensity was most intense in the superficial severely thermally-injured tissue and gradually decreased with depth. This zone of high ICG intensity was co-localized with high cellularity (shown in H&amp;E) consisting of a mixture of nonviable skin cells (shown in LDH) and inflammatory infiltrates. Using flow cytometry, the optimal concentration of ICG with the highest ICG florescence median intensity (FMI) and the best separation of live, apoptotic and necrotic cell populations was 2.5 μg/mL, which was used for subsequent flow cytometry experiments. For both fibroblasts and keratinocytes, the ICG FMI was significantly higher in the necrotic cell population than that of either the live or apoptotic cell population, suggesting higher affinity of ICG to necrotic cells. The ICG FMI of necrotic cells with longer heat exposure (5 minutes) was significantly higher than that of necrotic cells with shorter heat exposure (2.5 minutes), suggesting that the binding sites for ICG increase with the degree of thermal injury. Conclusions This study demonstrates the necrotic avidity of ICG in burned skin tissue and two primary skin cell types. Further studies are needed to study the ICG binding characteristics with inflammatory cell populations and single cell suspensions dissociated from human burn tissue. Applicability of Research to Practice This, along with our pilot study of SWIG in patients, supports the feasibility of SWIG in guiding surgical decision-making in burn excision by defining thresholds of fluorescence intensity values.

69 Methamphetamine Positivity Prior to Burn Surgery Does not Adversely Affect Intraoperative or Inpatient Outcomes

Abstract Introduction The treatment of burn patients using amphetamines is challenging for hemodynamic and behavioral reasons. In addition, recent amphetamine use may also pose intraoperative risks. Due to insufficient literature to guide the safety and timing of operative care, wide practice variation exists in the operative timing for this patient population. We hypothesize that burn excision without negative amphetamine toxicology is safe. Methods We queried the operative and electronic health records of amphetamine-positive patients treated from 2017-2022 at two ABA verified burn centers. The practice guideline at Center A obtains admission toxicology only and proceeds with surgery based on hemodynamic status and operative urgency, whereas Center B sends daily toxicology until a negative test results. The primary safety outcome was the use of vasoactive agents during the index operation. This risk was modeled via logistic regression and adjusted for injury severity and hospital day for index operation. Secondary outcomes included death and inpatient complications. Results A total of 270 patients were identified during the study period. Mean age was 45.5 years (SD 12.9 years), median TBSA was 9.2% and the majority were male (76.7%). There were no significant differences in injury size, age, or male/female proportion between the two sites. Whereas Center A only tested once on admission, Center B obtained a median of 4 toxicology screens prior to surgery. There were no difference in mean induction systolic blood pressure between the 2 sites, although Center A had more patients who had SBP&amp;lt; 95 or &amp;gt;160mmHg on induction (one-way ANOVA p=0.596). The adjusted OR of requiring vasoactive support during surgery was not associated with negative toxicology status (p=0.821). A larger injury size (%TBSA &amp;gt;20) conferred a significant higher risk of vasoactive support (adj. OR 13.42 [3.90 – 46.23], p&amp;lt; 0.001). Clinical outcomes at the 2 sites were similar in the terms of mortality, number of operations, stroke, and hospital length of stay. Conclusions Comparison between 2 ABA verified burn centers identifies a significant variation in practice with regards to serial amphetamine screenings prior to burn surgery. This study indicates that negative toxicology does not impact intraoperative anesthesia management nor subsequent burn clinical outcomes. Applicability of Research to Practice Serial toxicology tests are unnecessary to guide operative timing of burn patients with amphetamine use.

