Greater Total Body Surface Area Research Articles

Pregabalin in severe burn injury pain: A double-blind, randomised placebo-controlled trial

This randomised, double-blind, placebo-controlled trial assessed the efficacy and tolerability of pregabalin to alleviate the neuropathic component of moderate to severe burn pain. Patients aged 18 to 65 years admitted to a burns unit with a 5% or greater total body surface area burn injury were screened to participate in the trial. Using the Neuropathic Pain Scale (NPS), patients scoring 4 or higher on ‘hot’ pain or ‘sharp’ pain were invited to participate. Consenting patients were randomly assigned to receive pregabalin or placebo for 28 days with individual dose titration commencing at 75 mg twice daily to a maximum pregabalin dose of 300 mg twice daily. The primary outcome measure was the patients’ daily response to the sharp and hot pain of the NPS. Secondary outcome measures included the remaining elements of the NPS, daily opioid requirement, length of hospital stay, pain at 6 months, and side effects of nausea, vomiting, drowsiness and giddiness. For patients administered pregabalin, the primary outcome measures hot ( P = .01) and sharp ( P = .04) pain were significantly reduced compared with those in patients administered placebo. Secondary outcome measures of itch, unpleasantness, surface pain, and procedural pain were significantly lower ( P < .05) in the pregabalin group. Adverse effects were uncommon, with no difference between the treatment groups. There was no significant difference between the pregabalin and placebo treatment groups with respect to opioid consumption, duration of hospital stay, or pain at 6 months. Pregabalin was efficacious and well tolerated in patients after severe burn injury and whose pain was characterised by features of acute neuropathic pain. In this study, pregabalin was well tolerated and significantly reduced several elements of the neuropathic pain scale including hot pain, unpleasantness of the pain, surface pain, and itch, and also significantly reduced procedural pain.

Effects of Cessation of a Structured and Supervised Exercise Conditioning Program on Lean Mass and Muscle Strength in Severely Burned Children

Suman OE, Herndon DN. Effects of cessation of a structured and supervised exercise conditioning program on lean mass and muscle strength in severely burned children. Objective To determine whether the benefits of exercise by burned children are maintained 3 months after the exercise program is concluded. Design Randomized, controlled prospective study. Setting Pediatric burn hospital. Participants Twenty severely burned children with a 40% or greater total body surface area burn, with main outcome measures completed before exercise training, immediately after 12 weeks of exercise training (intervention), and 12 weeks after training ended. Intervention Randomization into a 12-week standard rehabilitation program at home (n=9) or a 12-week standard hospital rehabilitation program supplemented with an exercise-training program beginning 6 months after burn injury (n=11). Main Outcome Measures Assessment of lean body mass (LBM) using dual-energy x-ray absorptiometry and of leg isokinetic muscle strength at a speed of 150°/s were done before, after the 12-week rehabilitation and exercise training program, and 3 months after the exercise program was completed (12mo postburn). The effects of exercise on the dependent variables were analyzed by repeated-measures analysis of variance. If we found a significant overall effect of time and/or intervention, we did a post hoc test for multiple comparison (Holm-Sidak). Results are expressed as mean ± standard error. Results The mean percentage increase in LBM and muscle strength was significantly greater in the exercise group (6.4%±1.9%, 40.7%±8.6%, respectively) than in the no-exercise group (1.9%±2.6% vs 3.4%±4.5%, respectively). Three months after cessation of the exercise program, LBM remained relatively unchanged in the no-exercise group (3.5%±1.8%). In contrast, LBM in the exercise group increased significantly (10.7%±4.8%, P=.03). In addition, muscle strength further increased by 17.9%±10.1% in the exercise group versus 7.2%±3.4% in the no-exercise group, although neither percentage increase was significant ( P=.08 for exercise vs P=.61 for no exercise). Absolute values in LBM and muscle strength for both groups at 12 months postburn continued to be below historical or concurrent age-matched, nonburned children. Conclusions Participation in an exercise program resulted in a greater improvement in LBM and muscle strength in the exercise group than in the no-exercise group. Three months after the exercise training ended, there were persistent mild-to-moderate increases in LBM and muscle strength. Absolute levels continued to be below previously reported nonburned, age-matched values, however, which underscores the need for continued exercise to improve LBM and muscle strength in severely burned children.