768 Intraoperative Use of Intravenous Methadone and Post-Operative Opioid Requirements in Adult Burn Patients

Abstract Introduction Post-operative pain management can be a significant challenge in patients undergoing burn excision. Standard pharmacologic pain management strategies include both opioid and non-opioid medications. Given the national overuse of opioids and the associated negative repercussions, it is prudent that we find ways manage pain with fewer or no opioids. We hypothesize that intraoperative administration of intravenous methadone will reduce the total morphine milligram equivalents (MME) used in the 36 hours following surgery. Methods This is a retrospective single-center cohort study of adult burn patients who underwent a first excision of full thickness burn between January 2019 through January 2021. The exposure group received intraoperative methadone while the control group did not. The primary outcome was total MME utilized in the 36 hours following surgery. Secondary outcomes included average pain score and post-anesthesia care unit (PACU) total MME utilized. Chi squared tests were used for statistical analysis of categorical variables and unpaired t-tests were used for continuous variables. Results The control group contained 35 subjects and the methadone group contained 19 subjects who did not differ in baseline characteristics. The average burned total body surface area (TBSA) was 9% in the control group and 18% in the methadone group (t(53)=-3.9, p &amp;lt; 0.01). Intraoperative narcotic requirements did differ between groups due to intravenous methadone utilization in the intervention group (t(53)=-15, p &amp;lt; 0.01). In the early post-operative period, the methadone group received 155 MME while the control group received 137 MME (t(53)=-0.36, p = 0.72). While in the PACU, patients in the methadone group received 5 MME while the control group received 12 MME (t(53)=1.60, p=0.12). Patient pain scores did not differ significantly between the groups (t(53)=-0.15, p=0.88). Conclusions Intraoperative utilization of methadone for burn surgery did not affect post-operative opioid usage in the first 36 hours or post-operative pain scores in a statistically significant manner. We acknowledge the data set is not large enough to power the study to detect a significant difference; additional data collection is ongoing to include several hundred subjects. Confounding variables such as different multimodal pain regimen techniques, % TBSA, extent of surgical excision, and history of opioid tolerance may exist within this data set. Further analysis is warranted to adequately power this study and account for potential confounding variables. Applicability of Research to Practice Intraoperative use of intravenous methadone may reduce use of opioid medications in the early post-operative period.

72 Multi-Spectral SWIR Imaging in Humans Reveals Correlations with Distinct Skin Burn Depths

Abstract Introduction Burn depth determination is a critical aspect of burn patient care but currently lacks accuracy in clinical practice. We have shown first in animal models and then in a two-patient characterization that Short Wave Infrared (SWIR) imaging, which penetrates tissue better than visual or near-infrared light and is very sensitive to water content, can distinguish between superficial and deep tissue necrosis. Here we present the findings from our pilot study of 10 patients showing the use of multi-spectral SWIR imaging of human burn injury as a potential technique for burn depth determination. Methods Ten patients admitted for mixed depth thermal injuries between 5-40% TBSA were analyzed using our SWIR assessment tool. Prior to burn excision the SWIR system was used to image burn areas and normal skin at 4 different SWIR wavelengths (Figure 1A). Standard photographs from imaged areas were collected and presented for 5 independent, blinded, surgeons’ assessments. Using the visual and SWIR images, 5-15 regions of interest (ROI) were selected from each of the burned areas and normalized to adjacent normal skin and the reflected light intensity in each ROI was averaged at each wavelength. Statistics were done using Mann-Whitney U tests. Results Visual and SWIR images were collected from burn areas in 10 patients for a total of 273 burn ROIs. The ROIs were assessed by the surgeons with ROIs being agreed upon as being superficial or superficial partial thickness (SPT) (n=47), deep partial thickness (DPT) (n=97), or full thickness (FT) (n=129) burns by a majority (60% or above) consensus. As seen in Figure 1B, the reflectance intensities (RIs) from superficial and SPT burns were significantly different than the DPT burns at the 1940 nm wavelength (p=0.05) and significantly different than FT burns at 1200 nm (p=0.008) and 1940 nm (p=0.009). When DPT and FT burns were compared there was a significant difference a 1200 nm (p=0.003) and 2250 nm (p=0.01). Conclusions Here we present a 10 patient SWIR pilot study demonstrating distinct ROIs of SWIR wavelengths for different burn depths based on consensus surgeon assessments. Overall, as burn depth increases, the 1200 and 2250 nm wavelengths show increasing RIs and 1940 nm show decreasing RIs. These results motivate further studies of SWIR imaging including pending histological analysis in the hope to non-invasively and accurately identify operative versus non-operative burns. Applicability of Research to Practice This new SWIR technology may enable us to more objectively assess burn depth, leading to improved surgical decision making and better patient outcomes.

Does early excision or skin grafting of severe burns improve prognosis? A retrospective cohort study.

The present study aimed to investigate the appropriate timing of excision or skin grafting of burn wounds in patients with severe burns. We retrospectively analyzed data from the Diagnosis Procedure Combination Database, a nationwide inpatient database in Japan. Patients with severe burns (burn index ≥10) who underwent excision or skin grafting within 7 days from September 2010 to March 2019 were included. We defined the early surgery group as patients who underwent excision or skin grafting within 2 days of admission and the delayed surgery group as those who underwent surgery within 3-7 days of admission. Propensity score matching was used to compare the in-hospital mortality between the two groups, yielding a cohort of 389 pairs. A total of 2362 eligible patients were categorized into the early surgery group (n=626) and delayed surgery group (n=1736). The overall in-hospital mortality was 19.6%. In-hospital mortality did not differ significantly between the early surgery (15.9%) and the delayed surgery groups (17.2%; p=0.70). These results suggest that excision or skin grafting within 2 days of admission was not associated with improved in-hospital mortality compared with surgery thereafter for patients with severe burns.

Burn excision within 48 hours portends better outcomes than standard management: A nationwide analysis.

Previous studies have debated the optimal time to perform excision and grafting of second- and third-degree burns. The current consensus is that excision should be performed before the sixth hospital day. We hypothesize that patients who undergo excision within 48 hours have better outcomes. The American College of Surgeons Trauma Quality Programs data set was used to identify all patients with at least 10% total body surface area second- and third-degree burns from years 2017 to 2019. Patients with other serious injuries (any Abbreviated Injury Scale, >3), severe inhalational injury, prehospital cardiac arrest, and interhospital transfers were excluded. International Classification of Diseases, Tenth Revision , procedure codes were used to ascertain time of first excision. Patients who underwent first excision within 48 hours of admission (early excision) were compared with those who underwent surgery 48 to 120 hours from admission (standard therapy). Propensity score matching was performed to control for age and total body surface area burned. A total of 2,270 patients (72% male) were included in the analysis. The median age was 37 (23-55) years. Early excision was associated with shorter hospital length of stay (LOS), and intensive care unit LOS. Complications including deep venous thrombosis, pulmonary embolism, ventilator-associated pneumonia, and catheter-associated urinary tract infection were significantly lower with early excision. There was no significant difference in mortality. Performance of excision within 48 hours is associated with shorter hospital LOS and fewer complications than standard therapy. We recommend taking patients for operative debridement and temporary or, when feasible, permanent coverage within 48 hours. Prospective trials should be performed to verify the advantages of this treatment strategy. Therapeutic/Care Management; Level III.