Contribution of Acute Kidney Injury Toward Morbidity and Mortality in Burns: A Contemporary Analysis

Severe acute kidney injury (AKI) that requires dialytic support, a relatively uncommon complication in severely burned adults, is associated with a substantially increased mortality rate. It is not known whether milder forms of AKI have prognostic importance in burns. We performed an observational cohort analysis of consecutive patients with major burns admitted to the burn care unit of a tertiary-care center from 1998 to 2003. Our main outcome measures were AKI stratified by the Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage kidney disease (RIFLE) classification and mortality. AKI occurred in 81 of 304 patients (26.6%) with burns on 10% or greater total-body surface area. Risk factors for AKI on multivariate analysis were inhalational injury, catheter infection, and sepsis. Patients with AKI stratified by using the RIFLE classification had greater mortality, greater requirement of artificial ventilation, and longer durations of intensive care unit and hospital stays. Mortality was not significantly different among those with the "Risk" and "Injury" strata of RIFLE AKI compared with those without AKI, but mortality increased significantly with the "Failure" (60%) strata. In multivariate analysis, age, greater total-body surface area, inhalational injury, and the RIFLE classification of Failure were each independent predictors of death. In conclusion, the mortality of patients with burns with severe AKI remains high and unchanged in the modern era of critical care medicine. The RIFLE classification added prognostic information regarding morbidity in patients with milder forms of AKI.

Observations of Psoriasis in the Absence of Therapeutic Intervention Identifies Two Unappreciated Morphologic Variants, Thin-Plaque and Thick-Plaque Psoriasis, and their Associated Phenotypes

Psoriatic plaque thickness is a clinical measure of psoriasis severity. We have observed that patients tend to revert to a baseline thickness of psoriatic plaques when in an untreated state, and hypothesized that other features of psoriasis could associate with this trait. Data prospectively collected on 500 participants in the Utah Psoriasis Initiative were used for the study. In response to a question assessing plaque thickness when disease was at its worst, 144 (28.8%) reported thick plaques, 123 (24.6%) reported thin plaques, and 233 (46.6%) reported intermediate thickness. For patients with "worst-ever" disease at enrollment (n=122), there was significant correlation of thickness between assessment by the patient and the physician (r=0.448, P-value 0.01). Thick plaques associated with male gender, increased body mass index, nail disease, psoriatic arthritis, larger plaques, more body sites, and greater total body surface area affected. Thin plaques associated with eczema, guttate psoriasis, and skin cancer. We suggest that this is preliminary evidence that plaque thickness is an easily measured trait that associates with other clinical features of psoriasis, and that stratification on this phenotype may be useful in further defining the genetic basis of this disease.

Long-term psychosocial adaptation of children who survive burns involving 80% or greater total body surface area.

To examine the psychosocial adjustment of survivors of massive pediatric burn injuries, the change in adjustment across time, and the impact on parents. Patients/parents were assessed at regular intervals postburn using standardized tests of adjustment. Patients who could not be included in standardized longitudinal assessments were administered questionnaires by mail/telephone. The Child Behavior Checklist, the Teacher Report Form, the Youth Self Report Form, and the Parenting Stress Index were utilized to assess adjustment. On all objective measures, the group of survivors and their parents were within normal limits. Adjustment neither improved nor deteriorated over time. Children who survive massive burn injuries can achieve positive psychosocial adaptation.

Long-Term Psychosocial Adaptation of Children who Survive Burns Involving 80% or Greater Total Body Surface Area

Long-Term Psychosocial Adaptation of Children who Survive Burns Involving 80% or Greater Total Body Surface Area

Psychosocial sequelae of pediatric burns involving 80% or greater total body surface area.

Important questions for pediatric burn care specialists relate to the quality of life for those children who survive the most severe burn injuries. This study examines the psychological adjustment of 25 children who survived injuries > or = 80% total body surface area and the impact of such injury on the families. Data were analyzed from the most recent assessment, with the Child Behavior Checklist, Teacher Report Form, Piers-Harris Children's Self-Concept Scale, Parenting Stress Index, and a parental questionnaire designed by the authors. As a group, the children's behavioral problems as reported by both parents and teachers were within normal limits. Measures of parental stress, however, clearly differentiated the burn population. These parents attributed more stress to characteristics of their children. Children with > or = 80% TBSA burns develop positive feelings about themselves and appear no more troubled than a comparable group of nonburned children. The impact on the families is significant, however, and must be considered of consequence in the rehabilitation of the burned child.