A comparative study of outcomes of burns across multiple levels of care

BackgroundBurn injuries are a significant contributor to the burden of diseases. The management of burns at specialised burn centres has been shown to improve survival. However, in low- and middle-income countries (LMICs) major burns are managed at non-specialised burn centres due to resource constraints. There is insufficient data on survival from treatment at non-specialised burn centres in LMICs. This study aimed to compare the outcomes of burns treatment between a specialised burn centre and five non-specialised centres. MethodsA prospective cohort study was conducted on patients aged 18 years or above from January 1, 2021 to September 30, 2021. Participants were selected from the admission register at the emergency department. All burns irrespective of the mechanism of injury or %TBSA were included. Data were entered into REDCap. Statistical analysis of outcomes such as positive blood culture, length of hospital stay (LOHS) and 90-day mortality between specialised burn versus non-specialised centres was performed. Furthermore, an analysis of risk factors for mortality was performed and survival data computed. ResultsOf the 488 study participants, 36% were admitted to a specialised burn centre compared to 64% admitted to non-specialised centres. The demographic characteristics were similar between centres. Patients at the specialised burn centre compared to non-specialised centres had a significantly higher inhalation injury of 30.9% vs 7.7% (p < 0.001), > 10%TBSA at 83.4% vs 45.7% (p < 0.001), > 20%TBSA at 46.9% vs 16.6% (p < 0.001), and a median (IQR) ABSI score of 6 (5−7) vs 5 (4−6) (p < 0.0001). Furthermore, patients from specialised burn vs non-specialised centres had a longer median (IQR) time from injury to first burn excision at 7 (4−11) vs 5 (2−10) days, higher rate of burn sepsis 69% vs 35%, increased LOHS 17 (11−27) vs 12 (6−22) days, and 90-day mortality rates at 19.4% vs 6.4%. After adjusting for cofounding variables, survival data showed no difference between specialised burn and non-specialised centres (HR 1.8 95% CI 1.0–3.2, p = 0.05). ConclusionAlthough it appears that the survival of burn patients managed at non-specialised centres in a middle-income country is comparable to those managed at specialised burn centres, there is uncounted bias in our survival data. Hence, a change in practice is not advocated. However, due to resource constraint specialised burn centres in addition to managing major burns should provide training and support to the non-specialised centres.

To bleed or not to bleed? Case series and discussion of haemorrhage risk with enzymatic debridement in burn injuries.

Surgical burn excision (along with skin grafting) carries the risk of blood loss. The use of enzymatic debridement agents such as Nexobrid® has gained increased popularity as an alternative to surgical debridement in the management of burns with its reported benefits of selective burn debridement, minimising blood loss and potentially reducing the need for skin grafting. However, there is limited evidence regarding its effects on bleeding. Currently, the manufacturer declares there is no evidence for increased risk of localised bleeding and its systemic effects upon coagulation are less clear. We present two clinical cases demonstrating the possible effects of Nexobrid® on coagulation and bleeding at the debridement site. Comparisons are drawn with the manufacturers' guidance as well as evaluating the current recommendations of its use. Nexobrid® is a novel therapy and there are few adverse effects reported in the literature. The basis of its appeal is the reduced blood loss at the debridement site and the selectivity it possesses in preserving healthy dermis. However, our cases have demonstrated that haemorrhage can occur and that those using Nexobrid® should be mindful of the potential bleeding risk from varicosities within the burn wound. We have also illustrated that Nexobrid® can be used in patients with pre-existing clotting disorders without requiring the use of blood products. However, we emphasise the importance of haematological support for its safe administration. Nexobrid®, a debriding agent that contains enzymes, has been developed as an alternative to surgery which for most surgeons is the traditional method of removing dead tissue following a burn injury. The active agent is bromelain and this is derived from the stems of pineapples. This novel treatment is increasingly being used in the management of middle to deep skin thickness burns and it seems to have a number of benefits such as reducing blood loss, reducing the need for skin grafting as well as being able to treat burns in certain areas of the body that would be technically challenging to remove in the standard fashion. It simply targets the dead tissue leaving viable remnants of the skin that would hopefully allow healing to occur without the need for surgical intervention. Being a relatively new concept, current evidence regarding the safety and value of Nexobrid® continues to develop. In 2020, an agreement guideline outlining best practice with the use of Nexobrid® was published. In this statement, it was advised that caution should be taken when using Nexobrid® in patients who have blood clotting disturbances as this could increase the likelihood of bleeding. However, they did not mention that excessive bleeding can potentially occur with this treatment.We present two clinical cases demonstrating the possible effects of Nexobrid® on the clotting system and bleeding at the application site. Comparisons are drawn with the manufacturers' guidance as well as assessing the current recommendations of its use. We illustrate that Nexobrid® can be safely used in patients with pre-existing clotting disturbances if the correct procedures are performed. We also highlight the potential complication of excessive bleeding if Nexobrid® is used in patients who have co-existing enlarged surface veins along with their burn injury. We feel the guidance should be updated to reflect these findings.