The Use of Intestinal Antibiotics to Delay or Prevent Infections in Patients with Burns

Bacterial colonization and infection of wounds in seriously burned patients often comes from the patient's indigenous bowel flora. A prospective randomized clinical trial that involved 30 patients with 20% or greater total body surface area burns was undertaken to evaluate the use of a standard antibiotic bowel preparation in the delay or prevention of bacterial colonization of the burn wound and sepsis. Certain enteric bacteria were seen less frequently in the treated group (Enterobacter organisms), but other bacteria appeared more often in the treated group (Proteus organisms and enterococci). The average time of colonization of the burn wounds was 6.1 days in the treated group and 6.7 days in the control group. Blood cultures were positive for enteric organisms earlier in the treatment group. Pseudomonads appeared earlier in the wound and blood cultures of the treated group than in the control group. The effect of antibiotic bowel suppression in patients with burns is varied and unpredictable. The bowel preparation may select certain organisms and lead to earlier colonization of the wounds. Overall outcome and survival was not improved by the use of an antibiotic bowel preparation in these patients.

Intramuscular pressure in the burned arm: measurement and response to escharotomy

Using a wick catheter technique, sequential measurements of intramuscular pressure were obtained in 31 burned arms in 18 patients. Abnormally high pressures were recorded in 90 percent of extremities and exceeded the potentially harmful level of 30 mm Hg in 42 percent. Correlation of intramuscular pressure with signs and symptoms of extremity compression, including Doppler pulses, was poor. Intramuscular pressure elevation appeared to parallel edema formation beneath the burn wound. A high incidence of pressure measurements in excess of 30 mm Hg was found in patients who had 30 percent or greater total body surface area injury (67 percent), 10 percent or greater full-thickness burns (75 percent), and extremities with circumferential involvement (57 percent). In every case escharotomy produced a dramatic decrease in intramuscular pressure, while a randomized group of extremities that were not decompressed developed sustained pressures as high as 64 mm Hg despite the presence of intact Doppler pulses. Extremities treated in this manner appeared slower in resolving edema and regaining motion and strength. Measurement of intramuscular pressure beneath the burn eschar is recommended in evaluating all patients at risk from extremity burns.

A Comparison of Leukocyte Function and Burn Mortality

Of the several tests which measure leukocyte bactericidal competency only one, chemotaxis, has been reported to reflect both leukocyte dysfunction and patient mortality in major thermal injury. To validate the reliability that chemotaxis reflects mortality functional chemotactic index (FCI) was measured in leukocytes from 33 patients with 30% or greater total body surface area burns. Additionally, nitroblue tetrazolium (NBT) reduction and O2 consumption were compared to FCI. Significant decreases were seen in FCI values compared to normals. No differences, however, were seen in FCI values between surviving and nonsurviving patients. NBT reduction and O2 consumption also showed decreases with a significant difference between the mean decrease in surviving and nonsurviving patients. While the data show all these laboratory tests to be reflective of significant impairments in host defense, they do not appear to be reliable as predictive indices of patient survival and therefore should not be interpreted as such.

A Comparison of Leukocyte Function and Burn Mortality

Of the several tests which measure leukocyte bactericidal competency only one, chemotaxis, has been reported to reflect both leukocyte dysfunction and patient mortality in major thermal injury. To validate the reliability that chemotaxis reflects mortality functional chemotactic index (FCI) was measured in leukocytes from 33 patients with 30% or greater total body surface area burns. Additionally, nitroblue tetrazolium (NBT) reduction and O2 consumption were compared to FCI. Significant decreases were seen in FCI values compared to normals. No differences, however, were seen in FCI values between surviving and nonsurviving patients. NBT reduction and O2 consumption also showed decreases with a significant difference between the mean decrease in surviving and nonsurviving patients. While the data show all these laboratory tests to be reflective of significant impairments in host defense, they do not appear to be reliable as predictive indices of patient survival and therefore should not be interpreted as such.