Impact of surgical first excision delay on function for heat-press hand injury by the Quick-DASH questionnaire: Series over 20 years

BackgroundHeat-press hand burn leads to complex and severe lesions, with potentiation of thermal burn by the crushing mechanism. Management remains poorly codified, and the surgical strategies found in the literature remain contradictory. The objective of our study is to report our experience and define the first burn excision delay through functional evaluation with a Quick-DASH questionnaire. MethodsWe carried out a retrospective study of 20 burned hands by heat-press managed in our burn unit between 2002 and 2021. Following data were collected, at least one year after the accident: Quick-DASH score, which was our primary endpoint, injury assessment according to the Tajima's classification, overall surgical management, and impact on their professional activity. A descriptive statistical analysis of these data was performed followed by a univariate analysis to assess the correlation between delay to first surgical excision and the long-term functional result (Quick-DASH score and time before return to work). ResultsBurns were Tajima grade 1 (supra-fascial dermal burn) in 35 % of cases, grade 2 (exposure of subfascial structures) in 45 % and grade 3 (bone or joint exposure) in 20 %. There were no cases of bone fractures.We received 18 out of 20 questionnaires with no significant differences between those who send back or not. The median QuickDash score was 7.15 [IQR 0–52.25]. The first surgical excision was performed with a median of 8 days after the accident [min: 0; max: 20]. The median time before return to work was 24 weeks [IQR 17–42.25]. Only 11 patients (55 %) were able to go on the initial employment. Spearman test found a strong trend for a negative correlation between the time to the first excision and the QuickDash score (ρ = −0.46; r2 = 0.087; p = 0.053). ConclusionAccording to observations made in our unit and in agreement with Tajima, who first described heat-press injury, the first surgical excision should be performed approximately one week after the accident. Subsequent excisions may be performed to reassess the lesions and complete the debridement, with reconstruction to follow. Multidisciplinary management is still necessary, including early and intensive physiotherapy, psychological support, and assessment by an occupational physician.

Retrospective Study from a Single Center on the Efficacy of Pulsed Lavage Following Excision of Burns ≥30% of the Total Body Surface Area in 63 Patients.

BACKGROUND Ensuring the take rate of skin grafting and reducing the mortality of patients with severe burns have remained big challenges worldwide. This retrospective study from a single center aimed to evaluate the efficacy of pulsed lavage following excision of burns ≥30% of the total body surface area (TBSA) in 63 patients. MATERIAL AND METHODS Among 63 patients, the types of burns sustained were severe burns and extremely severe burns (≥30% TBSA). The degrees of the burns were second degree and third degree, and the causes were thermal, chemical, and electric. Patients with early aggressive excision were divided into a pulsed lavage group and control group. The constituent of the lavage fluid was 0.9% physiological saline. The evaluation of wound healing and complications was based on the wound healing rate and time, clinical symptoms, and examination. We determined the take rate of skin grafting, positive rate of postoperative bacterial cultures, changes in perioperative serum C-reactive protein (CRP) and procalcitonin (PCT) levels, and incidence of secondary grafting. RESULTS The take rate of skin grafting and the decreased rates of perioperative serum CRP and PCT levels were significantly higher in the pulsed lavage group than in the control group (P<0.05). Moreover, the positive rate of wound postoperative bacterial cultures and mortality in the pulsed lavage group showed remarkably lower levels (P<0.05). CONCLUSIONS Pulsed lavage following excision of burns ≥30% TBSA increased the take rate of skin grafting, alleviated the positive rate of postoperative bacterial cultures, decreased serum CRP and PCT levels, and reduced mortality.